Endoscopic ultrasound versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a randomized trial comparing two management strategies

Clinical Practice Guidelines for post-ERCP pancreatitis 2023

The Clinical Practice Guidelines for post-ERCP pancreatitis (PEP) 2023 provide updated recommendations for the prevention, diagnosis, and management of PEP. Endoscopic retrograde cholangiopancreatography (ERCP), a valuable procedure for diagnosing and treating pancreatobiliary diseases, can result in PEP as the most common adverse event. Since the first guidelines were published in 2015, advances in techniques and new research findings have necessitated this revision. The guidelines developed using the GRADE methodology target adult patients undergoing ERCP. They offer a comprehensive framework for clinicians to minimize the risk of PEP. For high-risk patients, endoscopic ultrasound before ERCP is recommended to avoid unnecessary procedures. The guidelines also discuss procedural and patient-related risk factors for PEP, highlighting that operator experience does not significantly affect PEP rates if performed under the supervision of skilled endoscopists. The diagnostic criteria include monitoring serum pancreatic enzyme levels postprocedure, and early computed tomography is advised in suspected cases. For treatment, the guidelines recommend following acute pancreatitis protocols. Key preventive measures include the use of temporary pancreatic duct stents and rectal nonsteroidal anti-inflammatory drugs, both of which are supported by strong evidence for reducing the incidence of PEP. Overall, these guidelines aim to enhance clinical outcomes by reducing PEP incidence and improving its management through evidence-based practices.

Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone-induced acute cholangitis and pancreatitis

Urgent or emergency endoscopic retrograde cholangiopancreatography (ERCP) is indicated for gallstone-induced acute cholangitis and pancreatitis. The technique and optimal timing of ERCP depend on the disease state, its severity, anatomy, patient background, and the institutional situation. Endoscopic transpapillary biliary drainage within 24 h is recommended for moderate to severe acute cholangitis. The clinical outcomes of biliary drainage with nasobiliary drainage tube placement and plastic stent placement are comparable, and the choice is made on a case-by-case basis considering the advantages and disadvantages of each. The addition of endoscopic sphincterotomy (EST) is basically not necessary when performing drainage alone, but single-session stone removal following EST is acceptable in mild to moderate cholangitis cases without antithrombotic therapy or coagulopathy. For gallstone pancreatitis, early ERCP/EST are recommended in cases with impacted gallstones in the papilla. In some cases of gallstone pancreatitis, a gallstone impacted in the papilla has already spontaneously passed into the duodenum, and early ERCP/EST lacks efficacy in such cases, with unfavorable findings of cholangitis or cholestasis. If it is difficult to diagnose the presence of gallstones impacted in the papilla on imaging, endoscopic ultrasonography can be useful in determining the indication for ERCP.

National clinical practice guidelines for the treatment of symptomatic gallstone disease: 2021 recommendations from the Danish Surgical Society

BACKGROUND AND OBJECTIVE

Gallstones are highly prevalent, and more than 9000 cholecystectomies are performed annually in Denmark. The aim of this guideline was to improve the clinical course of patients with gallstone disease including a subgroup of high-risk patients. Outcomes included reduction of complications, readmissions, and need for additional interventions in patients with uncomplicated gallstone disease, acute cholecystitis, and common bile duct stones (CBDS).

METHODS

An interdisciplinary group of clinicians developed the guideline according to the GRADE methodology. Randomized controlled trials (RCTs) were primarily included. Non-RCTs were included if RCTs could not answer the clinical questions. Recommendations were strong or weak depending on effect estimates, quality of evidence, and patient preferences.

RESULTS

For patients with acute cholecystitis, acute laparoscopic cholecystectomy is recommended (16 RCTs, strong recommendation). Gallbladder drainage may be used as an interval procedure before a delayed laparoscopic cholecystectomy in patients with temporary contraindications to surgery and severe acute cholecystitis (1 RCT and 1 non-RCT, weak recommendation). High-risk patients are suggested to undergo acute laparoscopic cholecystectomy instead of drainage (1 RCT and 1 non-RCT, weak recommendation). For patients with CBDS, a one-step procedure with simultaneous laparoscopic cholecystectomy and CBDS removal by laparoscopy or endoscopy is recommended (22 RCTs, strong recommendation). In high-risk patients with CBDS, laparoscopic cholecystectomy is suggested to be included in the treatment (6 RCTs, weak recommendation). For diagnosis of CBDS, the use of magnetic resonance imaging or endoscopic ultrasound prior to surgical treatment is recommended (8 RCTs, strong recommendation). For patients with uncomplicated symptomatic gallstone disease, observation is suggested as an alternative to laparoscopic cholecystectomy (2 RCTs, weak recommendation).

CONCLUSIONS

Seven recommendations, four weak and three strong, for treating patients with symptomatic gallstone disease were developed. Studies for treatment of high-risk patients are few and more are needed.

ENDORSEMENT

The Danish Surgical Society.

EUS versus MRCP to perform ERCP in patients with intermediate likelihood of choledocholithiasis: a randomised controlled trial

OBJECTIVE

In patients with an intermediate likelihood of choledocholithiasis, European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommend endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) to diagnose choledocholithiasis to make the indication for endoscopic retrograde cholangiopancreatography (ERCP) treatment; there is no randomised control trial to compare both in this setting.

DESIGN

Patients with suspected choledocholithiasis satisfying ESGE guideline's intermediate likelihood were screened for this single-centre randomised controlled trial between November 2019 and May 2020. The enrolled patients were randomised to either EUS or MRCP. ERCP was performed in stone positive cases or if clinical suspicion persisted during follow-up. Negative cases underwent a further 6-month clinical follow-up. Main outcome was accuracy (sensitivity/specificity) of both tests to diagnose choledocholithiasis, with ERCP or follow-up as a gold standard.

RESULTS

Of 266 patients, 224 patients (mean age: 46.77±14.57 years; 50.9 % female) were enrolled; overall prevalence of choledocholithiasis was 49.6%, with a higher frequency in the MRCP group (63/112 vs 46/112 for EUS). Both sensitivity of EUS and MRCP were similarly high (92%-98%), without significant differences between the two groups. The negative predictive value and likelihood ratio + were significantly higher in EUS arm (p<0.05). The percentage of ERCPs either incorrectly halted back (false negatives: EUS: 2 vs MRCP: 5) or performed unnecessarily (false positives: EUS: 1 vs MRCP: 2) was low in both groups.

CONCLUSION

The performance parameters of both EUS and MRCP are comparable for detecting choledocholithiasis in the intermediate-risk group of choledocholithiasis and the choice of a test should be based on local expertise, availability of resources and patient preference.

TRIAL REGISTRATION NUMBER

NCT04173624.

Role of EUS at high risk for choledocholithiasis without severe cholangitis and visible stone on cross-sectional imaging: A multicenter randomized clinical trial

Background and Objectives:

The prevalence of choledocholithiasis in the high-risk group of choledocholithiasis has been reported to be slightly more than 50% when there is no definite cholangitis. Replacement of diagnostic endoscopic retrograde cholangiography (ERC) with an EUS-first approach may be beneficial in these patients.

Materials and Methods:

In this prospective, multicenter study, patients with dilated common bile duct and serum total bilirubin levels of 1.8–4 mg/dL were randomly allocated to undergo either EUS first, followed by subsequent ERC if necessary (EUS group) or ERC only (ERC group). The primary endpoint was the incidence of negative outcomes associated with a false-negative diagnosis of the choledocholithiasis or the endoscopic procedure. The secondary endpoints were the rate of diagnostic ERC and hospital stay length related to the endoscopic procedure.

Results:

Of 90 patients who were randomly assigned, the final analysis involved 42 in the EUS group and 44 in the ERC group. The negative outcomes were not significantly different between the EUS and ERC groups (2.4% vs. 6.8%; P = 0.62). The rate of diagnostic ERC was significantly lower in the EUS group (2.4% vs. 47.7%; P < 0.001). The hospital stay length related to the endoscopic procedure was significantly shorter in the EUS group (1.8 ± 1.0 vs. 2.5 ± 1.2 days; P = 0.001).

Conclusion:

In selected high-risk choledocholithiasis patients, an EUS-first strategy significantly decreased the rate of diagnostic ERC and hospital stay but did not achieve a significant reduction in negative endoscopic procedure outcomes.

A deep learning-based system for bile duct annotation and station recognition in linear endoscopic ultrasound

BACKGROUND

Detailed evaluation of bile duct (BD) is main focus during endoscopic ultrasound (EUS). The aim of this study was to develop a system for EUS BD scanning augmentation.

METHODS

The scanning was divided into 4 stations. We developed a station classification model and a BD segmentation model with 10681 images and 2529 images, respectively. 1704 images and 667 images were applied to classification and segmentation internal validation. For classification and segmentation video validation, 264 and 517 videos clips were used. For man-machine contest, an independent data set contained 120 images was applied. 799 images from other two hospitals were used for external validation. A crossover study was conducted to evaluate the system effect on reducing difficulty in ultrasound images interpretation.

FINDINGS

For classification, the model achieved an accuracy of 93.3% in image set and 90.1% in video set. For segmentation, the model had a dice of 0.77 in image set, sensitivity of 89.48% and specificity of 82.3% in video set. For external validation, the model achieved 82.6% accuracy in classification. In man-machine contest, the models achieved 88.3% accuracy in classification and 0.72 dice in BD segmentation, which is comparable to that of expert. In the crossover study, trainees' accuracy improved from 60.8% to 76.3% (P < 0.01, 95% C.I. 20.9-27.2).

INTERPRETATION

We developed a deep learning-based augmentation system for EUS BD scanning augmentation.

FUNDING

Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Hubei Province Major Science and Technology Innovation Project, National Natural Science Foundation of China.

Efficacy of the Endoscopic Ultrasound-first Approach in Patients with Suspected Common Bile Duct Stone to Avoid Unnecessary Endoscopic Retrograde Cholangiopancreatography

Objective Endoscopic ultrasound (EUS) is a safe and accurate examination for evaluating the presence of common bile duct stones (CBDSs). The EUS-first approach, where EUS is performed before endoscopic retrograde cholangiopancreatography (ERCP) for patients suspected of having CBDSs, may help reduce the risk of ERCP-related adverse events and save manpower by avoiding unnecessary ERCP. To evaluate the efficacy of the EUS-first approach in patients with suspected CBDSs. Methods Between April 2012 and March 2016, 104 patients who underwent the EUS-first approach for suspected CBDSs were retrospectively evaluated. The relevant outcomes were the short- and long-term adverse event rates and the ERCP avoidance rate. Results EUS findings were positive for CBDSs in 52 patients, showed sludge formation or possible CBDSs in 4 patients, and were negative for CBDSs in 42 patients (but positive for other diseases in 6). Sixty-two patients (62/104, 59.6%) underwent ERCP, and proper treatments were successfully performed in all but 1 who underwent only cholangiography. In the remaining 42 patients (42/104, 40.4%), ERCP was omitted based on the EUS findings. Early adverse events were recognized in 0% of the EUS-only group and 8 patients (12.9%) in the EUS+ERCP group (p=0.02). Regarding late adverse events, recurrent CBDSs occurred in 1 patient (2.3%) in the EUS-only group and 2 (3.2%) in the EUS+ERCP group (p=1.0). Conclusion The EUS-first approach in patients with suspected CBDSs was useful for reducing early adverse events associated with ERCP without increasing the late adverse event rate, as EUS enabled the avoidance of unnecessary ERCP.

Dynamic liver test patterns do not predict bile duct stones

BACKGROUND

Numerous models have been developed to predict choledocholithiasis. Recent work has shown that these algorithms perform suboptimally. Identification of clinical predictors with high positive and negative predictive value would minimize adverse events associated with unnecessary diagnostic endoscopic retrograde cholangiopancreatography (ERCP) while limiting the use of expensive tests including magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) for indeterminate cases.

METHODS

Consecutive unique inpatients who received their first ERCP at Los Angeles County Medical Center between January 2010 and November 2016 for suspected bile duct stones were reviewed. The primary outcome was the proportion of patients with specific combinations of liver enzyme patterns, transabdominal ultrasound, and clinical features who had stones confirmed on ERCP. As a secondary outcome, we assessed the performance of the American Society for Gastrointestinal Endoscopy (ASGE) risk stratification algorithm in our population.

RESULTS

Of the 604 included patients, bile duct stones were confirmed in 410 (67.9%). Detailed assessment of liver enzyme patterns alone and in combination with clinical features and imaging findings yielded no highly predictive algorithms. Additionally, the ASGE high-risk criterion had a positive predictive value of only 68% for stones. For the 236 patients for whom MRCP was performed, this imaging modality was shown to have highest predictive value for the presence of stones on ERCP.

CONCLUSION

Exhaustive exploration of various threshold values and dynamic patterns of liver enzymes combined with clinical features and basic imaging findings did not reveal an algorithm to accurately predict the presence of stones on ERCP. The ASGE risk stratification criteria were also insensitive in our population. Though desirable, there may be no "perfect" combination of clinical features that correlate with persistent bile duct stones. MRCP or EUS may be considered to avoid unnecessary ERCP and associated complications.

Long term outcome of EUS-based strategy for suspected choledocholithiasis but negative CT finding

OBJECTIVES

The American Society for Gastrointestinal Endoscopy (ASGE) guidelines offered the risk-stratified approach in suspected choledocholithiasis. Previous studies have raised concern about the insufficient accuracy of the guideline, especially in high probability group. The purposes of this study were to authenticate the stratification and clinical predictors of the guidelines for suspected choledocholithiasis with no visible choledocholithiasis on computed tomography (CT) and to make clear the clinical strategy of endoscopic ultrasonography (EUS).

MATERIALS AND METHODS

We carried out the retrospective single-center study of 156 patients with suspected choledocholithiasis but negative findings on CT who underwent EUS for about 8 years at Samsung Medical Center. We assessed the clinical predictors of the ASGE guidelines in predicting the presence of choledocholithiasis and the outcome of the EUS.

RESULTS

Fifty-three of the 156 patients had positive findings on EUS that included choledocholithiasis (n = 43, 27.6%) or obstructive papillitis (n = 10, 6.4%). Among the 53 patients, 51 (96.2%) had choledocholithiasis or obstructive papillitis on ERCP. The 101 patients of 103 patients with negative finding on EUS did not show biliary events during follow-up period. EUS accuracy was 98.7% (sensitivity 100%; specificity 98.1%). Among the 49 patients with high probability, 21 (42.9%) had choledocholithiasis on ERCP. In 107 patients who were classified as intermediate probability, 30 (27.3%) had choledocholithiasis. There were no complications related to EUS.

CONCLUSIONS

Not only intermediate probability group but also high probability group without definite acute cholangitis may require EUS. Application of EUS for suspected choledocholithiasis is highly accurate, safe and reduces unnecessary invasive ERCP in 57.1% of patients with high probability group.

The emerging role of non-radiation endoscopic management of biliary tract disorders

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic and therapeutic technique into a therapeutic-centered modality for managing biliary disorders. Despite its many therapeutic benefits, radiation exposure from ERCP fluoroscopy is of concern and should be minimized as much as possible. Although the use of personal equipment offers significant protection against radiation, attention has been given to the development of non-radiation-based ERCP techniques. To this end, digital cholangioscopy and endoscopic ultrasound-assisted ERCP have emerged as alternatives to standard ERCP. Both techniques have sufficient feasibility and potential diagnostic accuracy to eliminate the need for fluoroscopy. Here we discuss the advances in non-radiation ERCP techniques and their role in the management of biliary stones.

Predictors for choledocholitiasis in patients undergoing endoscopic ultrasound

AIM

Biliary lithiasis is common in most western countries. Symptomatic patients will also have choledocholithiasis in 10% of the cases. For patients with intermediate probability of CBD stones, the recommended imaging studies are endoscopic ultrasound (EUS) or MRCP. This study aims to identify early factors that can be used as predictors for the presence of CBD stones, and by that to find which patient should undergo ERCP without an early EUS.

METHODS

This is a retrospective cohort study including all patients who underwent EUS for suspected choledocholithiasis at the Soroka University Medical Center (SUMC) in the years 2009-2014. Data collection was performed by manual surveillance of patients' computerized files and data gathering after approval by the Soroka Institutional Review Board Results: One hundred seventy-five (175) patients were included in the study. The average age was 57, and 111 patients were women (64.2%). Sixty-two patients (35%) had common bile duct stones by EUS and underwent an ERCP. Eighty-two percent of those 62 patients were found to have CBD stones at ERCP. Patients found positive for CBD stones by EUS were older than those who were negative (52 vs. 71 respectively, p < .001). These patients were also found to have a higher prevalence of ischemic heart disease and congestive heart failure. Common bile duct dilatation ≥8mm and gallstones presence in abdominal ultrasonography were more common in patients found positive for CBD stones by EUS than in those who were found negative (45% vs. 24% p < .05, and 81% vs. 66% p < .05, respectively). Alkaline phosphatase (ALP) serum levels higher than 300 IU/L were found to be the only independent predictor for the existence of CBD stones (OR = 2.98, p = .001(. When ALP serum levels lower than 150 IU/L or GGT lower than 150 IU/L were measured, the probability of having CBD stones was low (NPV of 90% and 87%, respectively).

CONCLUSIONS

ALP serum levels higher than 300 IU/L are an independent predictor for the presence of CBD stones. EUS is an excellent screening tool for choledocholithiasis before performing ERCP. In most patients who undergo an early EUS, a subsequent diagnostic ERCP will not be needed.

Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound: To Be One Traveler in Converging Roads

Background

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were initially introduced into the world of gastroenterology as purely diagnostic procedures. With progressive evolution of intervention, both these techniques conquered fields in the treatment of many conditions that had once been exclusively surgical domains. Nowadays, more and more clinical situations have an indication to perform both EUS and ERCP, and these two techniques are frequently required at the same time for the same patient. More than competitors, ERCP and EUS are truly complementary, with great ability for mutual aid. They share their main indications, equipment, accessories, and main technical gestures.

Objectives and Methods

We review the major indications to perform both techniques, sequentially or complementarily, describe the common things that these two techniques essentially share, and discuss the ERCP-EUS single session. Also, the issues of learning curves and education of upcoming biliopancreatic endoscopists are highlighted.

Conclusion

In recent years the complementation between ECRP and EUS has been growing both from a diagnostic and a therapeutic point of view, allowing optimization of the use of these techniques and the creation of a more systematized approach of patients with biliopancreatic pathology. Endoscopists with experience in both techniques will be increasingly important, suggesting a parallel formation in the training plans of future endoscopists with interest in the area.

Diagnostic Value of Endoscopic Ultrasonography in Symptomatic Patients with High and Intermediate Probabilities of Common Bile Duct Stones and a Negative Computed Tomography Scan

Background/Aims

When computed tomography (CT) does not indicate choledocholithiasis in highly suspicious patients, there is no definite consensus on the subsequent modality. Endoscopic ultrasonography (EUS) indicates fewer procedure-related complications than endoscopic retrograde cholangiopancreatography (ERCP) and has a lower cost than magnetic resonance cholangiopancreatography. Therefore, we aimed to investigate the diagnostic value of EUS in patients with suspected choledocholithiasis and negative CT findings.

Methods

Between March 2008 and November 2014, we retrospectively evaluated 200 patients with negative CT findings and high or intermediate probabilities of choledocholithiasis. All patients initially underwent EUS followed by ERCP as a confirmatory criterion standard. The primary outcome in these patients was the accuracy of EUS in the detection of choledocholithiasis. The secondary outcome was the clinical prediction of common bile duct (CBD) stones in this group.

Results

EUS indicated choledocholithiasis in 165 of the 200 patients, and ERCP confirmed choledocholithiasis in 161 patients (80.5%). The accuracy of EUS in the detection of choledocholithiasis was 94.0% (sensitivity, 97.5%; specificity, 79.5%; positive predictive value, 95.2%; negative predictive value, 88.6%). A multivariate analysis demonstrated that choledocholithiasis was strongly predicted by EUS detection of choledocholithiasis, an age >55 years and a clinical diagnosis of cholangitis.

Conclusions

An EUS-first approach is recommended for patients with suspected CBD stones and negative CT findings.

The utility and yield of endoscopic ultrasonography for suspected choledocholithiasis in common gastroenterology practice

BACKGROUND AND STUDY AIM

Endoscopic ultrasonography (EUS) is an established diagnostic modality for diagnosing common bile duct (CBD) stones. Its use has led to a reduction in the number of endoscopic retrograde cholangiopancreatography (ERCP) procedures performed for suspected choledocholithiasis. We aimed to explore the role of EUS in detecting CBD stones and/or sludge in common gastroenterology practice.

PATIENTS AND METHODS

We reviewed case records of 268 consecutive patients who underwent (EUS) procedures performed to confirm or rule out the presence of CBD stones and/or sludge between November 2006 and January 2011 in the Reinier de Graaf Hospital, Delft, The Netherlands, which is a nonacademic community hospital.

RESULTS

On the basis of EUS findings, 169 of 268 (63%) patients did not undergo ERCP and were therefore not exposed to its risk of complications. Patients with positive findings on EUS (n=99) all underwent ERCP and endoscopic sphincterotomy. Only 57 of 99 (58%) had positive findings at ERCP. The main contributing factors to this finding seem to be time interval between EUS and ERCP and the type of CBD content (i.e. sludge, one CBD stone or more than one CBD stone) described.

CONCLUSION

In our common gastroenterology practice, EUS plays an important role in selecting patients suspected to have CBD stones or sludge for ERCP. Much is to be learned about the probability of spontaneous passage of CBD stones and sludge into the duodenum.

Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography: Can they be successfully combined?

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) have much in common, including their main indications (biliopancreatic disorders), powerful therapeutic capacities and a steep learning curve. Over the years they have evolved from novel diagnostic procedures to interventional therapeutic techniques, but along different paths (different scopes or devices and endoscopists specializing exclusively in one or the other technique). However, EUS has gradually developed into a therapeutic technique that requires skills in the use of ERCP devices and stents, leading some ERCP specialists to explore the therapeutic potential of EUS. The corresponding literature, which has grown exponentially, includes recent experiments on combining the two techniques, which have gradually come to be used in routine care in a number of centers, with positive technical, clinical and financial outcomes. We review EUS and ERCP as individual or combined procedures for managing biliopancreatic disorders.

Comparing cost-effectiveness between endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in diagnosis of common bile duct stone in patients with predefined risks: A study from a developing country

Background and Objectives:

Endoscopic ultrasound (EUS) achieves results comparable to endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of common bile duct (CBD) stone, but studies from the western have shown EUS to be less expensive in patients with intermediate risk for CBD stones. The aim of this study was to compare the costs of EUS and ERCP in the diagnosis of CBD stones in a developing country.

Materials and Methods:

A prospective study was done with 141 patients with suspected CBD stones, categorized as having high or intermediate risk for CBD stone. All underwent EUS, and the high-risk patients had ERCP after the EUS. For intermediate-risk patients, an ERCP was done at the discretion of the attending physician. The CBD stone was confirmed by ERCP in patients who underwent both EUS and ERCP. Patients who received EUS only were followed up every 3 months for 1 year. The false negative rate in patients with EUS and ERCP was estimated in the clinical follow-up.

Result:

One hundred and forty-one patients (141: 83 females, 58 males) with a mean age ± standard deviation (SD) of 55.71 ±18.68 years were recruited. Ninety-four (94) patients underwent both EUS and ERCP. ERCP confirmed the diagnosis in 83 of 85 patients (97.6%) with CBD stone detected by EUS. Forty-seven (47) patients with a negative EUS and no ERCP done were symptom-free during the follow-up. The overall sensitivity, specificity, positive predictive value, and negative predictive value of EUS were 97.6%, 80%, 97.6%, and 80% respectively. An EUS-based strategy for high-risk patients was 15% more expensive than an ERCP-based strategy, but the EUS-based strategy reduced the cost to 37.78% less than the ERCP-based strategy in intermediate-risk patients. The EUS-based strategy was cost-saving when the CBD stone prevalence was less than 52.5%.

Conclusion:

EUS is safer and less costly than ERCP for CBD stone diagnosis in patients with intermediate risk.

Routine endoscopic ultrasound in moderate and indeterminate risk patients of suspected choledocholithiasis to avoid unwarranted ERCP: A prospective randomized blinded study

BACKGROUND

Endoscopic ultrasound (EUS) is the most sensitive test for diagnosis of common bile duct stones and it may avoid unnecessary endoscopic retrograde cholangiopancreatography (ERCP).

AIM

The purpose of this study was to evaluate whether EUS done initially would avoid unnecessary ERCP in patients with moderate or indeterminate risk for occurrence of choledocholithiasis.

METHODS

Patients with biliary colic or acute biliary pancreatitis, who were referred for suspected choledocholithiasis on the basis of alterations in liver function tests were prospectively included over 12 months period in blinded randomized fashion. Endoscopic ultrasonography was performed for all patients. Patients were randomized to two groups. ERCP was done in all patients in group A irrespective of the EUS findings, while in the group B, ERCP was done only in those patients in whom EUS was suggested the presence of common bile duct stone or sludge.

RESULTS

A total of 50 patients were randomized into each group. EUS diagnosed common bile duct stones in 24 out of 50 patients (48 %) in group A, and ERCP identified common bile duct stones in 23 of those 24 patients. Twenty-eight out of 50 patients had common bile duct stones/sludge in group B, which were removed by subsequent ERCP. However, ERCP could be avoided in 22 cases (44 %) of group B and none of these patients had biliary symptoms up to 6 months of follow up.

CONCLUSION

In patients with moderate or indeterminate risk for choledocholithiasis, prior EUS done for confirmation of choledocholithiasis avoids unnecessary ERCP in almost half of the cases.

Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy

Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of "risk of carrying CBDS" has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of "under-studying" by poor diagnostic work up or "over-studying" by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. "Low risk" patients do not require further examination before laparoscopic cholecystectomy. Two main "philosophical approaches" face each other for patients with an "intermediate to high risk" of carrying CBDS: on one hand, the "laparoscopy-first" approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the "endoscopy-first" attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.

Diagnostic yield of endoscopic ultrasonography in patients with intermediate or high likelihood of choledocholithiasis: a retrospective study from one university-based endoscopy center

BACKGROUND

Diagnosis of choledocholithiasis requires clinical manifestations and imaging examination findings suggesting a stone in the common bile duct (CBD), but these factors are not highly sensitive or specific. The choledocholithiasis management algorithm proposed by the American Society for Gastrointestinal Endoscopy (ASGE) may not be appropriate for patients who fulfill the clinical criteria for a high likelihood of choledocholithiasis. Endoscopic ultrasonography (EUS) may replace endoscopic retrograde cholangiopancreatography (ERCP) for the detection of CBD stones in all patients. The aims of this study were to determine the diagnostic yield and optimal timing of EUS in patients with an intermediate or high likelihood of choledocholithiasis requiring therapeutic ERCP.

METHODS

Patients with suspected choledocholithiasis who underwent EUS between June 2009 and January 2012 were retrospectively reviewed. The patients were divided into two groups based on the likelihood of choledocholithiasis according to the clinical predictors described by the ASGE guidelines: an intermediate likelihood group and a high likelihood group. The demographic data, clinical manifestations at presentation, blood test results, EUS and ERCP findings, and clinical manifestations during the follow-up period were recorded and analyzed.

RESULTS

Ninety-three patients were enrolled in the study (52.7% in the intermediate likelihood group and 47.3% in the high likelihood group). CBD stones were detected in 22.44% of patients in the intermediate likelihood group and 38.63% of patients in the high likelihood group. EUS had a sensitivity of 100% and specificity of 80% for detection of CBD stones. An alkaline phosphatase level of > 133 mg/dL (area under the curve, 0.576) was the only factor that was significantly associated with detection of CBD stones in patients who underwent EUS > 7 days after the initial clinical presentation (odds ratio 4.87, p = 0.01).

CONCLUSIONS

EUS is an accurate diagnostic tool for the detection of CBD stones, and can prevent the unnecessary use of ERCP. This study found that use of clinical criteria alone might not provide a good prediction of the presence of CBD stones, even in patients who fulfill the criteria for a high likelihood of choledocholithiasis.

What is the Risk of Diagnostic Endoscopic Retrograde Cholangiopancreatography before Cholecystectomy?

Many surgeons prefer to perform endoscopic retrograde cholangiopancreatography (ERCP) before cholecystectomy, specifically in patients at significant risk of having biliary pathology. However, a preoperative diagnostic ERCP, without the use of an endoscopic ultrasound or magnetic retrograde cholangiopancreatoscopy, remains controversial. This is the result of the risk of either performing an unnecessary procedure and/or the development of post-ERCP pancreatitis (PEP). We performed a retrospective review of all surgeon-performed ERCPs at our institution between July 2011 and May 2013. This was done to examine patients who had pericholecystectomy ERCP. We had 550 ERCPs performed at our institution during this time period, 169 of which were pericholecystectomy procedures. We divided the 169 patients who had a diagnostic procedure (Diagnostic group) from those who had known biliary pathology before intervention (Therapeutic group). As a result, 34 patients (20.1%) were placed in the Diagnostic group and 135 patients (79.9%) in the Therapeutic group. Of the 34 Diagnostic patients, four (11.8%) developed PEP. Fifteen (44.1%) had unnecessary procedures, two of which had PEP (2.9%). Of the 135 ERCPs in the Therapeutic group, 18 patients (13.4%) developed PEP. Five of the 11 who had unnecessary procedures developed PEP. Based on the low incidence of complications, diagnostic ERCP has an acceptable rate of pancreatitis and/or unnecessary procedures when performed in highly selected patients and before cholecystectomy when compared with patients undergoing therapeutic ERCP. However, more aggressive use of diagnostic imaging before ERCP should be adopted given the number of unnecessary procedures performed.

Usefulness of intraductal ultrasonography in icteric patients with highly suspected choledocholithiasis showing normal endoscopic retrograde cholangiopancreatography

BACKGROUND

Choledocholithiasis is one of the causes of jaundice and may require urgent treatment. Endoscopic retrograde cholangiopancreatography (ERCP) has been the primary management strategy for choledocholithiasis. However, small stones can be overlooked during ERCP.

AIM

The aim of this study was to evaluate the accuracy of intraductal ultrasonography (IDUS) for detecting choledocholithiasis in icteric patients with highly suspected common bile duct (CBD) stones without definite stone diagnosis on ERCP.

METHODS

Ninety-five icteric (bilirubin ≥ 3 mg/dL) patients who underwent ERCP for highly suspected choledocholithiasis without definite filling defects on cholangiography were prospectively enrolled in the present study. We evaluated the bile duct using IDUS for the presence of stones or sludge. Reference standard for choledocholithiasis was endoscopic extraction of stone or sludge.

RESULT

Bile duct stones were detected with IDUS in 31 of 95 patients (32.6%). IDUS findings were confirmed by endoscopic stone extraction in all patients. The mean diameter of CBD stones detected by IDUS was 2.9 mm (range 1-7 mm). IDUS revealed biliary sludge in 24 patients (25.2%) which was confirmed by sludge extraction in 21 patients (87.5%). In dilated CBD, detection rate of bile duct stone/sludge based on IDUS was significantly higher than in non-dilated CBD (p = 0.004).

CONCLUSION

IDUS is useful for the detection of occult CBD stone on ERCP in icteric patients with highly suspected CBD stones.

Prospective evaluation of early endoscopic ultrasonography for triage in suspected choledocholithiasis: results from a large single centre series

BACKGROUND

Endoscopic ultrasonography is accurate, safe, and cost-effective in diagnosing common bile duct stones, thus suggesting the possibility to avoid invasive endoscopic retrograde cholangiopancreatography.

AIM

To prospectively evaluate the diagnostic and therapeutic performance of early endoscopic ultrasonography in suspected choledocholithiasis.

PATIENTS AND METHODS

All consecutive patients presenting to the Emergency Department with suspicion of choledocholithiasis between January 2010 and January 2012 were evaluated and categorized as low, moderate, or high probability of choledocholithiasis, according to accepted criteria. Endoscopic endosonography was carried out within 48 h from the admission and endoscopic retrograde cholangiopancreatography was performed soon in case of confirmed choledocholithiasis.

RESULTS

Overall 179 patients were included: 48 (26.8%) were classified as low, 65 (36.3%) as moderate, and 66 (36.9%) as high probability of choledocholithiasis. Of the 86 patients with common bile duct stones at endoscopic endosonography, endoscopic retrograde cholangiopancreatography confirmed the finding in 79 (92%). By multivariate analysis only the common bile duct diameter proved an independent predictor of common bile duct stones.

CONCLUSIONS

Early endoscopic endosonography is accurate in identifying choledocholithiasis allowing immediate endoscopic treatment and significant spare of unnecessary endoscopic retrograde cholangiopancreatography. This approach can be useful as a triage test to select patients not needing endoscopic retrograde cholangiopancreatography, allowing, in selected cases, their early discharge.

Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: testing the current guidelines

BACKGROUND

Current guidelines include an algorithm for predicting choledocholithiasis. Presence of any very strong predictor or both strong predictors confers a high (>50%) probability of choledocholithiasis. Absence of predictors confers low risk (<10%) of choledocholithiasis. Other combinations have an intermediate risk of choledocholithiasis.

AIM

Determine accuracy of the proposed algorithm in predicting choledocholithiasis.

METHODS

Retrospective analysis of all endoscopic retrograde cholangiopancreatographies performed for suspected choledocholithiasis in 3 years in a Tertiary care hospital and a community hospital serviced by The University of Texas Health Science Center at Houston Division of Gastroenterology. Application of the guidelines, and comparing results to endoscopic retrograde cholangiopancreatography findings.

RESULTS

A total of 1080 endoscopic retrograde cholangiopancreatographies were performed; 521 for choledocholithiasis. Most patients were Hispanic and female. Univariate analysis: presence of any very strong predictor and both strong predictors had an OR for choledocholithiasis of 3.30 and 2.36 respectively. Multivariate analysis: odds of choledocholithiasis with any very strong predictor was 2.87, and both strong predictors 3.24. Choledocholithiasis was present in 71.5%, and 41% of patients with high, and intermediate risk respectively.

CONCLUSION

This study confirms the utility of clinical predictors for the diagnosis of choledocholithiasis. All of the very strong predictors and one of the strong predictors increased the odds of choledocholithiasis. Patients with high risk for choledocholithiasis had a probability of 79% of choledocholithiasis. Sensitivity and specificity of current predictors are too low to obviate the possible need of non-invasive tests to confirm or exclude choledocholithiasis in all risk groups.

The diagnostic accuracy of endoscopic ultrasound in suspected biliary obstruction and its impact on endoscopic retrograde cholangiopancreatography burden in real clinical practice: a consecutive analysis

BACKGROUND AND AIMS

Performing endoscopic ultrasound (EUS) before endoscopic retrograde cholangiopancreatography (ERCP) has been described to be useful in cases of suspected biliary obstruction where EUS can triage patients for ERCP. We aimed to determine the diagnostic accuracy of EUS and its impact on ERCP burden in real clinical practice. We also evaluated the safety and efficacy of EUS+ERCP in a single endoscopic session.

PATIENTS AND METHODS

Four hundred and eighteen consecutive patients with suspected but unexplained biliary obstruction referred for EUS before possible ERCP were evaluated. The diagnostic accuracy of EUS and its value in predicting the need for ERCP were determined. EUS established whether pancreaticobiliary disorder (PBD) was present and whether therapeutic ERCP was required. These decisions were matched with ERCP findings, histology, clinical course, and follow-up. Where ERCP was indicated, it was performed in the same endoscopic session.

RESULTS

EUS was performed in 412/418 patients (feasibility 98.5%), and ERCP was considered necessary in 64% (ERCP avoided in 36%). The single-session EUS and ERCP was safe and effective (264 patients). The diagnostic accuracy of EUS was as follows: choledocholithiasis 99%, malignant strictures 90%, and benign strictures 92%. EUS showed pathology in 42% of patients who had a nondilated biliary system at initial investigations. When EUS indicated a normal common bile duct (n=119), this had a 100% positive predictive value for non-necessity for ERCP. The median overall follow-up period was 12 months (range 6-34 months).

CONCLUSION

EUS demonstrated high diagnostic accuracy in this mixed group of PBD. This accurately guided ERCP need and avoided unnecessary ERCP in 36%. EUS and ERCP in the same endoscopic session for the evaluation and management of PBD is technically feasible, with safety and efficacy profiles equivalent to that of each procedure performed independently in different sessions.

Role of endoscopic ultrasonography in patients with intermediate probability of choledocholithiasis but a negative CT scan

BACKGROUND/GOALS

Despite the increased role of endoscopic ultrasonography (EUS) in diagnosis, few studies have evaluated its impact on the management of choledocholithiasis in a clinical setting for patients for whom computed tomography (CT) was conducted initially. Our aim in this study was to evaluate the role of EUS in patients with a diagnosis of intermediate probability of choledocholithiasis with a negative CT scan result.

STUDY

A total of 98 patients who were diagnosed with symptomatic cholelithiasis with intermediate probability of choledocholithiasis were evaluated prospectively. Twenty-six of the 98 patients (26.5%) were diagnosed with choledocholithiasis by CT scans. The remaining 72 patients underwent EUS.

RESULTS

Twenty-five of the 72 patients were shown to have choledocholithiasis (n=20/72, 27.8%) or papillitis with biliary outflow obstruction (n=5/72, 6.9%) on EUS. These 25 patients with positive EUS findings underwent endoscopic sphincterotomy, and choledocholithiasis was endoscopically confirmed in 23 of the 25 patients (92.0%). Postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis occurred in 3 patients (12.0% of the 25 patients who received ERCP, 4.2% of all 72 patients). Forty-seven patients with no evidence of choledocholithiasis on EUS were followed-up for a median period of 340 days (range, 185 to 755 d), and no recurrent biliary events occurred in these patients during this period. The sensitivity and specificity of EUS for choledocholithiasis was 87.0% and 100%, respectively.

CONCLUSIONS

An EUS-first strategy in patients with intermediate probability of choledocholithiasis but a negative CT scan is very useful and can reduce the need to perform invasive ERCP.

Modern management of common bile duct stones

It is imperative for gastroenterologists to understand the different formations of bile duct stones and the various medical treatments available. To minimize the complications of endoscopic retrograde cholangiopancreatography (ERCP), it is critical to appropriately assess the risk of bile duct stones before intervention. Biliary endoscopists should be comfortable with the basic techniques of stone removal, including sphincterotomy, mechanical lithotripsy, and stent placement. It is important to be aware of advanced options, including laser and electrohydraulic stone fragmentation, and papillary dilatation for problematic cases. The timing and need for ERCP in those who require a cholecystectomy is also a consideration.

Linear echoendoscope-guided ERCP for the diagnosis of occult common bile duct stones

BACKGROUND

Less than 67% of patients with intermediate risk for common bile duct (CBD) stones require therapeutic intervention. It is important to have an accurate, safe, and reliable method for the definitive diagnosis of CBD stones before initiating therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Few publications detail the diagnostic efficacy of linear echoendoscopy (EUS) for CBD stones.

METHODS

30 patients with biliary colic, pancreatitis, unexplained derangement of liver function tests, and/or dilated CBD without an identifiable cause were enrolled in the study. When a CBD stone was disclosed by linear EUS, ERCP with stone extraction was performed. Patients who failed ERCP were referred for surgical intervention. If no stone was found by EUS, ERCP would not be performed and patients were followed-up for possible biliary symptoms for up to three months.

RESULTS

The major reason for enrollment was acute pancreatitis. The mean predicted risk for CBD stones was 47% (28-61). Of the 12 patients who were positive for CBD stones by EUS, nine had successful ERCP, one failed ERCP (later treated successfully by surgical intervention) and two were false-positive cases. No procedure-related adverse events were noted. For those 18 patients without evidence of CBD stones by EUS, no false-negative case was noted during the three-month follow-up period. Linear EUS had sensitivity, specificity, positive and negative predicted values for the detection of CBD stones of 1, 0.9, 0.8 and 1, respectively.

CONCLUSION

Linear EUS is safe and efficacious for the diagnosis of occult CBD stones in patients with intermediate risk for the disease.

Is endoscopic ultrasound needed as an add-on test for gallstone diseases without choledocholithiasis on multidetector computed tomography?

BACKGROUND

Choledocholithiasis commonly occurs in patients with symptomatic cholelithiasis. Although the recently developed multidetector computed tomography (MDCT) scan enhances the ability to diagnose choledocholithiasis, this technique is considered to have some limitations for evaluating the common bile duct (CBD).

AIM

The purpose of this study was to evaluate the necessity for performing endoscopic ultrasound (EUS) as an add-on test to detect choledocholithiasis in patients who were diagnosed with gallstone disease without choledocholithiasis based on MDCT.

METHODS

Three hundred twenty patients with gallstone disease and no evidence of CBD stones according to MDCT underwent EUS between March 2006 and April 2011. If CBD stones were suspected based on the EUS results or clinical symptoms, a final diagnosis was obtained by endoscopic retrograde cholangiopancreatography (ERCP). The patients' medical records were retrospectively analyzed based on clinical symptoms, biochemical findings, and results of the imaging studies.

RESULTS

CBD stones were not detected with MDCT in 41 (12.8 %) out of 320 patients with gallstone disease. The causes for these discrepancies could be attributed to small stone size (n = 19, 46.3 %), isodensity (n = 18, 43.9 %), impacted stones (n = 1, 2.4 %), and misdiagnosis (n = 3, 7.3 %). If EUS were used as a triage tool, unnecessary diagnostic ERCP and its complications could be avoided for 245 (76.6 %) patients.

CONCLUSIONS

MDCT may not be a primary technique for detecting CBD stones. EUS should be performed instead as an add-on test to evaluate the CBD for patients with gallstone-related disease. In particular, EUS should be routinely recommended for patients with abnormal liver enzyme levels, pancreatitis, and dilated CBD.

Advances in the investigation of obstructive jaundice

The causes of obstructive jaundice are varied, and timely, accurate methods of investigation are essential to avoid the development of complications. Imaging, invasive or non-invasive, should be carefully selected depending on the suspected underlying pathology in order to determine the degree and level of obstruction along with tissue acquisition and staging where relevant. Several imaging techniques will also allow subsequent therapeutic interventions to be carried out. This article reviews advances in the investigation of obstructive jaundice, highlighting recent developments, many of which at present remain restricted to large centres of expertise, but are likely to become more widespread in use as research progresses and local experience continues to improve.

Pancreatico-biliary endoscopic ultrasound: a systematic review of the levels of evidence, performance and outcomes

Our aim was to record pancreaticobiliary endoscopic ultrasound (EUS) literature of the past 3 decades and evaluate its role based on a critical appraisal of published studies according to levels of evidence (LE). Original research articles (randomized controlled trials, prospective and retrospective studies), meta-analyses, reviews and surveys pertinent to gastrointestinal EUS were included. All articles published until September 2011 were retrieved from PubMed and classified according to specific disease entities, anatomical subdivisions and therapeutic applications of EUS. The North of England evidence-based guidelines were used to determine LE. A total of 1089 pertinent articles were reviewed. Published research focused primarily on solid pancreatic neoplasms, followed by disorders of the extrahepatic biliary tree, pancreatic cystic lesions, therapeutic-interventional EUS, chronic and acute pancreatitis. A uniform observation in all six categories of articles was the predominance of LE III studies followed by LE IV, II b, II a, I b and I a, in descending order. EUS remains the most accurate method for detecting small (< 3 cm) pancreatic tumors, ampullary neoplasms and small (< 4 mm) bile duct stones, and the best test to define vascular invasion in pancreatic and peri-ampullary neoplasms. Detailed EUS imaging, along with biochemical and molecular cyst fluid analysis, improve the differentiation of pancreatic cysts and help predict their malignant potential. Early diagnosis of chronic pancreatitis appears feasible and reliable. Novel imaging techniques (contrast-enhanced EUS, elastography) seem promising for the evaluation of pancreatic cancer and autoimmune pancreatitis. Therapeutic applications currently involve pancreaticobiliary drainage and targeted fine needle injection-guided antitumor therapy. Despite the ongoing development of extra-corporeal imaging modalities, such as computed tomography, magnetic resonance imaging, and positron emission tomography, EUS still holds a leading role in the investigation of the pancreaticobiliary area. The major challenge of EUS evolution is its expanding therapeutic potential towards an effective and minimally invasive management of complex pancreaticobiliary disorders.

Endosonography versus endoscopic retrograde cholangiopancreatography in diagnosing extrahepatic biliary obstruction

OBJECTIVE

Endosonography (EUS) performed prior to endoscopic retrograde cholangiopancreatography (ERCP) or surgery in patients with a low to moderate probability of choledocholithiasis can reduce morbidity, mortality and costs.

AIMS

This study aimed at evaluating the sensitivity and specificity of EUS and transabdominal ultrasonography (TUS) compared to ERCP in a cohort of 100 patients diagnosed with extrahepatic biliary obstruction.

METHODS

There were four working groups. The first group processed the initial data including history, physical examination and assessment of laboratory markers of cholestasis. The second group examined TUS. The third group examined the pancreas and biliary tree using EUS, always prior to ERCP. The fourth working group carried out ERCP.

RESULTS

The sensitivity and accuracy of EUS in the diagnosis of common bile duct dilatation were 84% and 83%, respectively, i.e. significantly higher (p=0.0001) than TUS (46% and 66%, respectively). The specificities of methods (82%, 91%) were not significantly different (p=0.218). The sensitivity and accuracy of EUS in the diagnosis of pathological content of the common bile duct were 88% and 92%, respectively, i.e. significantly higher (p<0.0001) than TUS (33% and 64%). The specificities of the methods (96%, 94%) were not significantly different (p=0.641). The incidence of choledocholithiasis in the high-risk group was significantly higher than in the moderate-risk group (p=0.012).

CONCLUSION

Radial EUS is a method with high sensitivity, specificity, positive and negative predictive values. It should therefore be preferred to ERCP in patients with low or moderate risk of choledocholithiasis.

[Diagnostic endoscopic ultrasonography in the gastrointestinal tract]

Endoscopic ultrasonography is a relatively new technology that combines the use of flexible fiberoptic endoscopes with high-resolution ultrasound technology. It proved to be highly accurate and useful in the staging of gastrointestinal malignancies, as well as in characterizing the nature of subepithelial lesions and disorders of the pancreaticobiliary system. In this overview the variety of current evidence based diagnostic options of endoscopic ultrasonography are discussed.

Role of ERCP in patients after hematopoietic stem cell transplantation

BACKGROUND

The role of ERCP in evaluating patients with hepatobiliary dysfunction after hematopoietic stem cell transplantation (HSCT) has not been well-defined.

OBJECTIVE

The aim of this study was to better define the role of ERCP after HSCT by reviewing our institutional experience, including indications, findings, and outcomes.

DESIGN

Retrospective review of ERCP findings and outcomes in patients after HSCT.

SETTING

MD Anderson Cancer Center from 1997 to 2009.

PATIENTS

A total of 40 patients had ERCP after HSCT during the study period.

INTERVENTION

ERCP.

MAIN OUTCOME MEASUREMENTS

Overall survival.

RESULTS

A total of 40 patients had ERCP after HSCT during the study period. Seventeen patients had biliary strictures (group 1), and 13 proved to be malignant. Ten patients had common duct stones (group 2). Thirteen patients (group 3) had neither stones nor stricture. Findings in group 3 included bile duct leak (1), dilation without stricture (2), resolution of pretransplant strictures (3), biliary sludge (1), or normal ducts (6). The normal subset proved to have hepatic graft-versus-host disease (GVHD) (3), hepatic drug toxicity (1), hepatic recurrence of myeloma (1), or pancreatitis with biliary sludge (1). Patients with GI GVHD were equally distributed among the 3 groups. Group 1 had 100% mortality with median time to death being 85 days after ERCP. Group 2 had 30% mortality with median time to death of 584 days after ERCP. Ten of 13 patients in Group 3 died at a median of 148 days after ERCP. The only procedural complication was a mild case of pancreatitis.

LIMITATIONS

Retrospective study at a single center.

CONCLUSION

One in every 130 post-HSCT patients required ERCP evaluation. Biliary stricture is frequently caused by recurrent or new malignancy, particularly after autologous HSCT. GI GVHD is not associated with biliary stricture. ERCP procedural risks in HSCT patients are acceptable.

Endoscopic ultrasound for non-gastroenterologists: what you need to know

Endoscopic ultrasound (EUS) combines the use of flexible fiberoptic endoscopes with high-resolution ultrasound technology. It is increasingly used for the evaluation, staging, and diagnosis of many luminal and extraluminal gastrointestinal (GI) cancers, as well as non-GI tract ailments, including the staging of lung cancer. In the past decade, EUS has become available on a wide scale, with an increasing number of indications. The technology has been shown to be comparable with and often more sensitive than computed tomography scan and magnetic resonance imaging in staging many malignancies. The use of fine-needle aspiration and ultrasound-guided injection also allows for accurate tissue diagnosis and therapy of GI ailments. Despite increasing availability and indications for EUS over the past decade, general internists may not be aware of EUS technology, when to order an EUS, and how to integrate the results of an EUS into their management decisions. This article will review the general indications for EUS referral, limitations, and role of EUS in the practice of general medicine.

Role of pancreatic endoscopic ultrasonography in 2010

Endoscopic ultrasonography (EUS) was introduced 25 years ago aiming at better visualization of the pancreas compared to transabdominal ultrasonography. This update discusses the current evidence in 2010 concerning the role of EUS in the clinical management of patients with pancreatic disease. Major indications of EUS are: (1) Detection of common bile duct stones (e.g. in acute pancreatitis); (2) Detection of small exo- and endocrine pancreatic tumours; and (3) Performance of fine needle aspiration in pancreatic masses depending on therapeutic consequences. EUS seems to be less useful in cases of chronic pancreatitis and cystic pancreatic lesions. Moreover the constant improvement of computed tomography has limited the role of EUS in pancreatic cancer staging. On the other hand, new therapeutic options are available due to EUS, such as pancreatic cyst drainage and celiac plexus neurolysis, offering a new field in which new techniques may arise. So the main goal of this review is to determine the exact role of EUS in a number of pancreatic and biliary diseases.

Endoscopic ultrasonography in diseases of the gallbladder

In recent years, endoscopic ultrasonography (EUS) has emerged as an important tool for the diagnosis and management of pancreaticobiliary disease. The close proximity of the echoendoscope to the biliary system allows detailed imaging of the gallbladder and adjacent structures. EUS is useful for the detection of occult cholelithiasis and biliary sludge and in the evaluation of suspected choledocholithiasis. It can be used to classify and predict neoplasia in polypoid lesions of the gallbladder and also to diagnose and stage gallbladder carcinoma. This article reviews the use of EUS in these diseases of the gallbladder.

Single-session endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography for evaluation of pancreaticobiliary disorders

BACKGROUND

Endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) often are required in the evaluation and treatment of patients with pancreaticobiliary disorders. Few reports of single-session EUS-ERCP have raised questions regarding its safety and accuracy or about which procedure should be performed first.

METHODS

Data from 2005 to 2009 were reviewed from a prospectively maintained EUS-ERCP database at a single tertiary care cancer center. Sensitivity and specificity of EUS and fine-needle aspiration (FNA), bile duct cannulation rate, duration of procedure, and complications were evaluated.

RESULTS

Of the 35 patients (15 men and 20 women) studied, 28 had a final diagnosis of malignancy, and 7 had benign disorders. All the patients underwent ERCP and EUS, with FNA performed for 28 patients (80%). For 22 of the 35 patients (62.8%), EUS was the first procedure performed. The sensitivity of EUS-FNA for malignancy was 96.4%. The bile duct cannulation rate during ERCP was 97.1%. Five patients required a precut sphincterotomy for bile duct access, and one patient with chronic pancreatitis had a failed cannulation despite a EUS-guided rendezvous. A stent was successfully placed in 29 patients (96%). No major complications occurred, and no contrast leak was seen when FNA was performed before the cholangiogram. One patient had periduodenal bleeding after FNA, which was managed conservatively. The mean duration of the procedure was 83.7 min.

CONCLUSION

Single-session EUS-ERCP can be performed safely and with efficacy similar to that of the procedures performed separately.

Endoscopic ultrasound in the evaluation of pancreaticobiliary disorders

The close proximity of the endoscopic ultrasound probe to the pancreas coupled with the ability to perform fine needle aspiration has made endoscopic ultrasound an extremely important technique for the evaluation of both benign and malignant pancreaticobiliary disorders. In parallel to the widespread importance of diagnostic endoscopic ultrasound, the therapeutic and interventional applications of this procedure are expanding and may become a major breakthrough in the management of pancreaticobiliary diseases. This article focuses on the utility and recent advances of endoscopic ultrasound in the diagnostic evaluation pancreaticobiliary disorders and analyses the data of well established interventional procedures such as celiac plexus neurolysis and pseudocyst drainage. Moreover, the more innovative procedures, such endoscopic ultrasound-guided biliary and pancreatic ducts access and drainage and the experimental use of direct endoscopic ultrasound-guided therapy of both solid and cystic pancreatic lesions will also be reviewed.

Endosonography in the management of biliopancreatic disorders

Over the past two decades, endoscopic endosonography (EUS) has evolved into an indispensible diagnostic and therapeutic utility in the diagnosis and treatment of patients with pancreatobiliary disease. In this article, we summarise its current potential and provide an update of the latest literature.

Systematic review of endoscopic ultrasonography versus endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis

BACKGROUND

Endoscopic ultrasonography (EUS) has emerged as an accurate diagnostic alternative to endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to perform a systematic review of all randomized controlled trials of EUS-guided ERCP versus ERCP alone in patients with suspected choledocholithiasis.

METHODS

The search for eligible studies was carried out using the MEDLINE, Cochrane Central Register of Controlled Trials, and Science Citation Index electronic databases. Meta-analysis was conducted using a random-effects model.

RESULTS

Four trials containing 213 patients randomized to EUS-guided ERCP and 210 to ERCP alone were selected. In the EUS-guided ERCP group, ERCP was avoided in 143 patients (67.1 per cent) when EUS did not detect choledocholithiasis. The use of EUS significantly reduced the risk of overall complications (relative risk 0.35 (95 per cent confidence interval (c.i.) 0.20 to 0.62); P < 0.001) and post-ERCP acute pancreatitis (relative risk 0.21 (95 per cent c.i. 0.06 to 0.83); P = 0.030).

CONCLUSION

By performing EUS first, ERCP may be safely avoided in two-thirds of patients with common bile duct stones. Application of EUS in the selection of patients for therapeutic ERCP significantly reduces the complication rate.

Single session versus separate session endoscopic ultrasonography plus endoscopic retrograde cholangiography in patients with low to moderate risk for choledocholithiasis

BACKGROUND AND AIM

Endoscopic ultrasonography (EUS) is a minimally invasive diagnostic tool for common bile duct stones (CBDS) and may be used to select patients for therapeutic endoscopic retrograde cholangiography (ERC). The aim of this trial is to compare, in patients with non-high-risk for CDBS, the clinical and economic impact of EUS plus ERC performed in a single endoscopic session versus EUS plus ERC in two separate sessions.

METHODS

During an 11-month period, all adult patients admitted to the emergency department with suspicion of CBDS were categorized into either high-risk or non-high-risk groups, on the basis of clinical, biochemical, or transabdominal ultrasound findings. Patients in the non-high-risk group were randomized to receive EUS plus ERC in one single or in two separate sessions.

RESULTS

Eighty patients were recruited and randomized. Forty patients underwent EUS plus ERC in a single session and 40 patients underwent EUS plus ERC in two separate sessions. Negative EUS examination for CBDS avoided unnecessary ERC to 33 patients. Out of 47 patients with positive EUS (25 from the single session group and 22 from the double session), ERC confirmed the presence of CBDS in 46 cases (EUS sensitivity 100% and specificity 98%). Average time of procedure and hospitalization were significantly shorter in the single session group compared to the two session group. The single session strategy was also less expensive.

CONCLUSION

Endoscopic ultrasonography plus ERC with sphincterotomy and stone extraction performed during the same endoscopic session was safe and efficacious with a reduction of procedure time, hospitalization and costs.

Clinicians' attitudes towards endoscopic ultrasound: a survey of four European countries

OBJECTIVE

Despite the documented effectiveness of endoscopic ultrasound (EUS) in research studies, data on the utilization of this technology in clinical practice are scarce. The aim of this study was to assess EUS availability and accessibility as well as EUS utilization among clinicians from different European countries.

MATERIAL AND METHODS

A direct mail survey was sent to members of the national gastroenterological associations in Sweden, Norway, Greece, and the United Kingdom.

RESULTS

Out of 2361 clinicians with valid addresses, 593 (25.1%) responded. Overall, EUS was available to 43% of clinicians within their practice but availability varied from 23% in Greece to 56% in the United Kingdom. More than 50% of respondents evaluating patients with esophageal cancer, rectal cancer, or pancreaticobiliary disorders had utilized EUS during the previous year, but utilization varied considerably among different countries, being more frequent in the United Kingdom. In logistic regression analyses, factors independently related to EUS utilization were mainly EUS availability and accessibility as well as perceived utility of EUS (p <0.05 for all). Respondents considered the lack of trained endosonographers (79%) and high cost (52%) as the main barriers to wider EUS use.

CONCLUSIONS

The majority of responding clinicians use EUS but overall utilization varies considerably among different countries. There is considerable variation in EUS service availability and accessibility among countries which, together with perceived usefulness of EUS, is a major determinant of EUS utilization. A shortage of trained endosonographers and the high cost are major barriers to wider EUS use. The findings of this study might help to define policies aimed at development of EUS services.

EUS versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a prospective randomized trial

BACKGROUND

Factors affecting diagnostic accuracy and comparison of patients in the follow-up period for negative outcomes are not thoroughly investigated in a randomized trial.

OBJECTIVE

Our purpose was to compare diagnostic accuracy, complications, and number of interventions.

DESIGN

Prospective, unicentric, single-blind, randomized study.

SETTING

Single tertiary referral university hospital.

PATIENTS

One hundred twenty patients with intermediate risk for common bile duct (CBD) stones were randomized to either an EUS-first, endoscopic retrograde cholangiography (ERC)-second (n = 60) versus an ERC-only (n = 60) procedure.

INTERVENTIONS

EUS, ERC, sphincterotomy, and balloon sweeping of CBD when needed.

MAIN OUTCOME MEASUREMENTS

Sensitivity of EUS versus ERC, factors affecting diagnostic capability, complications, total number of endoscopic procedures.

RESULTS

The sensitivity and specificity of ERC were 75% (95% CI, 42%-93%) and 100% (95% CI, 95%-100%), respectively. The sensitivity and specificity of EUS were 91% (95% CI, 59%-99%) and 100% (95% CI, 95%-100%), respectively. EUS is more sensitive than ERC in detecting stones smaller than 4 mm (90% vs 23%, P < .01). Although not significant, there was a trend for an increased number of endoscopic procedures in the ERC group compared with the EUS group (98 vs 83). The post-ERC pancreatitis rate was 6 in 120 (5%) in all study patients, and the post-ERC pancreatitis rate in patients with an undilated CBD was 5 of 53 (9.43%). The independent factors for post-ERC pancreatitis are undilated CBD (risk ratio [RR] 6.320; 95% CI, 1.703-11.524, P = .009), allocation into the ERC group (RR 2.107; 95% CI, 1.330-3.339, P = .02), female sex (RR 1.803; 95% CI, 1.155-2.813, P = .03), and age less than 40 years (RR 1.888; 95% CI, 1.245-2.863, P = .01). Kaplan-Meier analysis revealed higher rate of negative outcome in the ERC group than in the EUS group (P = .049, log-rank test).

CONCLUSION

The EUS-first approach is not associated with further risk for subsequent endoscopic procedures. Patients with an undilated CBD should be investigated by the EUS-first approach to prevent post-ERC pancreatitis.