Early EUS of the bile duct before endoscopic sphincterotomy for acute biliary pancreatitis

The Usefulness of Early Endoscopic Ultrasonography in Acute Biliary Pancreatitis with Undetectable Choledocholithiasis on Multidetector Computed Tomography

Background/Aims

EUS can detect bile duct stones (BDS) that are undetectable on multidetector computed tomography (MDCT). BDS associated with acute biliary pancreatitis (ABP) are small and tend to be excreted spontaneously. This study evaluated the usefulness of early EUS in patients with ABP and undetectable BDS on MDCT.

Methods

Forty-one patients with ABP and undetectable BDS on MDCT underwent EUS within 24 hours of admission and were diagnosed with BDS, sludge, dilated common bile duct (CBD), or normal CBD. ERCP was performed in patients with BDS, sludge, or clinical deterioration. The diagnostic yield and the effects of early EUS on morbidity, mortality, and the length of hospitalization were evaluated.

Results

EUS detected BDS or sludge in 48.8% of patients examined. BDS was the diagnosis in 13 patients, sludge in seven, and neither for 21 patients. ERCP was performed in 20 patients with BDS or sludge, in two patients with coexisting cholangitis, and in one patient with worsening liver function tests. ERCP identified BDS in 12 patients and sludge in seven. No lesions were diagnosed in four patients by ERCP. All patients improved, and the length of hospitalization in patients with ERCP was 9.0 days, without ERCP 7.1 days. Two patients with major complications by ERCP were hospitalized for a prolonged time.

Conclusions

Early EUS may be useful to select patients for therapeutic ERCP in cases of suspected ABP with undetectable BDS on MDCT.

Clinical usefulness of intraductal ultrasonography for the management of acute biliary pancreatitis

BACKGROUND AND AIM

Identifying a bile duct (BD) stone in patients with acute biliary pancreatitis (ABP) is important for the management and prevention of recurrent attack of pancreatitis. However, small BD stones may not be detected on endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to prospectively evaluate the usefulness of intraductal ultrasonography (IDUS) in patients suspected to have ABP but with no evidence of choledocholithiasis on ERCP.

METHODS

A total 92 patients suspected with ABP without evidence of BD stones on imaging studies including ERCP were enrolled. Wire-guided IDUS was performed during ERCP in all patients. Stones or sludge detected by IDUS were confirmed after endoscopic sphincterotomy (EST) and extraction. If IDUS finding was negative, then we swept the BD with a balloon catheter and/or basket without EST. After endoscopic management, comparison between IDUS and endoscopic finding was carried out to determine the diagnostic accuracy of IDUS.

RESULTS

Among the 92 patients, IDUS revealed BD stones in 33 (35.9%). All 33 patients' stones were confirmed by endoscopic visualization after EST and BD exploration. During the mean follow up of 24 months, recurrent pancreatitis did not occur in 90 of 92 patients (97.9%) with ABP after endoscopic treatment according to the IDUS findings.

CONCLUSIONS

IDUS improves diagnostic accuracy for the detection of clinically occult BD stones in patients suspicious ABP. IDUS-guided endoscopic management for patients with ABP can avoid unnecessary EST and help prevent recurrent pancreatitis.

Role of diagnostic and therapeutic endoscopic ultrasonography in benign pancreatic diseases

Standard imaging of pancreas is generally obtained by computed tomography and magnetic resonance imaging. However endoscopic ultrasound (EUS) has become an indispensable tool for the diagnosis of various pancreatic diseases. Because of the close proximity of the EUS probe to the pancreas, EUS provides excellent images of the pancreas. In this review, we discuss the role of EUS in the clinical management of patients with benign pancreatic diseases, i.e., various forms of pancreatitis.

Endoscopic treatment of the choledocholithiasis--effectiveness, safety and limitations of the method

Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is accepted referred method of treatment of the choledocholithiasis.

THE AIM OF THE STUDY

Evaluation of efficacy and safety of the endoscopic treatment of the biliary tract stones.

MATERIAL AND METHODS

Results of 3309 Endoscopic Retrograde Cholangio-Pancreatography (ERCP) carried out in Division of Endoscopy of the General Surgery Department in the period 2000 - 2010. The retrospective analysis of the indications, process, findings and final results of 1698 ERCP and Endoscopic Sphincterotomy (ES) was performed with intention to treat of the biliary tract stones.

RESULTS

The 883 (52%)patients with coexisted gall-bladder and biliary tract stones were the principal group. The second group included 580 (34.2%) patients with residual choledocholithiasis after cholecystectomy and biliary tract surgery. Moreover ERCP, ES and endoscopic evacuation of biliary stones have been urgently carried out in 159 (9.4%) cases with acute biliary pancreatitis. Lastly ERCP with re-sphincterotomy and removal of the stones was performed in 75 (4.4%) patients with recurrent choledocholithiasis. The procedure was effective in 1561 (92%) patients. When removal of the stones was not possible, decompression of the biliary tract by implantation of the plastic stent was done in 63 (3.7%) cases. Ineffective procedure was noted in 74 (4.3%) patients. The most commonly observed complication was acute pancreatitis. Because of: post ES bleeding, acute haemmorhagic and necrotic pancreatitis, impacted Dormia basket and peripapillary duodenal perforation 10 patients (0.5%) had to be operated. Two patients (0.1%) died.

CONCLUSIONS

1. Endoscopic treatment of choledocholithiasis is highly effective but risk factors of complications with urgency an intensive conservative management and surgical intervention have to be considered. 2. After ES, if surgical evacuation of the stones have to be carry out, post operative biliary tract drainage (by T tube) is not necessary.

EUS finding of geographic hyperechoic area is an early predictor for severe acute pancreatitis

BACKGROUND/OBJECTIVES

Endoscopic ultrasonography (EUS) is an accurate imaging modality for delineating pancreatobiliary structures, however, its clinical application of acute pancreatitis (AP) is limited. Therefore, we sought to characterize the typical EUS features of AP and to determine whether early EUS findings may have prognostic significance.

METHODS

Between March 2008 and October 2010, 90 patients with AP and 90 patients without pancreatic disease who underwent EUS were enrolled. An EUS examination was performed within 48 h of admission in AP, and all EUS findings were retrospectively analyzed.

RESULTS

Among 90 patients, 27 (30%) were diagnosed with severe AP. Multivariate analysis revealed the presence of peripancreatic fluid (OR 13.9, 95%, CI: 1.6-123.6), heterogenous (OR 7.2, 95% CI: 1.7-30.4) and hypoechoic parenchymal echogenicity (OR 10.0, 95% CI: 3.9-25.8) were significant EUS features in AP, as compared to those in the control group. Comparison between mild and severe AP showed that geographic hyperechoic area (GHA) of pancreas was a predictive factor (OR 2.9, 95% CI: 1.1-8.2, p = 0.04) for the severe form, and that AP patients with GHA had significantly longer duration of fever, abdominal pain and hospital stay than those without GHA (5.5 vs. 1 day (s), p = 0.002; 4 vs. 3 days, p = 0.023; 11 vs. 8 days, p = 0.021, respectively).

CONCLUSIONS

Typical EUS features of AP are a heterogenous hypoechoic parenchymal changes with peripancreatic fluid collection. The novel EUS variable of GHA in the early phase of AP seems to have prognostic value and could be correlated with a worse clinical outcome.

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.

Conservative management of cholestasis with and without fever in acute biliary pancreatitis

The presence of cholestasis in both mild and severe forms of acute biliary pancreatitis (ABP) does not justify, of itself, early endoscopic retrograde cholangiography (ERC) or endoscopic sphincterotomy (ES). Clinical support treatment of acute pancreatitis for one to two weeks is usually accompanied by regression of pancreatic edema, of cholestasis and by stone migration to the duodenum in 60%-88% of cases. On the other hand, in cases with both cholestasis and fever, a condition usually characterized as ABP associated with cholangitis, early ES is normally indicated. However, in daily clinical practice, it is practically impossible to guarantee the coexistence of cholangitis and mild or severe acute pancreatitis. Pain, fever and cholestasis, as well as mental confusion and hypotension, may be attributed to inflammatory and necrotic events related to ABP. Under these circumstances, evaluation of the bile duct by endo-ultrasonography (EUS) or magnetic resonance cholangiography (MRC) before performing ERC and ES seems reasonable. Thus, it is necessary to assess the effects of the association between early and opportune access to the treatment of local and systemic inflammatory/infectious effects of ABP with cholestasis and fever, and to characterize the possible scenarios and the subsequent approaches to the common bile duct, directed by less invasive examinations such as MRC or EUS.

Calcium and reactive oxygen species in acute pancreatitis: friend or foe?

SIGNIFICANCE

Acute pancreatitis (AP) is a debilitating and, at times, lethal inflammatory disease, the causes and progression of which are incompletely understood. Disruption of Ca(2+) homeostasis in response to precipitants of AP leads to loss of mitochondrial integrity and cellular necrosis.

RECENT ADVANCES

While oxidative stress has been implicated as a major player in the pathogenesis of this disease, its precise roles remain to be defined. Recent developments are challenging the perception of reactive oxygen species (ROS) as nonspecific cytotoxic agents, suggesting that ROS promote apoptosis that may play a vital protective role in cellular stress since necrosis is avoided.

CRITICAL ISSUES

Fresh clinical findings have indicated that antioxidant treatment does not ameliorate AP and may actually worsen the outcome. This review explores the complex links between cellular Ca(2+) signaling and the intracellular redox environment, with particular relevance to AP.

FUTURE DIRECTIONS

Recent publications have underlined the importance of both Ca(2+) and ROS within the pathogenesis of AP, particularly in the determination of cell fate. Future research should elucidate the subtle interplay between Ca(2+) and redox mechanisms that operate to modulate mitochondrial function, with a view to devising strategies for the preservation of organellar function.

EUS in exploring the etiology of mild acute biliary pancreatitis with a negative finding of biliary origin by conventional radiological methods

BACKGROUND AND AIM

Conventional radiological methods, including transcutaneous ultrasonography (US), computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP) are non-invasive and recommended for the detection of etiologies of acute biliary pancreatitis (ABP). There are still, however, a number of patients whose etiologies cannot be found by these methods. The value of endoscopic ultrasound (EUS) for this population is still unknown. The aim of the present study was to evaluate the role of EUS in exploring the unknown etiology of mild ABP.

METHODS

The data from patients with mild ABP admitted to Changhai Hospital, Shanghai, China, from June 2006 to December 2009 were retrospectively collected, and the results of the imaging methods in detecting biliary disorders were analyzed.

RESULTS

A total of 223 patients with mild ABP underwent both US and CT. Of these, 106 underwent additional MRCP. There were still 37 patients with unknown biliary etiologies, even after the use of the conventional methods mentioned earlier. EUS was conducted in 33 of these patients. Abnormalities associated with the etiology of mild ABP were found in 14 cases (42.4%) confirmed by subsequent endoscopic retrograde cholangiopancreatography, with biliary stones in 11 cases, biliary sludge in two cases, and ampullary adenocarcinoma in one case.

CONCLUSION

The results suggest that EUS is helpful in the identification of the etiology of mild biliary pancreatitis when conventional radiological imaging is negative or equivocal.

Role of endoscopic ultrasound during hospitalization for acute pancreatitis

Endoscopic ultrasound (EUS) is often used to detect the cause of acute pancreatitis (AP) after the acute attack has subsided. The limited data on its role during hospitalization for AP are reviewed here. The ability of EUS to visualize the pancreas and bile duct, the sonographic appearance of the pancreas, correlation of such appearance to clinical outcomes and the impact on AP management are analyzed from studies. The most important indication for EUS appears to be for detection of suspected common bile duct and/or gall bladder stones and microlithiasis. Such an approach might avoid diagnostic endoscopic retrograde cholangio-pancreatography with its known complications. The use of EUS during hospitalization for AP still appears to be infrequent but may become more frequent in future.

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.

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.

Endoscopic ultrasound in pancreatic disease--its influence on surgical decision-making. An update 2008

Endoscopic ultrasonography (EUS) was introduced about 25 years ago with the primary aim of better visualization of the pancreas as compared to transabdominal ultrasonography. This review discusses the current evidence in 2008 concerning the role of EUS in the clinical management of patients, with a special emphasis on its impact on surgical therapy. According to the literature, good indications are detection of common bile duct stones (e.g. in acute pancreatitis), the detection of small exo- and endocrine pancreatic tumors, the performance of fine-needle aspiration in pancreatic masses depending on therapeutic consequences. In other areas such as diagnosis of chronic pancreatitis and cystic pancreatic lesions, the contribution of EUS seems limited. Pancreatic cancer staging is discussed controversially due to conflicting evidence and certainly has lost grounds due to improvements in CT technology. Therapeutic EUS is, however, more widely accepted and may replace other techniques, e.g. in pancreatic cyst drainage and celiac plexus neurolysis; further techniques of interest are being developed.

Acute biliary pancreatitis: detection of common bile duct stones with endoscopic ultrasound

OBJECTIVES

To determine prospectively the sensitivity and specificity of endoscopic ultrasound (EUS) for detecting common bile duct stones (CBS) in patients with acute biliary pancreatitis in whom transabdominal ultrasound was negative for CBS.

METHODS

In 38 consecutive patients with acute biliary pancreatitis who were negative for CBS by transabdominal ultrasound, EUS was performed before endoscopic retrograde cholangiopancreatography (ERCP). The endoscopist performing ERCP was blind to the results of EUS. The primary goal of EUS and ERCP was to confirm or exclude CBS. The reference standard for CBS was endoscopic extraction of bile duct stones after endoscopic sphincterotomy. When both procedures, EUS and ERCP excluded CBS, it was assumed that there were no CBS and endoscopic sphincterotomy was not performed. The results EUS and ERCP were compared with the McNemar test.

RESULTS

Twenty-five of the 38 patients (66%) had CBS. EUS and ERCP were false negative in one patient each, EUS was false positive in two patients and ERCP in one patient. The sensitivity of both EUS and ERCP was 96%. The specificity of EUS and ERCP was 85 and 92%, respectively. The difference between EUS and ERCP was not significant (P=0.9).

CONCLUSION

EUS proved to be as sensitive as ERCP for detection of CBS in patients with acute biliary pancreatitis. Therefore, EUS could be used as the first-line procedure in patients with acute biliary pancreatitis when therapeutic ERCP is not needed. By this approach a substantial number of unnecessary diagnostic ERCP procedures could be avoided.

Choledocholithiasis, ascending cholangitis, and gallstone pancreatitis

Gallstone disease is encountered commonly in clinical practice. The diagnosis of biliary stones has become less problematic with current, less-invasive imaging methods. The relatively invasive endoscopic techniques should be reserved for therapy and not used for diagnosis. Acute cholangitis and gallstone pancreatitis are two major complications that require prompt recognition and timely intervention to limit morbidity and prevent mortality or recurrence. Appropriate noninvasive diagnostic studies, adequate monitoring/supportive care, and proper patient selection for invasive therapeutic procedures are elements of good clinical practice.

Endoscopic ultrasonography for evaluating patients with recurrent pancreatitis

Acute recurrent pancreatitis (ARP) is still a complex diagnostic and therapeutic challenge in clinical practice. In up to 30% of cases of ARP, it is not possible to establish the etiology of the disease. In the other 70%, many factors play an etiological role in ARP: microlithiasis, sphincter of Oddi dysfunction (SOD), pancreas divisum, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatic tumors or chronic pancreatitis are diagnosed. EUS should be useful in ARP as it is sensitive for diagnosing bile duct stones, gallbladder sludge, pancreatic lesions, ductal abnormalities and chronic pancreatitis. Endoscopic ultrasound (EUS) appears to be diagnostic in the majority of patients with previously unexplained pancreatitis, and offers an alternative to endoscopic retrograde cholangiopancreatography (ERCP) as the initial diagnostic test in patients with ARP.

Diagnostic approach to patients with acute idiopathic and recurrent pancreatitis, what should be done?

Acute recurrent pancreatitis (ARP) is a common clinical condition that may be difficult to diagnose. Endoscopic ultrasound (EUS) is proposed to be a safe first line test of choice in the majority of patients. When interventions are needed to remove biliary stones, evaluate sphincter of Oddi or pancreas divisum, endoscopic retrograde cholangiopancreatography (ERCP) is recommended. Magnetic resonance cholangiopancreatography (MRCP) can be a suitable alternative from a diagnostic standpoint although may not be widely available. Finally, genetic testing is increasingly used to detect certain mutations that are associated with this diagnosis.

When is pancreatitis considered to be of biliary origin and what are the implications for management?

Acute pancreatitis is a disease caused by gallstones in 40-60% of patients. Identification of these patients is extremely important, since there are specific therapeutic interventions by endoscopic sphincterotomy and/or cholecystectomy. The combination of trans-abdominal ultrasound (stones in the gallbladder and/or main bile duct) and elevated serum alanine transaminase (circa >60 IU/l within 48 h of presentation) indicates gallstones as the cause in the majority of patients with acute pancreatitis. In the presence of a severe attack this is a strong indication for intervention by endoscopic sphincterotomy. The presence of a significant main bile duct dilatation is also strongly indicative of gallstones and should prompt the use of endoluminal ultrasonography: >8 mm diameter with gallbladder in situ, or >10 mm following cholecystectomy if aged <70 years and >12 mm, respectively, if > or = 70 years. In mild pancreatitis surgically fit patients should be treated by cholecystectomy, and intra-operative cholangiography, as pre-operative biliary imaging is not efficient in this setting. Patients who are not fit for cholecystectomy should undergo prophylactic endoscopic sphincterotomy to prevent further attacks. In the post-acute-phase, pancreatitis patients in whom the aetiology is uncertain should undergo endoluminal ultrasonography. Thisis the most sensitive method for the detection of cholelithiasis and choledocholithiasis and may reveal alternative aetiological factors such as a small ampullary or pancreatic cancer. A number of recent studies have shown that bile crystal analysis, a marker for microlithiasis, increases the yield of positive results over and above endoluminal ultrasonography, and should be considered as part of the modern investigative algorithm.

Endoscopic ultrasound: a meta-analysis of test performance in suspected biliary obstruction

BACKGROUND & AIMS

Endoscopic ultrasound (EUS) achieves high-resolution images of the bile duct and pancreas, while avoiding the risks of ERCP (endoscopic retrograde cholangiopancreatography). It appears comparable to MRCP (magnetic resonance cholangiopancreatography), although its use is less widely disseminated. We aimed to summarize EUS test performance in suspected biliary disease with meta-analysis.

METHODS

MEDLINE search (January 1987-September 2006), selected reference lists, external experts, and manual search of abstracts were used. Studies permitting (re)construction of 2 x 2 tables for EUS versus a gold standard were used. Random-effects models were used to estimate pooled sensitivity and specificity after adjusting for a number of potential confounders. Summary receiver operating characteristic analysis, with the sensitivity corresponding to the point on the receiver operating characteristic curve where sensitivity equals specificity (Q*) and area under the curve, was performed. The effects of sample size, quality, disease prevalence and spectrum, pancreatitis, echoendoscope type, and EUS era on diagnostic performance were assessed. Performance regarding presence of obstruction, choledocholithiasis, and malignancy was analyzed.

RESULTS

Thirty-six eligible, non-overlapping studies met inclusion criteria (3532 subjects). EUS had a high overall pooled sensitivity (88%; 95% confidence interval, 85%-91%) and specificity (90%; 87%-93%) for biliary obstruction (area under the curve = 0.97; Q* = 0.92). EUS had higher sensitivity (89%; 87%-91%) and specificity (94%; 91%-96%) for choledocholithiasis than for malignancy (sensitivity, 78%; 69%-85%; specificity, 84%; 78%-91%). Smaller studies and ones mainly studying patients with suspected strictures were associated with lower test performance.

CONCLUSIONS

There is excellent overall accuracy for EUS in diagnosing choledocholithiasis, with less impressive results for malignancy (when fine-needle aspiration is not used).

Role of endoscopic ultrasonography in prevention of unnecessary endoscopic retrograde cholangiopancreatography: a prospective study of 150 patients

OBJECTIVE

The purpose of this study was to evaluate the impact of substituting endoscopic ultrasonography (EUS) for endoscopic retrograde cholangiopancreatography (ERCP) in cases of a low to intermediate risk for choledocholithiasis.

METHODS

During a 16-month period, patients who were referred for suspected choledocholithiasis, biliary colic, or acute biliary pancreatitis on the basis of alterations in liver enzyme values with or without gallstones seen on transabdominal ultrasonography were included. Endoscopic ultrasonography was performed for all patients. Patients with common bile duct stones underwent ERCP. Cholecystectomy was recommended in all patients with symptomatic gallstones. Cases were followed for 12 months.

RESULTS

A total of 150 patients were included. Choledocholithiasis was diagnosed by EUS in 39 patients (26.0%) and was confirmed by ERCP in 30 (77.0%). Fifty-one patients had a normal common bile duct, and follow-up for 12 months showed no abnormalities except in 1 patient. Cholecystectomy without ERCP was recommended for the remaining 60 patients who had symptomatic gallstones or sludge. Endoscopic retrograde cholangiopancreatography was avoided by this approach in 110 patients (73.3%).

CONCLUSIONS

In a low to intermediate risk for choledocholithiasis, EUS can preclude the need for ERCP in most cases.

EUS diagnosis and simultaneous endoscopic retrograde cholangiography treatment of common bile duct stones by using an oblique-viewing echoendoscope

BACKGROUND

MRCP and EUS have replaced ERCP in the diagnosis of biliary diseases, but the latter is needed for treatment. This study evaluates a new approach in the management of common bile duct stones, by using an oblique-viewing echoendoscope.

METHODS

Nineteen patients with acute abdominal pain associated with increased liver tests entered the study. Evaluation of the biliary tree was performed by using an oblique-viewing echoendoscope (JF-UM20; Olympus Europe GmbH, Hamburg, Germany). When biliary stones or sludge were found, bile duct cannulation and sphincterotomy were performed in the same session.

RESULTS

Bile duct stones were diagnosed by EUS in 4 patients and biliary sludge in 12; the subsequent cholangiography and sphincterotomy with stone extraction confirmed the diagnosis in all patients. Bile duct cannulation failed in 1 patient. EUS showed features of chronic pancreatitis in 3 cases. The mean time for the whole procedure (EUS plus endoscopic retrograde cholangiography with biliary treatment) was 27 minutes. No procedure-related complications were observed.

CONCLUSION

This new approach appears to be feasible and safe, providing an accurate diagnosis and, at the same time, an appropriate treatment of common bile duct stones when needed. With technical improvements, this extended EUS technique could be used as the first-line procedure in patients with biliopancreatic diseases.

Does the Advent of Endoscopic Ultrasound (EUS) Sound the Death Knell for Endoscopic Retrograde Cholangiopancreatography (ERCP)?

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) has been the premier diagnostic and therapeutic endoscopic procedure in the management of pancreatic and biliary diseases (PBD). The use of endoscopic ultrasound (EUS), including EUS-guided fine needle aspiration (FNA), of pancreatic and biliary tumours has become more widely available in the last decade and has gradually replaced diagnostic ERCP. Together with EUS, other imaging modalities like magnetic resonance cholangiopancreatography (MRCP) have resulted in a decrease in the number of ERCPs. With the advent of interventional EUS, ERCP is at risk of being completely eclipsed. Methods: A search of all relevant articles on EUS and ERCP from Medline and peer-reviewed journals. Results: This review article examines the exact place of ERCP and EUS and their relative contributions in the management algorithm of PBD. Conclusion: Although diagnostic EUS, including EUS-guided FNA, is well established in the evaluation of PBD, interventional EUS is still in its infancy and its true potential is unknown. Therefore, therapeutic ERCP still has a vital, albeit smaller role to play in the treatment of pancreatic and biliary diseases. Key words: Biliary diseases, Endoscopic retrograde cholangiopancreatography, Endosonography, Pancreatic

Laparoscopy for abdominal emergencies

BACKGROUND

Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment.

METHODS

A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain.

RECOMMENDATIONS

Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen.

CONCLUSIONS

Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

Clinico-biochemical prediction of biliary cause of acute pancreatitis in the era of endoscopic ultrasonography

BACKGROUND

Occult biliary stones escape detection on conventional investigations, and clinico-biochemical systems proposed for predicting biliary pancreatitis has low predictive values.

AIM

To evaluate the accuracy of clinico-biochemical parameters for prediction of biliary pancreatitis in patients undergoing endoscopic ultrasonography.

METHODS

Early endoscopic ultrasonography was performed on 139 patients presenting with acute pancreatitis within 24 h of admission. The aetiologies of all patients were determined after complete evaluations, and clinico-biochemical characteristics of patients with a biliary cause (biliary group) and non-biliary causes (non-biliary group) were compared.

RESULTS

Biliary pancreatitis was diagnosed in 107 patients and 32 patients had non-biliary causes. The biliary group belonged to a significantly older age group, had a female predominance, significantly more derangement of liver function and a higher incidence of severe attack of acute pancreatitis. On multivariate analysis, female sex, age >58 years and serum alanine aminotransferase >150 U/L were independent predictive factors for biliary cause of acute pancreatitis. Using these three factors for prediction of biliary cause, the sensitivity was 93% and overall accuracy was 85%.

CONCLUSION

Clinico-biochemical prediction for biliary cause of acute pancreatitis improves in the era of endoscopic ultrasonography with a higher sensitivity and overall accuracy. In centres where endoscopic ultrasonography is inaccessible or local expertise is unavailable, clinico-biochemical prediction of biliary cause of acute pancreatitis may provide a useful alternative in the initial management of this group of patients.

The detection of bile duct stones in suspected biliary pancreatitis: comparison of MRCP, ERCP, and intraductal US

OBJECTIVES

Early ERCP and endoscopic sphincterotomy for stone extraction can benefit the prognosis in patients with severe biliary pancreatitis, but are associated with complications. The ability to identify choledocholithiasis by noninvasive means in biliary pancreatitis is limited. The aim of this study was evaluation of the ability of MRCP to detect choledocholithiasis in patients with acute biliary pancreatitis. In addition, we investigated whether intraductal US (IDUS) could help manage these patients.

METHODS

Thirty-two patients with suspected biliary pancreatitis were studied prospectively. MRCP was performed immediately before ERCP by separate blinded examiners within 24 h of admission. Wire-guided IDUS was performed during ERCP within 72 h of admission, regardless of the results of MRCP. Using endoscopic extraction of a stone as the reference standard, the diagnostic yield of MRCP was compared with transabdominal US, CT, ERCP, and IDUS.

RESULTS

The sensitivity of US, CT, MRCP, ERCP, and IDUS for identifying choledocholithiasis was 20.0%, 40.0%, 80.0%, 90.0%, and 95.0%, respectively. The overall agreement between MRCP and ERCP was 90.6% for choledocholithiasis (kappa= 0.808, p < 0.01). The sensitivity of MRCP for detecting choledocholithiasis decreased with dilated bile ducts (bile duct diameter > 10 mm, 72.7% vs 88.9%). The combination of ERCP and IDUS improved accuracy in the diagnosis of choledocholithiasis.

CONCLUSIONS

MRCP can be used to select patients with biliary pancreatitis who require ERCP. IDUS may be applied in the management of biliary pancreatitis if ERCP is performed.

Endoskopska ultrasonografija u holedoholitijazi

Diagnosis of choledocholithiasis is still difficult to establish and presents a great challenge in gastroenterology and surgery of biliary tract, since it requires expensive and sophisticated examining techniques. 10 to 15% of patients with symptomatic cholelithiasis were presented with choledocholithiasis as well. By EUS is possible to establish a diagnosis of choledocholithiasis with accuracy of 90 to 100% and precisely estimate dimensions of revealed stones. The main purpose of this survey is to present a great importance and many advantages of EUS as a contemporary diagnostic method. All patients were examined by Olympus equipment for endoscopic ultrasound with radial probe working with the frequency of 7,5 and 12 MHz at the Department for Endoscopic Ultrasound of the Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia. They were previously diagnosed with choledocholithiasis by ERCP method. We examined 16 patients, which were selected by estimated risk for cholelithiasis. We have tried to evaluate the importance of diameter of choledochus, defined by common ultrasonography, as well as values of alkaline phosphatase and serum GT. We defined 3 groups of patients: group no.1, with 2 patients presented with a low risk for choledocholithiasis; group no.2, with 6 patients with a moderate risk for choledocholithiasis, and group no.3, with 8 patients presented with significant risk for cholelithiasis. According to obtained results, EUS presents the most effective method for detecting of choledocholithiasis, which is sometimes even more efficient than ERCP. After choledocholithiasis is previously revealed by EUS, it is much easier to decide if some invasive method such as EPT or precut papillotomy has to be used. EUS is always recommended as a diagnostic method when it is necessary to avoid some expected complications, such as pancreatitis.

Biliary stones: including acute biliary pancreatitis

The widespread availability of endoscopic ultrasound has facilitated the evaluation of the pancreas and extrahepatic biliary system. Endosonography has been shown to be highly sensitive in the detection of choledocholithiasis (especially in patients with small stones and nondilated bile ducts) and gallbladder microlithiasis; however, the use of this technique in relation to endoscopic retrograde cholangiography and laparoscopic surgery in gallstone disease remains confusing. This article highlights the clinical performance and results of endoscopic ultrasound in this context and proposes strategies in relation to its use in association with endoscopic retrograde cholangiopancreatography and surgery in common clinical practice. Endosonography allows the correct identification of patients with acute biliary pancreatitis and proves an important adjunct in eliminating other causes of undetermined pancreatitis.

Idiopathic acute pancreatitis

After routine investigations, including a thorough history, routine laboratory study, and noninvasive imaging with transcutaneous ultrasonogram, 10% to 25% of cases of acute pancreatitis have no readily identifiable cause and are termed idiopathic. But modern medicine has made notable advances in uncovering various causes of acute pancreatitis, and several new diagnostic tools that allow clinicians to less invasively approach the patient without sacrificing the diagnostic yield have been introduced. By being knowledgeable of these new changes and by their proper use in a proper circumstances, clinicians will be able to find the cause more accurately and earlier. This better management will not only improve the well-being of the patients but also reduce the number of "true" idiopathic acute pancreatitis to a minimum.

Gallstone pancreatitis: when is endoscopic retrograde cholangiopancreatography truly necessary?

Acute pancreatitis is an inflammation of the pancreas that can, in a minority of patients, lead to local complications, multiorgan failure, and death. Gallstones are the most common cause of acute pancreatitis in Western countries. The majority of patients with acute gallstone pancreatitis have mild disease and recover within 3 to 5 days with bed rest and intravenous fluid replacement. In up to 20% of patients, severe pancreatitis develops and can involve pancreatic tissue necrosis and multiorgan failure. Recent advances in the care of patients with gallstone-induced pancreatitis include better severity stratification on hospital admission, more aggressive fluid resuscitation in the early disease course, early use of antibiotics in patients with pancreatic necrosis, a shift from parenteral to enteral feeding regimens, a better defined and less aggressive approach to pancreatic surgery, and the possibility to remove impacted gallstones endoscopically. Urgent endoscopic retrograde cholangiopancreatography and sphincterotomy are recommended in patients with signs of cholangitis or jaundice, ultrasound evidence of dilated common bile duct, or evidence of severe disease.

Predicting and preventing post-ERCP pancreatitis

Pancreatitis is rightly the most feared complication of endoscopic retrograde cholangiopancreatography (ERCP). Ten percent to 15% of cases of post-ERCP pancreatitis (PEP) are severe by clinical and radiologic criteria. Such cases carry significant morbidity and mortality and are responsible for the vast majority of ERCP-related deaths. The prediction and prevention of PEP have been of great interest to endoscopists since the introduction of ERCP 30 years ago. Prediction and diagnosis of PEP have become more accurate with the widespread availability of serum amylase estimation. A variety of cytokines (eg, interleukin -1, IL-6, and IL-8) and acute phase reactants (eg, C-reactive protein) are also elevated in the serum in acute pancreatitis, and these form the basis of evolving tests for PEP. Urine testing (for amylase) in acute pancreatitis is obsolete, but it may soon undergo a revival in the form of a rapid (3-minute) dipstick test for trypsinogen-2, a sensitive and specific test for this disease. The prevention of PEP takes multiple forms. The following steps are recommended for clinicians: 1) avoid ERCP when other, less invasive or noninvasive imaging tests can do the job (eg, CT or magnetic resonance imaging); 2) avoid high-risk (of PEP) procedures, such as needle-knife papillotomy, balloon dilation of the biliary sphincter, and pancreatic sphincterotomy, and take steps to reduce risk when these procedures are unavoidable; 3) ensure that those who perform ERCP have adequate training and experience; and 4) consider pharmacologic intervention. Despite a depressing catalog of drug interventions that have failed over the years (eg, antihistamines, anticholinergics, and corticosteroids), three agents have recently shown promise: somatostatin; its octapeptide analogue, octreotide; and gabexate mesylate, a protease inhibitor.