Endoscopic ultrasonography in detection of cholelithiasis in patients with biliary pain and negative transabdominal ultrasonography

Biliary Dyskinesia and Hyperkinesis

Biliary dyskinesia refers to a group of functional and motility disorders of the biliary system in patients presenting with typical biliary pain, but without any visible structural abnormalities on standard imaging. The Rome IV Criteria establishes diagnostic criteria for functional gallbladder disorder (gallbladder dyskinesia and biliary hyperkinesia), functional biliary sphincter of Oddi disorder (biliary dyskinesia), and pancreatic sphincter of Oddi disorder. Many diagnostic adjuncts such as hepatobiliary scintigraphy and sphincter of Oddi manometry exist, although these results are supportive and not necessarily diagnostic for biliary dyskinesia. Surgical intervention is most successful when selecting for patients with typical biliary pain.

Practical approach to linear endoscopic ultrasound examination of the gallbladder

The gallbladder (GB) is a susceptible organ, prone to various pathologies that can be identified using different imaging techniques. Transabdominal ultrasound (TUS) is typically the initial diagnostic method due to its numerous well-established advantages. However, in cases of uncertainty or when a definitive diagnosis cannot be established, computed tomography (CT) or magnetic resonance imaging may be employed to provide more detailed information. Nevertheless, CT scans may sometimes offer inadequate spatial resolution, which can limit the differentiation of GB lesions, particularly when smaller yet clinically relevant abnormalities are involved. Conversely, endoscopic ultrasound (EUS) provides higher frequency compared to TUS, superior spatial resolution, and the option for contrast-enhanced harmonic imaging, enabling a more comprehensive examination. Thus, EUS can serve as a supplementary tool when conventional imaging methods are insufficient. This review will describe the standard EUS examination of the GB, focusing on its endosonographic characteristics in various GB pathologies.

Gallstones as a cause in presumed acute alcoholic pancreatitis: observational multicentre study

BACKGROUND

Data on the incidence and clinical relevance of gallstones in patients with suspected acute alcoholic pancreatitis are lacking and are essential to minimize the risk of recurrent acute pancreatitis. The aim of this study was to assess the incidence of gallstones and the associated rate of recurrent acute pancreatitis in patients with presumed acute alcoholic pancreatitis.

METHODS

Between 2008 and 2019, 23 hospitals prospectively enrolled patients with acute pancreatitis. Those diagnosed with their first episode of presumed acute alcoholic pancreatitis were included in this study. The term gallstones was used to describe the presence of cholelithiasis or biliary sludge found during imaging. The primary outcome was pancreatitis recurrence during 3 years of follow-up.

RESULTS

A total of 334 patients were eligible for inclusion, of whom 316 were included in the follow-up analysis. Gallstone evaluation, either during the index admission or during follow-up, was performed for 306 of 334 patients (91.6%). Gallstones were detected in 54 patients (17.6%), with a median time to detection of 6 (interquartile range 0-42) weeks. During follow-up, recurrent acute pancreatitis occurred in 121 of 316 patients (38.3%), with a significantly higher incidence rate for patients with gallstones compared with patients without gallstones (59% versus 34.2% respectively; P < 0.001), while more patients with gallstones had stopped drinking alcohol at the time of their first recurrence (41% versus 24% respectively; P = 0.020). Cholecystectomy was performed for 19 patients with gallstones (36%). The recurrence rate was lower for patients in the cholecystectomy group compared with patients who did receive inadequate treatment or no treatment (5/19 versus 19/34 respectively; P = 0.038).

CONCLUSION

Gallstones were found in almost one in every five patients diagnosed with acute alcoholic pancreatitis. Gallstones were associated with a higher rate of recurrent pancreatitis, while undergoing cholecystectomy was associated with a reduction in this rate.

Natural Course of Common Bile Duct Microlithiasis

BACKGROUND

Common bile duct microlithiasis (CBDM) with a diameter of ≤ 3 mm can pass spontaneously without causing any symptoms, but in some cases, it can also cause severe cholangitis and pancreatitis. The optimal strategy for managing CBDM is yet to be determined.

METHODS

Data of 154 patients with CBDM were collected and divided into two groups: with endoscopic retrograde cholangiopancreatography (with ERCP, n = 82) and without ERCP (n = 72). Clinical outcomes, including the incidence of unfavorable outcomes (UOs), such as cholangitis and pancreatitis, were observed and compared between the two groups.

RESULTS

The incidence of UOs was significantly lower in the ERCP group than in the without ERCP group (3.7% vs. 23.6%, respectively, p < 0.001). Moreover, the total number of readmissions was also lower in the ERCP group than in the without ERCP group (p < 0.001). A multivariate analysis adjusted for age, sex, and the American Society of Anesthesiologists (ASA) class revealed that endoscopic sphincterotomy (EST) and cholecystectomy were associated with a lower risk of UOs.

CONCLUSION

The high rate of UOs in CBDM patients without ERCP suggests that its natural clinical course may not be as favorable as previously suggested. This finding implies that efforts should be made to clear the bile ducts.

The Role of Endoscopic Ultrasound in the Diagnosis of Gallbladder Lesions

Gallbladder (GB) diseases represent various lesions including gallstones, cholesterol polyps, adenomyomatosis, and GB carcinoma. This review aims to summarize the role of endoscopic ultrasound (EUS) in the diagnosis of GB lesions. EUS provides high-resolution images that can improve the diagnosis of GB polypoid lesions, GB wall thickness, and GB carcinoma staging. Contrast-enhancing agents may be useful for the differential diagnosis of GB lesions, but the evidence of their effectiveness is still limited. Thus, further studies are required in this area to establish its usefulness. EUS combined with fine-needle aspiration has played an increasing role in providing a histological diagnosis of GB tumors in addition to GB wall thickness.

Usefulness of endoscopic ultrasound in patients with minilithiasis and/or biliary sludge as a cause of symptoms of probable biliary origin after cholecystectomy

INTRODUCTION

Endoscopic ultrasound (EUS) is a more sensitive technique than transabdominal ultrasound for the diagnosis of gallstones. This greater sensitivity, especially in the diagnosis of microlithiasis/biliary sludge, facilitates the indication of cholecystectomy in patients with symptoms of probable biliary origin but may result in over-indication of this surgery.

OBJECTIVES

Evaluate the role of EUS in the diagnosis of minilithiasis/biliary sludge in patients with digestive symptoms of probable biliary origin by resolving the symptoms after cholecystectomy. Analyse factors related to the remission of symptoms following cholecystectomy.

PATIENTS AND METHODS

Retrospective, longitudinal, single-centre study based on a prospective database of 1.121 patients undergoing EUS. Seventy-four patients were identified as meeting inclusion-exclusion criteria (diagnosed with minilithiasis/sludge by EUS after presenting digestive symptoms of probable biliary origin without a history of complicated cholelithiasis). A telephone questionnaire for symptoms was conducted with cholecystectomized patients. Factors related to a good response were analysed with logistic regression analysis.

RESULTS

Of the 74 patients, 50 were cholecystectomized (67.5%), mean age 49 years (SEM 2.26) (41 women). Seventy percent of patients (35/50) presented remission of symptoms with median follow-up 353.5 days (95% CI, 270-632.2). The only variable associated with remission of symptoms was the presence of typical biliary colic with an OR of 7.8 (95% CI, 1.8-34; p=0.006). No complications associated with EUS were recorded. One patient (2%) suffered haemoperitoneum and 18% (9/50) suffered diarrhoea following cholecystectomy.

CONCLUSIONS

EUS is a very useful technique for the indication of cholecystectomy in patients with minilithiasis/sludge and typical symptoms of biliary colic.

Utility of liver function tests in acute cholecystitis

BACKGROUNDS/AIMS

Common bile duct stones (CBDS) affect the management of acute cholecystitis (AC). This study aims to investigate the utility of liver function tests (LFTs) in predicting the presence of CBDS in AC patients.

METHODS

Retrospective cohort study of adult patients with AC found in the American College of Surgeons National Surgical Quality Improvement Program database from 2008 to 2016. Patients were classified into two groups, without CBDS (AC-) and with CBDS (AC+). LFT results namely total bilirubin, SGOT and ALP were collected and categorized into normal and abnormal with the cut-offs of 1.2 mg/dl for total bilirubin, 40 U/L for SGOT and 120 IU/L for ALP. Measures of diagnostic accuracy for individual and combinations of LFTs were computed.

RESULTS

A total of 32,839 patients were included in the study, with 8,801 (26.8%) AC+ and 24,038 (73.2%) AC- patients. Their mean age was 52.4 (±18.6) years and over half (59.1%) were females. Mean LFT results were significantly higher in the AC+ group for total bilirubin (1.82 vs 0.97), SGOT (110.9 vs 53.3) and ALP (164.4 vs 102.3) (p<0.0001). The proportions of abnomal LFTs were significantly higher in the AC+ group for total bilirubin (47.7% vs 20.2%), SGOT (62.8% vs 27.1%) and ALP (56.6% vs 21.0%) (p<0.0001). Among AC+, the odds of having abnormal results for bilirubin, SGOT and ALP were found to be 3.61, 4.54 and 4.90 times higher than among AC-, respectively.

CONCLUSIONS

Abnormal LFTs are strong predictors for the presence of CBDS in patients with AC. Normal LFTs should be interpreted with caution as some patients with AC and CBDS might not present with characteristic abnormalities in results.

Trends of Cholecystectomies for Presumed Biliary Dyskinesia in Children in the United States

BACKGROUND

Biliary dyskinesia (BD) is a controversial clinical entity. Standardized diagnostic test and management guidelines are lacking in children. Published data suggest that long-term outcomes of surgical and medical management are similar. We sought to determine national population-based trends of cholecystectomies performed in children for BD and associated healthcare expenditure in the United States during a 10-year period.

METHODS

Using Nationwide Inpatient Sample and the International Classification of Diseases, the 9th revision clinical modification codes, we identified children who had a cholecystectomy for BD from 2002 to 2011 in the United States.

RESULTS

A total of 66,380 cholecystectomies were identified as primary procedural diagnosis using weighted analysis from 2002 to 2011 in children. BD was the primary indication for cholecystectomy in 6674 (10.8%) of the patients. During the study period, the number of cholecystectomies performed for BD in children increased from 6.6% in 2002 to 10.6% in 2011, and a majority were adolescent white females. The annual health care expenditure for surgical management of BD for children in the US was estimated to almost $16 million/year.

CONCLUSIONS

Despite lack of standardized diagnostic criteria and variable outcomes of surgical intervention reported in pediatric literature, cholecystectomies are commonly performed for children with BD in the United States. Consensus guidelines for the diagnosis and management of this controversial disorder in children are needed.

The role of endoscopic ultrasound in the diagnosis of gallbladder diseases

Endoscopic ultrasound (EUS) has recently played an increasing role in the diagnosis of gallbladder diseases. This review aims to summarize the role of EUS in the diagnosis of gallbladder lesions. EUS provides high-resolution images that can improve the diagnosis of gallbladder polypoid lesions and microlithiasis, in addition to evaluating gallbladder thickness and staging of gallbladder carcinoma. Contrast-enhancing agents may be useful for the differential diagnosis of gallbladder lesions, but the evidence of their effectiveness is still limited and further studies are required in this area to establish its usefulness. Endoscopic ultrasound combined with fine needle aspiration has played an increasing role in providing histological diagnosis of gallbladder tumors in addition to gallbladder thickening.

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.

Can Laparoscopic Cholecystectomy Prevent Recurrent Idiopathic Acute Pancreatitis?: A Prospective Randomized Multicenter Trial

OBJECTIVE

The aim of the present trial was to ascertain whether laparoscopic cholecystectomy (LCC) can prevent recurrent attacks of idiopathic acute pancreatitis (IAP).

SUMMARY

Up to 50% to 75% of IAP may be due to microlithiasis, which is undetectable by conventional imaging methods.

METHODS

This randomized, prospective trial included 85 patients (39 in the LCC and 46 in the control group) in 8 hospitals in Finland. We included adult patients (over 18 years) with their first attack of IAP. The diagnosis of IAP was based on the exclusion of common etiological reasons for acute pancreatitis (AP), whereafter the patients were randomized into conservative watchful waiting (controls) or LCC group. The primary end point was the number of patients with recurrent AP during the follow-up. All recurrent attacks of AP after an initial IAP episode were registered.

RESULTS

During a median follow-up of 36 (5-58) months, the recurrence of IAP was significantly higher in the control group than in LCC group (14/46 vs. 4/39, P = 0.016), as was also the number of recurrences (23/46 vs. 8/39, P = 0.003). In the subgroup of patients with at least 24 months' follow-up, the recurrence was still higher among controls (14/37 vs. 4/35, P = 0.008). In patients with normal liver function, recurrence was also significantly higher in the control than in the LCC group (13/46 vs. 4/39, P = 0.026). During surgery, 23/39 (59%) of the gallbladders were found to contain biliary stones or sludge.

CONCLUSIONS

LCC can effectively prevent the recurrence of IAP when all other possible etiologies of pancreatitis are carefully excluded. A total of 5 patients needed to be treated (NNT-value) to prevent 1 IAP.

Long-term Outcomes of Symptomatic Gallbladder Sludge

GOALS AND BACKGROUND

Long-term outcomes of symptomatic gallbladder (GB) sludge are not fully established. This study aimed to determine whether patients with symptomatic GB sludge could experience subsequent biliary events.

STUDY

This study investigated consecutive patients who presented with typical biliary pain and underwent abdominal ultrasonography from March 2003 to December 2012. A prospectively maintained database of these patients, excluding those with gallstones, was reviewed retrospectively. We compared the development of biliary events such as acute cholecystitis, acute cholangitis, and acute pancreatitis between both GB sludge and non-GB sludge cohorts.

RESULTS

In all, 58 and 70 patients were diagnosed with and without GB sludge, respectively. The 5-year cumulative biliary event rate was significantly higher in the GB sludge (33.9% vs. 15.8%, P=0.021) and the hazard ratio of subsequent biliary events was 2.573 (95% confidence interval, 1.124-5.889; P=0.025) in patients with GB sludge. The 5-year cumulative rate of each biliary event was higher in the GB sludge cohort (15.6% vs. 5.3% in acute cholecystitis, 15.5% vs. 5.3% in acute cholangitis, 18.4% vs. 11.1% in acute pancreatitis, respectively), although it was not statistically significant. Among the GB sludge cohort, subsequent biliary events were less frequent in patients who underwent cholecystectomy compared with those who did not (2/16, 12.5% vs. 17/42, 40.4%; P=0.067).

CONCLUSIONS

GB sludge accompanying typical biliary pain can cause subsequent biliary events and cholecystectomy may prevent subsequent biliary events. Therefore, GB sludge would be considered as a culprit of biliary events.

Gallbladder dysfunction: how much longer will it be controversial?

BACKGROUND

Motility disorders of the biliary tree [biliary dyskinesia, including both gallbladder dysfunction (GBD), and sphincter of Oddi dysfunction] are difficult to diagnose and to treat.

SUMMARY

There is controversy in the literature in particular regarding the criteria that should be used to select patients for cholecystectomy (CCY) in cases of suspected GBD. The current review covers the history, diagnosis, and treatment of GBD. Key Messages: Only >85% of patients with suspected GBD have relief following CCY, a much lower rate than the nearly 100% success rate following CCY for gallstone disease. Unfortunately, the literature is lacking, and there are no universally agreed-upon criteria for selecting which patients to refer for operation, although cholecystokinin (CCK)-enhanced hepatobiliary iminodiacetic acid scan is often used, with emphasis on an abnormally low gallbladder ejection fraction or pain reproduction at CCK administration. There is a clear need for large, well-designed, more definitive, prospective studies to better identify the indications for and efficacy of CCY in cases of GBD.

Cholelithiasis presented as chronic right back pain

Chronic right back pain is a symptom in both biliary lithiasis and chronic cholecystitis. Ten percent of the population in the world suffers from biliary lithiasis. Only 20% are symptomatic. The first diagnostic test of choice is an abdominal ultrasound. When a suggestive clinical sign of biliary colic with negative abdominal ultrasound is identified, we should consider the option of carrying out an endoscopic ultrasound in order to rule out microlithiasis. The case discussed in the report presented with chronic right back pain, which is an atypical manifestation of biliary lithiasis and chronic cholecystitis. It is important to know about the atypical manifestations of the prevalent illnesses as well as the limits of the diagnostic tests, in order to avoid diagnostic delays which may cause complications that could worsen a patient's prognosis. This case should contribute to the medical knowledge and must have educational value or highlight the need for a change in clinical practice, especially in primary care.

Role of sonography in assessing complications after laparoscopic cholecystectomy

Laparoscopic cholecystectomy, which was introduced to the arsenal of surgical procedures in the middle of the 1980s, is a common alternative for conventional cholecystectomy. Its primary advantage is less invasive character which entails shorter hospitalization and faster recovery. Nevertheless, the complications of both procedures are comparable and encompass multiple organs and tissues. The paper presents ultrasound presentation of the surgical bed after laparoscopic cholecystectomy and of complications associated with this procedure. In the first week following the surgery, the presence of up to 60 ml of fluid in the removed gallbladder bed should be considered normal in certain patients. The fluid will gradually absorb. In single cases, slight amounts of fluid are detected in the peritoneal cavity, which also should not be alarming. Carbon dioxide absorbs from the peritoneal cavity within two days. Ultrasound assessment of the surgical bed after cholecystectomy is inhibited by hemostatic material left during the surgery. Its presentation may mimic an abscess. In such cases, the decisive examination is magnetic resonance imaging but not computed tomography. On the other hand, rapidly accumulating fluid around the liver is an alarming symptom, particularly when there is inadequate blood supply or when peritoneum irritation symptoms develop. Depending on the suspected cause of the patient's deteriorating condition, it is essential to perform urgent computed tomography angiography, celiac angiography or endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography. The character of the fluid collection may be determined by its ultrasound-guided puncture. This procedure allows for aspiration of fluid and placement of a drain. Moreover, transabdominal ultrasound examination after laparoscopic cholecystectomy may contribute to the identification of: dropped stones in the right hypochondriac region, residual fragment of the gallbladder with possible concretions, undiagnosed choledocholithiasis, existing cholestasis, pseudoaneurysm of the hepatic artery, portal vein thrombosis and hematoma as well as hernias of the abdominal walls. Moreover, ultrasound examination helps to identify optimal sites in the abdominal integuments, which enables collision-free access to the peritoneal cavity.

Symptomatic cholelithiasis and functional disorders of the biliary tract

Symptomatic cholelithiasis and functional disorders of the biliary tract present with similar signs and symptoms. The functional disorders of the biliary tract include functional gallbladder disorder, dyskinesia, and the sphincter of Oddi disorders. Although the diagnosis and treatment of symptomatic cholelithiasis are relatively straightforward, the diagnosis and treatment of functional disorders can be much more challenging. Many aspects of the diagnosis and treatment of functional disorders are in need of further study. This article discusses uncomplicated gallstone disease and the functional disorders of the biliary tract to emphasize and update the essential components of diagnosis and management.

Gallstone pancreatitis: a review

Gallstone disease is the most common cause of acute pancreatitis in the Western world. In most cases, gallstone pancreatitis is a mild and self-limiting disease, and patients may proceed without complications to cholecystectomy to prevent future recurrence. Severe disease occurs in about 20% of cases and is associated with significant mortality; meticulous management is critical. A thorough understanding of the disease process, diagnosis, severity stratification, and principles of management is essential to the appropriate care of patients presenting with this disease. This article reviews these topics with a focus on surgical management, including appropriate timing and choice of interventions.

Natural history of acalculous biliary symptoms

INTRODUCTION

The radiological criteria for the diagnosis of gallbladder disease rely largely on the detection of calculi using ultrasonography. Patients may, however, suffer symptoms typical of biliary pain without detectable gallstones. The aim of this study was to identify a cohort of patients presenting with recurrent episodes of biliary symptoms in the absence of identifiable pathology on ultrasonography and to record the outcome of subsequent imaging investigations.

METHODS

Records of patients having abdominal ultrasonography during a four-month period in 2006 were accessed retrospectively and those with symptoms suggesting biliary disease were identified. Radiology records were reviewed over a five-year follow-up period to identify patients undergoing further imaging for recurrent biliary symptoms and outcomes were recorded.

RESULTS

A total of 512 patients had ultrasonography for investigation of symptoms consistent with biliary disease. Almost half (41.2%) of these were found to have gallbladder pathology on ultrasonography and 4.7% of patients went on to have further investigations for similar symptoms without achieving a diagnosis. The median age of this group was 47 years and 75% of these patients were female. During the follow-up period, 2.6% of patients with biliary symptoms and initially normal ultrasonography developed gallstones and in 1.3% pancreatitis was demonstrated on imaging.

CONCLUSIONS

A small minority of patients who present with biliary symptoms and have no abnormality on ultrasonography present with recurrent symptoms or develop significant biliary pathology. These patients should be identified by interview at routine follow-up visits and further investigations should be considered.

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.

Are liver function tests, pancreatitis and cholecystitis predictors of common bile duct stones? Results of a prospective, population-based, cohort study of 1171 patients undergoing cholecystectomy

OBJECTIVE

The purpose of this study was to explore the accuracy of elevated liver function values, age, gender, pancreatitis and cholecystitis as predictors of common bile duct stones (CBDS).

METHODS

All patients operated on for gallstone disease over a period of 3 years in a Swedish county of 302,564 citizens were registered prospectively. Intraoperative cholangiography (IOC) was used to detect CBDS.

RESULTS

A total of 1171 patients were registered; 95% of these patients underwent IOC. Common bile duct stones were found in 42% of patients with elevated liver function values, 20% of patients with a history of pancreatitis and 9% of patients with cholecystitis. The presence of CBDS was significantly predicted by elevated liver function values, but not by age, gender, history of acute pancreatitis or cholecystitis. A total of 93% of patients with normal liver function tests had a normal IOC. The best agreement between elevated liver function values and CBDS was seen in patients undergoing elective surgery without a history of acute pancreatitis or cholecystitis.

CONCLUSIONS

Although alkaline phosphatase (ALP) and bilirubin levels represented the most reliable predictors of CBDS, false positive and false negative values were common, especially in patients with a history of cholecystitis or pancreatitis, which indicates that other mechanisms were responsible for elevated liver function values in these patients.

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.

EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain

BACKGROUND

Primary upper endoscopy (EGD) and transabdominal US (TUS) are often performed in patients with upper abdominal pain.

OBJECTIVE

Primary: Determine whether the combination of EGD and EUS was equivalent to EGD plus TUS in the diagnostic evaluation of upper abdominal pain. Secondary: Compare EUS versus TUS in detecting abdominal lesions, and compare EGD by using an oblique-viewing echoendoscope versus the standard, forward-viewing endoscope in detecting mucosal lesions.

DESIGN

Prospective, paired design.

SETTING

Six academic endoscopy centers.

PATIENTS

This study involved patients with upper abdominal pain referred for endoscopy.

INTERVENTION

All patients had EGD, EUS, and TUS. The EGD was done using both an oblique-viewing echoendoscope and the standard, forward-viewing endoscope (randomized order) by two separate endoscopists in a blinded fashion, followed by EUS. TUS was performed within 4 weeks of EGD/EUS, also in a blinded fashion.

FOLLOW-UP

telephone interviews and chart reviews.

MAIN OUTCOME MEASUREMENTS

Diagnose possible etiology of upper abdominal pain and detect clinically significant lesions.

RESULTS

A diagnosis of the etiology of upper abdominal pain was made in 66 of 172 patients (38%). The diagnostic rate was 42 of 66 patients (64%) for EGD plus EUS versus 41 of 66 patients (62%) for EGD plus TUS, which was statistically equivalent (McNemar test; P = .27). One hundred ninety-eight lesions were diagnosed with either EUS or TUS. EUS was superior to TUS for visualizing the pancreas (P < .0001) and for diagnosing chronic pancreatitis (P = .03). Two biliary stones were detected only by EUS. Two hundred fifty-one mucosal lesions were similarly diagnosed with EGD with either the standard, forward-viewing endoscope or the oblique-viewing echoendoscope (kappa = 0.48 [95% CI, .43-.54]). EGD with the standard, forward-viewing endoscope was preferred for biopsies.

LIMITATIONS

No cost analysis.

CONCLUSION

The combination of EGD with EUS is equivalent to EGD plus TUS for diagnosing a potential etiology of upper abdominal pain. EUS is superior to TUS for detecting chronic pancreatitis. EGD combined with EUS should be considered in the first-line diagnostic evaluation of patients with upper abdominal pain.

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.

Functional gallbladder disorder: gallbladder dyskinesia

Functional gallbladder disorder, commonly referred to as gallbladder dyskinesia, is characterized by the occurrence of abdominal pain resembling gallbladder pain but in the absence of gallstones. The diagnosis and management of this condition can be confusing even for the most astute clinician. The aim of this article is to clarify the identification and management of patients with suspected functional gallbladder disorder.

Biliary dyskinesia

Functional disorders of the biliary tract include gallbladder dyskinesia (GBD) and sphincter of Oddi dysfunction (SOD). The diagnosis of GBD is made if the gallbladder ejection fraction is less than 35% to 40% using cholecystokinin cholescintigraphy. Despite slightly inferior outcomes compared with calculous disease, patients who have GBD should be treated with cholecystectomy. SOD is most often noted in the postcholecystectomy patient and symptoms can be biliary or pancreatic in nature. The gold standard for diagnosis remains manometry, with basal biliary or pancreatic sphincter pressures measuring greater than 40 mm Hg. Patients who have increased pressures may benefit from endoscopic sphincterotomy.

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.

[I Brazilian consensus of endoscopic ultrasonography]

BACKGROUND

In the last 20 years, several papers have focused on demonstrating the impact of endoscopic ultrasonography findings on the management of different clinical scenarios in digestive disease. This fact is an indirect evidence of the difficulty of popularization of the method. On other hand, the limited availability of endoscopic ultrasonography in Brazil is a direct evidence of this limitation. This was the rationale for the organization of a consensus meeting on endoscopic ultrasonography. It was aimed to identify the best evidence that support the use of endoscopic ultrasonography in gastroenterology.

METHODS

A panel of experts on endoscopic ultrasonography was selected based on the files of the Gastroenterology and Endoscopy Societies and on the registries of endoscope manufacturers. Two members of the meeting selected the relevant topics that were transformed into questions. The topics and the questions were debated among the experts five months before the consensus meeting. The experts were asked to perform systematic reviews in order to answer the questions so it could be possible to grade the answers based on the strength of the evidence. During the two days of the meeting the answers were presented, debated and voted. Consensus was reached when a minimum of 70% of the voters were in agreement. The final consensus report was submitted to the experts' evaluation and approval.

RESULTS

Seventy nine questions were debated by the experts at the pre-Consensus meeting. As the result of this debate 85 questions came out and were assigned to the members of the panel. During the Consensus meeting 22 experts debated and voted 85 answers. Consensus was reached for several clinical scenarios for which the impact of endoscopic ultrasonography findings were supported by level 1 evidences: differential diagnosis of subepithelial lesions and thickening of gastric folds, staging and diagnosis of unresectable esophageal cancer, indirect signs of peritoneal involvement of gastric cancer, MALT gastric lymphoma and rectal cancer staging, diagnosis of common bile duct and gallbladder stones, diagnosis of chronic pancreatitis and differential diagnosis of a solid mass in chronic pancreatitis, differential diagnosis of the pancreatic cyst, prediction of the results of the endoscopic treatment of esophageal varices and diagnosis and staging of non-small cell lung cancer.

CONCLUSIONS

There are the highest levels of evidences that support the indication of endoscopic ultrasonography for several digestive diseases and even for non-small cell lung cancer.

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.

Gallstone disease: Microlithiasis and sludge

'Sludge' is the solid material which results from the slow settling of particles dispersed in a liquid medium. Biliary sludge in the gallbladder can be detected by transabdominal ultrasonography, and the typical echoes derive mainly from pigment precipitates mixed with cholesterol crystals. A portion of biliary sludge contains comparatively large particles (1-3 mm) called microliths, the formation of which is an obligatory intermediate step in the development of all types of gallstone. Microlithiasis and sludge in bile may cause colicky pain, cholecystitis, cholangitis, and acute pancreatitis, and are thus of clinical relevance. In these patients treatment follows the guidelines of symptomatic gallstone disease, and strategies include long-term application of ursodeoxycholic acid, endoscopic papillotomy, or preferably laparoscopic cholecystectomy.

Gallstone disease: Symptoms and diagnosis of gallbladder stones

The clinical aspects and the diagnostic features of gallstone disease are described. The natural history of silent gallstones is overviewed, and the risk of developing symptoms and complications is also discussed. The importance of colicky pain as a specific gallstone symptom is highlighted, and the role of both laboratory tests and diagnostic investigations for differential diagnosis is discussed. Finally, we describe the diagnostic features of gallbladder stone disease, including indications, sensitivity, specificity, and limitations of different test investigations under special circumstances.

Current management of acute pancreatitis

The incidence of acute pancreatitis varies considerably between regions and is estimated at 5-80 per 100,000 population. The mortality rate of acute edematous-interstitial pancreatitis is below 1%, whereas 10-24% of patients with severe acute pancreatitis die. The early prognostic factors that can be used to determine whether the clinical course is likely to be severe are three or more signs of organ failure according to the Ranson or Imrie scores, the presence of nonpancreatic complications, and the detection of pancreatic necrosis by imaging techniques. Elevated C-reactive protein levels above 130 mg/l can also predict a severe course of acute pancreatitis with high sensitivity. Although no causal treatment exists, replacing the dramatic fluid loss that takes place in the early disease phase is critical and determines the patient's prognosis. Adequate pain relief with opiates is another therapeutic priority. In patients with pancreatic necrosis, the high mortality rate between the third and fourth week after the initial episode is determined largely by the development of pancreatic infection, and can therefore be reduced by early antibiotic treatment. Early enteral nutrition for the treatment of acute pancreatitis has been shown to be superior and much more cost-effective than parenteral nutrition. Infected pancreatic necrosis or pancreatic abscess are two of the few remaining indications for open surgery in acute pancreatitis. Even when indicated, surgery is frequently delayed or even replaced by minimally invasive surgical techniques.