Incidental biliary dilation in the era of the opiate epidemic: High prevalence of biliary dilation in opiate users evaluated in the Emergency Department

BACKGROUNDBiliary dilation is frequently related to obstruction; however, non-obstructive factors such as age and previous cholecystectomy have also been reported. In the past two decades there has been a dramatic increase in opiate use/dependence and utilization of cross-sectional abdominal imaging, with increased detection of biliary dilation, particularly in patients who use opiates.AIMTo evaluate associations between opiate use, age, cholecystectomy status, ethnicity, gender, and body mass index utilizing our institution’s integrated informatics platform. METHODSOne thousand six hundred and eighty-five patients (20% sample) presenting to our Emergency Department for all causes over a 5-year period (2011-2016) who had undergone cross-sectional abdominal imaging and had normal total bilirubin were included and analyzed.RESULTSCommon bile duct (CBD) diameter was significantly higher in opiate users compared to non-opiate users (8.67 mm vs 7.24 mm, P < 0.001) and in patients with a history of cholecystectomy compared to those with an intact gallbladder (8.98 vs 6.72, P < 0.001). For patients with an intact gallbladder who did not use opiates (n = 432), increasing age did not predict CBD diameter (r² = 0.159, P = 0.873). Height weakly predicted CBD diameter (r² = 0.561, P = 0.018), but weight, body mass index, ethnicity and gender did not.CONCLUSIONOpiate use and a history of cholecystectomy are associated with CBD dilation in the absence of an obstructive process. Age alone is not associated with increased CBD diameter. These findings suggest that factors such as opiate use and history of cholecystectomy may underlie the previously-reported association of advancing age with increased CBD diameter. Further prospective study is warranted.     

Role of endoscopic ultrasound in pediatric patients: A single tertiary center experience and review of the literature

BACKGROUND Although endoscopic ultrasound(EUS) is now widely available and has an established role in adults, the utility of EUS and EUS-guided fine needle aspiration(EUS-FNA) in pediatrics is insufficiently described compared to adults and is supported by only a few studies.AIM To report the experience of a single tertiary center in the use of EUS and EUS-FNA in a pediatric population and to further assess its safety, feasibility, and clinical impact on management.METHODS A retrospective study of 13 children(aged 18 years or younger) identified from our medical database was conducted. A retrospective review of demographic data, procedure indications, EUS findings, and the clinical impact of EUS on the subsequent management of these patients was performed.RESULTS During the 4-year study period, a total of 13(1.7%) pediatric EUS examinations out of 749 EUS procedures were performed in our unit. The mean age of these 8 females and 5 males was 15.6 years(range: 6-18). Six of the 13 EUS examinations were pancreatobiliary(46.1%), followed by mediastinal 2/13(15.4%), peri-gastric 2/13(15.4%), abdominal lymphadenopathy 1/13(7.7%), tracheal 1/13(7.7%) and rectal 1/13(7.7%). Overall, EUS-FNA was performed in 7 patients(53.8%) with a diagnostic yield of 100%. The EUS results had a significant impact on clinical care in 10/13(77%) cases. No complications occurred in these patients during or after any of the procedures.CONCLUSION EUS and EUS-FNA in the pediatric population are safe, feasible, and have a significant clinical impact on the subsequent management; thus avoiding invasive and unnecessary procedures.