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

Abstract

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.     

EUS vs MRCP for detection of choledocholithiasis

BACKGROUND: Numerous published studies have shown the high diagnostic performance of both EUS and MRCP compared with ERCP for the detection of choledocholithiasis. DESIGN: We undertook a systematic review of all published randomized, prospective trials that compared EUS with MRCP with the primary aim being to compare the overall diagnostic accuracy for the detection of choledocholithiasis in patients with suspected biliary disease. METHODS: A MEDLINE review was performed. We identified 5 randomized, prospective, blinded trials comparing MRCP and EUS for the detection of choledocholithiasis, with subsequent ERCP or intraoperative cholangiography as a criterion standard. The study-specific variables for EUS and MRCP for choledocholithiasis were calculated from the data, and analyses were performed by using aggregated variables (sensitivity, specificity, positive and negative predictive values, and likelihood ratios). RESULTS: The pooled data set consisted of 301 patients. The aggregated sensitivities of EUS and MRCP for the detection of choledocholithiasis were 0.93 and 0.85, respectively, whereas their specificities were 0.96 and 0.93, respectively. The aggregated positive predictive values for EUS and MRCP were 0.93 and 0.87, respectively, with the corresponding negative predictive values of 0.96 and 0.92, respectively. Positive likelihood ratios were >10 for both tests, and corresponding negative likelihood ratios approached 0.10 for both tests. No statistically significant differences between EUS and MRCP were found in our analysis. CONCLUSIONS: EUS and MRCP have high diagnostic performance overall. Our analysis showed no statistically significant difference between the modalities. We recommend taking into consideration other factors, such as resource availability, experience, and cost considerations in deciding between these 2 tests.     

EUS和MRCP对胆总管结石诊断准确性试验的Meta分析

目的通过Cochrane协作网推荐的头对头比较的诊断准确性试验(DTA)的Meta分析方法,系统评价和比较超声内镜(EUS)和磁共振胰胆管成像(MRCP)对胆总管结石的诊断价值。方法检索Ovid Medline、PubMed、EmBase、Cochrane Library、Clinical Trials和ISI Web of Knowledge数据库中建库至2019年1月有关EUS和MRCP对胆总管结石诊断价值的文献。公认的参考标准为经内镜逆行胰胆管造影(ERCP)、术中胆管造影(IOC)或阴性病例临床随访>3个月。使用QUADAS-2工具评价纳入研究的质量。采用RevMan 5.2、STATA 12和Meta-DiSc 1.4软件进行Meta分析,合并诊断效应量,绘制森林图和SROC曲线并计算曲线下面积(AUC),比较EUS和MRCP对胆总管结石的诊断效能。结果共纳入32项研究中的5项,累计病例272例。纳入的研究均未表现出高偏倚风险。随机效应模型合并统计显示,EUS诊断胆总管结石的灵敏度为0.97,特异度为0.90,阳性似然比为7.54,阴性似然比为0.07,诊断比值比(DOR)为162.55。MRCP诊断胆总管结石的灵敏度为0.87,特异度为0.92,阳性似然比为8.99,阴性似然比为0.19,DOR为79.02。EUS的合并DOR明显高于MRCP(P=0.008),进一步分析表明,这主要是由于EUS的灵敏度显著高于MRCP(P=0.006)。两种方式的特异度差异无统计学意义(P=0.42)。SROC曲线显示,EUS和MRCP的AUC分别为0.9771和0.9523,Q*统计量分别为0.9320和0.8936,但差异无统计学意义(P>0.05)。结论EUS和MRCP对胆总管结石均能提供良好的诊断准确性,但EUS具有更高的诊断准确性和灵敏度,且具有相当的特异度。在适当的情况下,EUS应被纳入胆总管结石疑似患者的诊断方式中。     

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.     

磁共振胰胆管造影、超声内镜与逆行胰胆管造影诊断阻塞性黄疸的价值

目的：比较磁共振胰胆管造影（MRCP）、超声内镜（EUS）与内镜逆行胰胆管造影（ERCP）诊断阻塞性黄疸的价值。方法：39例阻塞性黄疸患者分别行MRCP、EUS和ERCP。MRCP采用重T2加权及超快速自旋回波水成像技术进行,EUS和ERCP按常规进行。结果：MRCP、EUS与ERCP诊断准确率分别为87．2％（34／39例）、94．9％（37／39例）和97．4％（38／39例）;对恶性狭窄的诊断准确率分别为61．5％（8／13例）、84．6％（11／13例）和92．3％（12／13例）;对胆总管结石的诊断准确率均为100．0％（21／21例）。结论：MRCP为无创性检查,在明确阻塞性黄疸病因时可作为首选方法,目前尚不能取代ERCP。EUS作为诊断胆、胰系统疾病的重要方法,与MRCP和ERCP结合,能提高阻塞性黄疸诊断 的准确率。     

Suspected choledocholithiasis: endoscopic ultrasound or magnetic resonance cholangio-pancreatography? A systematic review

There is a lack of consensus on the optimal noninvasive strategy for patients with suspected choledocholithiasis after a negative transabdominal ultrasound and/or computed tomography. A meta-analysis was conducted to compare the diagnostic ability of endoscopic ultrasound (EUS) and magnetic resonance cholangio-pancreatography (MRCP) in patients with suspected common bile duct (CBD) stones. A search, using the following terms 'MRCP', 'EUS' and 'Choledocholithiasis' in Pubmed and Cochrane Controlled Trials Register, was performed. Abstract books and reference list of review articles, as well as relevant studies, were also searched to complete our EUS versus MRCP for choledocholithiasis comparison studies database. The analysis demonstrated that, with respect to sensitivity, specificity and accuracy, there was no statistically significant difference between EUS and MRCP for the detection of choledocholithiasis. Our meta-analysis of prospective comparison of MRCP and EUS for the detection of choledocholithiasis yielded statistically similar diagnostic values for both techniques.     

Cost‐effectiveness of endoscopic ultrasonography,magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography in patients suspected of pancreaticobiliary disease

Background: It is not known whether initial endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) is more cost effective than endoscopic retrograde cholangiopancreatography (ERCP). Methods: A cost‐effectiveness analysis of EUS, MRCP and ERCP was performed on 163 patients. The effectiveness of an investigation was defined as the percentage of patients with no need for further evaluation after the investigation in question had been performed. Costs were assumed from the budget‐holder's point of view. Results: MRCP, EUS and ERCP had a total accuracy of 0.91, 0.93 and 0.92, respectively. Eighty‐four (52%) patients needed endoscopic therapy in combination with ERCP, giving an effectiveness of MRCP, EUS, and ERCP of 0.44, 0.45 and 0.92, respectively. The cost‐effectiveness of MRCP, EUS, and ERCP was 6622, 7353 and 4246 Danish Kroner (DKK) per fully investigated and treated patient (1 DKK?=?0.14 EUR). Conclusion: Within a patient population with a probability of therapeutic ERCP in 50% of the patients, ERCP was the most cost‐effective strategy.     

Comparison of endoscopic ultrasonography and magnetic resonance cholangiopancreatography in the diagnosis of pancreatobiliary diseases: a prospective study

OBJECTIVES: To compare the diagnostic value of endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) in: (a) patients with a dilated biliary tree unexplained by ultrasonography (US) (group 1), and (b) the diagnosis of choledocholithiasis in patients with nondilated biliary tree (group 2). METHODS: Patients were prospectively evaluated with EUS and MRCP. The gold standard used was surgery or EUS-FNA and ERCP, intraoperative cholangiography, or follow-up when EUS and/or MRCP disclosed or precluded malignancy, respectively. Likelihood ratios (LR) and pretest and post-test probabilities for the diagnosis of malignancy and choledocholithiasis were calculated. RESULTS: A total of 159 patients met one of the inclusion criteria but 24 of them were excluded for different reasons. Thus, 135 patients constitute the study population. The most frequent diagnosis was choledocholithiasis (49% in group 1 and 42% in group 2, P= 0.380) and malignancy was more frequent in group 1 (35%vs 7%, respectively, P < 0.001). When EUS and MRCP diagnosed malignancy, its prevalence in our series (35%) increased up to 98% and 96%, respectively, whereas it decreased to 0% and 2.6% when EUS and MRCP precluded this diagnosis. In patients in group 2, when EUS and MRCP made a positive diagnosis of choledocholithiasis, its prevalence (42%) increased up to 78% and 92%, respectively, whereas it decreased to 6% and 9% when any pathologic finding was ruled out. CONCLUSIONS: EUS and MRCP are extremely useful in diagnosing or excluding malignancy and choledocholithiasis in patients with dilated and nondilated biliary tree. Therefore, they are critical in the approach to the management of these 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.     

The clinical impact and cost implication of endoscopic ultrasound on use of endoscopic retrograde cholangiopancreatography in a Canadian university hospital.

BACKGROUND: Endoscopic ultrasound (EUS) is a safe alternative to endoscopic retrograde cholangiopancreatography (ERCP) for diagnostic biliary imaging in choledocholithiasis. Evidence linking a decline in diagnostic ERCP with the introduction of EUS in clinical practice is limited. OBJECTIVE: To assess the clinical impact and cost implications of a new EUS program on diagnostic ERCP at a tertiary referral centre. PATIENTS AND METHODS: A retrospective review was performed of data collected during the first year of EUS at the University of Alberta Hospital (Edmonton, Alberta). Patients were referred for ERCP because of suspicion of choledocholithiasis based on clinical, biochemical and/or radiological parameters. If they were assessed to have an intermediate probability of choledocholithiasis, EUS was performed first. ERCP was performed if EUS suggested choledocholithiasis, whereas patients were clinically followed for six months if their EUS was normal. Cost data were assessed from a third-party payer perspective, and cost savings were expressed in terms of ERCP procedures avoided. RESULTS: Over 12 months, 90 patients (63 female, mean age 58 years) underwent EUS for suspected biliary tract abnormalities. EUS suggested choledocholithiasis in 20 patients (22%), and this was confirmed by ERCP in 17 of the 20 patients. EUS was normal in 69 patients, and none underwent a subsequent ERCP during a six-month follow-up period. One patient had pancreatic cancer and did not undergo ERCP. The sensitivity and specificity of EUS for choledocholithiasis were 100% and 96%, respectively. A total of 440 ERCP procedures were performed over the same 12-month period, suggesting that EUS resulted in a 14% reduction in ERCP procedures (70 of 510). There were no complications of EUS. The cost of 90 EUS procedures was $42,840, compared with $108,854 for 70 ERCP procedures. The cost savings for the first year were $66,014. CONCLUSION: EUS appears to be accurate, safe and cost effective in diagnostic biliary imaging for suspected choledocholithiasis. The impact of EUS is the avoidance of ERCP in selected cases, thereby preventing the risk of complications. Diagnostic ERCP should not be performed in centres and regions with physicians trained in EUS.     

Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis

Background: Choledocholithiasis is a major source of morbidity among patients undergoing cholecystectomy for symptomatic gallstones. There is no consensus on the best approach to diagnosing bile duct stones. We compared the safety, accuracy, diagnostic yield, and cost of EUS- and ERCP-based approaches. Methods: Sixty-four consecutive pre- and post-cholecystectomy patients referred for endoscopic retrograde cholangiopancreatography (ERCP) for suspected choledocholithiasis were prospectively evaluated in a blinded fashion. All were stratified into risk groups using predefined criteria. Endoscopic ultrasonography (EUS) and ERCP were sequentially performed by two endoscopists. Results: The success rates of EUS and ERCP were 98% and 94%, respectively. The accuracy of EUS for diagnosing choledocholithiasis was 94%. EUS provided an additional or alternative diagnosis to bile duct stones in 21% of patients. The complication rate of EUS was significantly lower than diagnostic ERCP. An EUS-based strategy costs less than diagnostic ERCP in patients with low, moderate, or intermediate risk. Conclusions: EUS is comparably accurate, but safer and less costly than ERCP for evaluating patients with suspected choledocholithiasis. It is useful in patients with an increased risk of having common bile duct stones based on clinical criteria and those with contraindications for or prior unsuccessful ERCP. EUS may enable selective performance of ERCP and improve the cost-effectiveness of diagnosing choledocholithiasis. (Gastrointest Endosc 1998;47:439-48.)     

超声内镜对胆胰疾病诊断价值的探讨

目的 探讨超声内镜（EUS）对胆胰疾病的诊断价值。方法 采用超声胃镜（频率为7．5MHz和20Mnz），应用水囊法结合水充盈法，对54例临床疑为胆胰病变的患者进行EUS检查，并与腹部B超、CT及ERCP比较。结果 EUS、US、CT、ERCP对胆胰疾病诊断的阳性率分别为92．6％（50/54）、57．4％（31／54）、64．8％（35／54）及76．2％（32／42）。EUS对胰腺癌诊断的阳性率达100％。高于腹部B超、CT及ERCP；EUS对胆总管结石及慢性胰腺炎的准确率分别为100％和88．9％。结论 EUS对胆胰疾病的诊断率高于腹部B超，CT及ERCP影像检查，尤其对胆管扩张病因的定位及定性诊断均有较大的诊断价值。     

Endosonography-guided fine needle aspiration biopsy in the evaluation of pancreatic masses

OBJECTIVES: Diagnosis of pancreatic tumors can be problematic. This study aimed to determine the performance of endoscopic ultrasound-guided fine needle aspiration biopsy (EUS FNA) in pancreatic malignancy when prior biopsies performed by CT guidance or ERCP were negative. METHODS: A total of 185 patients with known or suspected pancreatic masses were prospectively evaluated with EUS FNA. Before EUS FNA, all patients were evaluated with abdominal CT (61 with CT-guided biopsy) and 91 with ERCP (41 had brushings or biopsy). RESULTS: EUS had greater sensitivity than CT in detecting a mass (99% vs 57%, p < 0.0001). In 58 patients with negative CT-guided biopsies, EUS FNA had 90% sensitivity for malignancy, 50% specificity for benign disease and 84% accuracy. Similarly, in 36 patients with negative ERCP tissue sampling, results for EUS FNA were 94%, 67% and 92%, respectively. Complications were mild and infrequent (0.5%). CONCLUSION: EUS FNA of pancreatic masses safely and accurately diagnoses pancreatic malignancy when prior biopsy techniques have been unsuccessful.     

Controversial issues in biliary pancreatitis: When should we perform MRCP and ERCP?

ObjectivesThe majority of bile duct stones (BDS) that cause acute biliary pancreatitis (ABP) pass spontaneously into the duodenum. If not passed, they worsen the prognosis or cause recurrence. Therefore, they must be treated. The purpose of this study was to assess the number and timing of spontaneous passage of BDS using magnetic resonance cholangiopancreatography (MRCP) and to determine the effect of this approach on endoscopic retrograde cholangiopancreatography (ERCP).MethodsSixty patients diagnosed with ABP were evaluated prospectively. MRCP was performed between the 1st and 4th days of an acute attack in all the patients. A control MRCP was performed after 7 days in patients with MRCP-identified choledocholithiasis. Patients in whom BDS were visible on imaging or who showed no decrease in bilirubin or cholestasis enzymes underwent ERCP.ResultsMRCP revealed choledocholithiasis in 20 (33%) of the 60 patients. In the control MRCP imaging, choledocholithiasis was detected in 16 of 20 (80% of those who had stone initially) patients. ERCP was performed in these patients and in 2 patients who did not have BDS on the control MRCP but whose bilirubin values and cholestatic enzyme levels had not decreased. ERCP verified choledocholithiasis in 16 of the 18 patients. The positive predictive value of MRCP was 93.7% (15/16).ConclusionsMRCP performed in the second week in ABP patients with a nonworsening prognosis and a suspicion of choledocholithiasis will give more specific results. This will avoid unnecessary ERCP and the potential morbidity and mortality that can develop with this invasive procedure.     

荟萃分析:超声内镜和ERCP诊断胆总管结石的比较

目的 通过荟萃分析对超声内镜和ERCP对胆总管结石诊断能力进行比较.方法 从Pubmed、Embase、Elsevier Science Direct和中国期刊全文数据库中检索比较超声内镜和ERCP对怀疑有胆总管结石病人诊断能力的前瞻性研究.对各项研究中的敏感性、特异性、准确率的比数比(OR)行荟萃分析,采用固定效应模型或随机效应模型进行数据统计分析.结果 共有5项对照研究入选(n=325).超声内镜的敏感性显著高于ERCP(146/159 vs 134/159,固定效应模型:OR 2.02,95%CI=1.01-4.03,P=0.05).超声内镜和ERCP对检测胆总管结石的特异性相似(161/166 vs 164/166,固定效应模型:OR 0.49,95% CI=0.12-1.99,P＞0.05).超声内镜的准确性略高于ERCP,但没有显著性差异(307/325 vs 298/325,固定效应模型:OR 1.53,95% CI=0.83-2.80,P＞0.05).ERCP相关的不良反应发生率显著高于超声内镜(P＜0.01).结论 由于准确率、安全性高,侵入性相对较小,超声内镜可认为是诊断胆总管结石的理想检查项目并能替代诊断性ERCP.对于这两种方法 的选择,应该取决于病人的一般状况、医疗单位所具备的能力,以及病灶是否可能需要采取进一步的介入治疗.     

ORBIT score: an useful predictor of small bowel rebleeding in patients under chronic anticoagulation

Background and study aims: Available scoring systems to assess the risk for major bleeding in patients on chronic anticoagulation seem inadequate in predicting higher diagnostic yields of small bowel capsule endoscopy (SBCE) or higher rebleeding rates in patients with suspected small bowel bleeding. The aim of this study was to evaluate the ability of the new ORBIT score in predicting positive findings of SBCE or higher rebleeding rates in chronically anticoagulated patients with suspected small bowel bleeding.

Patients and methods: Retrospective analysis of 570 patients who consecutively underwent SBCE for the study of suspected small bowel bleeding. For each of the 67 patients who were on chronic anticoagulation, ORBIT score (Older age, Reduced hemoglobin/hematocrit, Bleeding history, Insufficient kidney function and Treatment with antiplatelets) was calculated. Patients were classified as high-risk (ORBIT score?≥4) or low/intermediate-risk (ORBIT score?<4). Data on SBCE findings, diagnostic yield and rebleeding were compared between groups.

Results: When ORBIT score was calculated, 41 and 26 patients were classified as low/intermediate-risk and high-risk, respectively. When low/intermediate-risk and high-risk groups were compared, no differences were found in the diagnostic yield of SBCE (39.0% vs. 23.1%; p?=?.176). However, in high-risk patients, rebleeding was significantly more common than in low/intermediate-risk patients (80.0% vs. 36.6%; p?=?.003).

Conclusions: In patients presenting with suspected small bowel bleeding and on chronic anticoagulation, the new ORBIT score seems promising in identifying those with a higher risk of rebleeding, in whom a closer follow-up and a more aggressive diagnostic and therapeutic strategy is advisable.     

The accuracy of endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, computed tomography, and transabdominal ultrasound in the detection and staging of primary ampullary tumors

BACKGROUND/AIMS: To compare the accuracy between EUS (endoscopic ultrasound), ERCP (endoscopic retrograde cholangiopancreatography), CT (computed tomography), and transabdominal US (ultrasound) in the detection and staging of primary ampullary tumors. We will also try to discuss the influence of endobiliary stent on EUS in staging ampullary tumors. METHODOLOGY: Twenty-one patients with ampullary tumors were evaluated by EUS, ERCP, CT, and US before operation. The accuracy was assessed with TNM staging and compared with the surgical-pathological findings. RESULTS: EUS was superior to CT and US in detecting ampullary tumors, but EUS and ERCP are of similar sensitivity (EUS 95%, ERCP 95%, CT 19%, US 5%). EUS was superior to CT and US in T staging (EUS 75%, CT 5%, US 0%) and detecting lymph node metastasis (EUS 50%, CT 33%, US 0%) of ampullary tumors. The accuracy of EUS in T and N staging of ampullary tumors tended to be decreased in the presence of endobiliary stent (stenting: T 71%, N 75%; nonstenting T 83%, N 100%), but there was no statistical significance. CONCLUSIONS: EUS was superior to CT and US in assessing primary ampullary tumors, but it was not significantly superior to ERCP in detecting ampullary tumors. The presence of endobiliary stent may decrease the accuracy of EUS in staging ampullary tumors.     

EUS: a meta-analysis of test performance in suspected choledocholithiasis

BACKGROUND: EUS has been proposed as a less invasive means of diagnosing choledocholithiasis and may eliminate the need for ERCP and its associated risks. The literature pertaining to EUS for the diagnosis of choledocholithiasis reports widely varying sensitivities and specificities. OBJECTIVE: To more precisely estimate the diagnostic accuracy of EUS in suspected choledocholithiasis. DESIGN: MEDLINE and EMBASE databases were used to identify prospective cohort studies in which the results of EUS were compared with the results of an acceptable criterion standard, including ERCP, intraoperative cholangiography, or surgical exploration. Two independent reviewers extracted standardized data and assessed trial quality. A random effects model was used to estimate the sensitivity, specificity, likelihood, and diagnostic odds ratio (DOR), and a summary receiver operating characteristic curve was constructed. All predefined potential sources of heterogeneity were explored by subgroup analysis and meta-regression. PATIENTS: A total of 2673 patients with suspected choledocholithiasis were reported in 27 studies that satisfied the inclusion criteria. RESULTS: EUS had a high overall pooled sensitivity of 0.94 (95% CI, 0.93-0.96), a specificity of 0.95 (95% CI, 0.94-0.96), and an area under the curve of 0.98. Three variables appeared to yield a higher DOR: a higher disease prevalence, an adequate time interval between index test and criterion standards, and the presence of verification bias. LIMITATIONS: Misclassification of patients by imperfect criterion standards could potentially underestimate the performance of an EUS. CONCLUSIONS: An EUS is a noninvasive test, with excellent overall sensitivity and specificity for diagnosing choledocholithiasis. An EUS should, therefore, be used to select patients for a therapeutic ERCP to minimize the risk of complications associated with unnecessary diagnostic ERCP.     

EUS Yield in Evaluating Biliary Dilatation in Patients with Normal Serum Liver Enzymes

The finding of common bile duct (CBD) dilatation on abdominal imaging frequently results in additional testing. It has been our impression that endoscopic ultrasound (EUS) evaluation of a dilated CBD is a low-yield examination in the setting of normal serum liver enzymes. We therefore sought to evaluate the EUS yield in evaluating CBD dilatation in patients with normal as compared to elevated serum liver enzymes. A retrospective review was performed to identify patients referred for EUS evaluation of a dilated CBD in the absence of obvious pathology on prior imaging. Charts were reviewed for patient symptoms, presence of elevated serum liver enzymes, imaging studies before EUS, and EUS findings. Exclusion criteria included clinical jaundice, known biliary stricture, mass lesion or stone, and previously sphincterotomy and/or stent placement. Forty-seven patients were identified: 32 with normal and 15 with elevated serum liver enzymes. There was no difference in mean CBD diameter between these two groups (8.51 vs. 8.79 mm, p=0.854). Of the entire group, 15 patients had undergone prior magnetic resonance cholangiopancreatography (MRCP); an additional 7 patients had undergone prior endoscopic retrograde cholangiopancreatography (ERCP). EUS findings to explain CBD dilatation were found more commonly in patients with elevated compared with normal serum liver enzymes (53% vs. 6%, p=0.001). Periampullary diverticula and choledocholithiasis were the most common findings; of 32 patients with normal serum liver enzymes, one periampullary diverticulum and one CBD stone were found, respectively. The CBD stone had been missed by prior MRCP examination. Of 15 patients with elevated serum liver enzymes, there were 3 cases of choledocholithiasis, 4 periampullary diverticula, and 1 ampullary tumor. EUS should be the test of choice for further evaluation of CBD dilatation when index imaging is normal. Although the EUS yield is low in cases of biliary dilatation in the setting of normal serum liver enzymes, its preferential use would potentially avoid unnecessary MRCP and ERCP.     

Can endoscopic ultrasound or magnetic resonance cholangiopancreatography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis

OBJECTIVES: ERCP is the gold standard for pancreaticobiliary evaluation but is associated with complications. Less invasive diagnostic alternatives with similar capabilities may be cost-effective, particularly in situations involving low prevalence of disease. The aim of this study was to compare the performance of endoscopic ultrasound (EUS) with magnetic resonance cholangiopancreatography (MRCP) and ERCP in the same patients with suspected extrahepatic biliary disease. The economic outcomes of EUS-, MRCP-, and ERCP-based diagnostic strategies were evaluated. METHODS: Prospective cohort study of patients referred for ERCP with suspected biliary disease. MRCP and EUS were performed within 24 h before ERCP. The investigators were blinded to the results of the alternative imaging studies. A cost-utility analysis was performed for initial ERCP, MRCP, and EUS strategies for these patients. RESULTS: A total of 30 patients were studied. ERCP cholangiogram failed in one patient, and another patient did not complete MRCP because of claustrophobia. The final diagnoses (N = 28) were CBD stone (mean = 4 mm; range = 3-6 mm) in five patients; biliary stricture in three patients, and normal biliary tree in 20. Two patients had pancreatitis after therapeutic ERCP, one after precut sphincterotomy followed by a normal cholangiogram. EUS was more sensitive than MRCP in the detection of choledocolithiasis (80% vs 40%), with similar specificity. MRCP had a poor specificity and positive predictive value for the diagnosis of biliary stricture (76%/25%) compared to EUS (100%/100%), with similar sensitivity. The overall accuracy of MRCP for any abnormality was 61% (95% CI = 0.41-0.78) compared to 89% (CI = 0.72-0.98) for EUS. Among those patients with a normal biliary tree, the proportion correctly identified with each test was 95% for EUS and 65% for MRCP (p < 0.02). The cost for each strategy per patient evaluated was $1346 for ERCP, $1111 for EUS, and $1145 for MRCP. CONCLUSIONS: In this patient population with a low disease prevalence, EUS was superior to MRCP for choledocholithiasis. EUS was most useful for confirming a normal biliary tree and should be considered a low-risk alternative to ERCP. Although MRCP had the lowest procedural reimbursement, the initial EUS strategy had the greatest cost-utility by avoiding unnecessary ERCP examinations.