Endoscopic retrograde cholangiography for pediatric choledocholithiasis: Assessing the need for endoscopic intervention

AIM:To assess pediatric patients for choledocholithiasis.We applied current adult guidelines to identify predictivefactors in children.METHODS:A single-center retrospective analysis was performed at a tertiary children's hospital.We evaluated 44 consecutive pediatric patients who underwent endoscopic retrograde cholangiography(ERCP) for suspected choledocholithiasis.Patients were stratified into those with common bile duct stones(CBDS) at ERCP vs those that did not using the American Society of Gastrointestinal Endoscopy(ASGE) guidelines(Very Strong and Strong criteria) for suspected CBDS.RESULTS:CBDS were identified in 84% at the time of ERCP.Abdominal ultrasound identified CBDS in 36% of patients.Conjugated bilirubin ≥ 0.5 mg/d L was an independent risk factor for CBDS(P = 0.003).The Very Strong(59.5%) and Strong(48.6%) ASGE criteria identified the majority of patients(P = 0.0001).A modified score using conjugated bilirubin had a higher sensitivity(81.2% vs 59.5%) and more likely to identify a stone than the standard criteria,odds ratio of 25.7 compared to 8.8.Alanine aminotransferase and gamma-glutamyl transferase values identified significant differences in a subset of patients with odds ratio of 4.1 and 3.25,respectively.CONCLUSION:Current adult guidelines identified the majority of pediatric patients with CBDS,but specific pediatric guidelines may improve detection,thus decreasing risks and unnecessary procedures.     

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 retrograde cholangiography in the diagnosis of liver diseases

ERC is mainly used either for the investigation of extrahepatic cholestasis or for the evaluation of common bile duct stones. Contrary to non-invasive procedures in liver diseases (laboratory investigation, ultrasound, computer tomography), ERC is only indicated when the biliary system might be involved in the underlying process. In these cases application of ERC depends on the question whether optimal visualization of the biliary tree will further assist in the therapeutic management of the disease. In primary and secondary sclerosing cholangitis ERC is the diagnostic procedure of choice.     

胰腺肿瘤的内镜超声诊断

胰腺深处人体腹膜后位,肿瘤发生常隐匿起病,如为恶性,确诊已属晚期,外科根除率低,预后极差,其中胰腺癌5年生存率只有4％,且化放疗均不敏感,能否延长生存,其前提是早期诊断。     

Endoscopic retrograde cholangiography in the diagnosis and treatment of mucobilia

Objective. Some biliary neoplasms secrete copious mucin into bile ducts, yet the management of mucobilia is not well known. The objective of this study was to analyze 16 patients with copious mucin in the biliary tract stressing the diagnostic and therapeutic aspects of endoscopic retrograde cholangiography (ERC). Material and methods. Sixteen patients with mucobilia were found among 5635 cases of ERC from October 1999 to October 2006 in our institution. Diagnostic and therapeutic ERC as well as clinical features were retrospectively analyzed. Results. Mucin had a greater impact than the neoplasm itself on the cholangiogram and clinical presentation. ERC failed to show the tumors but a disproportionate or aneurysmal dilatation of the segmental or lobar duct correlated with the tumor-bearing duct was evident. Endoscopic managements included clearance of intraductal mucin and/or endoscopic nasobiliary drainage (ENBD). Three patients were excluded from outcome assessment because of non-specific symptoms or spontaneously subsiding jaundice. Among the 13 patients eligible for assessment, subjective improvement in symptoms and/or a decrease in jaundice along with subsiding cholangitis following ERC was observed in 5 of the 7 patients that underwent both clearance of intraductal mucin and ENBD (ENBD function was poor in all 7 patients), in 1 patient who underwent only clearance of intraductal mucin, and in 3 of the 5 patients who underwent only ENBD. The three patients with progressive jaundice, despite endoscopic management, had advanced disease. Conclusions. ERC revealed the tumor-bearing duct but not the extent of the disease in most of the patients with mucobilia. When mucobilia is encountered during ERC, the management should include clearance of as much intraductal mucin as possible. ENBD is frequently obstructed by mucin and may be helpful only in selected cases.     

Endoscopic ultrasonography for preoperative diagnosis and localization of insulinomas

BACKGROUND: Endoscopic ultrasonography (EUS) is generally accepted as a sensitive method for the detection of small pancreatic tumors. We report our experience with EUS for preoperative imaging of insulinomas. METHODS: Nine patients with clinical and biochemical signs of insulinoma were examined by EUS using a 7.5/12 MHz radial-scanning ultrasound endoscope prior to surgery. EUS outcome was evaluated on the basis of surgery (open or laparoscopic) and examination of the resected specimens. RESULTS: Two EUS-negative patients appeared, by reassessment of clinical and biochemical data, not to have an insulinoma and were not operated on. EUS correctly imaged and localized five of seven insulinomas that were surgically removed. One isoechoic tumor in the pancreatic head and one pedunculated tumor connected to the caudal side of the pancreatic body were missed by EUS. EUS could demonstrate the size and shape of the imaged tumors, as well as their relationship to adjacent structures, such as the pancreatic duct, bile duct, and large vessels. CONCLUSIONS: Our experience with seven insulinomas accords with previous reports claiming EUS to be the method of choice for preoperative imaging and localization of pancreatic islet cell tumors.     

Echo-endoscopy versus endoscopic retrograde cholangiography for the diagnosis of choledocholithiasis: the influence of the size of the stone and diameter of the common bile duct

BACKGROUND: Endoscopic retrograde cholangiography is highly accurate in diagnosing choledocholithiasis, but it is the most invasive of the available methods. Endoscopic ultrasonography is a very accurate test for the diagnosis of choledocholithiasis with a risk of complications similar to that of upper gastrointestinal endoscopy. AIM: To compare the accuracy of endoscopic ultrasonography and endoscopic retrograde cholangiography in the diagnosis of common bile duct stones before laparoscopic cholecystectomy and to analyze endoscopic ultrasound results according to stone size and common bile duct diameter. PATIENTS AND METHODS: Two hundred and fifteen patients with symptomatic gallstones were admitted for laparoscopic cholecystectomy. Sixty-eight of them (31.7%) had a dilated common bile duct and/or hepatic biochemical parameter abnormalities. They were submitted to endoscopic ultrasonography and endoscopic retrograde cholangiography. Sphincterotomy and sweeping of the common bile duct were performed if endoscopic ultrasonography or endoscopic retrograde cholangiography were considered positive for choledocholithiasis. After sphincterotomy and common bile duct clearance the largest stone was retrieved for measurement. Endoscopic or surgical explorations of the common bile duct were considered the gold-standard methods for the diagnosis of choledocholithiasis. RESULTS: All 68 patients were submitted to laparoscopic cholecystectomy with intraoperative cholangiography with confirmation of the presence of gallstones. Endoscopic ultrasonography was a more sensitivity test than endoscopic retrograde cholangiography (97% vs. 67%) for the detection of choledocholithiasis. When stones >4.0 mm were analyzed, endoscopic ultrasonography and endoscopic retrograde cholangiography presented similar results (96% vs. 90%). Neither the size of the stone nor the common bile duct diameter had influence on endoscopic ultrasonographic performance. CONCLUSIONS: For a group of patients with an intermediate or moderate risk with respect to the likelihood of having common bile duct stones, endoscopic ultrasonography is a better test for the diagnosis of choledocholithiasis when compared to endoscopic retrograde cholangiography mainly for small-sized calculi.     

Endoscopic retrograde cholangiography in the diagnosis of biliary malformations in infants

The differentiation of infantile biliary malformations from primary parenchymal diseases is difficult. The recent development of a pediatric side-viewing endoscope (PJF Endoscope; Olympus Corporation of America) provided an opportunity to investigate the usefulness of endoscopic retrograde cholangiography (ERC) for precise visualization of the extrahepatic biliary passages in infants with persistent cryptogenic cholestasis. ERC was performed in 12 patients, with visualization of the existing extrahepatic bile ducts in 4. The entire biliary system was visualized in one, excluding extrahepatic biliary atresia and choledochal cyst. The reduced caliber of the intrahepatic bile ducts and histological observations in a percutaneous liver biopsy supported the diagnosis of intrahepatic biliary hypoplasia in this case. An intact hepatic portochole cystostomy was documented in one, although the intrahepatic biliary system was not delineated. Atresia of the hepatic bile ducts proximal to the gallbladder was documented in two. Of the eight patients in whom extrahepatic bile ducts were not visualized by ERC, six had extrahepatic biliary atresia confirmed at exploratory laparotomy. The papilla of Vater could not be located in four of these six infants. The remaining two had neonatal hepatitis. ERC may offer a useful alternative to operative cholangiography in selected infants with persistent cholestasis and acholic stools.     

Endoscopic ultrasonography for the diagnosis and selecting treatment of esophageal leiomyoma

Background and Aim: To investigate the clinical value of endoscopic ultrasonography (EUS) with miniature ultrasonic probes (MUP) for the diagnosis and treatment of esophageal leiomyoma. Methods: A total of 229 patients with esophageal leiomyoma, diagnosed using EUS, with 12‐MHz MUP and a double‐cavity electronic endoscope, were enrolled. The clinical characteristics of the patients were analyzed, and those who had therapeutic indications received endoscopic resection or surgical excision. Postoperative histological diagnostic results were compared with the preoperative diagnosis of EUS. All patients, including those with or without endoscopic resection or surgical excision were periodically followed up with EUS. Results: Of the 229 patients, 118 received endoscopic resection, and seven received surgical excision. Postoperative histology showed that 110 patients were completely consistent with the preoperative diagnosis of EUS, and the diagnostic accuracy of EUS was 88.6%. No treatment‐related complications occurred among the patients who received endoscopic resection or surgical excision, and no recurrence was observed during the follow‐up examinations. Conclusions: Esophageal leiomyoma is a benign tumor of the esophagus. EUS is a useful technique for the diagnosis of esophageal leiomyoma and for making treatment‐related decisions.     

内镜超声对皮革胃的诊断价值

目的　探讨内镜超声检查 (EUS)对皮革胃的诊断价值。方法　对 2 1例皮革胃患者行EUS检查 ,并将其结果与内镜、胃肠道钡餐、CT检查及术后病理结果进行对照研究。结果　皮革胃的EUS声像图表现为 (1 )病灶处胃壁第 2、3、4层明显增厚 ,所侵犯胃壁层次结构消失 ,胃壁增厚处平均 (1 6 8± 0 37)cm ;(2 )大多数 (95 2 4 % )呈低回声改变 ;(3)EUS下病灶范围超过内镜所见异常区域 ;(4 ) 85 7%的患者病变沿胃的横轴生长呈连续性分布 ;(5 )病灶边界较容易分辨 ,但图像放大观察交界处模糊 ,是皮革胃浸润生长的标志。EUS对皮革胃的诊断符合率为 90 4 8% ,显著高于常规内镜检查的 5 2 38% (P =0 0 0 95 )、胃肠道钡餐的 6 1 1 1 % (P =0 0 396 )及CT检查的 35 2 9% (P =0 0 0 5 9)。术前EUS对皮革胃的T、N分期诊断的准确性分别为 80 95 %、85 71 % ,EUS对皮革胃可切除性判断的准确率为 71 4 3%。结论　EUS能提高内镜诊断皮革胃的准确率并对其病变的范围和可切除性的判断有重要的价值     

Endoscopic ultrasonography in the diagnosis of gastric submucosal tumor

Endoscopic ultrasonography contributed to a correct diagnosis in 24 of 25 patients with gastric submucosal tumor, including 10 extrinsic compressions and 14 intraparietal growths. Leiomyoma and lipoma were easily recognized. In one case, an unusual group of gastric varices was clearly differentiated from a pedunculated polyp prior to polypectomy. In gastric submucosal tumors, endoscopic ultrasonography can greatly reduce the need for aggressive and risky biopsy techniques or exploratory laparotomy.     

Endoscopic ultrasonography in the differential diagnosis of pancreatic disease

Endoscopic ultrasonography was performed in 25 patients with suspected pancreatic disease. Cancer of the pancreas was recognized in 9 of 10 cases with 1 false negative and 2 false positive diagnoses. Chronic pancreatitis was recognized in 89% of cases. Technical difficulties limited the success of the examination in 24% of cases. The presence or absence of pancreatic disease can be determined in most cases by endoscopic ultrasonography. Differential diagnosis by endoscopic ultrasonography (EUS) is correct in the majority of cases. We have not discovered any specific EUS finding(s) that are pathognomonic for pancreatic cancer or chronic pancreatitis.     

Endoscopic papillary balloon dilatation versus endoscopic sphincterotomy in the treatment for choledocholithiasis: a meta-analysis

Background and Aim: Endoscopic papillary balloon dilatation (EPBD) and endoscopic sphincterotomy (EST) are two common nonsurgical treatments endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. The aim of this study was to compare the efficacy and safety of EPBD and EST in the treatment for choledocholithiasis, confining the analysis to work reported in the last decade. Methods: The rate of overall postoperative complications was chosen as the primary outcome, and 10 other outcomes were secondary outcomes. Relative risk (RR) or Peto odds ratio (OR) were computed as the measures of pooled effects. We planned sensitivity analyses a priori for examining the change in robustness of the sensitivity to excluding studies with some inappropriate objects, technique defects or without full‐text acquisition. Results: For complete stone removal, EPBD was similar to EST (95% vs. 96%, P = 0.36) and overall postoperative complications (14.0% vs. 11.7%, P = 0.53). The incidence of post‐ERCP cholangitis (2.5% vs. 1.8%, P = 0.40), basket impaction (0.9% vs. 0%, P = 0.16) and perforation (0.0% vs. 0.4%, P = 0.17) were equivalent between EPBD and EST. On the other hand, EPBD caused more post‐ERCP pancreatitis (PEP) (9.4% vs. 3.3%, P < 0.00001), but less hemorrhage (0.1% vs. 4.2%, P < 0.00001). People undergoing EPBD required more use of endoscopic mechanical lithotripsy (35.0% vs. 26.2%, P = 0.0004). The results of sensitivity analyses showed no substantial change. Conclusion: EPBD is comparable to EST for stone extraction, though it requires more endoscopic mechanical lithotripsy (EML). EPBD may outweigh EST for patients with coagulopathy; however, it may cause more PEP.     

Magnetic resonance cholangiography using half-Fourier acquisition for diagnosing choledocholithiasis

Objective: Magnetic resonance cholangiography (MRC), using a half-Fourier acquisition single-shot turbo spin-echo (HASTE) sequence, noninvasively provides very rapid (1–2 s) and high-quality images of the biliary tract. We assessed the diagnostic usefulness of HASTE-MRC for choledocholithiasis.
Methods: A total of 101 patients with suspected choledocholithiasis underwent MRC, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP). In 97 patients in whom ERCP fully depicted the common bile duct, we retrospectively analyzed the capability of MRC to image the common bile duct and to diagnose choledocholithiasis, in comparison with that of ultrasonography.
Results: In 34 patients, ERCP demonstrated bile duct stones, which were confirmed at endoscopic or surgical treatment. The common bile duct was fully delineated in 98% by MRC and in 70% by ultrasonography. MRC (91%) was more sensitive than ultrasonography (71%) for detecting choledocholithiasis (   p < 0.05  ). MRC demonstrated bile duct stones in all patients with stones ≥11 mm but missed calculi in the 29% of patients with small (3–5 mm) stones. MRC was capable of detecting choledocholithiasis regardless of bile duct caliber. The specificity of MRC (100%) was higher than that of ultrasonography (95%).
Conclusion: HASTE-MRC, a fast and noninvasive procedure, can accurately diagnose choledocholithiasis although the detectability for small stones is limited.     

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.