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.     

Value of MR cholangiography in the diagnosis of obstructive diseases of the biliary tree: a study of 58 cases

Objective: The aim of this study was to evaluate magnetic resonance cholangiography (MRC) in the diagnosis of biliary tree obstruction.
Methods: Fifty-eight consecutive patients underwent MRC (GYROSCAN ACS II 1.5 Tesla, TSE T2 axial/coronal-MIP sequences) for clinical and biochemical signs of main bile duct obstruction. MRC images were interpreted by two radiologists and consensus was established according to presence or absence of main bile duct dilation, choledocholithiasis, and malignant or benign stricture. MRC was compared to a final diagnosis established by ultrasound and CT in 19 cases, endoscopic retrograde cholangiopancreatography (ERCP) in 25, intraoperative cholangiography and exploration in 14, and clinical, biochemical, and histological presentation when relevant. Included were single or multiple choledocholithiasis (28, including 11 ≤ 3 mm), malignant (10) and benign (12) strictures, and intrahepatic cholestasis (9).
Results: Overall, MRC was sensitive (94%) and specific (92%) in detecting main bile duct dilation and choledocholithiasis (86% and 97%), but was less sensitive (64%) for small stones ≤ 3 mm. Sensitivity for stones > 3 mm was 100%. For benign and malignant strictures, MRC was less sensitive (67% and 80%) but remained specific (98% and 96%). In the detection of normal main bile duct, MRC was highly sensitive (100%) and specific (94%). Diagnostic accuracy ranged from 91% to 98%.
Conclusions: MRC appears to be specific for choledocholithiasis and sensitive except for small stones. Results for biliary stricture are less satisfactory, but remain specific. Our data confirm that MRC can be useful in the diagnostic workup of main bile duct obstruction.     

Gallstone Pancreatitis: A Prospective Study on the Incidence of Cholangitis and Clinical Predictors of Retained Common Bile Duct Stones

Objective: The aim of this study was to define the incidence of cholangitis in gallstone pancreatitis, in the absence of cholangitis, to identify the clinical predictors of persistent common bile duct (CBD) stones at endoscopic retrograde cholangiography (ERCP) or at intraoperative cholangiography (IOC).
Methods: A total of 122 consecutive patients with acute gallstone pancreatitis were prospectively evaluated for the presence of CBD stones as determined by elective ERCP or IOC. Urgent ERCP was restricted to patients with concomitant cholangitis. APACHE II scores and serial laboratory data were obtained.
Results: Four (3%) patients had cholangitis and all underwent urgent ERCP successfully. Eighteen (15%) patients without cholangiogram were excluded. The remaining 100 patients underwent elective ERCP or IOC on a mean of hospital day 6.8. Twenty-one (21%) patients had persistent CBD stones. Univariate analysis detected significant differences in serum total bilirubin, ALT, and alkaline phosphatase levels between patients with and without persistent CBD stones. On multivariate analysis, serum total bilirubin on hospital day 2 was the best predictor of CBD stones. A serum total bilirubin level > 1.35 mg/dl had a sensitivity of 90.5% and specificity of 63%. Age, gender, mean APACHE II score, amylase, and presence of CBD dilation on ultrasound were not predictive of CBD stones.
Conclusions: In patients with gallstone pancreatitis, 1) cholangitis is uncommon, and 2) the best clinical predictor of persistent CBD stones is serum total bilirubin on hospital day 2.     

Imaging of the common bile duct in patients undergoing laparoscopic cholecystectomy.

Options for managing the common bile duct during laparoscopic cholecystectomy include routine peroperative cholangiography and selected preoperative endoscopic retrograde cholangiopancreatography (ERCP). The use of these methods was reviewed in 350 patients with symptomatic gall stones referred for laparoscopic cholecystectomy. Unit A (n = 114) performed routine cystic duct cholangiography but undertook preoperative ERCP in patients at very high risk of duct stones only; unit B (n = 236) performed selected preoperative ERCP on the basis of known risk factors for duct stones. The detection rate for common bile duct stones was similar for units A and B (16% v 20%). In unit A, five of seven patients who had preoperative ERCP had duct stones. Operative cholangiography was technically successful in 90% of patients and duct stones were confidently identified in 13, one of whom went on to immediate open duct exploration. Postoperative ERCP identified duct stones in only four patients, indicating spontaneous passage in eight. In unit B, preoperative ERCP was undertaken in 76 of 236 (32%) patients and duct stones were identified in 47 (20%). Duct clearance was successful in 42 (18%) but failed in five (2%), necessitating elective open duct exploration. Both protocols for imaging the common bile duct worked well and yielded satisfactory short term results.     

Over-the-wire US catheter probe as an adjunct to ERCP in the detection of choledocholithiasis

BACKGROUND: Intraductal ultrasound (IDUS) as an adjunct to ERCP for detection of extrahepatic bile duct stones is technically easy, accurate, and safe. This prospective study evaluated IDUS with an "over-the-wire" catheter US probe as an adjunct to ERCP. METHODS: Sixty-five patients, highly suspected to have choledocholithiasis, underwent IDUS during ERCP. The IDUS probe was inserted by means of the duodenoscope into the bile duct without performing a sphincterotomy. All stones identified by IDUS or retrograde cholangiography were removed with either a basket or retrieval balloon after endoscopic sphincterotomy. RESULTS: The final diagnosis was choledocholithiasis in 59 patients. Bile duct diameter ranged from 0.6 to 2.3 cm and stone size from 2 mm to 2 cm. IDUS successfully identified all stones in these patients. IDUS resulted in 2 false-positive diagnoses in the remaining 6 patients without stones (overall accuracy 97%, sensitivity 100%, specificity 67%). Cholangiography detected stones in 55 of the patients with stones (accuracy 94%, sensitivity 93%, specificity 100%). CONCLUSION: IDUS, a safe, technically easy procedure, is highly accurate in the detection of extrahepatic bile duct stones regardless of the diameter of the bile ducts. The "over-the-wire" technique preserves access to the cannulated duct. IDUS is an excellent adjunct to ERCP for the diagnosis of choledocholithiasis. IDUS differentiates stones from air bubbles and prevents unnecessary sphincterotomy.     

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.     

Detection of choledocholithiasis: comparison of unenhanced spiral CT, US, and ERCP

BACKGROUND/AIMS: ERCP is an established method for the diagnosis and treatment of common bile duct stones, however, it is invasive, time-consuming, and expensive. The purpose of this study was to determine whether unenhanced spiral CT and US, compared with ERCP, have sufficient sensitivity and negative predictive value to be useful screening techniques in patients suspected of having choledocholithiasis. METHODOLOGY: Over a period of 2 years, 82 patients with clinically suspected choledocholithiasis underwent unenhanced spiral computed tomography and US immediately before undergoing endoscopic retrograde cholangiopancreatography. CT/US scans and ERCP images were evaluated for the presence of bile duct stones, ampullary stones, and extrahepatic biliary dilatation. RESULTS: Unenhanced spiral computed tomography (US) depicted common bile duct stones in 24 (23) of 28 patients found to have stones at endoscopic retrograde cholangiopancreatography. Five patients had stones impacted at the ampulla, all (two) of which were detected with CT (US). Computed tomography (US) had a sensitivity of 86% (82%) and a specificity of 98% (98%) in the diagnosis of choledocholithiasis. CONCLUSIONS: Both unenhanced spiral CT and US are useful for evaluating suspected common bile duct stones. Unenhanced spiral CT is especially useful when the patient is likely to have ampullary stones and is a safe, more available and less expensive alternative to magnetic resonance cholangiography.     

Contribution of magnetic resonance cholangiopancreatography to the management of patients with suspected common bile duct stones

OBJECTIVES: To evaluate the value of magnetic resonance cholangiography (MRC) as a systematic first-line investigation in the management of patients with suspected common bile duct stones. METHODS: Ninety-nine consecutive patients with clinical suspicion of choledocolithiasis were prospectively explored by MRC. All MRCs were interpreted by two radiologists with knowledge of the patient's clinical condition and laboratory results. In case of discrepancy, a third opinion was obtained to reach consensus. The definitive diagnosis was established on the basis of endoscopic exploration of the common bile duct (n=40), clinical and biological follow-up at 6 Months (n=55) or other investigations (n=4). The clinician's level of confidence, management options implemented, and impact of management decisions were used to assess the contribution of MRC. The diagnostic accuracy of MRC for common bile duct stones was also determined. RESULTS: At the observed level of confidence (85.9%), MRC identified a differential diagnosis in 7.1% of patients avoiding unnecessary endoscopic exploration in 59.6%. Systematic first-line MRC enabled appropriate management in 83.8% of patients. The sensitivity, specificity, and positive and negative predictive values of MRC for the diagnosis of common bile duct stones were 95.7%, 98.7%, 95.7% and 98.7%, respectively, with excellent inter-observer agreement (kappa=0.915). CONCLUSION: Magnetic resonance cholangiography can be used to efficiently screen patients who may need further invasive exploration of the common bile duct. It specifically identifies patients requiring therapeutic ERCP.     

Multidetector computed tomography cholangiography with multiplanar reformation for the assessment of patients with biliary obstruction

BACKGROUND: We sought to evaluate the diagnostic use of multidetector computed tomography (MDCT) cholangiography with multiplanar reformation (MPR) for the assessment of patients with biliary obstruction. METHODS: MDCT cholangiography with the MPR technique was performed in 58 patients who were thought to have biliary obstruction. No cholangiographic contrast agent was administered. MRCP in 24 patients, Endoscopic retrograde cholangiopancreatography (ERCP) in 46 patients and percutaneous transhepatic cholangiography (PTC) in 24 patients were performed. Eighteen patients underwent biopsy or surgery. The findings on MDCT cholangiography were compared with those of MRCP, ERCP, PTC, biopsy or surgery. RESULTS: The findings of MDCT cholangiography were as follows: choledocholithiasis (n = 34, 56.7%), malignant stricture (n = 14, 23.3%), benign stricture (n = 1, 1.7%), and cholelithiasis (n = 11, 18.3%). A small common bile duct (CBD) stone in one patient could not be detected on MDCT cholangiography. One patient with a small stone in distal CBD detected on MDCT cholangiography had no stone on ERCP. Two patients with initial diagnoses of CBD stones by MDCT cholangiography were disclosed to have malignant bile duct stricture by reference examination. The sensitivity and specificity of MDCT cholangiography for the diagnosis of bile duct stones were 96.9% and 96.2%, respectively. The sensitivity and specificity of MDCT cholangiography for the diagnosis of bile duct stricture were 85.7% and 100%, respectively. The overall accuracy of MDCT cholangiography for the diagnoses of the causes of biliary obstruction was 89.8%. CONCLUSION: MDCT cholangiography with the MPR technique is a fast and non-invasive technique with relatively high sensitivity and specificity for the diagnoses of the causes of biliary obstruction.     

ENDOSCOPIC SPHINCTEROTOMY OF THE PAPILLA OF VATER: AN ANALYSIS OF 300 CASES

Endoscopic sphincterotomy was performed on 300 patients with biliary and/or pancreatic disease during the period 1978–1983. The most frequent indications were choledocholithiasis after cholecystectomy (59%), choledocholithiasis without cholecystectomy (17%) and presumed motility disorders of the sphincter of Oddi (15%). In choledocholithiasis, stones passed spontaneously or were extracted from the bile duct in 147 of 164 patients (90%) in whom the outcome was determined by cholangiography immediately after stone extraction or by a second retrograde cholangiogram. In presumed motility disorders, only 51% of patients have shown sustained improvement in symptoms. Complications were uncommon (5%) but included bleeding from the margins of the incision, pancreatitis, cholangitis and an entrapped Dormia basket; no patient died. Duodenal diverticula were more frequent (p<0.005) in patients with bile duct stones after cholecystectomy (28%) than in patients in whom retrograde cholangiography did not reveal stones (9%) but the presence of diverticula did not influence the outcome of the procedure. Endoscopic sphincterotomy is a safe and effective procedure of particular relevance to elderly patients with choledocholithiasis after cholecystectomy and to high-risk patients with choledocholithiasis without cholecystectomy.     

Microscopic examination of bile directly collected during endoscopic cannulation of the papilla

The usefulness of microscopic examination of pure bile directly collected from the biliary tract during endoscopic retrograde cholangiography and without hormonal simulation was prospectively evaluated in 72 patients. According to clinical, biochemical, ultrasonographic, and radiographic data, the patients were separated into two groups: group 1, patients with proven stones (N = 50), and group 2, patients with suspected microlithiasis presenting symptoms suggestive of cholelithiasis but without evidence of macroscopic stones at echography or cholangiography (N = 22). Cholesterol crystals and/or bilirubinate granules were observed (eg, positive examination) in the bile of 41 of the 50 patients of group 1 (82%). Among patients of group 2, seven (32%) had a positive bile examination: cholecystectomy (N = 2) or endoscopic sphincterotomy (N = 5) disclosed minute stones in all cases. In the 15 patients of group 2 with a negative bile examination, cholecystectomy (N = 3), sphincterotomy (N = 2), and clinical (and/or echographic) 20-month follow-up (N = 9) revealed biliary lithiasis in only one patient, in whom recurrent cholangitis led to disclosure of one bile duct stone. According to these results, microscopic examination of bile samples collected during endoscopic retrograde cholangiography exhibited a sensitivity and a specificity for cholelithiasis recognition of 82.7% and 100%, respectively, with a positive predictive value of 88%. We conclude that the accuracy of this method makes it useful to investigate and manage patients with suspected microlithiasis.     

Magnetic resonance cholangiography in patients with biliary disease: its role in primary sclerosing cholangitis

BACKGROUND/AIM: Magnetic resonance cholangiography (MRC) is a non-invasive diagnostic procedure whose role in the management of patients with primary sclerosing cholangitis (PSC) is unclear. The aim of this study was to determine the usefulness of MRC in the evaluation of the biliary tree in patients with suspected biliary disease, and in particular, PSC. METHODS: MRC and invasive cholangiography (ERCP or PTC) were both performed in 73 patients, (33 male, 40 female, mean age 56 years) with clinical and/or biochemical evidence of cholestasis. Images were interpreted by two radiologists unaware of the results of other studies. RESULTS: Forty-two patients (58%) had benign biliary disease, including 23 patients (32%) with PSC; 9 patients (12%) had malignant biliary disease; and 22 patients (30%) had a normal biliary tree. Diagnostic quality images were obtained in 73/73 (100%) of MRC, and in 70/73 (96%) of invasive cholangiography (68 ERCP's, 2 PTC's) procedures. Using ERCP/PTC findings as the reference standard, MRC had an accuracy greater than 90% in the diagnosis of normal bile ducts, biliary dilatation, biliary obstruction, bile duct stones, and PSC. Using the final diagnosis, MRC had an overall diagnostic accuracy of 90% in the detection of biliary disease compared to 97% for invasive cholangiography. Additional diagnostic/therapeutic interventions were performed during ERCP in 73% of patients with PSC and in 43% of patients without PSC (p=0.02). CONCLUSIONS: MRC has excellent diagnostic accuracy in the presence of biliary disease. Because of its noninvasive nature, MRC may have advantages over invasive cholangiography when diagnosis is the major goal of the procedure.     

Imaging tests for accurate diagnosis of acute biliary pancreatitis

Gallstones represent the most frequent aetiology of acute pancreatitis in many statistics all over the world, estimated between 40%-60%. Accurate diagnosis of acute biliary pancreatitis(ABP) is of outmost importance because clearance of lithiasis [gallbladder and common bile duct(CBD)] rules out recurrences. Confirmation of biliary lithiasis is done by imaging. The sensitivity of the ultrasonography(US) in the detection of gallstones is over 95% in uncomplicated cases, but in ABP, sensitivity for gallstone detection is lower, being less than 80% due to the ileus and bowel distension. Sensitivity of transabdominal ultrasonography(TUS) for choledocolithiasis varies between 50%-80%, but the specificity is high, reaching 95%. Diameter of the bile duct may be orientative for diagnosis. Endoscopic ultrasonography(EUS) seems to be a more effectivetool to diagnose ABP rather than endoscopic retrograde cholangiopancreatography(ERCP),which should be performed only for therapeutic purposes.As the sensitivity and specificity of computerized tomography are lower as compared to state-of-the-art magnetic resonance cholangiopancreatography(MRCP)or EUS,especially for small stones and small diameter of CBD,the later techniques are nowadays preferred for the evaluation of ABP patients.ERCP has the highest accuracy for the diagnosis of choledocholithiasis and is used as a reference standard in many studies,especially after sphincterotomy and balloon extraction of CBD stones.Laparoscopic ultrasonography is a useful tool for the intraoperative diagnosis of choledocholithiasis.Routine exploration of the CBD in cases of patients scheduled for cholecystectomy after an attack of ABP was not proven useful.A significant rate of the so-called idiopathic pancreatitis is actually caused by microlithiasis and/or biliary sludge.In conclusion,the general algorithm for CBD stone detection starts with anamnesis,serum biochemistry and then TUS,followed by EUS or MRCP.In the end,bile duct microscopic analysis may be performed by bile harvested during ERCP in case of recurrent attacks of ABP and these should be followed by laparoscopic cholecystectomy.     

The case for laparoscopic common bile duct exploration

The modern surgeon's approach to choledocholithiasis depends his or her view of cholangiography. During the early 1990 there was a swing away from cholangiography, which had previously been common practice. This was because of perceptions of difficulty with the technique, the time it took, and perhaps an implied increase in costs because of the time factor. There was no evidence on which to base this decision. This led to a marked upswing in the use of endoscopic retrograde cholangiopancreatography (ERCP). There were a large number of ERCPs with normal results performed prior to laparoscopic cholecystectomy. This paper states the case for intraoperative cholangiography and common bile duct clearance at the time of cholecystectomy. It is hoped that this technique will be adopted so patients can undergo a single procedure to remove their gallstones and common bile duct stones if they exist and to decrease the incidence of normal preoperative ERCPs and the need for a second procedure postoperatively to clear stones if they are found.     

Are duodenal diverticula associated with choledocholithiasis?

The results of 250 consecutive ERCP examinations were analysed in order to assess whether or not juxtapapillary duodenal diverticula are associated with choledocholithiasis. Cholangiography showed common bile duct stones in 71 patients of whom 25 (35%) had periampullary diverticula. Clear bile ducts were shown in 99, of whom only 12 had diverticula (12%) (p less than 0.05). After allowing for the differences in age between the two groups, patients with choledocholithiasis were 2.6 times (95% CI: 1.14-5.93) more likely to have a periampullary diverticulum than patients without choledocholithiasis. In the remaining 80 patients, cholangiography was either not successful or not indicated. Further clinical follow up and/or investigation have failed to reveal duct stones in any and only 10 (13%) of these 80 patients had diverticula. Overall, 47 patients had diverticula: 25 (53%) had duct stones, four may have had stones and 18 had none. Three or more years after cholecystectomy 59% of patients with duct stones had diverticula, while only 13% with clear ducts had them. These results show a significant association between periampullary duodenal diverticula and choledocholithiasis.     

Helical computed tomographic cholangiography versus endosonography for suspected bile duct stones: a prospective blinded study in non-jaundiced patients

BACKGROUND: Helical computed tomography performed after intravenous administration of a cholangiographic contrast material (HCT-cholangiography) may be useful for detecting bile duct stones in non-jaundiced patients. However, this method has never been compared with other non-invasive biliary imaging tests. AIMS: To compare prospectively HCT-cholangiography and endosonography (EUS) in a group of non-jaundiced patients with suspected bile duct stones. METHODS: Fifty two subjects underwent both HCT-cholangiography and EUS. Endoscopic retrograde cholangiography (ERCP), with or without instrumental bile duct exploration, served as a reference method, and was successful in all but two patients. RESULTS: Thirty four patients (68%) were found to have choledocholithiasis at ERCP. The sensitivity for HCT-cholangiography in stone detection was 85%, specificity 88%, and accuracy 86%. For EUS the sensitivity was 91%, specificity 100%, and accuracy 94%. The differences were not significant. No serious complications occurred with either method. CONCLUSIONS: HCT-cholangiography and EUS are safe and comparably accurate methods for detecting bile duct stones in non-jaundiced patients.     

Routine intravenous cholangiography, selective ERCP, and endoscopic treatment of bile duct stones before laparoscopic cholecystectomy.

BACKGROUND: No procedure has yet been identified as the standard for the detection and management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy. METHODS: A prospective study involved 1305 patients undergoing elective laparoscopic cholecystectomy. Intravenous cholangiography was performed on all patients except those with jaundice or cholangitis, acute pancreatitis, or allergy to contrast material. Patients underwent endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy when there was a strong suspicion of choledocholithiasis, positive or inconclusive findings on intravenous cholangiography or allergy to contrast material with signs of possible choledocholithiasis. Intraoperative cholangiography was performed when patients did not undergo ERC or intravenous cholangiography and whenever the surgeon was in doubt about biliary anatomy or biliary clearance. RESULTS: Two hundred thirty-one patients (17.7%) were referred for preoperative ERC; 14 of them were referred for open surgery because of failure of ERC or sphincterotomy. Only 54 patients underwent intraoperative cholangiography. Bile duct stones, detected in 186 cases (14.2%) (68 of which were asymptomatic), were removed before surgery in 162 cases (87.1%) and during surgery in 20 (10.7%). Self-limited pancreatitis occurred in 3.6% of the patients after sphincterotomy. Laparoscopic cholecystectomy was performed in 98.7% of the cases. The conversion rate was 8% if sphincterotomy had been performed previously, and 3% after standard laparoscopic cholecystectomy (p < 0.001). The morbidity rate was 5% and the mortality rate 0.08%. During the follow-up period 4 patients had retained stones that were treated endoscopically. CONCLUSIONS: Preoperative ERC followed by laparoscopy is the best approach to treatment of patients with cholecystolithiasis and suspected choledocholithiasis.     

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.)     

Biliary stones and stenoses: diagnostic value of magnetic resonance cholangiography.

BACKGROUND/AIMS: To evaluate the accuracy of magnetic resonance cholangiography for detection of bile duct calculi and stenosis. METHODS: Half-Fourier single-shot rapid acquisition with relaxation enhancement sequence magnetic resonance cholangiography was performed prospectively in 68 patients who were suspected of having choledocholithiasis or biliary tree stenosis. On the basis of findings at ultrasound, computed tomography, endoscopic retrograde or percutaneous cholangiography, intraoperative cholangiography or choledocoscopy and exploration, final diagnoses were normal bile ducts (n=8), choledocholithiasis (n=28), benign or malignant stenosis (n=32). RESULTS: Choledocholithiasis was diagnosed with a sensitivity of 96% and a specificity of 98%. False negative readings occurred due to stones less than two mm at in size at the distal common bile duct. A false diagnosis of choledocholithiasis (single impacted stone) by magnetic resonance cholangiography occurred in only one case for whom the final diagnosis was main bile duct adenocarcinoma, suspected on endoscopic retrograde cholangiography and confirmed at surgery. Bile duct stenosis was diagnosed with a sensitivity of 97% and a specificity of 94%. CONCLUSIONS: With magnetic resonance cholangiography, bile duct calculi and stenosis can be diagnosed with high accuracy. It is a fast, accurate and noninvasive alternative to endoscopic retrograde cholangiography in the evaluation of biliary tract disease.     

What features on intraoperative cholangiogram predict endoscopic retrograde cholangiopancreatography outcome in patients post cholecystectomy?

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is a procedure performed to remove bile duct stones. Intraoperative cholangiography (IOC) is often performed at the time of cholecystectomy to determine the presence of intraductal stones. However, many of the ERCP procedures performed for this indication fail to find any intraductal stones. Given that ERCP carries significant patient morbidity, we investigated whether there are features on IOC that can guide ERCP patient selection.MethodsA retrospective analysis of 152 patients who had an IOC filing defect and a subsequent ERCP was performed.ResultsSmall single stones greater than or equal to 4.5 mm on IOC can be used to predict the presence of stones on a subsequent ERCP. Furthermore, ERCPs performed for single filling defects smaller than 4.5 mm are more likely to be negative if performed later rather than earlier, suggesting that small stones can pass over time. We show that 80% of these stones will pass by 11 days after the IOC.ConclusionSingle small stones on IOC should be given adequate time to pass into the intestine. Imaging should be performed to determine if the stone has passed into the intestine after day 11 prior to performing a therapeutic ERCP.