Prospective evaluation of early endoscopic ultrasonography for triage in suspected choledocholithiasis: results from a large single centre series

Suspected common bile duct stones: reduction of unnecessary ERCP by pre-procedural imaging and timing of ERCP

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice to remove sludge/stones from the common bile duct (CBD). In a small but clinically important proportion of patients with suspected choledocholithiasis ERCP is negative. This is undesirable because of ERCP associated morbidity. We aimed to map the diagnostic pathway leading up to ERCP and evaluate ERCP outcome.

METHODS

We established a prospective multicenter cohort of patients with suspected CBD stones. We assessed the determinants that were associated with CBD sludge or stone detection upon ERCP.

RESULTS

We established a cohort of 707 patients with suspected CBD sludge or stones (62% female, median age 59 years). ERCP was negative for CBD sludge or stones in 155 patients (22%). Patients with positive ERCPs frequently had pre-procedural endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) imaging (44% vs. 35%; P = 0.045). The likelihood of ERCP sludge and stones detection was higher when the time interval between EUS or MRCP and ERCP was less than 2 days (odds ratio 2.35; 95% CI 1.25-4.44; P = 0.008; number needed to harm 7.7).

CONCLUSIONS

Even in the current era of society guidelines and use of advanced imaging CBD sludge or stones are absent in one out of five ERCPs performed for suspected CBD stones. The proportion of unnecessary ERCPs is lower in case of pre-procedural EUS or MRCP. A shorter time interval between EUS or MRCP increases the yield of ERCP for suspected CBD stones and should, therefore, preferably be performed within 2 days before ERCP.

Endoscopic Ultrasonography in Pediatric Patients with Pancreatobiliary Disease: Single-Center Trial

PURPOSE

The use of Endoscopic ultrasonography (EUS) in pediatric patients is not as common as in adults. The aim of this study is to evaluate the role of EUS in the diagnosis of pancreatobiliary disease in childhood.

METHODS

Between December 2016 and January 2018, the findings of patients who underwent EUS were evaluated retrospectively.

RESULTS

Of the 41 patients included in the study 25 were girls (61.0%), mean age was 12.2±4.2 years. EUS was performed for biliary colic in 21 (51.2%), for recurrent pancreatitis in 12 (29.2%), for cholecystitis/cholangitis in 5 (12.2%), and for acute pancreatitis in 3 (7.4%) patients. EUS had a significant clinical effect in the decision of treatment and follow-up of 6/21 biliary colic cases, in diagnosis and follow-up of 6/12 recurrent pancreatitis cases, in decision-making and monitoring of invasive procedures (ERCP/surgery) of 3/5 acute cholecystitis/cholangitis and 2/3 of acute pancreatitis cases as well as in follow-up of the other cases. The effectiveness of EUS in determining direct treatment and invasive intervention was 43.9%. None of the patients had complications related to the EUS procedure.

CONCLUSION

Although current guidelines show that EUS can be used in pediatric patients, this is limited to a few published studies. In this study, it is shown that EUS is a safe method for the diagnosis, follow-up and treatment of common pancreatobiliary pathologies in childhood.

Standardization of common bile duct size using ultrasound in pediatric patients

BACKGROUND/PURPOSE

The incidence of choledocholithiasis is increasing. The diagnosis of common bile duct (CBD) obstruction is based on abnormal CBD size. Establishing norms for CBD size in children would improve diagnostic accuracy. We analyzed ultrasounds (US) to determine normal pediatric CBD size based on age and then validated this against patients with choledocholithiasis.

METHODS

A retrospective review was conducted for children less than 21 years of age with US defined CBD size. Patients were stratified into age groups by ANOVA statistical analysis. Secondary analysis included patients with confirmed choledocholithiasis in comparison to the normal cohort.

RESULTS

A total of 778 patients had US without pathology. Group 1 (<1 year) had a mean CBD of 1.24±0.54 mm, group 2 (1-10 years) 1.97±0.71 mm, and group 3 (>10 years) 2.98±1.17 mm, p<0.05. Fourteen additional patients were found to have choledocholithiasis with a mean CBD size of 8.1 mm. All patients with choledocholithiasis had CBD sizes outside of our normal range, but only 50% of patients had enlarged CBD size based on adult normal range of values.

CONCLUSION

Normal CBD size in children is less than a normal adult patient. More accurate normal values will aid in determining if a child needs further evaluation for possible obstruction of the CBD.

TYPE OF STUDY

diagnostic Level of evidence: III.

Similarities and differences between biliary sludge and microlithiasis: Their clinical and pathophysiological significances

The terms biliary sludge and cholesterol microlithiasis (hereafter referred to as microlithiasis) were originated from different diagnostic techniques and may represent different stages of cholesterol gallstone disease. Although the pathogenesis of biliary sludge and microlithiasis may be similar, microlithiasis could be preceded by biliary sludge, followed by persistent precipitation and aggregation of solid cholesterol crystals, and eventually, gallstone formation. Many clinical conditions are clearly associated with the formation of biliary sludge and microlithiasis, including total parenteral nutrition, rapid weight loss, pregnancy, organ transplantation, administration of certain medications, and a variety of acute and chronic illnesses. Numerous studies have demonstrated complete resolution of biliary sludge in approximately 40% of patients, a cyclic pattern of disappearing and reappearing in about 40%, and progression to gallstones in nearly 20%. Although only a minority of patients with ultrasonographic demonstration of biliary sludge develop gallstones, it is still a matter of controversy whether microlithiasis could eventually evolve to cholesterol gallstones. Biliary sludge and microlithiasis are asymptomatic in the vast majority of patients; however, they can cause biliary colic, acute cholecystitis, and acute pancreatitis. Biliary sludge and microlithiasis are most often diagnosed ultrasonographically and bile microscopy is considered the gold standard for their diagnosis. Specific measures to prevent the development of biliary sludge are not practical or cost-effective in the general population. Laparoscopic cholecystectomy offers the most definitive therapy on biliary sludge. Endoscopic sphincterotomy or surgical intervention is effective for microlithiasis-induced pancreatitis. Ursodeoxycholic acid can effectively prevent the recurrence of solid cholesterol crystals and significantly reduce the risk of recurrent pancreatitis.

Current clinical algorithms for predicting common bile duct stones have only moderate accuracy

BACKGROUND AND AIM

A risk-stratified approach for selecting patients likely to harbor common bile duct (CBD) stones to proceed directly to endoscopic or surgical stone clearance, rather than undergo less invasive testing, has been proposed. We assessed the performance of three clinical algorithms used to predict CBD stones.

METHODS

All patients undergoing first-time endoscopic retrograde cholangiopancreatography (ERCP) in 2011-2012 as a result of suspected CBD stones were enrolled prospectively in a clinical database. Data such as imaging test findings and liver function tests (LFTs) were collected 48 h prior to and on the day of ERCP. Patients were stratified into different risk groups for harboring CBD stones according to three clinical algorithms using imaging and laboratory data. Findings on ERCP were used as gold standard. Performance characteristics of each algorithm were separately calculated for each time point of LFT assessment.

RESULTS

Overall, 186 patients were analyzed, 75% of whom presented CBD stones on ERCP. Proportion of patients categorized as high-risk for harboring CBD stones varied among the three algorithms (67% vs 73% vs 56%). Also, the algorithms showed only moderate, albeit comparable, accuracy for predicting the presence of CBD stones (0.65, 95% confidence interval [CI] 0.62-0.68 vs 0.68, 95% CI 0.63-0.67 vs 0.59, 95% CI 0.57-0.61). Similar results were obtained when performance characteristics were recalculated using LFT from 48 h prior to ERCP (data not shown).

CONCLUSION

Three diagnostic algorithms commonly used for predicting CBD stones have comparable but only moderate accuracy. Further research is warranted to improve risk stratification of patients with suspected CBD stones.

Accuracy of Imaging Modalities in Choledocholithiasis: A Real-Life Data

In this retrospective study of real-life data, we aimed to determine the diagnostic accuracy in patients with choledocholithiasis of some current imaging modalities, including ultrasonography (US), computerized tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP). This study utilized a database of imaging records from 86 consecutive patients with ERCP-proven choledocholithiasis in a single-center outpatient clinic. Features of the stones found, namely number, size, localization, choledochal dilation and cholestasis, were determined using various imaging modalities and liver function tests (LFTs). Our study focused on a total of 86 patients (43 female; 43 male) who underwent the ERCP procedure. Hepatobiliary ultrasound was performed in 71 (82.6%); MRCP in 59 (68.6%); and CT in 13 (15.1%) patients. All 86 patients had choledocholithiasis: 59 (68.6%) with multiple stones and 21 (24.4%) with stones over 10 mm in diameter. Sensitivity for the presence of choledocholithiasis was 40.8% for US, 76.9% for CT, and 86.4% for MRCP, where ERCP was taken as the reference method. Even though US, CT, and MRCP are widely used as noninvasive imaging modalities for CL, in our real-life data their sensitivity for choledocholithiasis was lower than expected. MRCP is preferred when a nontherapeutic but only diagnostic evaluation is aimed for; however, while highly competent in establishing the level of choledochal dilation, it had a low yield in differentiating the localization, size, and number of the stone(s).

The role of endoscopic ultrasound in children with Pancreatobiliary and gastrointestinal disorders: a single center series and review of the literature

BACKGROUND

The role of endoscopic ultrasound (EUS) in the management of pancreatobiliary and digestive diseases is well established in adults, but it remains limited in children. The aim of this study was to evaluate the feasibility, safety, and clinical impact of EUS use in children.

METHODS

This is a retrospective analysis of a prospectively acquired database of consecutive pediatric (< 18 years) patients presenting an indication for EUS for pancreatobiliary and gastrointestinal disorders.

RESULTS

Between January 2010 and January 2016, 47 procedures were performed in 40 children (mean age of 15.1 ± 4.7 years; range 3-18). The majority of EUS (n = 32; 68.1%) were performed for pancreatobiliary and upper gastrointestinal pathologies, including suspected common bile duct stones (CBDs), acute biliary pancreatitis, recurrent/chronic pancreatitis, cystic pancreatic mass, recurrent hypoglycemia, duodenal polyp, gastric submucosal lesion, and perigastric abscess. In only 2 out of 18 children with suspected CBDs or acute biliary pancreatitis, EUS confirmed CBDs. EUS-guided fine needle aspiration was performed in 3 (6.4%) patients. Fifteen (31.9%) procedures were performed for lower gastrointestinal tract disorders, including suspected anal Crohn's disease, fecal incontinence, and encopresis. Overall, EUS had a significant impact on the subsequent clinical management in 87.2% of patients.

CONCLUSION

The present findings were consistent with results observed in the current relevant literature and support EUS as a safe and feasible diagnostic and therapeutic tool, which yields a significant clinical impact in children with pancreatobiliary and gastrointestinal disorders.

Endoscopic Ultrasonography Can Prevent Unnecessary Diagnostic Endoscopic Retrograde Cholangiopancreatography Even in Patients with High Likelihood of Choledocholithiasis and Inconclusive Ultrasonography: Results of a Prospective Study

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is the initial therapy recommended for patients with high likelihood of choledocholithiasis. To determine whether endoscopic ultrasonography (EUS) can prevent diagnostic ERCPs in patients with high probability of choledocholithiasis and inconclusive ultrasonography (US).

Methods

All patients with high likelihood of choledocholithiasis and negative US underwent EUS. ERCP was performed for the patients who showed a definite stone/sludge on EUS. Patients without choledocholithiasis were followed up for 3 months. The primary outcome was avoidance of diagnostic ERCP.

Results

We included 78 patients (51 women; 27 men). Of these, 25 and 7 (total 41%) were diagnosed with choledocholithiasis and sludge, respectively; stone/sludge was removed in 96.9% of the patients. EUS ruled out choledocholithiasis in 38 patients (48.7%). Two of them were found to have choledocholithiasis on follow-up. The sensitivity, specificity, positive and negative predictive value of EUS for detecting choledocholithiasis were 93.9%, 97.3%, 96.9%, and 94.7%, respectively. Unnecessary ERCP was avoided in 57.7% of the patients by using the EUS-first approach.

Conclusions

EUS is a highly accurate and safe procedure. EUS can replace ERCP as the initial investigation in patients with a high probability of choledocholithiasis. It avoids unnecessary ERCP; hence, decreasing related costs and complications.

Role and timing of endoscopy in acute biliary pancreatitis

The role and timing of endoscopy in the setting of acute biliary pancreatitis (ABP) is still being debated. Despite numerous randomized trials have been published, there is an obvious lack of consensus on the indications and timing of endoscopic retrograde cholangiopancreatography (ERCP) in ABP in meta-analyses and nationwide guidelines. The present editorial has been written to clarify the role of endoscopy in ABP. In clinical practice the decision to perform an ERCP is often based on biochemical and radiological criteria despite they already have been shown to be unreliable predictors of common bile duct stone presence. Endoscopic ultrasonography (EUS) is not currently a worldwide standard diagnostic procedure early in the course of acute biliary pancreatitis, but it has been shown to be accurate, safe and cost effective in diagnosing biliary obstructions compared with magnetic resonance cholangiopancreatography and ERCP and therefore in preventing unnecessary ERCP and its related complications. Early EUS in ABP allows, if appropriate, immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.

Early endoscopic ultrasonography in acute biliary pancreatitis: A prospective pilot study

AIM: To investigate the clinical usefulness of early endoscopic ultrasonography (EUS) in the management of acute biliary pancreatitis (ABP).

METHODS: All consecutive patients entering the emergency department between January 2010 and December 2012 due to acute abdominal pain and showing biochemical and/or radiological findings consistent with possible ABP were prospectively enrolled. Patients were classified as having a low, moderate, or high probability of common bile duct (CBD) stones, according to the established risk stratification. Exclusion criteria were: gastrectomy or patient in whom the cause of biliary obstruction was already identified by ultrasonography. All enrolled patients underwent EUS within 48 h of their admission. Endoscopic retrograde cholangiopancreatography was performed immediately after EUS only in those cases with proven CBD stones or sludge. The following parameters were investigated: (1) clinical: age, sex, fever; (2) radiological: dilated CBD; and (3) biochemical: bilirubin, AST, ALT, gGT, ALP, amylase, lipasis, PCR. Association between presence of CBD stone at EUS and the individual predictors were assessed by univariate logistic regression. Predictors significantly associated with CBD stones (P < 0.05) were entered in a multivariate logistic regression model.

RESULTS: A total of 181 patients with pancreatitis were admitted to the emergency department between January 2010 and December 2012. After exclusion criteria a total of 71 patients (38 females, 53.5%, mean age 58 ± 20.12 years, range 27-89 years; 33 males, 46.5%, mean age 65 ± 11.86 years, range 41-91 years) were included in the present study. The probability of CBD stones was considered low in 21 cases (29%), moderate in 26 (37%), and high in the remaining 24 (34%). The 71 patients included in the study underwent EUS, which allowed for a complete evaluation of the target sites in all the cases. The procedure was completed in a mean time of 14.7 min (range 9-34 min), without any notable complications.The overall CBD stone frequency was 44% (31 of 71), with a significant increase from the group at low pretest probability to that at moderate (OR = 5.79, P = 0.01) and high (OR = 4.25, P = 0.03) pretest probability.

CONCLUSION: Early EUS in ABP allows, if appropriate, immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.

Predicting the likelihood of a persistent bile duct stone in patients with suspected choledocholithiasis: accuracy of existing guidelines and the impact of laboratory trends

BACKGROUND

Existing guidelines aim to stratify the likelihood of choledocholithiasis to guide the use of ERCP versus a lower-risk diagnostic study such as EUS, MRCP, or intraoperative cholangiography.

OBJECTIVE

To assess the performance of existing guidelines in predicting choledocholithiasis and to determine whether trends in laboratory parameters improve diagnostic accuracy.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care hospital.

PATIENTS

Hospitalized patients presenting with suspected choledocholithiasis over a 6-year period.

INTERVENTIONS

Assessment of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, its component variables, and laboratory trends in predicting choledocholithiasis.

MAIN OUTCOME MEASUREMENTS

The presence of choledocholithiasis confirmed by EUS, MRCP, or ERCP.

RESULTS

A total of 179 (35.9%) of the 498 eligible patients met ASGE high-probability criteria for choledocholithiasis on initial presentation. Of those, 99 patients (56.3%) had a stone/sludge on subsequent confirmatory test. Of patients not meeting high-probability criteria on presentation, 111 (34.8%) had a stone/sludge. The overall accuracy of the guidelines in detecting choledocholithiasis was 62.1% (47.4% sensitivity, 73% specificity) based on data available at presentation. The accuracy was unchanged when incorporating the second set of liver chemistries obtained after admission (63.2%), suggesting that laboratory trends do not improve performance.

LIMITATIONS

Retrospective study, inconsistent timing of the second set of biochemical markers.

CONCLUSION

In our cohort of patients, existing choledocholithiasis guidelines lacked diagnostic accuracy, likely resulting in overuse of ERCP. Incorporation of laboratory trends did not improve performance. Additional research focused on risk stratification is necessary to meet the goal of eliminating unnecessary diagnostic ERCP.