EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain

Comparison of Endoscopic Ultrasound and Transabdominal Ultrasound in the Detection of Gallbladder and Common Bile Duct Microlithiasis

OBJECTIVE

Endoscopic ultrasonography (EUS) is an emerging method with a wide range of potential uses in gastroenterology, including the detection of bile duct stones and the identification of early ductal alterations in suspected patients. This study was designed to compare the diagnostic yield of EUS and transabdominal ultrasound (TUS) in the detection of gallbladder and common bile duct (CBD) microlithiasis.

METHOD

Patients with biliary colic with normal initial TUS were the subjects of this prospective study. EUS scan was performed on all recruited patients and linear endoscopes were used for the EUS examination. Cholecystectomy and histological analysis were done in patients within two weeks after EUS revealing cholelithiasis whereas the cases of CBD stone/microlithiasis were confirmed by endoscopic retrograde cholangiopancreatography (ERCP). The mean values of all hematological characteristics were independently determined for males and females and then compared using Student's t-test. For statistical significance, a p-value of 0.05 or below was used.

RESULTS

A total of 131 patients, including 77 females and 54 males, with a mean age of 38.41 ± 14.78 years were examined. All 78 (59.5%) individuals who had cholecystectomy were found to have gallstones or microlithiasis as successfully diagnosed by EUS. The sensitivity and specificity of EUS were 92.9% and 100%, respectively, for CBD stones and 98.8% and 100%, respectively, for the detection of gallbladder microlithiasis. The agreement between EUS and TUS was fair for CBD stones (κ = 0.214) and very weak for microlithiasis (κ = -0.093).

CONCLUSION

EUS demonstrates a superior yield over TUS in detecting gallbladder stones and CBD microlithiasis, offering a more reliable diagnostic modality.

LIMITATION

This was a single-center study.

Etiological Diagnosis of Linear-Array Endoscopic Ultrasonography in Distal Common Bile Duct Dilatation

ABSTRACT

The etiology of distal common bile duct (CBD) dilatation is complex. Linear-array endoscopic ultrasonography (EUS) can not only visualize the distal and surrounding structures of the bile duct closely but also obtain pathological specimens by fine-needle aspiration, which provides an important basis for the diagnosis and differential diagnosis. The purpose of this study was to evaluate the diagnostic value of linear-array EUS in the etiology of distal CBD dilatation. Patients with distal CBD dilatation underwent linear-array EUS in the endoscopic center of The Second Affiliated Hospital of Soochow University and Traditional Chinese Medicine Hospital of Kunshan were collected from January 2015 to June 2019. The pathology results after surgery, endoscopic pathology, computed tomography (CT), and magnetic resonance imaging (MRI) results were retrospectively analyzed. The diagnostic accuracy of linear-array EUS and CT or MRI was compared. For the diagnosis of choledocholithiasis, the diagnostic accuracy of linear-array EUS was 97.5%, which was significantly higher than that of MRI (86.36%) and CT (89.74) (P < 0.001 and 0.006, respectively). The diagnostic accuracy of linear-array EUS for periampullary tumors was 93.75%, which was higher than MRI and CT with an accuracy of 82.73% and 80.34% (P = 0.004 and 0.001, respectively). Linear EUS was effective for the etiological diagnosis of distal CBD dilatation.

Depictability of the upper gastrointestinal tract on forward‐viewing radial endoscopic ultrasonography versus standard upper esophagogastroduodenoscopy

Objectives

Esophagogastroduodenoscopy (EGD) is a widely used modality for investigating the upper gastrointestinal (GI) tract, similar to endoscopic ultrasonography (EUS) for the pancreaticobiliary system. A recent and novel forward‐viewing radial EUS has potential as an EGD. However, this potential has not yet been evaluated and reported in the literature. We compared the depictability of the upper GI tract on EUS using a standard EGD.

Methods

This was a prospective study in a single session in an identical patient and it was conducted at a single center.

Results

Sixty‐nine participants were enrolled in this study. A forward‐viewing radial EUS revealed equivalent visualizing performance compared with the standard EGD, except for the retroflex view of the three angular areas. Depiction scores of the anterior wall, lesser curvature, and posterior wall of the angulus in the retroflex view in the forward‐viewing radial EUS were 1.94 (95% confidence interval [CI], 1.36–2.52), 2.03 (95% CI, 1.48–2.58), and 1.93 (95% CI, 1.35–2.50), respectively. These scores were significantly lower compared with those of standard EGD scores of 2.97 (95% CI, 2.86–3.08), 2.97 (95% CI, 2.86–3.78), and 2.96 (95% CI, 2.83–3.09], respectively; p < 0.001). The rate of full‐mark score in these three angular areas was significantly lower in the forward‐viewing radial EUS than in the standard EGD (21/69, 30.4%; 23/69, 33.3%; 21/69, 30.4% vs. 67/69; 97.1%, 67/69; 97.1%, 66/69; 95.7%, p < 0.001 for all).

Conclusions

Although forward‐viewing radial EUS has the potential to simultaneously investigate the upper GI and pancreaticobiliary systems, it is too early to introduce it for this purpose.

What should be known prior to performing EUS?

Direct referral of patients for EUS – instead of preprocedural consultation with the endosonographer – has become standard practice (like for other endoscopic procedures) as it is time- and cost-effective. To ensure appropriate indications and safe examinations, the endosonographer should carefully consider what information is needed before accepting the referral. This includes important clinical data regarding relevant comorbidities, the fitness of the patient to consent and undergo the procedure, and the anticoagulation status. In addition, relevant findings from other imaging methods to clarify the clinical question may be necessary. Appropriate knowledge and management of the patients’ anticoagulation and antiplatelet therapy, antibiotic prophylaxis, and sedation issues can avoid unnecessary delays and unsafe procedures. Insisting on optimal preparation, appropriate indications, and clear clinical referral questions will increase the quality of the outcomes of EUS. In this paper, important practical issues regarding EUS preparations are raised and discussed from different points of view.

What should be known prior to performing EUS exams? (Part II)

In “What should be known prior to performing EUS exams, Part I,” the authors discussed the need for clinical information and whether other imaging modalities are required before embarking EUS examinations. Herewith, we present part II which addresses some (technical) controversies how EUS is performed and discuss from different points of view providing the relevant evidence as available. (1) Does equipment design influence the complication rate? (2) Should we have a standardized screen orientation? (3) Radial EUS versus longitudinal (linear) EUS. (4) Should we search for incidental findings using EUS?

The Clinical Utility of Evaluating the Luminal Upper Gastrointestinal Tract During Linear Endoscopic Ultrasonography

BACKGROUND

The clinical utility of performing esophagogastroduodenoscopy (EGD) before linear endoscopic ultrasonography (L-EUS) to evaluate the luminal upper gastrointestinal (GI) tract is not well established.

GOALS

The study was aimed to determine the prevalence of clinically meaningful luminal abnormalities (any luminal finding requiring further evaluation with mucosal biopsy or initiation of treatment) in patients undergoing L-EUS. The study also sought to compare the ability of the gastroscope and the linear echoendoscope in identifying these lesions.

STUDY

A prospective, multicenter cohort study enrolled patients undergoing L-EUS for nonluminal indications. All patients underwent EGD followed by L-EUS by 2 different endoscopists. The second endoscopist was blinded to the results of the initial EGD. The identification of clinically meaningful luminal lesions and quality of endoscopic visualization of the upper GI tract were measured.

RESULTS

In the cohort of 175 patients, 52 (29.7%) patients had clinically meaningful luminal findings seen in the upper GI tract. There was no significant difference in the number of clinically meaningful lesions identified on EGD and L-EUS (25.1% vs. 22.9%, P=0.39). No significant difference was found in the miss rate of clinically meaningful lesions between the 2 modalities (EGD: 4.5% vs. EUS: 6.9%, P=0.39).

CONCLUSIONS

A substantial minority of patients undergoing L-EUS for nonluminal indications will have clinically meaningful luminal findings. The endoscopic evaluation of the luminal upper GI tract can be adequately achieved using the linear echoendoscope.

Performing forward-viewing endoscopy at time of pancreaticobiliary EUS and ERCP may detect additional upper gastrointestinal lesions

BACKGROUND AND STUDY AIMS

It is unknown whether significant incidental upper gastrointestinal lesions are missed when using non-forward-viewing endoscopes without completing a forward-viewing exam in linear endoscopic ultrasound (EUS) or endoscopic retrograde cholangiopancreatography (ERCP) exams. We evaluated whether significant upper GI lesions are missed during EUS and ERCP when upper endoscopy is not performed routinely with a gastroscope.

PATIENTS AND METHODS

A retrospective analysis was performed in which an EGD with a forward-viewing gastroscope was performed after using a non-forward-viewing endoscope (linear echoendoscope, duodenoscope, or both) during a single procedure. Upper gastrointestinal tract findings were recorded separately for each procedure. Significant lesions found with a forward-viewing gastroscope were defined as findings that led to a change in the patient's medication regimen, additional endoscopic surveillance/interventions, or the need for other imaging studies.

RESULTS

A total of 168 patients were evaluated. In 83 patients, a linear echoendoscope was used, in 52 patients a duodenoscope was used, and in 33 patients both devices were used. Clinically significant additional lesions diagnosed with a gastroscope but missed by a non-forward-viewing endoscope were found in 30 /168 patients (18 %). EGD after linear EUS resulted in additional lesion findings in 17 /83 patients (20.5 %, χ(2) = 13.385, P = 0.00025). EGD after use of a duodenoscope resulted in additional lesions findings in 10 /52 patients (19.2 %, χ(2) = 9.987, P = 0.00157). EGD after the use of both a linear echoendoscope and a duodenoscope resulted in additional lesions findings in 3/33 patients (9 %, χ(2) = 3.219, P = 0.07).

CONCLUSION

Non forward-viewing endoscopes miss a significant amount of incidental upper gastrointestinal lesions during pancreaticobiliary endoscopy. Performing an EGD with a gastroscope at the time of linear EUS or ERCP can lead to increased yield of upper gastrointestinal lesions.

Endoscopic or surgical intervention for painful obstructive chronic pancreatitis

BACKGROUND

Endoscopy and surgery are the treatment modalities of choice for patients with chronic pancreatitis and dilated pancreatic duct (obstructive chronic pancreatitis). Physicians face, without clear consensus, the choice between endoscopy or surgery for this group of patients.

OBJECTIVES

To assess and compare the effects and complications of surgical and endoscopic interventions in the management of pain for obstructive chronic pancreatitis.

SEARCH METHODS

We searched the following databases in The Cochrane Library: CENTRAL (2014, Issue 2), the Cochrane Database of Systematic Reviews (2014, Issue 2), and DARE (2014, Issue 2). We also searched the following databases up to 25 March 2014: MEDLINE (from 1950), Embase (from 1980), and the Conference Proceedings Citation Index - Science (CPCI-S) (from 1990). We performed a cross-reference search. Two review authors independently performed the selection of trials.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of endoscopic or surgical interventions in obstructive chronic pancreatitis. We included trials comparing endoscopic versus surgical interventions as well as trials comparing either endoscopic or surgical interventions to conservative treatment (i.e. non-invasive treatment modalities). We included relevant trials irrespective of blinding, the number of participants randomised, and the language of the article.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. Two authors independently extracted data from the articles. We evaluated the methodological quality of the included trials and requested additional information from study authors in the case of missing data.

MAIN RESULTS

We identified three eligible trials. Two trials compared endoscopic intervention with surgical intervention and included a total of 111 participants: 55 in the endoscopic group and 56 in the surgical group. Compared with the endoscopic group, the surgical group had a higher proportion of participants with pain relief, both at middle/long-term follow-up (two to five years: risk ratio (RR) 1.62, 95% confidence interval (CI) 1.22 to 2.15) and long-term follow-up (≥ five years, RR 1.56, 95% CI 1.18 to 2.05). Surgical intervention resulted in improved quality of life and improved preservation of exocrine pancreatic function at middle/long-term follow-up (two to five years), but not at long-term follow-up (≥ 5 years). No differences were found in terms of major post-interventional complications or mortality, although the number of participants did not allow for this to be reliably evaluated. One trial, including 32 participants, compared surgical intervention with conservative treatment: 17 in the surgical group and 15 in the conservative group. The trial showed that surgical intervention resulted in a higher percentage of participants with pain relief and better preservation of pancreatic function. The trial had methodological limitations, and the number of participants was relatively small.

AUTHORS' CONCLUSIONS

For patients with obstructive chronic pancreatitis and dilated pancreatic duct, this review shows that surgery is superior to endoscopy in terms of pain relief. Morbidity and mortality seem not to differ between the two intervention modalities, but the small trials identified do not provide sufficient power to detect the small differences expected in this outcome.Regarding the comparison of surgical intervention versus conservative treatment, this review has shown that surgical intervention in an early stage of chronic pancreatitis is a promising approach in terms of pain relief and pancreatic function. Other trials need to confirm these results because of the methodological limitations and limited number of participants assessed in the present evidence.

Initial experience of direct-to-test endoscopic ultrasonography for suspected choledocholithiasis

BACKGROUND AND AIMS

Endoscopic ultrasound has become an invaluable tool in the investigation of patients with suspected pancreatobiliary disease. We set out to determine whether a "direct-to-test" endoscopic ultrasound procedure could be offered to selected patients with suspected choledocholithiasis.

METHODS AND RESULTS

We included patients referred to our general gastroenterology service with clinical history, symptomatology and/or laboratory results compatible with choledocholithiais. Almost all patients had already had a transabdominal ultrasound performed at the request of their general practitioner. All patients underwent direct-to-test day-case endoscopic ultrasound under conscious sedation. Procedures were performed by a single practitioner using an oblique-viewing radial echoendoscope. The diagnostic yield and frequencies of discharge, onward referral and follow-up were determined. Overall diagnostic yield of direct-to-test endoscopic ultrasound was 61%. The most common diagnoses were cholelithiasis (18%) and choledocholithiasis (11%); one periampullary cancer was also detected. A definitive outcome (discharge or referral for a therapeutic procedure) occurred in 14 of 28 patients (50%). The remaining 14 patients underwent further out-patient evaluation. Eventual diagnoses in this group included autoimmune hepatitis, primary biliary cirrhosis and drug-induced hepatitis.

CONCLUSIONS

For patients with suspected biliary disease, direct-to-test endoscopic ultrasound has a high diagnostic yield, and may be an appropriate mode of investigation.

Endoscopic ultrasound in the evaluation of chronic upper abdominal pain of unknown etiology: a retrospective chart review examining the efficacy of EUS in determining a new diagnosis

GOALS

To explore the utility of endoscopic ultrasound (EUS) in the evaluation of chronic upper abdominal pain (UAP) of undetermined etiology.

BACKGROUND

Chronic UAP is a common problem with a challenging diagnosis and management. The role of EUS in the diagnosis of UAP may minimize additional testing; however, few studies describe the percentage of new diagnoses yielded in these patients.

STUDY

We conducted a retrospective analysis by reviewing electronic medical records at Scott and White Memorial Hospital, Texas A&M Health Sciences Center for patients with abdominal pain for ≥ 12 months not explained by previous workup referred for EUS for chronic UAP from January 1, 1998 through October 1, 2007. Patients with previous EUS in past 12 months were excluded from the study. Patient demographic data and imaging performed 6 months before and 24 months after EUS were reviewed and results documented.

RESULTS

EUS was successful at diagnosing a new clinical etiology of chronic UAP in 33 patients (8.89%) with previous workup that was unrevealing for a definitive diagnosis. The most frequent diagnoses included pancreaticobiliary tree abnormalities, chronic pancreatitis, and fatty liver disease.

CONCLUSIONS

Our results support the fact that the majority of patients UAP with prior imaging will have no identifiable organic etiology found on EUS to explain their pain; however, we suggest that EUS be considered in patients with suspected pancreatic or biliary pathology.

Endoscopic ultrasound, the one-stop shop for abdominal pain?

The Endosonography for Right Sided and Acute Upper Intestinal Misery (EFRAIM) study indicates that the yield of endoscopic ultrasound (EUS) is equivalent if not superior to upper endoscopy combined with transabdominal ultrasound in patients presenting with acute discomfort. Furthermore, this strategy may be more cost effective as EUS simultaneously enables assessment of intraluminal disease as well as extra intestinal pathology. These results are in sync with prior studies demonstrating the hegemony of EUS in the assessment of pancreaticobiliary disease and its role in the assessment of enigmatic chronic abdominal pain. Nevertheless, EUS does not permit assessment for appendicitis or genitourinary catastrophe. Thus a careful history and physical examination to localize pain to the right upper quadrant and epigastrium is essential.

Endosonography For Right-sided and Acute Upper Intestinal Misery: the EFRAIM study: A prospective, randomized, controlled, blinded study

BACKGROUND

Acute upper abdominal pain is a frequent symptom leading to hospital admission.

OBJECTIVE

To determine whether a primary intra- and extraluminal diagnostic approach enabled by endoscopic ultrasound is as effective as a conventional diagnostic algorithm of transabdominal ultrasound followed by oesophagogastroduodenoscopy.

METHODS

A total of 240 patients who presented with acute right-sided and/or upper abdominal pain were prospectively recruited. Exclusion criteria were chronic pain, malignancy, prior abdominal surgery, bleeding, peritonitis, and elevated liver enzymes or lipase as defined 3-times higher than upper reference value. All patients underwent first transabdominal ultrasound and were then randomized (1 : 1) to either endoscopy followed by endoscopic ultrasound or vice versa. Patients and respective examiners were blinded to prior findings.

RESULTS

A total of 223 patients were included. Endoscopic ultrasound provided a higher diagnostic yield than the combination of transabdominal ultrasound and endoscopy (62.3 vs. 50.7%; p = 0.001). For mucosal/intraluminal lesions, we observed a very good agreement between both endoscopic modalities (kappa 0.89). The agreement for pancreatic and biliary causes was good between both ultrasound modalities (kappa 0.66).

CONCLUSIONS

Due to its high diagnostic yield, endoscopic ultrasound as a primary diagnostic modality appears to be a valuable option in patients with acute upper abdominal pain.

Endoscopic or surgical intervention for painful obstructive chronic pancreatitis

BACKGROUND

Endoscopy and surgery are the treatment modalities of choice in patients with obstructive chronic pancreatitis. Physicians face the decision between endoscopy and surgery for this group of patients, without clear consensus.

OBJECTIVES

To assess and compare the effectiveness and complications of surgical and endoscopic interventions in the management of pain for obstructive chronic pancreatitis.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE and the Conference Proceedings Citation Index; and performed a cross-reference search. Two review authors performed the selection of trials independently.

SELECTION CRITERIA

All randomised controlled trials (RCTs) investigating endoscopic or surgical interventions for obstructive chronic pancreatitis. All trials were included irrespective of blinding, number of patients randomised and language of the article.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data from the articles. The methodological quality of included trials was evaluated. Authors were requested additional information in the case of missing data.

MAIN RESULTS

We screened 2082 publications and identified three eligible trials. Two trials compared endoscopic intervention to surgical intervention. These included a total of 111 patients, 55 in the endoscopic group and 56 in the surgical group. A higher proportion of patients with pain relief was found in the surgical group compared to the endoscopic group (partial or complete pain relief: RR 1.62, 95% confidence interval (CI) 1.11 to 2.37; complete pain relief: RR 2.45, 95% CI 1.18 to 5.09). Surgical intervention resulted in improved quality of life and improved preservation of exocrine pancreatic function in one trial. The number of patients did not allow for a reliable evaluation of morbidity and mortality between the two treatment modalities. One trial compared surgical intervention to conservative treatment. It included 32 patients: 17 in the surgical group and 15 in the conservative group. The trial showed that surgical intervention resulted in a higher percentage of patients with pain relief and better preservation of pancreatic function. The trial had methodological limitations and the number of patients was relatively small.

AUTHORS' CONCLUSIONS

For patients with obstructive chronic pancreatitis and dilated pancreatic duct, this review showed that surgery is superior to endoscopy in terms of pain control. Morbidity and mortality seemed not to differ between the two intervention modalities, but the small trials identified do not provide sufficient power to detect the small differences expected in this outcome.Regarding the comparison of surgical intervention versus conservative treatment, this review has shown that surgical intervention in an early stage of chronic pancreatitis seems to be a promising approach in terms of pain control and pancreatic function. Confirmation of these results is needed in other trials due to the methodological limitations and limited number of patients of the present evidence.