The diameter of common bile duct does not predict the cause of extrahepatic cholestasis. Surg Laparosc Endosc Percutan Tech. 2009;19:25-28. [PMID: 19238062 DOI: 10.1097/sle.0b013e31818a6685]

Clinical utility of linear endosonography in patients with unexplained biliary dilatation and negative MRCP, with predictors for detection of neoplastic lesions

Background and study aims

Unexplained biliary dilatation (UBD) frequently represents a diagnostic dilemma. Linear endosonography (EUS), with its close proximity to the pancreaticobiliary system and the ability for tissue acquisition, could have a role in revealing etiologies of UBD particularly in the context of negative other non-invasive modalities. However, in such patients, the decision for this semi-invasive procedure is usually debatable and often needs justification. Thus, we aimed to evaluate the diagnostic utility of linear EUS in patients with UBD after negative magnetic resonance cholangiopancreatography (MRCP) and to delineate predictors for EUS ability to detect neoplastic lesions.

Patients and methods

This was a prospective diagnostic observational study between 2018 and 2021. Included patients with evidence of biliary dilatation on abdominal ultrasound and negative MRCP underwent linear EUS examination. Results were compared to the final diagnosis relied on histopathology after EUS-guided biopsy or surgery for neoplastic lesions, while ERCP, diagnostic EUS criteria plus histopathology for autoimmune pancreatitis, Rosemont criteria for chronic pancreatitis, and/or follow-up for 6 months were the gold standard tests for non-neoplastic etiologies. Logistic regression was conducted to reveal predictors of neoplasm detection by EUS.

Results

Sixty-one patients (mean age 60 years, 32 females) were enrolled; 13.1% of them were asymptomatic. The final diagnosis was categorized into 29 patients with and 32 without neoplasms. Sensitivity, specificity, positive, negative predictive values (PPV, NPV), and accuracy of EUS-positive findings were 98.3%, 100%, 100%, 66.7%, and 98.3%, respectively. Corresponding results for neoplasm identification were 100%, 93.8%, 93.5%, 100%, and 96.7%, respectively. The most common neoplastic etiologies were small pancreatic and ampullary masses. Common bile duct (CBD) diameter > 12.9mm and CA19-9 > 37.1 u/ML were independent predictors for pancreaticobiliary neoplasm at multivariate regression analysis.

Conclusion

Linear EUS appears to have a high accuracy in detecting etiologies of UBD, with higher sensitivity for small pancreatic, ampullary lesions, and CBD stones. CBD diameter > 12.9 mm and elevated CA19-9 > 37.1 u/ML should raise a concern about the presence of occult pancreaticobiliary neoplasm, and then, EUS may be warranted even in asymptomatic patients.

Is preoperative MRCP necessary for patients with gallstones? An analysis of the factors related to missed diagnosis of choledocholithiasis by preoperative ultrasound

Background

The diagnosis of associated choledocholithiasis prior to cholecystectomy for patients with gallstones is important for the surgical decision and treatment efficacy. However, whether ultrasound is sufficient for preoperative diagnosis of choledocholithiasis remains controversial, with different opinions on whether routine magnetic resonance cholangiopancreatography (MRCP) is needed to detect the possible presence of common bile duct (CBD) stones.

Methods

In this study, a total of 413 patients with gallstones who were admitted to the Department of General Surgery of the First Affiliated Hospital of Harbin Medical University in China for a period of 3 years and underwent both ultrasound and MRCP examinations were retrospectively analysed. After reviewing and screening these cases according to the literature, 11 indicators including gender, age, alanine aminotransferase, aspartate aminotransferase, total bilirubin, direct bilirubin, indirect bilirubin, alkaline phosphatase, γ-aminotransferase, CBD diameter, and concurrent acute cholecystitis were selected and comparatively analysed.

Results

Among the 413 patients, a total of 109 cases showed concurrent gallstones and choledocholithiasis, accounting for 26.39 % of all cases. Among them, 60 cases of choledocholithiasis were revealed by ultrasound examination, accounting for 55.05 %, while 49 cases of choledocholithiasis were not detected by ultrasound examination but were confirmed by MRCP instead (the missed diagnosis rate of ultrasound was 44.95 %). The results of statistical analysis suggested that alanine aminotransferase, acute cholecystitis, and CBD diameter were the three most relevant factors for missed diagnosis by ultrasound.

Conclusion

The accuracy of preoperative ultrasonography for the diagnosis of associated CBD stones for patients with gallstones is not high. However, elevated alanine aminotransferase, concurrent acute cholecystitis, and CBD diameter were identified as key factors that may affect the accuracy of the diagnosis. Thus, routine preoperative MRCP examination is suggested for patients with gallstones to rule out possible concomitant CBD stones.

Cholangiographic characteristics of common bile duct dilatation in children

AIM: To investigate whether children with congenital common bile duct dilatation (CBDD) differ from children with obstructive CBDD in cholangiographic characteristics.

METHODS: In this retrospective cohort study, the baseline data and the results of imaging analyses were reviewed among children who had endoscopic retrograde cholangiopancreatography (ERCP) due to CBDD. ERCP was performed on all pediatric patients by experienced pediatric endoscopists. The maximal transverse diameter of the common bile duct (CBD) was measured on ERCP. To assess whether age-adjusted CBDD could be used for differential diagnosis, a CBDD severity index (SI) was calculated by dividing the measured CBD diameter by the age-corrected maximal diameter of a normal CBD.

RESULTS: A retrospective medical chart review revealed that 85 consecutive children under 16 years of age with hepatobiliary disease and CBDD were referred to Seoul Asan Medical Center. Fifty-five (64.7%) children had congenital CBDD and 30 (35.3%) had obstructive CBDD. The two groups did not differ significantly in terms of clinical characteristics except for sex. The congenital and obstructive CBDD groups did not differ significantly in terms of mean CBD diameter (19.3 ± 9.6 mm vs 12.2 ± 4.1 mm, P > 0.05). However, congenital CBDD cases had a significantly higher mean SI than obstructive CBDD cases (3.62 ± 1.64 vs 1.98 ± 0.71, P = 0.01). In multivariate analysis, an SI value ≥ 2.32 and comorbidity with anomalous union of pancreaticobiliary duct (APBDU) in ERCP independently predicted congenital CBDD.

CONCLUSION: Measuring the CBD may aid the differential diagnosis of both CBDD and APBDU in children.

Endosonography for suspected obstructive jaundice with no definite pathology on ultrasonography

BACKGROUND/PURPOSE

Ultrasonography (US) cannot demonstrate all the etiologies of biliary tract dilatation in patients with jaundice. Thus, we evaluated the etiologic yield of endosonography (EUS) for suspected obstructive jaundice when no definite pathology was found on US. Additionally, we sought to identify the predictors of the most common etiologies.

METHODS

We performed a retrospective review of 123 consecutive patients who had undergone EUS for suspected obstructive jaundice when no definite pathology was identified on US.

RESULTS

The most common diagnoses included no pathological obstruction (n = 43), pancreatobiliary malignancy (n = 41), and choledocholithiasis (n = 28). Pancreatobiliary malignancy was associated with common bile duct (CBD) dilatation, and fever and elevated alanine aminotransferase were predictors of choledocholithiasis (p < 0.05). The accuracy of EUS was 95.9% (118/123) for overall cause of suspected obstructive jaundice, 100% (40/40) for no pathological finding, 100% (23/23) for ampullary cancer, 100% (13/13) for pancreatic cancer, 75% (3/4) for CBD cancer, and 92.9% (26/28) for choledocholithiasis, respectively. Besides the two patients with focal chronic pancreatitis misdiagnosed as with pancreatic cancer, EUS missed the lesions in one CBD cancer patient and two patients with choledocholithiasis. The overall accuracy of EUS in ascertaining pancreatobiliary malignancy and choledocholithiasis was comparable (97.6%, 40/41 vs. 92.9%, 26/28; p > 0.05).

CONCLUSION

Marked CBD dilatation (≥12 mm) should remind us of the high risk of malignancy, and the presence of CBD dilatation and fever is suggestive of choledocholithiasis. Negative EUS findings cannot assure any pathological obstruction in patients with clinically suspected obstructive jaundice.