Comparison of endoscopic ultrasonography and magnetic resonance cholangiopancreatography in the diagnosis of pancreatobiliary diseases: a prospective study

Practice guidelines for managing extrahepatic biliary tract cancers

Backgrounds/Aims

Reported incidence of extrahepatic bile duct cancer is higher in Asians than in Western populations. Korea, in particular, is one of the countries with the highest incidence rates of extrahepatic bile duct cancer in the world. Although research and innovative therapeutic modalities for extrahepatic bile duct cancer are emerging, clinical guidelines are currently unavailable in Korea. The Korean Society of Hepato-Biliary-Pancreatic Surgery in collaboration with related societies (Korean Pancreatic and Biliary Surgery Society, Korean Society of Abdominal Radiology, Korean Society of Medical Oncology, Korean Society of Radiation Oncology, Korean Society of Pathologists, and Korean Society of Nuclear Medicine) decided to establish clinical guideline for extrahepatic bile duct cancer in June 2021.

Methods

Contents of the guidelines were developed through subgroup meetings for each key question and a preliminary draft was finalized through a Clinical Guidelines Committee workshop.

Results

In November 2021, the finalized draft was presented for public scrutiny during a formal hearing.

Conclusions

The extrahepatic guideline committee believed that this guideline could be helpful in the treatment of patients.

Magnetic resonance cholangiopancreatography versus endoscopic ultrasound for diagnosis of choledocholithiasis: an updated systematic review and meta-analysis

INTRODUCTION

Both endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are used for the diagnosis of choledocholithiasis (CDL). Previous studies have shown conflicting results regarding the optimal diagnostic strategy for suspected CDL; hence, this meta-analysis was conducted.

METHODS

A comprehensive search of literature from 1990 till April 2022 was done of three databases for studies comparing EUS and MRCP to diagnose CDL.

RESULTS

A total of 12 studies were identified. The pooled sensitivity and specificity for EUS were 0.96 [95% confidence interval (CI) 0.92-0.98], and 0.92 (95% CI 0.85-0.96), respectively. The pooled sensitivity and specificity for MRCP were 0.85 (95% CI 0.78-0.90) and 0.90 (95% CI 0.79-0.96), respectively. EUS had a higher relative sensitivity [Relative risk (RR) 1.12, 95% CI 1.05-1.19], a higher diagnostic accuracy (Odds ratio 1.98, 95% CI 1.35-2.90) but comparable specificity (RR 1.02, 95% CI 0.96-1.08) with MRCP.

CONCLUSION

There is little difference concerning specificity, although EUS likely provides a higher sensitivity and accuracy for diagnosing CDL, compared to MRCP.

Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for the diagnosis of computed tomography-negative common bile duct stone: Prospective randomized controlled trial

OBJECTIVES

For suspected common bile duct stone (CBDS) missed on computed tomography (CT), there is no clear evidence on whether endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) is the better diagnostic tool. We aimed to compare the diagnostic accuracy of EUS and MRCP for cases of missed CBDS on CT.

METHODS

Patients suspected of having CBDS were enrolled and randomly allocated to the EUS or MRCP group. Upon the initial examination, those having CBDS or sludge formation underwent endoscopic retrograde cholangiopancreatography (ERCP), while those who were CBDS-negative underwent a second examination with either MRCP or EUS, which was distinct from the initial diagnostic procedure. The primary outcome was diagnostic accuracy, and the secondary outcomes were diagnostic ability, detection rate and characteristics of CBDS in the second examination, and the frequency of adverse events.

RESULTS

Between April 2019 and January 2021, 50 patients were enrolled in the study. The accuracy was 92.3% for EUS and 68.4% for MRCP (P = 0.055). EUS showed 100% sensitivity, 88.2% specificity, 81.8% positive predictive value, and 100% negative predictive value, and MRCP showed 33.3% sensitivity, 84.6% specificity, 50% positive predictive value, and 73.3% negative predictive value. The CBDS detection rate in the second examination was 0% for MRCP after a negative EUS and 35.7% for EUS after a negative MRCP (P = 0.041). No adverse events occurred in any of the patients.

CONCLUSIONS

Endoscopic ultrasound may be a superior diagnostic tool compared to MRCP for the detection of CBDS that are undetected on CT. (UMIN000036357).

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.

Management of Patients With Common Bile Duct Dilatation Without a Sonographic Evident Cause: Evaluating the Yield of Subsequent Magnetic Resonance Imaging and Findings Correlated With Causative Pancreaticobiliary Pathology

OBJECTIVES

The aims of the study were to evaluate the yield of magnetic resonance imaging (MRI) in patients with common bile duct (CBD) dilatation without a sonographic evident cause and to investigate sonographic and laboratory findings at presentation that might predict identification of underlying pancreaticobiliary pathology.

METHODS

Included were consecutive patients in whom MRI was performed for further evaluation of CBD dilatation detected on ultrasound (US), without a sonographic evident cause, from January 1, 2014, to December 31, 2014. Magnetic resonance imaging and clinical data were retrospectively reviewed. Patients were divided into two groups: patients with and without identified underlying causative pancreaticobiliary pathology. Ultrasound findings and laboratory results at presentation were compared between groups to identify findings suggestive of underlying pancreaticobiliary pathology.

RESULTS

Fifty-seven patients, with a mean age of 54 ± 16 years including 37 females (65%), underwent MRI. Specific pancreaticobiliary causes for CBD dilatation were identified in 38 patients (66%, 31 benign and 7 malignant). In the remaining patients, no cause was identified in 17 (30%) and MRIs were nondiagnostic in 2 patients. Magnetic resonance imaging accuracy for correctly identifying the underlying cause of CBD dilatation was 91%. Patients with associated intrahepatic bile duct dilatation on US and elevated alanine aminotransferase and alkaline phosphatase were more likely to have underlying pancreaticobiliary pathology (P < 0 .05). No patient with initial negative MRI had pancreaticobiliary malignancy.

CONCLUSIONS

Magnetic resonance imaging seems to be an accurate noninvasive method for identifying the underlying cause in most patients with CBD dilatation on US and in excluding pancreaticobiliary malignancy. Patients with associated intrahepatic bile duct dilatation and/or elevated liver enzymes are at higher risk of harboring underlying pancreaticobiliary pathology.

Diagnostic accuracy of endoscopic ultrasound in evaluation of patients with obstructive jaundice: single-center experience

Background/aims

We prospectively evaluated the role of endoscopic ultrasound (EUS) in detecting the cause of common bile duct (CBD) dilatation in patients in whom trans-abdominal ultrasound (TUS) could not demonstrate the cause of dilation as a proper second step in the diagnostic workup of patients with obstructive jaundice compared to magnetic resonance cholangiopancreatography (MRCP).

Methods

This study was conducted on patients with obstructive jaundice admitted to the inpatient ward or the outpatient endoscopy unit of Theodor Bilharz Research Institute (TBRI) during the period between January 2019 and August 2019. A patient with obstructive jaundice and TUS showed CBD dilatation with internal diameter ≥ 7 mm and biliary stricture.

Results

During the period between January 2019 and August 2019, 136 were recruited; 8 patients who were pregnant and 3 patients who had gastric bypass surgery were excluded. Sixty-five patients were diagnosed confidently by TUS as biliary stones and were excluded from the analysis. Sixty patients with obstructive jaundice and indefinite etiology on TUS were included in the final analysis. The final diagnosis of patients was 38 patients (63.33%) of malignant etiology [26 pancreatic cancer (43.33%), 4 cholangiocarcinoma (6.66%), and 8 with ampullary cancer (13.33%)] and 22 patients (36.67%) of benign etiology [10 calcular obstruction (16.66%), 8 benign stricture (13.33%), and 4 pancreatitis (6.66%)]. The sensitivity and specificity values for malignant stricture detected by EUS were 100% and 86.36%, respectively, with positive predictive value of 92.68%, negative predictive value of 100%, and accuracy of 95%, while MRI showed 82.14% sensitivity and 25% specificity with positive predictive value of 79.31 and accuracy of 69.4%. EUS supported correct diagnosis in 57 patients (95%: CI 86.08 to 98.96%) while MRI did it in 36 patients (69.44%: CI 51.89% to 83.65%).Only 43 (71.7%) patients needed endoscopic retrograde cholangiopancreatography (ERCP) for management of obstructive jaundice, sparing 17 patients (28.3%) unnecessary invasive procedures.

Conclusions

EUS is a minimally invasive method with low incidence of complications with high diagnostic accuracy in patients with dilated CBD and normal MRCP.

EUS versus MRCP to perform ERCP in patients with intermediate likelihood of choledocholithiasis: a randomised controlled trial

OBJECTIVE

In patients with an intermediate likelihood of choledocholithiasis, European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommend endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) to diagnose choledocholithiasis to make the indication for endoscopic retrograde cholangiopancreatography (ERCP) treatment; there is no randomised control trial to compare both in this setting.

DESIGN

Patients with suspected choledocholithiasis satisfying ESGE guideline's intermediate likelihood were screened for this single-centre randomised controlled trial between November 2019 and May 2020. The enrolled patients were randomised to either EUS or MRCP. ERCP was performed in stone positive cases or if clinical suspicion persisted during follow-up. Negative cases underwent a further 6-month clinical follow-up. Main outcome was accuracy (sensitivity/specificity) of both tests to diagnose choledocholithiasis, with ERCP or follow-up as a gold standard.

RESULTS

Of 266 patients, 224 patients (mean age: 46.77±14.57 years; 50.9 % female) were enrolled; overall prevalence of choledocholithiasis was 49.6%, with a higher frequency in the MRCP group (63/112 vs 46/112 for EUS). Both sensitivity of EUS and MRCP were similarly high (92%-98%), without significant differences between the two groups. The negative predictive value and likelihood ratio + were significantly higher in EUS arm (p<0.05). The percentage of ERCPs either incorrectly halted back (false negatives: EUS: 2 vs MRCP: 5) or performed unnecessarily (false positives: EUS: 1 vs MRCP: 2) was low in both groups.

CONCLUSION

The performance parameters of both EUS and MRCP are comparable for detecting choledocholithiasis in the intermediate-risk group of choledocholithiasis and the choice of a test should be based on local expertise, availability of resources and patient preference.

TRIAL REGISTRATION NUMBER

NCT04173624.

The role of endoscopic ultrasound in evaluating patients with bile duct dilation of unclear etiology

OBJECTIVE

Bile duct dilation (BDD) of unclear etiology is a common indication for further imaging via endoscopic ultrasound (EUS). We aimed to assess the yield of EUS in determining BDD etiology in patients with prior non-diagnostic imaging studies.

METHODS

A retrospective chart review was performed at a single, tertiary-care university hospital for patients referred for EUS for BDD with or without pancreatic duct dilation (PDD). EUS-guided fine needle aspiration (FNA) was performed if a focal lesion was identified. Cases with an etiology of BDD diagnosed or strongly suggested by prior imaging were excluded. EUS findings believed to represent a structural cause for BDD included a wide range of pancreaticobiliary and luminal pathology as well as patients' clinical factors.

RESULTS

In total, 307 patients were identified. Findings to explain BDD were found by EUS in 213 patients for a diagnostic yield of 69.4%. Patients with jaundice were significantly more likely to receive a diagnosis by EUS than those without (78.8% vs 55.3%, P < 0.01). Notably, 8.1% of patients with normal liver function test (LFT) had a EUS-diagnosed malignancy. Patients' age, narcotic use, concurrent PDD and prior cholecystectomy did not appear to influence the EUS yield.

CONCLUSIONS

EUS continues to play a substantial role in evaluating BDD of unclear etiology, most notably in patients with jaundice. In addition, given that 8.1% of asymptomatic patients without jaundice or abnormal LFT had malignancy diagnosed on EUS, the use of EUS for BDD of unclear etiology remains warranted.

Diagnostic yield of endoscopic ultrasonography for dilation of common bile duct of indeterminate cause

INTRODUCTION

with the widespread use of abdominal imaging, common bile duct (CBD) dilation is a common problem in the daily practice. However, the significance of a dilated CBD as a predictor of underlying disease has not been well elucidated and there are currently no guidelines for its approach.

METHODS

this was a retrospective study of patients who underwent endoscopic ultrasonography (EUS) from 2010 to 2017 due to a dilated CBD detected by transabdominal ultrasonography TUS (CBD ≥ 7 mm) or computed tomography (CT) (CBD ≥ 10 mm), with no identified cause (n = 56). The aims were to assess the diagnostic yield of EUS and to identify predictors for a positive EUS.

RESULTS

the majority of patients (n = 39) had normal findings on EUS. Abnormal EUS findings were found in 30% (n = 17) of the patients, which included choledocholithiasis (n = 6), ampuloma (n = 3), choledochal cyst (n = 2), benign CBD stenosis (n = 2), cyst of the head of the pancreas (n = 1), cholangiocarcinoma (n = 1), chronic pancreatitis (n = 1) and CBD compression due to adenomegaly (n = 1). Factors that positively related with findings on EUS were increased levels of gamma glutamyl transferase (331 U/l vs 104 U/l, p = 0.039), alkaline phosphatase (226 U/l vs 114 U/l, p = 0.041), total bilirubin (TB) (6.5 g/dl vs 1.2 g/dl, p = 0.035) and the presence of signs/symptoms (p = 0.042). Of the 21 patients (38%) who were asymptomatic with normal liver biochemical tests, four (19%) had findings on EUS.

CONCLUSIONS

the majority of patients with a dilation of the CDB have a normal EUS. Increased cholestasis enzymes, increased TB and the presence of signs and symptoms are predictors of a positive EUS.

Adenomyoma of the distal common bile duct demonstrated by endoscopic ultrasound: A case report and review of the literature

BACKGROUND

Adenomyomatous hyperplasia of the distal common bile duct (CBD) is very rare, with only scarce case reports in the literature. Diagnosis is usually based on imaging findings, and endoscopic biopsy is very difficult before operation. It is believed that adenomyomatous hyperplasia has little or no risk of malignant transformation.

CASE SUMMARY

A 68-year-old woman with abdominal pain in the right upper quadrant was referred to our hospital. Abdominal ultrasonography in the emergency ward revealed acute cholecystitis and dilated CBD. Laboratory findings showed elevated levels of transaminases, phosphatase, and γ-glutamyltranspeptidase. Pharmaceutical treatment for 3 d did not relieve the symptoms. Magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) showed proximal bile duct dilatation but could not identify the cause. Endoscopic ultrasonography (EUS) demonstrated a mixed echogenic mass in the distal CBD. During surgery, a firm mass was found in the distal CBD and the Whipple procedure was performed with the initial concern of malignancy. Histology showed diffuse adenomyomatous hyperplasia.

CONCLUSION

EUS may be a useful choice to diagnose adenomyoma of the distal CBD before operation, especially in patients with ambiguous MRCP/CT findings.

Combining endoscopic ultrasound and tumor markers improves the diagnostic yield on the etiology of common bile duct dilation secondary to periampullary pathologies

Background

Unexplained common bile duct (CBD) dilatation may be caused by many etiologies, such as periampullary tumors, a pancreatic neoplasm, choledocholithiasis or an inflammatory stenosis. The aim of this study is to evaluate the diagnostic yield of endoscopic ultrasonography (EUS) in patients with unexplained CBD dilatation, in combination with tumor markers, liver chemistry, symptoms, surgical history and whether there is dilatation of the pancreatic duct (PD).

Methods

From January 2016 to July 2017, 115 patients were referred for EUS in our center for CBD dilatation of an unknown etiology. A treatment plan is made based on the EUS result combined with the other clinical information. The final diagnosis is determined by surgical histology or follow-up of at least 3 months.

Results

The sensitivity, specificity and accuracy of EUS for patients with choledocholithiasis were 100.0% (10/10), 100.0% (105/105) and 100.0% (115/115), respectively. The sensitivity, specificity and accuracy of EUS for patients with periampullary tumor were 86.5% (32/37), 89.7% (70/78) and 88.7% (102/115), respectively. The sensitivity, specificity and accuracy of EUS for patients with inflammatory stenosis were 88.2% (60/68), 89.4% (42/47) and 88.7% (102/115), respectively. The overall accuracy of EUS for diagnosing an undetermined etiology for CBD dilatation was 88.7% (102/115) and was higher than the accuracy of ultrasound (US) (64.1%), computed tomography (CT) (66.2%), magnetic resonance imaging (MRI) (67.0%) or PET-CT (66.0%). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EUS combined with tumor markers for patients with malignant dilatation of CBD were 91.9% (34/37), 97.4% (76/78), 94.4% (34/36), 96.2% (76/79) and 95.7% (110/115), respectively. PD dilation (P=0.026) and weight loss (P=0.035) had significant predictive values of malignancy.

Conclusions

EUS is an effective diagnostic tool for determining the etiology of a CBD dilatation, and offers meaningful information for guiding a treatment plan. EUS used in conjunction with tumor markers has high yield in differentiating benign and malignant CBD dilatation. More attention should be paid to patients with PD dilation or weight loss to prevent misdiagnosis of malignant CBD dilation.

ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis

Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the contemporary literature regarding the following topics: EUS versus MRCP for diagnosis, the role of early ERCP in gallstone pancreatitis, endoscopic papillary dilation after sphincterotomy versus sphincterotomy alone for large bile duct stones, and impact of ERCP-guided intraductal therapy for large and difficult choledocholithiasis. Comprehensive systematic reviews were also performed to assess the following: same-admission cholecystectomy for gallstone pancreatitis, clinical predictors of choledocholithiasis, optimal timing of ERCP vis-à-vis cholecystectomy, management of Mirizzi syndrome and hepatolithiasis, and biliary stent therapy for choledocholithiasis. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. This body developed all recommendations founded on the certainty of the evidence, balance of risks and harms, consideration of stakeholder preferences, resource utilization, and cost-effectiveness.

Digital cholangioscopy can detect residual biliary stones missed by occlusion cholangiogram in ERCP: a prospective tandem study

Background and study aims  After stone removal in endoscopic retrograde cholangiopancreatography (ERCP), an occlusion cholangiogram (OC) is performed to confirm bile duct clearance. OC can miss residual stones that can lead to recurrent biliary symptoms. The aim of this study was to assess if digital peroral cholangioscopy (POC) increased the diagnostic yield of residual biliary stones that are missed with OC. Patients and methods  Patients having ERCP performed for choledocholithiasis were enrolled into the study only if they had one of the following criteria: dilated bile duct ≥ 12 mm and/or if lithotripsy was being performed. An OC was performed to confirm duct clearance after removal of stones followed by POC, based on inclusion criteria. The incremental yield of biliary stones missed by OC but confirmed by POC was then measured. A total of 96 POC procedures were performed on 93 patients in two tertiary care centers. Results  Residual biliary stones were found in 34 % of cases. The average bile duct size in cases with residual stones was 15.1 mm ± 0.7 mm. One- to three-mm stones were found in 41 % of cases, 4- to 7-mm stones in 45 % of cases, and ≥ 8-mm stones in 14 % of cases. Lithotripsy was performed in 13 % of cases and was significantly associated with residual stones (30 % vs. 3 %, P  < 0.001). Conclusions  Occlusion cholangiogram can miss residual stones in patients with dilated bile ducts and those receiving lithotripsy. Digital POC can increase the yield of residual stone detection in these patients and should be considered to confirm clearance of stones. (ClinicalTrials.gov-NCT03482375).

Postendoscopic retrograde cholangiopancreatography pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) has been a mainstay examination to clarify the biliary and pancreatic system. Not just diagnostic purpose, it could achieve therapeutic goal. Under the trend of more and more procedures about ERCP being interventional, the rate of adverse events after the procedure is increasing. Among them, post-ERCP pancreatitis (PEP) is the most common and sometimes tremendous complication. This mini-review will overview the PEP from definition, pathogenesis, and risk factors to prevention.

Identification of a serum biomarker panel for the differential diagnosis of cholangiocarcinoma and primary sclerosing cholangitis

The non-invasive differentiation of malignant and benign biliary disease is a clinical challenge. Carbohydrate antigen 19-9 (CA19-9), leucine-rich α2-glycoprotein (LRG1), interleukin 6 (IL6), pyruvate kinase M2 (PKM2), cytokeratin 19 fragment (CYFRA21.1) and mucin 5AC (MUC5AC) have reported utility for differentiating cholangiocarcinoma (CCA) from benign biliary disease. Herein, serum levels of these markers were tested in 66 cases of CCA and 62 cases of primary sclerosing cholangitis (PSC) and compared with markers of liver function and inflammation. Markers panels were assessed for their ability to discriminate malignant and benign disease. Several of the markers were also assessed in pre-diagnosis biliary tract cancer (BTC) samples with performances evaluated at different times prior to diagnosis. We show that LRG1 and IL6 were unable to accurately distinguish CCA from PSC, whereas CA19-9, PKM2, CYFRA21.1 and MUC5AC were significantly elevated in malignancy. Area under the receiver operating characteristic curves for these individual markers ranged from 0.73–0.84, with the best single marker (PKM2) providing 61% sensitivity at 90% specificity. A panel combining PKM2, CYFRA21.1 and MUC5AC gave 76% sensitivity at 90% specificity, which increased to 82% sensitivity by adding gamma-glutamyltransferase (GGT). In the pre-diagnosis setting, LRG1, IL6 and PKM2 were poor predictors of BTC, whilst CA19-9 and C-reactive protein were elevated up to 2 years before diagnosis. In conclusion, LRG1, IL6 and PKM2 were not useful for early detection of BTC, whilst a model combining PKM2, CYFRA21.1, MUC5AC and GGT was beneficial in differentiating malignant from benign biliary disease, warranting validation in a prospective trial.

Diagnostic accuracy of EUS compared with MRCP in detecting choledocholithiasis: a meta-analysis of diagnostic test accuracy in head-to-head studies

BACKGROUND AND AIMS

There is a wide range of reported sensitivity and specificity for EUS and MRCP in the diagnosis of choledocholithiasis, with lack of a proper meta-analysis of diagnostic test accuracy by using head-to-head comparison. Here, we aimed to compare the diagnostic accuracy of EUS and MRCP in detecting choledocholithiasis by using appropriate methodology recommended by the Cochrane Collaboration.

METHODS

A comprehensive electronic literature search up to January 2017 was done by 2 reviewers for prospective cohort studies comparing EUS and MRCP to a reference standard for detecting choledocholithiasis. The acceptable reference standards were considered ERCP, intraoperative cholangiography, or clinical follow-up >3 months for negative cases. Quality of the included studies was measured by using the QUADAS-2 tool. A bivariate hierarchical model was used to perform the meta-analysis of diagnostic test accuracy. Summary receiver operating characteristics were developed and the area under the curve was calculated.

RESULTS

A total of 5 of 32 studies were included. No study presented a high risk of bias. The pooled sensitivity and specificity were 0.97 (range, 0.91-0.99) and 0.90 (range, 0.83-0.94) for EUS and 0.87 (range, 0.80-0.93) and 0.92 (range, 0.87-0.96) for MRCP. The overall diagnostic odds ratio of EUS was significantly higher than the one with MRCP (162.5 vs 79.0, respectively; P = .008). Further analysis showed that this was mainly due to the significantly higher sensitivity of EUS as compared with that of MRCP (P = .006). The specificity was not significantly different between 2 modalities (P = .42).

CONCLUSION

Both EUS and MRCP provide good diagnostic accuracy, with EUS providing statically better diagnostic accuracy and sensitivity, with comparable specificity. EUS should be incorporated in the diagnostic algorithm in patients suspected of choledocholithiasis whenever appropriate.

Novel biomarkers and endoscopic techniques for diagnosing pancreaticobiliary malignancy

The UK incidence of pancreatic ductal adenocarcinoma is 9 per 100,000 population, and biliary tract cancer occurs at a rate of 1–2 per 100,000. The incidence of both cancers is increasing annually and these tumours continue to be diagnosed late and at an advanced stage, limiting options for curative treatment. Population-based screening programmes do not exist for these cancers, and diagnosis currently is dependent on symptom recognition, but often symptoms are not present until the disease is advanced. Recently, a number of promising blood and urine biomarkers have been described for pancreaticobiliary malignancy and are summarised in this review. Novel endoscopic techniques such as single-operator cholangioscopy and confocal endomicroscopy have been used in some centres to enhance standard endoscopic diagnostic techniques and are also evaluated in this review.

Updated guideline on the management of common bile duct stones (CBDS)

Common bile duct stones (CBDS) are estimated to be present in 10-20% of individuals with symptomatic gallstones. They can result in a number of health problems, including pain, jaundice, infection and acute pancreatitis. A variety of imaging modalities can be employed to identify the condition, while management of confirmed cases of CBDS may involve endoscopic retrograde cholangiopancreatography, surgery and radiological methods of stone extraction. Clinicians are therefore confronted with a number of potentially valid options to diagnose and treat individuals with suspected CBDS. The British Society of Gastroenterology first published a guideline on the management of CBDS in 2008. Since then a number of developments in management have occurred along with further systematic reviews of the available evidence. The following recommendations reflect these changes and provide updated guidance to healthcare professionals who are involved in the care of adult patients with suspected or proven CBDS. It is not a protocol and the recommendations contained within should not replace individual clinical judgement.

[The efficacy of endoscopic endosonography in diagnosis of benign and malignant stenoses of common bile duct]

AIM

To define criteria and to estimate diagnostic significance of endosonography in differential diagnosis of benign and malignant stenoses of common bile duct.

MATERIAL AND METHODS

We presented the results of survey and treatment of 57 patients with benign and malignant stenoses of common bile duct. The technique of endosonography is described. We have formulated major criteria of differential diagnostics of tumoral and non-tumoral lesion of extrahepatic bile ducts. Comparative analysis of endosonography, ultrasound, computed tomography and magnetic resonance cholangiopancreatography was performed.

RESULTS

Sensitivity, specificity and accuracy of endosonography in diagnosis of stenosis cause is 97.7%, 100% and 98.2% respectively. So it exceeds the efficacy of other diagnostic X-ray methods. In modern surgical clinic endosonography should be mandatory performed. It is necessary for final diagnostics of cause of common bile duct stenosis especially in case of its low location.

Endoscopic ultrasound versus magnetic resonance cholangiopancreatography in suspected choledocholithiasis: A systematic review

BACKGROUND AND OBJECTIVES

There is a lack of consensus about the optimal noninvasive strategy for patients with suspected choledocholithiasis. Two previous systematic reviews used different methodologies not based on pretest probabilities that demonstrated no statistically significant difference between Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) for the detection of choledocholithiasis. In this article, we made a comparison of the diagnostic ability of EUS and MRCP to detect choledocholithiasis in suspected patients.

METHODS

We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations with all published randomized prospective trials. We performed the systemic review using MedLine, EMBASE, Cochrane, LILACS, and Scopus reviews through May 2015. We identified eight randomized, prospective, blinded trials comparing EUS and MRCP. All the patients were submitted to a gold standard method. We calculated the study-specific variables and performed analyses using aggregated variables such as sensitivity, specificity, prevalence, positive predictive value (PPV) and negative predictive value (NPV), and accuracy.

RESULTS

Five hundred and thirty eight patients were included in the analysis. The pretest probability for choledocholithiasis was 38.7. The mean sensitivity of EUS and MRCP for detection of choledocholithiasis was 93.7 and 83.5, respectively; the specificity was 88.5 and 91.5, respectively. Regarding EUS and MRCP, PPV was 89 and 87.8, respectively, and NPV was 96.9 and 87.8, respectively. The accuracy of EUS and MRCP was 93.3 and 89.7, respectively.

CONCLUSIONS

For the same pretest probability of choledocholithiasis, EUS has higher posttest probability when the result is positive and a lower posttest probability when the result is negative compared with MRCP.

Computed Tomography and MRI of the Hepatobiliary System and Pancreas

MRI and computed tomographic (CT) imaging are becoming more common in the diagnosis of hepatobiliary and pancreatic disorders in small animals. With the advent of multislice CT scanners, sedated examinations in veterinary patients are feasible increasing the use of this imaging modality. CT and MRI provide additional information for dogs and cats with hepatobiliary and pancreatic diseases because of lack of superimposition of structures, operator dependence, and through intravenous contrast administration. This added value provides more information for diagnosis, prognosis, and surgical planning.

Asymptomatic Bile Duct Dilatation in Children: Is It a Disease?

PURPOSE

Bile duct dilatation is a relatively common sonographic finding; nevertheless, its clinical significance in children is controversial because little research has been done in the area. Therefore, we investigated the natural course and clinical significance of biliary duct dilatation in children.

METHODS

We performed a retrospective study of 181 children (range, 1-day-old to 17-year-old) in whom dilatation of the intrahepatic duct and/or common hepatic duct and/or common bile duct was detected by abdominal ultrasonography at the Severance Children's Hospital between November 2005 and March 2014. We reviewed and analyzed laboratory test results, clinical manifestations, and clinical course in these patients.

RESULTS

Pediatric patients (n=181) were enrolled in the study and divided into two groups. The first group included 59 subjects, without definitive cause of bile duct dilatation, who did not require treatment; the second group included 122 subjects, with definitive cause of bile duct dilatation or underlying biliary disease, who did require treatment. In the first group, 24 patients (40.7%) showed spontaneous resolution of bile duct dilatation, 20 patients (33.9%) showed no change, and 15 patients (25.4%) were lost to follow-up. In the second group, 31 patients were diagnosed with choledochal cysts, and 91 patients presented with biliary tract dilatations due to secondary causes, such as gallbladder or liver disease, post-operative complications, or malignancy.

CONCLUSION

Biliary dilatation in pediatric patients without symptoms, and without laboratory and other sonographic abnormalities, showed a benign clinical course. No pathologic conditions were noted on follow-up ultrasonography.

Endoscopic ultrasound in common bile duct dilatation with normal liver enzymes

In recent years, the description of isolated bile duct dilatation has been increasingly observed in subjects with normal liver function tests and nonspecific abdominal symptoms, probably due to the widespread use of high-resolution imaging techniques. However, there is scant literature about the evolution of this condition and the impact of endoscopic ultrasound (EUS) in the diagnostic work up. When noninvasive imaging tests (transabdominal ultrasound, computed tomography or magnetic resonance cholangiopancreatography) fail to identify the cause of dilatation and clinical or biochemical alarm signs are absent, the probability of having biliary disease is considered low. In this setting, using EUS, the presence of pathologic findings (choledocholithiasis, strictures, chronic pancreatitis, ampullary or pancreatic tumors, cholangiocarcinoma), not always with a benign course, has been observed. The aim of this review has been to evaluate the prevalence of disease among non-jaundiced patients without signs of cytolysis and/or cholestasis and the assessment of EUS yield. Data point out to a promising role of EUS in the identification of a potential biliary pathology. EUS is a low invasive technique, with high accuracy, that could play a double cost-effective role: identifying pathologic conditions with dismal prognosis, in asymptomatic patients with negative prior imaging tests, and excluding pathologic conditions and further follow-up in healthy subjects.

Accuracy of magnetic resonance cholangiography compared to operative endoscopy in detecting biliary stones, a single center experience and review of literature

AIM: To compare diagnostic sensitivity, specificity and accuracy of magnetic resonance cholangiopancreatography (MRCP) without contrast medium and endoscopic ultrasound (EUS)/endoscopic retrograde cholangiopancreatography (ERCP) for biliary calculi.

METHODS: From January 2012 to December 2013, two-hundred-sixty-three patients underwent MRCP at our institution, all MRCP procedure were performed with the same machinery. In two-hundred MRCP was done for pure hepatobiliary symptoms and these patients are the subjects of this study. Among these two-hundred patients, one-hundred-eleven (55.5%) underwent ERCP after MRCP. The retrospective study design consisted in the systematic revision of all images from MRCP and EUS/ERCP performed by two radiologist with a long experience in biliary imaging, an experienced endoscopist and a senior consultant in Hepatobiliopancreatic surgery. A false positive was defined an MRCP showing calculi with no findings at EUS/ERCP; a true positive was defined as a concordance between MRCP and EUS/ERCP findings; a false negative was defined as the absence of images suggesting calculi at MRCP with calculi localization/extraction at EUS/ERCP and a true negative was defined as a patient with no calculi at MRCP ad at least 6 mo of asymptomatic follow-up. Biliary tree dilatation was defined as a common bile duct diameter larger than 6 mm in a patient who had an in situ gallbladder. A third blinded radiologist who examined the MRCP and ERCP data reviewed misdiagnosed cases. Once obtained overall data on sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) we divided patients in two groups composed of those having concordant MRCP and EUS/ERCP (Group A, 72 patients) and those having discordant MRCP and EUS/ERCP (Group B, 20 patients). Dataset comparisons had been made by the Student’s t-test and χ² when appropriate.

RESULTS: Two-hundred patients (91 men, 109 women, mean age 67.6 years, and range 25-98 years) underwent MRCP. All patients attended regular follow-up for at least 6 mo. Morbidity and mortality related to MRCP were null. MRCP was the only exam performed in 89 patients because it did show only calculi into the gallbladder with no signs of the presence of calculi into the bile duct and symptoms resolved within a few days or after colecistectomy. The patients remained asymptomatic for at least 6 mo, and we assumed they were true negatives. One hundred eleven (53 men, 58 women, mean age 69 years, range 25-98 years) underwent ERCP following MRCP. We did not find any difference between the two groups in terms of race, age, and sex. The overall median interval between MRCP and ERCP was 9 d. In detecting biliary stones MRCP Sensitivity was 77.4%, Specificity 100% and Accuracy 80.5% with a PPV of 100% and NPV of 85%; EUS showed 95% sensitivity, 100% specificity, 95.5% accuracy with 100% PPV and 57.1% NPV. The association of EUS with ERCP performed at 100% in all the evaluated parameters. When comparing the two groups, we did not find any statistically significant difference regarding age, sex, and race. Similarly, we did not find any differences regarding the number of extracted stones: 116 stones in Group A (median 2, range 1 to 9) and 27 in Group B (median 2, range 1 to 4). When we compared the size of the extracted stones we found that the patients in Group B had significantly smaller stones: 14.16 ± 8.11 mm in Group A and 5.15 ± 2.09 mm in Group B; 95% confidence interval = 5.89-12.13, standard error = 1.577; P < 0.05. We also found that in Group B there was a significantly higher incidence of stones smaller than 5 mm: 36 in Group A and 18 in Group B, P < 0.05.

CONCLUSION: Major finding of the present study is that choledocholithiasis is still under-diagnosed in MRCP. Smaller stones (< 5 mm diameter) are hardly visualized on MRCP.

Cost-effectiveness analysis of endoscopic ultrasound versus magnetic resonance cholangiopancreatography in patients with suspected common bile duct stones

BACKGROUND

Patients with suspected common bile duct (CBD) stones are often diagnosed using endoscopic retrograde cholangiopancreatography (ERCP), an invasive procedure with risk of significant complications. Using endoscopic ultrasound (EUS) or Magnetic Resonance CholangioPancreatography (MRCP) first to detect CBD stones can reduce the risk of unnecessary procedures, cut complications and may save costs.

AIM

This study sought to compare the cost-effectiveness of initial EUS or MRCP in patients with suspected CBD stones.

METHODS

This study is a model based cost-utility analysis estimating mean costs and quality-adjusted life years (QALYs) per patient from the perspective of the UK National Health Service (NHS) over a 1 year time horizon. A decision tree model was constructed and populated with probabilities, outcomes and cost data from published sources, including one-way and probabilistic sensitivity analyses.

RESULTS

Using MRCP to select patients for ERCP was less costly than using EUS to select patients or proceeding directly to ERCP ($1299 versus $1753 and $1781, respectively), with similar QALYs accruing to each option (0.998, 0.998 and 0.997 for EUS, MRCP and direct ERCP, respectively). Initial MRCP was the most cost-effective option with the highest monetary net benefit, and this result was not sensitive to model parameters. MRCP had a 61% probability of being cost-effective at $29,000, the maximum willingness to pay for a QALY commonly used in the UK.

CONCLUSION

From the perspective of the UK NHS, MRCP was the most cost-effective test in the diagnosis of CBD stones.

Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones

BACKGROUND

Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are tests used in the diagnosis of common bile duct stones in patients suspected of having common bile duct stones prior to undergoing invasive treatment. There has been no systematic review of the accuracy of EUS and MRCP in the diagnosis of common bile duct stones using appropriate reference standards.

OBJECTIVES

To determine and compare the accuracy of EUS and MRCP for the diagnosis of common bile duct stones.

SEARCH METHODS

We searched MEDLINE, EMBASE, Science Citation Index Expanded, BIOSIS, and Clinicaltrials.gov until September 2012. We searched the references of included studies to identify further studies and of systematic reviews identified from various databases (Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA), Medion, and ARIF (Aggressive Research Intelligence Facility)). We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively.

SELECTION CRITERIA

We included studies that provided the number of true positives, false positives, false negatives, and true negatives for EUS or MRCP. We only accepted studies that confirmed the presence of common bile duct stones by extraction of the stones (irrespective of whether this was done by surgical or endoscopic methods) for a positive test, and absence of common bile duct stones by surgical or endoscopic negative exploration of the common bile duct or symptom free follow-up for at least six months for a negative test, as the reference standard in people suspected of having common bile duct stones. We included participants with or without prior diagnosis of cholelithiasis; with or without symptoms and complications of common bile duct stones, with or without prior treatment for common bile duct stones; and before or after cholecystectomy. At least two authors independently screened abstracts and selected studies for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently collected the data from each study. We used the bivariate model to obtain pooled estimates of sensitivity and specificity.

MAIN RESULTS

We included a total of 18 studies involving 2366 participants (976 participants with common bile duct stones and 1390 participants without common bile duct stones). Eleven studies evaluated EUS alone, and five studies evaluated MRCP alone. Two studies evaluated both tests. Most studies included patients who were suspected of having common bile duct stones based on abnormal liver function tests; abnormal transabdominal ultrasound; symptoms such as obstructive jaundice, cholangitis, or pancreatitis; or a combination of the above. The proportion of participants who had undergone cholecystectomy varied across studies. Not one of the studies was of high methodological quality. For EUS, the sensitivities ranged between 0.75 and 1.00 and the specificities ranged between 0.85 and 1.00. The summary sensitivity (95% confidence interval (CI)) and specificity (95% CI) of the 13 studies that evaluated EUS (1537 participants; 686 cases and 851 participants without common bile duct stones) were 0.95 (95% CI 0.91 to 0.97) and 0.97 (95% CI 0.94 to 0.99). For MRCP, the sensitivities ranged between 0.77 and 1.00 and the specificities ranged between 0.73 and 0.99. The summary sensitivity and specificity of the seven studies that evaluated MRCP (996 participants; 361 cases and 635 participants without common bile duct stones) were 0.93 (95% CI 0.87 to 0.96) and 0.96 (95% CI 0.90 to 0.98). There was no evidence of a difference in sensitivity or specificity between EUS and MRCP (P value = 0.5). From the included studies, at the median pre-test probability of common bile duct stones of 41% the post-test probabilities (with 95% CI) associated with positive and negative EUS test results were 0.96 (95% CI 0.92 to 0.98) and 0.03 (95% CI 0.02 to 0.06). At the same pre-test probability, the post-test probabilities associated with positive and negative MRCP test results were 0.94 (95% CI 0.87 to 0.97) and 0.05 (95% CI 0.03 to 0.09).

AUTHORS' CONCLUSIONS

Both EUS and MRCP have high diagnostic accuracy for detection of common bile duct stones. People with positive EUS or MRCP should undergo endoscopic or surgical extraction of common bile duct stones and those with negative EUS or MRCP do not need further invasive tests. However, if the symptoms persist, further investigations will be indicated. The two tests are similar in terms of diagnostic accuracy and the choice of which test to use will be informed by availability and contra-indications to each test. However, it should be noted that the results are based on studies of poor methodological quality and so the results should be interpreted with caution. Further studies that are of high methodological quality are necessary to determine the diagnostic accuracy of EUS and MRCP for the diagnosis of common bile duct stones.

Unexplained common bile duct dilatation with normal serum liver enzymes: diagnostic yield of endoscopic ultrasound and follow-up of this condition

BACKGROUND

There is scant literature about common bile duct (CBD) dilatation with normal liver function tests (LFTs).

AIMS

The aims of this study were to assess the diagnostic yield of endoscopic ultrasound (EUS) in patients with CBD dilatation, normal LFTs, and prior inconclusive imaging tests, and to assess the natural history of these subjects.

METHODS

We retrospectively reviewed our EUS database for patients referred for evaluation of CBD dilatation, normal LFTs, and prior inconclusive imaging. We excluded patients with a prior endoscopic retrograde cholangiopancreatography or a history of biliary obstruction, pancreatitis, or jaundice. Follow-up data were retrieved from medical records or by calling the general practitioners, referring specialists, patients, or their closest relatives.

RESULTS

A total of 57 patients were enrolled. The mean CBD diameter was 12.5±3.6 mm. The majority of patients (50.8%) were asymptomatic. Abnormal EUS findings were recorded in 12 (21%) subjects: 6 patients had a periampullary diverticulum, 2 had ampullary adenoma, 2 had signs of chronic pancreatitis, 1 had a cancer of the pancreatic head, and 1 had a 7 mm CBD stone. Neither age, sex, prior cholecystectomy, clinical presentation, CBD diameter, nor a dilated main pancreatic duct were predictors of abnormal EUS findings. None of the patients complained of biliary symptoms or showed abnormal LFTs on long-term follow-up.

CONCLUSIONS

CBD dilatation with normal liver chemistry is not always a benign condition. Even when prior imaging tests are negative, EUS may allow to diagnose conditions overlooked by standard diagnostic imaging.

Novel diagnostic and prognostic biomarkers in biliary tract cancer

INTRODUCTION

The worldwide incidence of biliary tract carcinoma (BTC, tumours of the bile ducts and gall-bladder) continues to rise, with the only potentially curative treatment remaining surgical resection or transplantation, possible in only a minority of patients. Late presentation and a paucity of effective treatments mandate the development of techniques for early lesion detection.

AREAS COVERED

This article reviews currently available biomarkers for the diagnosis and prognosis of BTC, as well as recently published studies describing novel serum, bile and urinary biomarkers.

EXPERT OPINION

The incorporation of novel analysis techniques, such as digital image analysis and fluorescence in situ hybridization, into existing management algorithms enhances the accuracy of brush cytology taken at the time of therapeutic endoscopy. However, a key goal is the discovery of reliable non-invasive biomarkers with high sensitivity and specificity. Recent advances in gene sequencing and expression, clonal evolution and tumour heterogeneity in other cancers should advance understanding of BTC tumour biology and facilitate biomarker discovery.

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.

Novel endoscopic approaches in the diagnosis and management of biliary strictures

Indeterminate bilary strictures present the clinician with a wide differential diagnosis. Histological confirmation is usually required for treatment, but tissue acquisition remains challenging. Novel developments in endoscopic technology, such as single operator cholangioscopy and confocal endomicroscopy, have led to improvements in diagnostic accuracy in recent years. In patients with non-resectable malignant biliary obstruction, effective biliary decompression improves symptoms and enables patients to undergo palliative therapies. Improvements in endoscopic techniques, biliary stents and the development of local ablative techniques have led to further improvements in stent patency and survival in these patients. In this article, we review emerging diagnostic and therapeutic techniques for the endoscopic management of indeterminate biliary strictures.

Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: testing the current guidelines

BACKGROUND

Current guidelines include an algorithm for predicting choledocholithiasis. Presence of any very strong predictor or both strong predictors confers a high (>50%) probability of choledocholithiasis. Absence of predictors confers low risk (<10%) of choledocholithiasis. Other combinations have an intermediate risk of choledocholithiasis.

AIM

Determine accuracy of the proposed algorithm in predicting choledocholithiasis.

METHODS

Retrospective analysis of all endoscopic retrograde cholangiopancreatographies performed for suspected choledocholithiasis in 3 years in a Tertiary care hospital and a community hospital serviced by The University of Texas Health Science Center at Houston Division of Gastroenterology. Application of the guidelines, and comparing results to endoscopic retrograde cholangiopancreatography findings.

RESULTS

A total of 1080 endoscopic retrograde cholangiopancreatographies were performed; 521 for choledocholithiasis. Most patients were Hispanic and female. Univariate analysis: presence of any very strong predictor and both strong predictors had an OR for choledocholithiasis of 3.30 and 2.36 respectively. Multivariate analysis: odds of choledocholithiasis with any very strong predictor was 2.87, and both strong predictors 3.24. Choledocholithiasis was present in 71.5%, and 41% of patients with high, and intermediate risk respectively.

CONCLUSION

This study confirms the utility of clinical predictors for the diagnosis of choledocholithiasis. All of the very strong predictors and one of the strong predictors increased the odds of choledocholithiasis. Patients with high risk for choledocholithiasis had a probability of 79% of choledocholithiasis. Sensitivity and specificity of current predictors are too low to obviate the possible need of non-invasive tests to confirm or exclude choledocholithiasis in all risk groups.

For biliary dilatation, a negative endosonography needs additional image studies in weight loss suggesting malignancy

BACKGROUND AND AIM

Biliary dilatation frequently raises concerns about the possibility of pancreatobiliary diseases. This study assessed the etiologic yield of endosonography (EUS) in this situation.

METHODS

A retrospective review was completed with 163 consecutive patients who had undergone EUS for a dilated common bile duct (CBD) without definite pathology on ultrasonography.

RESULTS

Binary logistic regression analysis disclosed that malignancy was positively related to weight loss and was inversely related to abdominal pain; nevertheless, choledocholithiasis was positively related to fever and elevated carbohydrate antigen 19-9 (p < 0.05). The accuracy of EUS was 95.1 % (155/163) for overall cause of biliary dilatation, 100 % (73/73) for no pathological finding, 96.3 % (26/27) for ampullary cancer, 84.6 % (11/13) for pancreatic cancer, 40.0 % (2/5) for CBD cancer, and 92.6 % (25/27) for choledocholithiasis, respectively. The accuracy of EUS decreased in the presence of malignancy (86.7 %, 39/45 vs. 98.3 %, 116/118, p = 0.006). EUS missed three CBD cancers, two pancreatic cancers, and one ampullary cancer; however, the diagnosis was rescued by computed tomography in two pancreatic cancers and one CBD cancer.

CONCLUSIONS

EUS is accurate in patients with fever suggestive of choledocholithiasis. However, a negative EUS finding should call for additional image studies in patients with weight loss suggestive of malignancy.

Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines

The management of patients with IBD requires evaluation with objective tools, both at the time of diagnosis and throughout the course of the disease, to determine the location, extension, activity and severity of inflammatory lesions, as well as, the potential existence of complications. Whereas endoscopy is a well-established and uniformly performed diagnostic examination, the implementation of radiologic techniques for assessment of IBD is still heterogeneous; variations in technical aspects and the degrees of experience and preferences exist across countries in Europe. ECCO and ESGAR scientific societies jointly elaborated a consensus to establish standards for imaging in IBD using magnetic resonance imaging, computed tomography, ultrasonography, and including also other radiologic procedures such as conventional radiology or nuclear medicine examinations for different clinical situations that include general principles, upper GI tract, colon and rectum, perineum, liver and biliary tract, emergency situation, and the postoperative setting. The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas such as the comparison of diagnostic accuracy between different techniques, the value for therapeutic monitoring, and the prognostic implications of particular findings.

Magnetic resonance (MR) imaging and MR cholangiopancreatography findings in cats with cholangitis and pancreatitis

Cholangiohepatitis/cholangitis is second only to hepatic lipidosis as the most common liver disease in cats and is often associated with concurrent pancreatitis. Magnetic resonance imaging (MRI) and MR cholangiopancreatography (MRCP) have developed into an accurate, highly sensitive and specific imaging tool for the diagnosis of biliary and pancreatic duct disorders in humans. In this prospective case series, 10 cats with suspected cholangitis and/or pancreatitis were enrolled based on clinical history, physical examination and appropriate diagnostic test results. MRI and MRCP sequences with secretin stimulation of the cranial abdomen were performed, and sonography and laparoscopic biopsies for histologic diagnosis were obtained for comparison. MRI detected pancreatic abnormalities in cats suspected of pancreatitis, including T1 pre-contrast hypointense and T2 hyperintense pancreatic parenchyma and a dilated pancreatic duct. The MRI findings of the liver were non-specific. Nine of 10 cats had biliary abnormalities, including gall bladder wall thickening, gall bladder wall moderate contrast enhancement and/or gall bladder debris. Eight of 10 cats had histologic evidence of pancreatitis, as well as hepatitis or cholangitis, with one cat diagnosed with hepatic lymphoma. The advantages of MRI/MRCP over sonography of these cats included the striking pancreatic signal changes associated with pancreatitis and the ability to comprehensibly assess and measure the pancreas and hepatobiliary structures without operator dependence or interference from bowel gas. MRI/MRCP imaging of the feline abdomen may be beneficial in cases with equivocal ultrasound imaging findings.

Common bile duct stones on multidetector computed tomography: Attenuation patterns and detectability

AIM: To investigate the attenuation patterns and detectability of common bile duct (CBD) stones by multidetector computed tomography (MDCT).

METHODS: Between March 2010 and February 2012, 191 patients with suspicion of CBD stones undergoing both MDCT and endoscopic retrograde cholangiopancreatography (ERCP) were enrolled and reviewed retrospectively. The attenuation patterns of CBD stones on MDCT were classified as heavily calcified, radiopaque, less radiopaque, or undetectable. The association between the attenuation patterns of CBD stones on MDCT and stone type consisting of pure cholesterol, mixed cholesterol, brown pigment, and black pigment and the factors related to the detectability of CBD stones by MDCT were evaluated.

RESULTS: MDCT showed CBD stones in 111 of 130 patients in whom the CBD stones were demonstrated by ERCP with 85.4% sensitivity. The attenuation patterns of CBD stones on MDCT were heavily calcified 34 (26%), radiopaque 31 (24%), less radiopaque 46 (35%), and undetectable 19 (15%). The radiopacity of CBD stones differed significantly according to stone type (P < 0.001). From the receiver operating characteristic curve, stone size was useful for the determination of CBD stone by MDCT (area under curve 0.779, P < 0.001) and appropriate cut-off stone size on MDCT was 5 mm. The factors related to detectability of CBD stones on MDCT were age, stone type, and stone size on multivariate analysis (P < 0.05).

CONCLUSION: The radiopacity of CBD stones on MDCT differed according to stone type. Stone type and stone size were related to the detectability by MDCT, and appropriate cut-off stone size was 5 mm.

Current endoscopic approach to indeterminate biliary strictures

Biliary strictures are considered indeterminate when basic work-up, including transabdominal imaging and endoscopic retrograde cholangiopancreatography with routine cytologic brushing, are non-diagnostic. Indeterminate biliary strictures can easily be mischaracterized which may dramatically affect patient’s outcome. Early and accurate diagnosis of malignancy impacts not only a patient’s candidacy for surgery, but also potential timely targeted chemotherapies. A significant portion of patients with indeterminate biliary strictures have benign disease and accurate diagnosis is, thus, paramount to avoid unnecessary surgery. Current sampling strategies have suboptimal accuracy for the diagnosis of malignancy. Emerging data on other diagnostic modalities, such as ancillary cytology techniques, single operator cholangioscopy, and endoscopic ultrasonography-guided fine needle aspiration, revealed promising results with much improved sensitivity.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Endoscopic diagnosis of biliary tract disease

PURPOSE OF REVIEW

Endoscopic diagnosis of biliary disease is challenging due to difficulties in access, visualization, and sampling. Recent advances in endoscopic technology, ancillary diagnostic methods, and our understanding of autoimmune pancreatitis (AIP) and IgG4-related cholangitis (IRC) have led to improvements in the endoscopic diagnosis of pancreaticobiliary disease.

RECENT FINDINGS

Single-operator cholangioscopy overcomes several of the limitations of mother-baby cholangioscopy enhancing the diagnostic accuracy in indeterminate pancreaticobiliary disease. Probe-based confocal laser endomicroscopy has been recently shown to provide a significantly higher accuracy for the diagnosis of malignant biliary strictures than achieved by endoscopic retrograde cholangiopancreatogram and standard tissue acquisition, and has the potential to develop into a useful adjunct method of cholangioscopy. Fluorescence in-situ hybridization increases the sensitivity of routine brush cytology without compromising specificity in patients with indeterminate biliary strictures. The diagnosis of AIP/IRC remains challenging. The recently published international consensus criteria for AIP have included data on the potential diagnostic utility of endoscopic retrograde pancreatogram and endoscopic ampullary biopsies.

SUMMARY

Recent technical advances as well as ancillary diagnostic methods have improved the diagnostic accuracy of conventional endoscopic techniques. Future refinement of endoscopic methods may further improve diagnostic approaches to biliary disease.

Role of magnetic resonance cholangiopancreatography for choledocholithiasis: analysis of patients with negative MRCP

OBJECTIVE

To investigate the negative predictive value of magnetic resonance cholangiopancreatography (MRCP) for common bile duct (CBD) stones and the prognosis of patients suspected to have choledocholithiasis in whom the MRCP was negative for CBD stones.

METHODS

We enrolled the patients suspected to have choledocholithiasis in whom the MRCP was negative for the CBD stones between January 2008 and March 2011 and retrospectively analyzed the outcomes of 115 patients.

RESULTS

Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 27 patients (23%, group 1), and none had CBD stones. The negative predictive value of MRCP was 100%. During a median follow-up of 18.3 months, acute cholangitis with newly developed CBD stones occurred in two patients. Eighty-eight patients (77%, group 2) did not undergo ERCP and all recovered from acute cholangitis without CBD surgery. During a median follow-up of 18.7 months, acute cholangitis, acute cholecystitis, gallstone pancreatitis, and pancreatico-biliary cancers occurred in four (4.6%), three (3.5%), one (1.2%), and three (3.5%) patients, respectively. New CBD stones were found in only two patients among four patients with recurrent acute cholangitis. No patient had recurrent cholangitis caused by MRCP-missed CBD stones. The rates of recurrent cholangitis and cholangitis-free survival did not differ between groups 1 and 2.

CONCLUSION

The negative predictive value of MRCP was very high. ERCP can be reserved for patients who are MRCP negative for choledocholithiasis, but close follow-up is needed because of recurrent cholangitis or pancreatico-biliary cancer.

Usefulness of magnetic resonance cholangiopancreatography in pancreatobiliary abnormalities in pediatric patients

BACKGROUND

Magnetic resonance cholangiopancreatography (MRCP) is an innovative and noninvasive technique for evaluating the biliary tree and pancreatic duct in children. The aim of this study was to assess the usefulness of MRCP as a noninvasive method to evaluate the biliary system in children.

METHODS

We retrospectively reviewed the records of patients undergoing MRCP between October 2002 and May 2007 for suspected biliary system abnormalities. MRCP findings were compared with other imaging modalities, operative findings, and clinical endpoints.

RESULTS

Complete data were available for 60 patients (35 girls, 25 boys; mean age 2 years, 33 children less than 1 year old). Ultrasound was performed in all 60 patients. Twenty-two patients had choledochal cyst, and 19 had a thin or invisible gall bladder. Endoscopic retrograde cholangiopancreatography was done in two patients. The sensitivities and specificities of MRCP for diagnosing choledochal cyst and biliary atresia were 100.0% and 100.0% and 86.7% and 100.0%, respectively. Surgery was performed in 37 patients, including 21 with a choledochal cyst, 14 with biliary atresia, and 1 with a pancreatic duct stone.

CONCLUSION

MRCP is useful method for evaluation of the pancreaticobiliary system in pediatric patients. It yields a high degree of accuracy in the diagnosis of biliary atresia and choledochal cyst.

Benefit of pronase in image quality during EUS

BACKGROUND

EUS is useful for diagnosis of GI disease. However, artifacts caused by gastric mucus may worsen visibility during EUS.

OBJECTIVE

To investigate the efficacy of premedication with pronase, the proteolytic enzyme, for improving imaging during EUS.

DESIGN

Blinded, randomized, prospective study.

SETTING

Tertiary-care referral center.

PATIENTS

This study involved 183 patients scheduled for EUS.

INTERVENTION

Patients were assigned to oral premedication with saline solution (group A), pronase and bicarbonate (group B), or pronase, bicarbonate, and simethicone (group C). Either conventional EUS or high-frequency catheter EUS (HFUS) was selected. Gastric cavity and gastric mucosal surface obscurity grades were assessed by using visibility scores from ultrasonographic images of each patient.

MAIN OUTCOME MEASUREMENTS

Means of visibility scores and proportion of images with better visibility scores of the gastric cavity and gastric mucosal surface. Lower scores indicate better visibility of the gastric mucosal surface and fewer artifacts within the gastric cavity on conventional EUS and HFUS.

RESULTS

Group B had significantly lower mean gastric cavity and gastric mucosal surface visibility scores than did groups A and C in both conventional EUS and HFUS. Group B also had a high proportion of images that had better gastric cavity and gastric mucosal surface visibility scores than did the other two groups in conventional EUS and HFUS.

LIMITATIONS

Small number of patients and no assessment of the amount of mucus before oral premedication.

CONCLUSION

Premedication for conventional EUS and HFUS by using a mixture of pronase and bicarbonate seems to decrease the number of gastric wall and lumen hyperechoic artifacts observed in patients given either saline solution or pronase/bicarbonate/simethicone.

Endoscopic diagnosis of extrahepatic bile duct carcinoma: Advances and current limitations

The accurate diagnosis of extrahepatic bile duct carcinoma is difficult, even now. When ultrasonography (US) shows dilatation of the bile duct, magnetic resonance cholangiopancreatography followed by endoscopic US (EUS) is the next step. When US or EUS shows localized bile duct wall thickening, endoscopic retrograde cholangiopancreatography should be conducted with intraductal US (IDUS) and forceps biopsy. Fluorescence in situ hybridization increases the sensitivity of brush cytology with similar specificity. In patients with papillary type bile duct carcinoma, three biopsies are sufficient. In patients with nodular or infiltrating-type bile duct carcinoma, multiple biopsies are warranted, and IDUS can compensate for the limitations of biopsies. In preoperative staging, the combination of dynamic multi-detector low computed tomography (MDCT) and IDUS is useful for evaluating vascular invasion and cancer depth infiltration. However, assessment of lymph nodes metastases is difficult. In resectable cases, assessment of longitudinal cancer spread is important. The combination of IDUS and MDCT is useful for revealing submucosal cancer extension, which is common in hilar cholangiocarcinoma. To estimate the mucosal extension, which is common in extrahepatic bile duct carcinoma, the combination of IDUS and cholangioscopy is required. The utility of current peroral cholangioscopy is limited by the maneuverability of the “baby scope”. A new baby scope (10 Fr), called “SpyGlass” has potential, if the image quality can be improved. Since extrahepatic bile duct carcinoma is common in the Far East, many researchers in Japan and Korea contributed these studies, especially, in the evaluation of longitudinal cancer extension.

Prospective comparison of endoscopic ultrasonography and magnetic resonance cholangiopancreatography in the etiological diagnosis of "idiopathic" acute pancreatitis

OBJECTIVES

The objectives of the study were to compare endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) in the etiological diagnosis of patients initially diagnosed with idiopathic acute pancreatitis and to determine the clinical and analytical factors related to the end result of these techniques.

METHODS

Forty-nine patients, initially diagnosed with idiopathic acute pancreatitis, were evaluated prospectively with EUS and MRCP. Diagnoses were compared between the 2 procedures. The clinical-evolutionary characteristics of these patients with regard to the results obtained with these techniques were compared.

RESULTS

In twenty-eight patients (57%), EUS and/or MRCP diagnosed at least 1 possible cause of acute pancreatitis. The diagnostic yield of EUS was higher than that of MRCP (51% vs 20%; P = 0.001). Cholelithiasis and biliary sludge (24%) were the most frequent EUS diagnoses, and pancreas divisum (8%) was the most frequent MRCP diagnosis. Only in 3 cases (6%) did MRCP identify additional features in patients etiologically undiagnosed using EUS. The EUS yield was lower in patients who had a previous cholecystectomy (11% vs 60%; P = 0.008).

CONCLUSIONS

Endoscopic ultrasonography and MRCP are useful techniques in the etiological diagnosis of acute pancreatitis of nonestablished cause. Endoscopic ultrasonography should be preferred for establishing a possible biliary etiology in patients who have not had a cholecystectomy.