Endoscopic ultrasound in patients with suspected choledocholithiasis
- Gavin C Harewood, MD
Gavin C Harewood, MD
- Department of Gastroenterology
- Beaumont Hospital, Dublin, Ireland
- Maurits J Wiersema, MD
Maurits J Wiersema, MD
- Clinical Assistant Professor of Medicine
- Indiana University School of Medicine
Choledocholithiasis (common bile duct stones) develops in up to 20 percent of patients with gallbladder stones . It is generally accepted that stones in the common bile duct should be removed, even if patients are asymptomatic, because they could eventually cause abdominal pain, pancreatitis, and/or cholangitis.
Diagnosis of common duct stones is not always straightforward. Clinical evaluation and biochemical tests are insufficiently accurate to reliably establish a firm diagnosis without confirmatory testing. As a result, imaging tests are routinely used to clarify the diagnosis.
The gold standard test in the past was endoscopic retrograde cholangiopancreatography (ERCP), which (compared with other tests such as ultrasonography) has the advantage of permitting intervention if a common bile duct stone is present. However, ERCP is invasive, may miss small stones, and may cause complications such as pancreatitis. Thus, it is frequently desirable to confirm the presence of choledocholithiasis before embarking upon an ERCP. The optimal type, timing, and choice among specific tests have not been clearly established and continue to be reevaluated as new technologies emerge.
The most commonly used initial test is a transabdominal ultrasound examination of the hepatobiliary system. The sensitivity of ultrasound for the detection of dilated bile ducts from biliary obstruction ranges in various studies from 55 to 91 percent [1-6]. The sensitivity increases with the serum bilirubin concentration and the duration of jaundice . A dilated extrahepatic bile duct on ultrasound suggests the possibility of an obstructing lesion. Ultrasound has similar sensitivity to computed tomography (CT) for detecting choledocholithiasis (75 percent in the presence of dilated ducts, 50 percent for nondilated ducts). Gas in the duodenum can obscure visualization of the distal common bile duct thereby decreasing sensitivity .
Four other approaches have also been used:
Subscribers log in hereLiterature review current through: May 2017. | This topic last updated: Dec 15, 2016.References
- Mitchell SE, Clark RA. A comparison of computed tomography and sonography in choledocholithiasis. AJR Am J Roentgenol 1984; 142:729.
- Pedersen OM, Nordgård K, Kvinnsland S. Value of sonography in obstructive jaundice. Limitations of bile duct caliber as an index of obstruction. Scand J Gastroenterol 1987; 22:975.
- Pasanen PA, Partanen KP, Pikkarainen PH, et al. A comparison of ultrasound, computed tomography and endoscopic retrograde cholangiopancreatography in the differential diagnosis of benign and malignant jaundice and cholestasis. Eur J Surg 1993; 159:23.
- Lapis JL, Orlando RC, Mittelstaedt CA, Staab EV. Ultrasonography in the diagnosis of obstructive jaundice. Ann Intern Med 1978; 89:61.
- Baron RL. Common bile duct stones: reassessment of criteria for CT diagnosis. Radiology 1987; 162:419.
- Laing FC, Jeffrey RB Jr, Wing VW, Nyberg DA. Biliary dilatation: defining the level and cause by real-time US. Radiology 1986; 160:39.
- Salem S, Vas W. Ultrasonography in evaluation of the jaundiced patient. J Can Assoc Radiol 1981; 32:30.
- Chak A, Hawes RH, Cooper GS, et al. Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis. Gastrointest Endosc 1999; 49:599.
- Onken JE, Brazer SR, Eisen GM, et al. Predicting the presence of choledocholithiasis in patients with symptomatic cholelithiasis. Am J Gastroenterol 1996; 91:762.
- Cohen ME, Slezak L, Wells CK, et al. Prediction of bile duct stones and complications in gallstone pancreatitis using early laboratory trends. Am J Gastroenterol 2001; 96:3305.
- Garrow D, Miller S, Sinha D, et al. Endoscopic ultrasound: a meta-analysis of test performance in suspected biliary obstruction. Clin Gastroenterol Hepatol 2007; 5:616.
- Tse F, Liu L, Barkun AN, et al. EUS: a meta-analysis of test performance in suspected choledocholithiasis. Gastrointest Endosc 2008; 67:235.
- Verma D, Kapadia A, Eisen GM, Adler DG. EUS vs MRCP for detection of choledocholithiasis. Gastrointest Endosc 2006; 64:248.
- De Castro VL, Moura EG, Chaves DM, et al. Endoscopic ultrasound versus magnetic resonance cholangiopancreatography in suspected choledocholithiasis: A systematic review. Endosc Ultrasound 2016; 5:118.
- Norton SA, Alderson D. Prospective comparison of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the detection of bile duct stones. Br J Surg 1997; 84:1366.
- Sugiyama M, Wada N, Atomi Y, et al. Diagnosis of acute pancreatitis: value of endoscopic sonography. AJR Am J Roentgenol 1995; 165:867.
- Canto MI, Chak A, Stellato T, Sivak MV Jr. Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis. Gastrointest Endosc 1998; 47:439.
- Topal B, Fieuws S, Tomczyk K, et al. Clinical models are inaccurate in predicting bile duct stones in situ for patients with gallbladder. Surg Endosc 2009; 23:38.
- Petrov MS, Savides TJ. Systematic review of endoscopic ultrasonography versus endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis. Br J Surg 2009; 96:967.
- Liu CL, Lo CM, Chan JK, et al. Detection of choledocholithiasis by EUS in acute pancreatitis: a prospective evaluation in 100 consecutive patients. Gastrointest Endosc 2001; 54:325.
- Corfield AP, Cooper MJ, Williamson RC. Acute pancreatitis: a lethal disease of increasing incidence. Gut 1985; 26:724.
- Corfield AP, Cooper MJ, Williamson RC, et al. Prediction of severity in acute pancreatitis: prospective comparison of three prognostic indices. Lancet 1985; 2:403.
- Park J, Fromkes J, Cooperman M. Acute pancreatitis in elderly patients. Pathogenesis and outcome. Am J Surg 1986; 152:638.
- Prat F, Edery J, Meduri B, et al. Early EUS of the bile duct before endoscopic sphincterotomy for acute biliary pancreatitis. Gastrointest Endosc 2001; 54:724.
- Liu CL, Fan ST, Lo CM, et al. Comparison of early endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the management of acute biliary pancreatitis: a prospective randomized study. Clin Gastroenterol Hepatol 2005; 3:1238.
- Dill JE, Hill S, Callis J, et al. Combined endoscopic ultrasound and stimulated biliary drainage in cholecystitis and microlithiasis--diagnoses and outcomes. Endoscopy 1995; 27:424.
- Liu CL, Lo CM, Chan JK, et al. EUS for detection of occult cholelithiasis in patients with idiopathic pancreatitis. Gastrointest Endosc 2000; 51:28.
- Frossard JL, Sosa-Valencia L, Amouyal G, et al. Usefulness of endoscopic ultrasonography in patients with "idiopathic" acute pancreatitis. Am J Med 2000; 109:196.
- Urbach DR, Khajanchee YS, Jobe BA, et al. Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration. Surg Endosc 2001; 15:4.
- Sahai AV, Mauldin PD, Marsi V, et al. Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholangiography, EUS, and ERCP. Gastrointest Endosc 1999; 49:334.