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Endoscopic ultrasound in patients with suspected choledocholithiasis

Gavin C Harewood, MD
Maurits J Wiersema, MD
Section Editor
Douglas A Howell, MD, FASGE, FACG
Deputy Editor
Kristen M Robson, MD, MBA, FACG


Choledocholithiasis (common bile duct stones) develops in up to 20 percent of patients with gallbladder stones [1]. 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 [7]. 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 [8].

Four other approaches have also been used:

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Literature review current through: Nov 2017. | This topic last updated: Dec 15, 2016.
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