Original article
Comparison of Early Endoscopic Ultrasonography and Endoscopic Retrograde Cholangiopancreatography in the Management of Acute Biliary Pancreatitis: A Prospective Randomized Study

https://doi.org/10.1016/S1542-3565(05)00619-1Get rights and content

Background & Aims: The role and potential benefits of endoscopic ultrasonography (EUS) in the management of acute biliary pancreatitis have not been documented. We report a large prospective randomized study comparing early EUS and endoscopic retrograde cholangiopancreatography (ERCP) in the management of these patients. Methods: A prospective randomized study was performed on 140 patients with acute pancreatitis suspected to have a biliary cause. The patients were randomized to have EUS (n = 70) or ERCP (n = 70) within 24 hours from admission. In the EUS group, when EUS detected choledocholithiasis, therapeutic ERCP was performed during the same endoscopy session. In the ERCP group, diagnostic ERCP was performed, followed by therapeutic endoscopy when choledocholithiasis was detected. Results: Examination of the biliary tree by EUS was successful in all patients in the EUS group, whereas cannulation of the common duct during ERCP was unsuccessful in 10 patients (14%) in the ERCP group (P = .001). Combined percutaneous ultrasonography and ERCP missed detection of cholelithiasis in 6 patients in the ERCP group. The overall morbidity rate was 7% in the EUS group, and that in the ERCP group was 14% (P = .172). The hospital stay and mortality rates were comparable in both groups. Conclusions: In selected patients with acute biliary pancreatitis, EUS could safely replace diagnostic ERCP in the management for selecting patients with choledocholithiasis for therapeutic ERCP with a higher successful examination rate, a higher sensitivity in the detection of cholelithiasis, and a comparable morbidity rate.

Section snippets

Methods

We performed a single-centered, open-labeled, prospective randomized controlled study to test the hypothesis that the management of patients with acute biliary pancreatitis could be improved by an early EUS examination. During a 30-month study period from July 2001–December 2003, 207 patients with the diagnosis of acute pancreatitis were managed at the Department of Surgery, Queen Mary Hospital, Hong Kong. One hundred forty patients with the first episode of acute pancreatitis, which was

Results

Among the 140 patients presenting with the first episode of acute pancreatitis with a suspected biliary cause included in the study, there were 62 men and 78 women with a median age of 69 years. Thirteen patients (9%) were clinically jaundiced, and 20 (14%) of them were febrile on admission. Sixty-eight patients (49%) were found to have a severe attack of acute pancreatitis with a Ranson’s score11 of 3 or more. Clinical parameters of both the EUS group and the ERCP group are listed in Table 1

Discussion

Although ERCP has been considered the gold standard for imaging the bile duct in patients with suspected biliary pancreatitis, and early ERCP with ES when choledocholithiasis is detected has been reported to reduce the morbidity rates,2, 3 this approach is characterized by a high number of unnecessary ERCPs. The complication rate associated with ERCP is significant with a nontrivial mortality rate.4 Large prospective case series have shown that the overall complication rates were 5%–6%, and the

References (22)

Cited by (117)

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

    2017, Gastrointestinal Endoscopy
    Citation Excerpt :

    These studies showed an excellent negative predictive value for EUS before ERCP, likely because of higher sensitivity consistent with our findings. The results of our study could hence emphasize more targeted ERCP procedures, given higher sensitivity and the fact that both EUS and ERCP could be done in the same session.28-30 The results of our meta-analysis should be interpreted with caution, given the limitations in conducting a meta-analysis.

  • Chapter 56 - Management of acute pancreatitis and complications

    2017, Blumgart's Surgery of the Liver, Biliary Tract and Pancreas: Sixth Edition
  • Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography: Can they be successfully combined?

    2016, Gastroenterologia y Hepatologia
    Citation Excerpt :

    EUS appears comparable to ERCP as a diagnostic test for CBD stones, is superior to other techniques for detecting biliary stones, and can be used to select patients who will need therapeutic ERCP. This results in a significantly lower risk of complications in comparison with the use of ERCP for both diagnosis and treatment of choledocholithiasis.30,36,40,41 By performing EUS first, ERCP may be safely avoided in patients with common bile duct stones.

View all citing articles on Scopus

Supported by the Sun C.Y. Research Foundation for Hepatobiliary and Pancreatic Surgery of the University of Hong Kong.

View full text