Original Articles
Wire-guided intraductal US: An adjunct to ERCP in the management of bile duct stones,☆☆

Presented in part as a poster at the annual meeting of the American Society for Gastrointestinal Endoscopy, May 2000, San Diego, California (Gastrointest Endosc 2000;51:AB186).
https://doi.org/10.1067/mge.2001.115006Get rights and content

Abstract

Background: Endoscopic retrograde cholangiography (ERC) may misdiagnose bile duct stones if air bubbles are introduced during contrast injection, and it may also fail to diagnose stones in the presence of bile duct dilation. Methods: Our aim was to determine whether intraductal US (IDUS) improves the accuracy of cholangiography and whether it is a useful adjunct in the management of bile duct stones. IDUS with a wire-guided US probe was performed after initial ERC in patients in whom bile duct stones were suspected. The diagnostic accuracy of ERC alone was compared with that of ERC plus IDUS. Results: ERC with IDUS was performed in 62 patients who were suspected to have bile duct stones. Both IDUS and ERC were performed by the same endoscopist, and ERC was performed with a C-arm fluoroscope. The presence of bile duct stones and/or sludge were confirmed after sphincterotomy and extraction in 34 patients. Overall, the accuracy of ERC combined with IDUS in the diagnosis of bile duct stone and/or sludge was higher than that of ERC alone (97% vs. 87%, p < 0.05). With dilated bile ducts, the diagnostic accuracy of ERC combined with IDUS was also higher than that of ERC alone (95.5% vs. 72.7%, p < 0.05). Additional diagnostic information provided by IDUS included identification of cystic duct stones in 5 patients, characterization of bile duct strictures in 2 patients, and choledochal varices in 1 patient. Performance of wire-guided IDUS required 5% of the total procedure time. Conclusions: IDUS improves diagnostic accuracy of ERC and is a useful adjunct to ERC when bile duct stones are suspected. (Gastrointest Endosc 2001;54:31-6.)

Section snippets

Patients and methods

Patients were eligible for inclusion in the study if they were referred for ERC because of a suspicion of choledocholithiasis based on 2 or more of the following: (1) right upper quadrant or epigastric pain, (2) abnormal serum transaminase, serum alkaline phosphatase, and/or total bilirubin, (3) history of acute pancreatitis, (4) recent or ongoing cholangitis, (5) biliary dilatation on transabdominal US and/or CT, and/or (6) bile duct stone and/or sludge diagnosed by US, CT, or ERCP performed

Results

Sixty-two (mean age 64.5 ± 1.3 years, 26 men) patients underwent both ERC and IDUS. Twenty-two patients had undergone cholecystectomy and 26 patients had concomitant cholecystolithiasis. Thirty-four (54.8%) patients had bile duct stones (29 patients) and/or sludge (5 patients) as confirmed by extraction and duodenoscopic visualization. Table 1 shows the comparative performance of ERC alone and ERC plus IDUS in correctly diagnosing the presence of bile duct stone and/or sludge.

. The comparative

Discussion

The role of EUS in the diagnosis of choledocholithiasis has been evaluated in a number of studies.9, 10, 11, 12, 13, 14 The potential advantage to EUS is that it is at least as accurate as ERCP but carries no risk of pancreatitis. However, the inability to perform endoscopic therapy raises questions about the clinical utility of EUS and its place in the diagnostic algorithm for suspected choledocholithiasis.13, 14 This limitation warrants a search for a better modality that uses the capability

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Reprint requests: Amitabh Chak, MD, Division of Gastroenterology, 11100 Euclid Ave., Cleveland, OH 44106.

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Gastrointest Endosc 2001;54:31-6

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