Introduction Endoscopic ultrasound (EUS) has become an invaluable investigation in the assessment of pancreatobiliary disease. EUS is superior to abdominal ultrasound in pancreatobiliary imaging having a sensitivity of >90% for choledocholithiasis and affording better views of the pancreas. Traditionally, patients tend to undergo EUS following specialist review. We are not aware of any reports of direct-to-test EUS for patients who have been assessed only by a general practitioner (GP). We propose that, in selected patients with suspected choledocholithiasis, direct-to-test EUS is safe and avoids specialist clinic review and the attendant delay, expense and inconvenience. Here we present our initial data on direct-to-test EUS in a teaching hospital setting.
Methods Twenty-four patients who had been referred to the gastroenterology department at our institution by their general practitioners between February 2005 and July 2009 were selected to be offered direct-to-test EUS. Selected patients had liver chemistry and/or symptomatology compatible with biliary pathology; all but one patient had had an abdominal ultrasound scan before referral. A patient information leaflet was sent in the post along with the appointment letter.
Results All patients accepted direct-to-test EUS appointment; the average time from referral to procedure was 6 weeks. The average patient age was 59 years (range 21–83); 17 out of 24 patients were female (71%). The clinical details were: biliary-type pain with abnormal liver chemistry but normal ducts on ultrasound (n=14); abnormal liver chemistry with duct dilatation but no stones identified on ultrasound (n=4); biliary-type pain, normal chemistry, with duct dilatation but no stones on ultrasound (n=3); progressive cholestatic liver chemistry post cholecystectomy with no duct dilatation on ultrasound (n=2); unexplained recent pancreatitis with a normal ultrasound (n=1). The EUS findings for the 24 patients were: normal examination (n=13), choledocholithiasis (n=3), gallstones (n=5), hepatic steatosis (n=2), periampullary tumour (n=1). Three of the cases of gallstones had not been previously identified on abdominal ultrasound scanning. The overall yield for pathology was 46%. There were no noted complications in any of the 24 cases. On the basis of the EUS examination, three patients were referred for ERCP, two for cholecystectomy, and one for a Whipple's procedure. This equates to a 25% onward referral rate for definitive treatment based on the direct-to-test EUS findings.
Conclusion Our initial data support the hypothesis that direct-to-test EUS for selected patients with suspected biliary disease is a safe investigation, with a high yield of significant pathology.
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