Diagnosis of choledocholithiasis: EUS or magnetic resonance cholangiography? A prospective controlled study

doi:10.1016/S0016-5107(99)70441-4

Gastrointestinal Endoscopy

Volume 49, Issue 1, January 1999, Pages 26-31

https://doi.org/10.1016/S0016-5107(99)70441-4 Get rights and content

Abstract

Background: Endoscopic ultrasonography (EUS) appears to be the best imaging method for the diagnosis of choledocholithiasis. The aim of this preliminary, prospective, controlled study was to assess the accuracy of EUS and magnetic resonance cholangiopancreatography (MRCP) in the diagnosis of common bile duct stones. Methods: From December 1995 through April 1997, all patients referred because of suspicion of the presence of common bile duct stones were included in the study. EUS and MRCP were performed. Each examination was performed by a different operator unaware of the result of the other procedure. The definitive diagnosis was established by means of endoscopic retrograde cholangiography with sphincterotomy or a surgical procedure. Results: Forty-three patients (18 men, 25 women) with a mean age of 60.9 ± 14.5 years (range 25 to 81 years) were included in the study. Eleven patients were excluded because of unavailability of magnetic resonance imaging(n = 5) or EUS (n = 6). Ten patients (31.2%) had choledocholithiasis. For this diagnosis, the sensitivity of EUS was 100%, the specificity was 95.4%, the positive predictive value was 90.9%, and the negative predictive value was 100%. The corresponding values for MRCP were 100%, 72.7%, 62.5%, and 100%, not significantly different from EUS results. The accuracy of EUS was 96.9%, and that of MRCP was 82.2%. Conclusion: This preliminary study confirmed EUS as an accurate and noninvasive procedure for the diagnosis of common bile duct stones. MRCP, which had a high sensitivity and high negative predictive value, might be an accurate technique for patients with a contraindication to EUS. (Gastrointest Endosc 1999;49:26-31.)

Section snippets

Inclusion criteria

From December 1995 through April 1997, patients were included if they had clinical or biochemical signs of choledocholithiasis according to the following criteria: combination of epigastric or right upper quadrant pain with fever or jaundice; one or two of the previous signs together with an elevation of serum alkaline phosphatase level or an elevation of serum γ-glutamyl transpeptidase or transaminase level more than the upper limit of normal; acute pancreatitis, defined as acute epigastric

RESULTS

From December 1995 through April 1997, 43 patients (18 men, 25 women) with a mean age of 60.9 ± 14.5 years (range 25 to 81 years) enrolled in the study. Eleven patients were excluded because magnetic resonance imaging (n = 5) or EUS (n = 6) was not available. Therefore 32 of 43 patients (74.4%) underwent EUS and MRCP. Median time between EUS and MRCP was 1 day (range 0 to 7 days). EUS was performed before MRCP in 12 instances and after MRCP in 20 instances. EUS and MRCP were successful in all

DISCUSSION

Diagnostic imaging of the biliary ductal system typically begins with noninvasive modalities such as ultrasonography or CT. However, information obtained with these techniques often is insufficient for diagnosis despite successive examinations that markedly increase the cost of diagnostic evaluation. In our study, 22 patients did not have choledocholithiasis. This ratio is high because patients were selected on few predictive features of choledocholithiasis.

Ultrasonography is the easiest,

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Cited by (220)

Usefulness of endoscopic ultrasound in patients with minilithiasis and/or biliary sludge as a cause of symptoms of probable biliary origin after cholecystectomy
2022, Gastroenterologia y Hepatologia
Endoscopic ultrasound (EUS) is a more sensitive technique than transabdominal ultrasound for the diagnosis of gallstones. This greater sensitivity, especially in the diagnosis of microlithiasis/biliary sludge, facilitates the indication of cholecystectomy in patients with symptoms of probable biliary origin but may result in over-indication of this surgery.
Evaluate the role of EUS in the diagnosis of minilithiasis/biliary sludge in patients with digestive symptoms of probable biliary origin by resolving the symptoms after cholecystectomy. Analyse factors related to the remission of symptoms following cholecystectomy.
Retrospective, longitudinal, single-centre study based on a prospective database of 1.121 patients undergoing EUS. Seventy-four patients were identified as meeting inclusion-exclusion criteria (diagnosed with minilithiasis/sludge by EUS after presenting digestive symptoms of probable biliary origin without a history of complicated cholelithiasis). A telephone questionnaire for symptoms was conducted with cholecystectomized patients. Factors related to a good response were analysed with logistic regression analysis.
Of the 74 patients, 50 were cholecystectomized (67.5%), mean age 49 years (SEM 2.26) (41 women). Seventy percent of patients (35/50) presented remission of symptoms with median follow-up 353.5 days (95% CI, 270–632.2). The only variable associated with remission of symptoms was the presence of typical biliary colic with an OR of 7.8 (95% CI, 1.8–34; p = 0.006). No complications associated with EUS were recorded. One patient (2%) suffered haemoperitoneum and 18% (9/50) suffered diarrhoea following cholecystectomy.
EUS is a very useful technique for the indication of cholecystectomy in patients with minilithiasis/sludge and typical symptoms of biliary colic.
La ecoendoscopia (USE) presenta mayor sensibilidad que la ecografía abdominal para el diagnóstico de litiasis biliar. Esta mayor sensibilidad, sobre todo en diagnóstico de microlitiasis/barro biliar, facilitaría una colecistectomía en pacientes con clínica digestiva de probable origen biliar, aunque podría inducir su sobre indicación.
Evaluar el papel de la USE en el diagnóstico de minilitiasis-barro biliar en pacientes con clínica digestiva de probable origen biliar y ecografía normal mediante la resolución de los síntomas después de colecistectomía. Analizar los factores relacionados con la remisión de la sintomatología tras colecistectomía.
Estudio retrospectivo, longitudinal, en un centro, sobre base de datos prospectiva de 1.121 pacientes sometidos a USE. Setenta y cuatro pacientes cumplían criterios inclusión-exclusión (realización USE para estudio de minilitiasis/barro por síntomas digestivos de probable origen biliar, sin historia de colelitiasis complicada). Se realizó cuestionario telefónico de síntomas a los pacientes colecistectomizados. Los factores relacionados con buena evolución se analizaron con análisis de regresión logística.
De los 74 pacientes, 50 fueron colecistectomizados (67,5%), edad media 49 años (ESM 2,26) (41 mujeres). El 70% de pacientes (35/50) presentó remisión de la sintomatología (mediana de seguimiento 353,5 días) (IC 95%, 270-632,2). La única variable asociada con una remisión de la sintomatología fue la presencia de cólico biliar típico con una OR de 7,8 (IC 95%, 1,8-34; p =0,006). No se registró ninguna complicación asociada a la USE. Un paciente (2%) sufrió hemoperitoneo y un 18% (9/50) presentaron diarrea post-colecistectomía.
La USE es de gran utilidad para la indicación de colecistectomía en los pacientes con minilitiasis-barro biliar y clínica típica de cólico biliar.
ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis
2019, Gastrointestinal Endoscopy
Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the contemporary literature regarding the following topics: EUS versus MRCP for diagnosis, the role of early ERCP in gallstone pancreatitis, endoscopic papillary dilation after sphincterotomy versus sphincterotomy alone for large bile duct stones, and impact of ERCP-guided intraductal therapy for large and difficult choledocholithiasis. Comprehensive systematic reviews were also performed to assess the following: same-admission cholecystectomy for gallstone pancreatitis, clinical predictors of choledocholithiasis, optimal timing of ERCP vis-à-vis cholecystectomy, management of Mirizzi syndrome and hepatolithiasis, and biliary stent therapy for choledocholithiasis. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. This body developed all recommendations founded on the certainty of the evidence, balance of risks and harms, consideration of stakeholder preferences, resource utilization, and cost-effectiveness.
Cholangitis: Causes, Diagnosis, and Management
2019, Surgical Clinics of North America
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
There is a wide range of reported sensitivity and specificity for EUS and MRCP in the diagnosis of choledocholithiasis, with lack of a proper meta-analysis of diagnostic test accuracy by using head-to-head comparison. Here, we aimed to compare the diagnostic accuracy of EUS and MRCP in detecting choledocholithiasis by using appropriate methodology recommended by the Cochrane Collaboration.
A comprehensive electronic literature search up to January 2017 was done by 2 reviewers for prospective cohort studies comparing EUS and MRCP to a reference standard for detecting choledocholithiasis. The acceptable reference standards were considered ERCP, intraoperative cholangiography, or clinical follow-up >3 months for negative cases. Quality of the included studies was measured by using the QUADAS-2 tool. A bivariate hierarchical model was used to perform the meta-analysis of diagnostic test accuracy. Summary receiver operating characteristics were developed and the area under the curve was calculated.
A total of 5 of 32 studies were included. No study presented a high risk of bias. The pooled sensitivity and specificity were 0.97 (range, 0.91-0.99) and 0.90 (range, 0.83-0.94) for EUS and 0.87 (range, 0.80-0.93) and 0.92 (range, 0.87-0.96) for MRCP. The overall diagnostic odds ratio of EUS was significantly higher than the one with MRCP (162.5 vs 79.0, respectively; P = .008). Further analysis showed that this was mainly due to the significantly higher sensitivity of EUS as compared with that of MRCP (P = .006). The specificity was not significantly different between 2 modalities (P = .42).
Both EUS and MRCP provide good diagnostic accuracy, with EUS providing statically better diagnostic accuracy and sensitivity, with comparable specificity. EUS should be incorporated in the diagnostic algorithm in patients suspected of choledocholithiasis whenever appropriate.
EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones
2016, Journal of Hepatology
Single-stage laparoscopic management of acute gallstone pancreatitis: Outcomes at different timings
2016, Hepatobiliary and Pancreatic Diseases International
Definitive therapy for gallstone pancreatitis requires eradication of gallstones with cholecystectomy and common bile duct (CBD) clearance. Current guidelines recommend this be done within the same admission and preferably by laparoscopic cholecystectomy and CBD exploration. We report our experience of laparoscopic single-stage management with cholecystectomy and intraoperative cholangiogram followed by laparoscopic bile duct exploration (LBDE) when necessary performed at three different stages.
From January 1998 to December 2012, 134 patients (100 females and 34 males) underwent single-stage laparoscopic management of gallstone pancreatitis. Patients were classified according to the timing of surgery: “A”, ≤7 days from symptom onset (n=27); “B”, 8 to 30 days (n=58) and “C”, >30 days (n=49).
LBDE was performed in 30 patients with a success rate of 100%. CBD stones were found in 25 patients (A: 22.2%, B: 22.4%, C: 12.2%). CBD stones were more common in patients undergoing surgery within 30 days of presentation than after this time point (P=0.35). Multiple choledocholithiasis was more frequent in patients treated within 7 days (P=0.04). The 30-day mortality after surgery was 0, with no conversion to an open approach. Overall complication rate was 11.9%, which did not differ significantly between patients treated within 7 days or after this time point (P=0.83).
This study demonstrated the feasibility and reproducibility of single-stage laparoscopic management of acute gallstone pancreatitis, which has a low complication rate at any stage. Patients undergoing early treatment have a higher incidence of choledocholithiasis and multiple stones than those treated after 30 days, supporting the passage of stones with time.

View all citing articles on Scopus

^☆: Reprint requests: Docteur Victor de Lédinghen, Service d'Hépato-Gastroentérologie, Hôpital du Haut-Lévêque, 33604 Pessac cedex, France.

^☆☆: 37/1/92453

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Diagnosis of choledocholithiasis: EUS or magnetic resonance cholangiography? A prospective controlled study☆,☆☆

Abstract

Section snippets

Inclusion criteria

RESULTS

DISCUSSION

Am J Surg

Am J Surg

Gastroenterology

Lancet

Gastroenterology

Gastrointest Endosc

Lancet

US diagnosis of choledocholithiasis: a reappraisal

Radiology

Biliary dilatation: defining the level and cause by real time US

Radiology

A comparison of computed tomography and sonography in choledocholithiasis

Am J Roentgenol

Common bile duct stones: reassessment of criteria for CT diagnosis

Radiology

Progress report: ERCP

Gut

Endoscopy

Endoscopic sphincterotomy in 1000 consecutive patients

Lancet