Do Normal Findings at Biliary Endoscopic Ultrasonography Obviate the Need for Endoscopic Retrograde Cholangiography in Patients with Suspicion of Common Bile Duct Stone? A Prospective Follow-Up Study of 238 Patients

Background and Study Aims: Biliary endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiography (ERC) are equally accurate for the diagnosis of common bile duct (CBD) stone. The aim of this prospective 1-year follow-up study was to determine whether normal findings at initial EUS obviated the need for ERC.
Patients and Methods: During a 17-month period, all patients referred for biliary EUS because of suspicion of CBD stone, in whom EUS findings were normal were included in the study. Early (1-month) and late (1-year) follow-up details were obtained by mail or telephone. The clinical course and need for ERC were recorded.

Results: 238 patients were enrolled. During follow-up, 59 (25 %) patients underwent cholecystectomy, with (n = 31) or without (n = 28) cholangiography, and 30 patients underwent ERC (13 %). CBD stone was found in 14 (6 %) patients. Of these 30 patients, ERC was done in 15 cases in the first week after EUS, because of persistent suspicion of a CBD stone which was found in 10 patients. The 15 late ERC procedures (carried out more than 1 week after EUS) revealed only one CBD stone. The negative predictive value of EUS for the diagnosis of CBD stones was 95.4 %.
Conclusions: Patients with suspicion of CBD stones but normal EUS findings have a low risk of needing ERC in a 1-year period.

References

• 1 Palazzo L, Girollet P P, Salmeron M. et al . Value of endoscopic ultrasonography in the diagnosis of common bile duct stones: comparison with surgical exploration and ERCP.  Gastrointest Endosc. 1995;  42 225-231
• 2 Prat F, Amouyal G, Amouyal P. et al . Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common bile duct lithiasis.  Lancet. 1996;  347 75-79
• 3 Mitchell S E, Clark R A. A comparison of computed tomography and sonography in choledocholithiasis.  Am J Roentgenol. 1984;  142 729-733
• 4 Laing F C, Jeffrey R B, Wing V W, Nyberg D A. Biliary dilatation: defining the level and cause by real-time US.  Radiology. 1986;  160 39-42
• 5 Cronan J J. US diagnosis of choledocholithiasis: a reappraisal.  Radiology. 1986;  161 133-134
• 6 Dong B, Chen M. Improved sonographic visualization of choledocholithiasis.  J Clin Ultrasound. 1987;  15 185-190
• 7 Stott M A, Farrands P A, Guyer P B. et al . Ultrasound of the common bile duct in patients undergoing cholecystectomy.  J Clin Ultrasound. 1991;  19 73-76
• 8 Pezzilli R, Billi P, Barakat B, D’Imperio N. et al . Ultrasonographic evaluation of the common bile duct in biliary acute pancreatitis patients: comparison with endoscopic retrograde cholangiopancreatography.  J Ultrasound Med. 1999;  18 391-394
• 9 Freeman M L, Nelson D B, Sherman S. et al . Complications of endoscopic biliary sphincterotomy.  N Engl J Med. 1996;  335 909-918
• 10 Cotton P B. ERCP.  Gut. 1977;  18 316-341
• 11 Davidson B R, Neoptolemos J P, Carr-Locke D L. Endoscopic sphincterotomy for common bile duct calculi in patients with gall bladder in situ considered unfit for surgery.  Gut. 1988;  29 114-120
• 12 Canto M I, Chak A, Stellato T, Sivak M V. Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis.  Gastrointest Endosc. 1998;  47 439-448
• 13 Vaira D, D’Anna L, Ainley C. et al . Endoscopic sphincterotomy in 1000 consecutive patients.  Lancet. 1989;  2 431-434
• 14 Baron R L. Common bile duct stones: reassessment of criteria for CT diagnosis.  Radiology. 1987;  162 419-424
• 15 Neitlich J D, Topazian M, Smith R C. et al . Detection of choledocholithiasis: comparison of unenhanced helical CT and endoscopic retrograde cholangiopancreatography.  Radiology. 1997;  203 753-757
• 16 Kwon A H, Uetsuji S, Yamada O. et al . Three-dimensional reconstruction of the biliary tract using spiral computed tomography.  Br J Surg. 1995;  82 260-263
• 17 Bret P M, Reinhold C. Magnetic resonance cholangiopancreatography.  Endoscopy. 1997;  29 472-486
• 18 Macaulay S E, Schulte S J, Sekijima J H. et al . Evaluation of a non-breath-hold MR cholangiography technique.  Radiology. 1995;  196 227-232
• 19 Chan Y L, Chan A C, Lam W W. et al . Choledocholithiasis: comparison of MR cholangiography and endoscopic retrograde cholangiography.  Radiology. 1996;  200 85-89
• 20 Mendler M H, Bouillet P, Sautereau D. et al . Value of MR cholangiography in the diagnosis of obstructive diseases of the biliary tree: a study of 58 cases.  Am J Gastroenterol. 1998;  93 2482-2490
• 21 Zidi S H, Prat F, Le Guen O. et al . Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis: prospective comparison with a reference imaging method.  Gut. 1999;  44 118-122
• 22 de Ledinghen V, Lecesne R, Raymond J M. et al . Diagnosis of choledocholithiasis: EUS or magnetic resonance cholangiography? A prospective controlled study.  Gastrointest Endosc. 1999;  49 26-31
• 23 Materne R, Van Beers B E, Gigot J F. et al . Extrahepatic biliary obstruction: magnetic resonance imaging compared with endoscopic ultrasonography.  Endoscopy. 2000;  32 3-9
• 24 Norton S A, Alderson D. Prospective comparison of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the detection of bile duct stones.  Br J Surg. 1997;  84 1366-1369
• 25 Caletti G, Fusaroli P. Endoscopic ultrasonography.  Endoscopy. 1999;  31 95-102
• 26 Chak A, Hawes R H, Cooper G S. et al . Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis.  Gastrointest Endosc. 1999;  49 599-604
• 27 Liu C L, Lo C M, Chan J K. et al . EUS for detection of occult cholelithiasis in patients with idiopathic pancreatitis.  Gastrointest Endosc. 2000;  51 28-32
• 28 Lightdale C J. Indications, contraindications, and complications of endoscopic ultrasonography.  Gastrointest Endosc. 1996;  43 15-19
• 29 Prat F, Jaoude J B, Ink O. et al . Endoscopic sphincterotomy for suspected choledocholithiasis in patients with and without stones.  Am J Gastroenterol. 1995;  90 727-731
• 30 Tham T C, Lichtenstein D R, Vandervoort J. et al . Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy.  Gastrointest Endosc. 1998;  47 50-56
• 31 Frossard J L, Hadengue A, Amouyal G. et al . Choledocholithiasis: a prospective study of spontaneous common bile duct stone migration.  Gastrointest Endosc. 2000;  51 175-179
• 32 Cotton P B, Baillie J, Pappas T N, Meyers W S. Laparoscopic cholecystectomy and the biliary endoscopist [editorial].  Gastrointest Endosc. 1991;  37 94-97
• 33 Cotton P B. Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy.  Am J Surg. 1993;  165 474-478
• 34 Edmundowicz S A, Aliperti G, Middleton W D. Preliminary experience using endoscopic ultrasonography in the diagnosis of choledocholithiasis.  Endoscopy. 1992;  24 774-778
• 35 Berdah S V, Orsoni P, Bege T. et al . Follow-up of selective endoscopic ultrasonography and/or endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy: a prospective study of 300 patients.  Endoscopy. 2001;  33 216-220