The Usefulness of Endoscopic Ultrasonography in the Diagnosis of Choledocholithiasis without Common Bile Duct Dilatation

Sang Ryul Lee; Jung Hwan Lee; Su-Yeon Lee; Hyung Hun Kim; Jong Hyeok Park; Soo Hyung Ryu; You Sun Kim; Jeong Seop Moon

doi:10.4166/kjg.2010.56.2.97

Journal List > Korean J Gastroenterol > v.56(2) > 1006767

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Lee, Lee, Lee, Kim, Park, Ryu, Kim, and Moon: The Usefulness of Endoscopic Ultrasonography in the Diagnosis of Choledocholithiasis without Common Bile Duct Dilatation

Original Article

Korean J Gastroenterol 2010;56(2):97-102.

Published online: 21 February 2010

DOI: https://doi.org/10.4166/kjg.2010.56.2.97

The Usefulness of Endoscopic Ultrasonography in the Diagnosis of Choledocholithiasis without Common Bile Duct Dilatation

Sang Ryul Lee, M.D., Jung Hwan Lee, M.D., Su-Yeon Lee, M.D., Hyung Hun Kim, M.D., Jong Hyeok Park, M.D., Soo Hyung Ryu, M.D., You Sun Kim, M.D., Jeong Seop Moon, M.D.

Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea

Correspondence to: Jung Hwan Lee, M.D. Department of Internal Medicine, Seoul Paik Hospital, 85, Jeo-dong 2-ga, Jung-gu, Seoul 100-032, Korea Tel: +82-2-2270-0012, Fax: +82-2-2270-0579 E-mail: jw0412@korea.com

Received 21 January 2010 Accepted 24 May 2010

Abstract

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is the most accurate modality in diagnosis of choledocholithiasis. However, it carries some complications. Endoscopic ultrasonography (EUS) is less invasive than ERCP and used for the diagnosis of choledocholithiasis. Recent studies showed that a usefulness of EUS for the diagnosis of small choledocholithiasis without common bile duct (CBD) dilatation. For such a rea-son, ERCP is being replaced by EUS in the diagnosis of bile duct stones. The aim of this study was to inves-tigate the accuracy of EUS for the diagnosis of choledocholithiasis without CBD dilatation.

Methods

A total of 66 patients with suspected choledocholithiasis without CBD dilatation were enrolled. EUS were performed in all cases within 48 hours after computed tomography (CT) or ultrasonography (US). Final diagnosis was obtained by ERCP or clinical course (minimum 6 months follow-up). We analyzed the accuracy of US, CT, and EUS, respectively.

Results

CT and US were performed in 51 and 15 cases, respectively. CBD stones were detected in 23 (35%) patients by ERCP. EUS showed 100% sensitivity, 95% specificity, 92% positive predictive value, and 100% negative predictive value for identifying CBD stones. CT or US showed 26%, 93%, 67%, and 70%, respectively. There were no EUS-related complications.

Conclusions

EUS was more effective than CT or US and as accurate as ERCP for the diagnosis of small choledocholithiasis without CBD dilatation. Thus, EUS may help to avoid unnecessary diagnostic ERCP and its complication.

Keywords: Choledocholithiasis, Common bile duct, Endoscopic ultrasonography

REFERENCES

1. Pickuth D. Radiologic diagnosis of common bile duct stones. Abdom Imaging. 2000; 25:618–621.

2. Freeman ML. Adverse outcomes of ERCP. Gastrointest Endosc. 2002; 56(suppl):S273–S282.

3. Amouyal P, Amouyal G, Lé vy P, et al. Diagnosis of choledocholithiasis by endoscopic ultrasonography. Gastroenterology. 1994; 106:1062–1067.

4. Freitas ML, Bell RL, Duffy AJ. Choledocholithiasis: evolving standards for diagnosis and management. World J Gastroenterol. 2006; 12:3162–3167.

5. Sugiyama M, Atomi Y. Endoscopic ultrasonography for diagnosing anomalous pancreaticobiliary junction. Gastrointest Endosc. 1997; 45:261–267.

6. Baron RL, Stanley RJ, Lee JK, et al. A prospective comparison of the evaluation of biliary obstruction using computed tomography and ultrasonography. Radiology. 1982; 145:91–98.

7. Snady H, Cooperman A, Siegel J. Endoscopic ultrasonography compared with computed tomography with ERCP in patients with obstructive jaundice or small peri-pancreatic mass. Gastrointest Endosc. 1992; 38:27–34.

8. Palazzo L, O'toole D. EUS in common bile duct stones. Gastrointest Endosc. 2002; 56(suppl):S49–S57.

9. Amouyal P, Palazzo L, Amouyal G, et al. Endosonography: promising method for diagnosis of extrahepatic cholestasis. Lancet. 1989; 2:1195–1198.

10. Kim JK, Park TE, Park SK, et al. Endoscopic ultrasonography in gallstone pancreatitis. Korean J Gastrointest Endosc. 1993; 13:733–737.

11. Joo JH, Park CW, Song DW, et al. Efficiency of endoscopic ultrasonography in diagnosis of choledocholithiasis prior to laparoscopic cholecystectomy. Korean J Gastroenterol. 1994; 26:690–696.

12. Roe IH, Kim JT, Song IH, Kim JW, Yun YS, Lim CY. Biliary tract & pancreas: effectiveness of endoscopic ultrasonography in detecting the extrahepatic choledocholithiasis. Korean J Gastrointest Endosc. 1997; 17:23–31.

13. Shim CS, Lee MS, Cho YD, Moon JH. The role of intraductal ultrasonography on the detection of small remnant stones and their differentiation from air-bubbles, after endoscopic papillary balloon dilatation. Korean J Gastrointest Endosc. 1999; 19:386–393.

14. Park HB, Yeo HS, Kang MW, et al. Diagnostic utility of endoscopic ultrasonograpy (EUS) for common bile duct (CBD) stones not confirmed by endoscopic retrograde cholangiopancreatography (ERCP). Korean J Gastrointest Endosc. 1999; 19:394–401.

15. You SS, Kim EY, Cheon JW, et al. The usefulness of endoscopic ultrasonography in the diagnosis of common bile duct stones. Korean J Gastrointest Endosc. 2005; 30:249–256.

16. de Lédinghen V, Lecesne R, Raymond JM, et al. Diagnosis of choledocholithiasis: EUS or magnetic resonance cholangiography? A prospective controlled study. Gastrointest Endosc. 1999; 49:26–31.

17. Canto MI, Chak A, Stellato T, Sivak MV Jr. Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis. Gastrointest Endosc. 1998; 47:439–448.

18. Palazzo L, Girollet PP, 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.

19. Koo JS, Lee HS, Jung SW, et al. Usefulness of endoscopic ultrasonography for diagnosing choledocholithiasis in patients with gallbladder stones. Korean J Gastrointest Endosc. 2007; 35:228–234.

20. Mortensen MB, Fristrup C, Holm FS, et al. Prospective evaluation of patient tolerability, satisfaction with patient information, and complications in endoscopic ultrasonography. Endoscopy. 2005; 37:146–153.

21. Napoleon B, Dumortier J, Keriven-Souquet O, Pujol B, Ponchon T, Souquet JC. 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. Endoscopy. 2003; 35:411–415.

22. Buscarini E, Tansini P, Vallisa D, Zambelli A, Buscarini L. EUS for suspected choledocholithiasis: do benefits outweigh costs? A prospective, controlled study. Gastrointest Endosc. 2003; 57:510–518.

23. Kohut M, Nowak A, Nowakowska-Dulawa E, Marek T, Kaczor R. Endosonography with linear array instead of endoscopic retrograde cholangiography as the diagnostic tool in patients with moderate suspicion of common bile duct stones. World J Gastroenterol. 2003; 9:612–614.

Fig. 1.

Abdominal computed tomography and endoscopic ultrasonography findings of common bile duct stone. (A) Abdominal computed tomography showed the common bile duct was not dilated without definite mass lesion. (B) Endoscopic ultrasonography showed a small hyperechoic foci with an acoustic shadowing in the common bile duct. The stone's size was about 5 mm. CBD, common bile duct; PV, portal vein.

Table 1.

Baseline Characteristics and Clinical Manifestations of 66 Patients

Age (mean, years)	58 (range 26-84)
Sex (male/female)	39/27 (59/41%)
Clinical manifestations
Biliary colic	52 (79%)
GB stone (＋)	49 (74%)
GB stone (−)	3 (5%)
Cholecystitis (＋)	23 (35%)
Cholecystitis (−)	29 (44%)
Abnormal LFT	6 (9%)
Silent GB stones	4 (6%)
Acute pancreatitis	4 (6%)

GB, gallbladder; LFT, liver function test.

Table 2.

Characteristics of Patients with or without CBD Stones

Patients with CBD stones		N=23 (%)
Stone size (mm)	＜5	12 (52%)
	5-7	6 (26%)
	＞7	5 (22%)
Combined GB stones		18 (78%)
Previous cholecystectomy		2 (9%)
Patients without CBD stones		N=43 (%)
GB stones with or without cholecystitis		39 (91%)
Acute pancreatitis with or without GB stones		4 (9%)

CBD, common bile duct; GB, gallbladder.

Table 3.

Diagnostic Accuracy of US, CT, and EUS for Diagnosing the CBD Stone

	Sensitivity	Specificity	PPV	NPV
US (15)	0% (0/3)	92% (11/12)	0% (0/1)	79% (11/14)
CT (51)	30% (6/20)	94% (29/31)	75% (6/8)	67% (29/43)
EUS (66)	100% (23/23)	95% (41/43)	92% (23/25)	100% (41/41)

CBD, common bile duct; CT, computed tomography; EUS, endoscopic ultrasonography; NPV, negative predictive value; PPV, positive predictive value; US, ultrasonography; NPV= D/(C＋ D); PPV=A/(A＋ B); Diagnostic accuracy=(A＋ D)/(A＋ B＋ C＋ D); A-stone (＋), examination (＋); B-stone (−), examination (＋); C-stone (＋), examination (−); D-stone (−), examination (−).

Table 4.

Diagnostic Concordance of Endoscopic Ultrasonography for Detecting the CBD Stone

		Final diagnosis
		Positive	Negative	Total
EUS	Positive	23	2	25
	Negative	0	41	41
	Total	23	43	66

CBD, common bile duct; EUS, endoscopic ultrasonography.

κ=0.935, p＜0.01.

Table 5.

Concordance between Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasonography for Detecting the CBD Stone

		ERCP
		Positive	Negative	Total
EUS	Positive	23	2	25
	Negative	0	9	9
	Total	23	11	34

CBD, common bile duct; EUS, endoscopic ultrasonography;

ERCP, endoscopic retrograde cholangiopancreatography.

κ=0.859, p＜0.01.

TOOLS

Similar articles