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Abstract
Background/Aims
EUS can detect bile duct stones (BDS) that are undetectable on multidetector computed tomography (MDCT). BDS associated with acute biliary pancreatitis (ABP) are small and tend to be excreted spontaneously. This study evaluated the usefulness of early EUS in patients with ABP and undetectable BDS on MDCT.
Methods
Forty-one patients with ABP and undetectable BDS on MDCT underwent EUS within 24 hours of admission and were diagnosed with BDS, sludge, dilated common bile duct (CBD), or normal CBD. ERCP was performed in patients with BDS, sludge, or clinical deterioration. The diagnostic yield and the effects of early EUS on morbidity, mortality, and the length of hospitalization were evaluated.
Results
EUS detected BDS or sludge in 48.8% of patients examined. BDS was the diagnosis in 13 patients, sludge in seven, and neither for 21 patients. ERCP was performed in 20 patients with BDS or sludge, in two patients with coexisting cholangitis, and in one patient with worsening liver function tests. ERCP identified BDS in 12 patients and sludge in seven. No lesions were diagnosed in four patients by ERCP. All patients improved, and the length of hospitalization in patients with ERCP was 9.0 days, without ERCP 7.1 days. Two patients with major complications by ERCP were hospitalized for a prolonged time.
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Fig. 1.
Endosonographic and endoscopic findings of choledocholithiasis. Endosonography revealed the presence of hyperechoic foci in the common bile duct; posterior shadowing (arrows) indicated choledocholithiasis (A, B), and amorphous materials in the common bile duct without posterior shadowing (arrow) indicated sludge (C). Endoscopy showed the presence of a single dark brown stone, which was extracted after endoscopic sphincterotomy (arrow) (D), and the presence of yellow amorphous material (sludge), which was drained during endoscopic retrograde cholangiopancreatography (arrows) (E, F).
Fig. 2.
Flow chart of the procedures used. MDCT, multidetector computed tomography; CBD, common bile duct.
Table 1.
Characteristics of Patients with and without Bile Duct Stones (BDS)/Sludge on Endosonography
Table 2
Diagnosis of Choledocholithiasis in Acute Biliary Pancreatitis on EUS and ERCP
| ERCP | EUS | |||
|---|---|---|---|---|
| Normal CBD (n=15) | Stone (n=13) | Sludge (n=7) | CBD dilation, only (n=6) | |
| ERCP (+) (n=23) | ||||
| Stone (n=12) | 0 | 11 | 1 | 0 |
| Sludge (n=7) | 1 a | 0 | 4 | 2 a |
| None (n=4) | 0 | 2 | 2 | 0 |
| ERCP (–) (n=18) | 14 | 0 | 0 | 4 |
Table 3.
Characteristics of Seven Patients with Discordant Diagnoses on EUS vs. ERCP
| Patient | Age (yr) | Sex | CBD diameter (mm) | Bilirubin (mg/dL) | ALT (IU/L) | EUS diagnosis | ERCP diagnosis | Interval between EUS and ERCP (day) | Cholangitis |
|---|---|---|---|---|---|---|---|---|---|
| 1 | 50 | Female | 7.0 | 9.21 | 414 | Dilation | Sludge | 1 | + |
| 2 | 66 | Male | 6.2 | 1.24 | 219 | Dilation | Sludge | 3 | – |
| 3 | 39 | Male | 5.0 | 10.63 | 491 | Normal | Sludge | 1 | + |
| 4 | 76 | Male | 14.0 a | 0.37 | 20 | Sludge | Normal | 1 | – |
| 5 | 77 | Male | 6.2 | 4.99 | 113 | Sludge | Normal | 1 | – |
| 6 | 61 | Male | 7.0 | 0.95 | 115 | BDS, 1.4 mm | Normal | 1 | – |
| 7 | 38 | Female | 5.0 | 0.32 | 358 | BDS, 3.0 mm | Normal | 1 | – |
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