Role of EUS in CBD

stones
A Aljebreen, MD, FRCPC
Head of Gastroenterology Unit, King Khalid
University Hospital, Riyadh, Saudi Arabia

8th International Workshop on Therapeutic Endoscopy

Egypt, Dec 11, 2006
 Overview
 Introduction
 Technique
 Performance of EUS in detection of
CBD stones
 EUS vs ERCP
 EUS vs MRCP
 Conclusion
 Introduction
 Common bile duct (CBD) stones occur in
10-15% of patients with symptomatic
gallstones undergoing cholecystectomy.
 ERCP
 overall complication rates of 5-10% and
 mortality rates of 0.02% to 0.5%.
 Introduction
 When the clinical features strongly suggest the
presence of CBD stones (high risk),
management is fairly straightforward.
 Unfortunately, the clinical picture is often
equivocal (low to moderate risk).
 Thus, an accurate, noninvasive, reliable, and
safe method would be highly advantageous.
 EUS is emerging as reliable substitutes for
diagnostic ERC.
 Introduction
 EUS has a procedural risk identical to that
of gastroscopy
 the rate of perforation is less than 1 in 2000.
 The extra hepatic ductal system can be
visualized completely by EUS in 96% of
patients*.

*Sugiyama. Gastrointest Endosc 1997; 45(2):143-146.

 EXAMINATION TECHNIQUE
 There are basically two positions.
 The first position is called the “apical” position
 The tip of the scope in the the apex, the balloon is inflated
 Counterclockwise torque will visualize the proximal CBD and
clockwise torque and insertion will visualize the distal CBD
 There are four landmarks that one should look for.
 The “duodenal fall-off” “MP of the duodenum”,
 The CBD,
 The pancreatic duct and
 The portal vein.
 The second position
 Transducer is positioned directly perpendicular to the papilla.
 This is important in some cases with impacted CBD stones.
 EUS performance in CBD stones

 In 1989, the first prospective and comparative

blind study was published reporting the results of
EUS in the diagnosis of CDB obstruction*.
 EUS is extremely accurate in diagnosing CBD
stones with a
 Sensitivity of 95%,
 Specificity of 98% and
 An accuracy of 96%
 These results are far superior to US (sensitivity
63%) and CT (sensitivity 71%)(19) and were
approximately equivalent to that of ERCP.

*Amouyal. Lancet 1989; 2(8673):1195-1198.

 EUS vs ERCP
 Several studies have compared EUS and ERCP in a
blinded fashion.
 The sensitivity of ERC was found to be 79-90%
compared to 88-100% for EUS with more false negative
results with ERCP.
 ERCP false negatives were due to small stones located within
dilated bile ducts
 EUS false negatives because of proximal CBD or IHD stones.
 Several additional advantages
 Gallbladder microlithiasis.
 Eliminate other obstructive pathologies such as small ampullary
tumors, cholangiocarcinoma...
 EUS vs ERCP
Author Design # of pts Sen Sp accuracy

Amouyal Prospective 62 97% 100% 98%

Napoleon Prospective 58 100% 90% 95%
Shim Prospective 132 89% 100% 97%
Palazzo Retrospective 422 95% 98% 96%
Prat Prospective 119 93% 97% 95%
Canto Prospective 64 84% 95% 94%
Kohut Prospective 134 93% 93% 94%
Buscarini Prospective 485 98% 99% 97%
Palazzo et al. GIE 1995; 42(3):225-231.
Prat et al. Lancet 1996; 347(8994):75-79.
Amouyal et al. Gastroenterology 1994; 106(4):1062-1067.
Shim et al. Endoscopy 1995; 27(6):428-432.
Buscarini et al. GIE 2003; 57(4):510-518.
 Limitations….
 Cholangiography was used predominately as
the reference standard for the presence or
absence of stones
 Problem? stones, especially if small, may be missed
by cholangiography.
 To overcome this problem, Napoleon followed,
for at least 1 year, 238 patients who had initial
normal EUS and found
 NPV of EUS was 95%
 Negative initial EUS should obviate the need for an
ERCP in patients with suspicion of CBD stones.

Napoleon et al. Endoscopy 2003; 35(5):411-415.

 EUS vs ERCP+ ES
 A prospective series of our first 60 patients
who were referred for ERC for suspicion of
choledocholithiasis
 All underwent radial EUS.
 EUS results were recorded as positive or
negative for CBD stones before starting
the ERC.

Aljebreen et al. GIE. 2006; 63 (5): AB274

 Methodology
 All patients underwent ERC and
sphincterotomy with basket or balloon
sweep of the bile duct as the standard of
reference for CBD stone.
 All procedures were performed during the
same endoscopy session by a single
endoscopiest who was blinded to the
clinical, biochemical and imaging data.

Aljebreen et al. GIE. 2006; 63 (5): AB274

 Results
 EUS diagnosed CBD stones in 24 patients (40%).
 65% had low to moderate risk for CBD stones.

EUS Total

ERCP Positive Negative

Positive 23 1 24
Negative 3 33 36
Total 26 34 60
Aljebreen et al. GIE. 2006; 63 (5): AB274
 EUS Diagnostic performance

 Sensitivity: 89% (95% CI: 76-100)

 Specificity: 97% (95% CI: 91-100)
 Diagnostic accuracy: 93% (95% CI: 87-99)
 Learning curve
First 30 EUS Last 30 EUS
procedures procedures

Sensitivity 85 (95% CI: 65-100) 92 (95% CI: 78-100)

Specificity 94 (95% CI: 83-100) 100

PPV (%) 92(95% CI: 76-100) 100

NPV 89 (95% CI: 74-100) 94 (95% CI: 84-100)

Accuracy 90% 97%

 Conclusion of the study
 EUS is highly accurate for the diagnosis of
choledocholithiasis.
 Tandem EUS and ERCP are relatively
safe with no complications specifically
attributable to performance of EUS.
 The EUS learning curve is relatively short
for CBD stones.

Aljebreen et al. GIE. 2006; 63 (5): AB274

 EUS VS MRCP for CBD stones

Author Study design # of MRC MRC EUS EUS

pats Sen SP Sen Sp
Ainsworth Prospective 163 87% 97% 90% 99%
De Ledinghen Prospective 32 100% 73% 100% 96%
Materne Prospective 50 78% 98% 89% 95%
Scheiman Prospective 28 40% 96% 80% 96%
Kondo Prospective 28 88% 73% 100% 50%
performance Prospective 301 85% 93% 93% 96%

*Verma et al. GIE 2006; 64(2):248-254.

 EUS or MRC for CBD stones?
 A systematic review*
 no significant differences between these
modalities.
 Sensitivity of MRC in detecting stones above
and below 5mm was 100% and 67%
respectively**.
 When deciding between EUS and MRCP,
clinicians should consider other factors,
 resource availability,
 experience, and costs.
*Verma et al. GIE 2006; 64(2):248-254.
**Kondo et al. Eur J Radiol 2005; 54(2):271-275.
Do benefits outweigh the costs?
 Cost-effectiveness of EUS in CBD stones
depends on the
 risk of stones,
 stone-related symptoms and
 operator expertise.
 Expert IOC was the least costly for intermediate
risk patients when risk of stones is between 17-
34%, however, if expert EUS is available,
 0-10% “low” risk of stones merits “expectant
management”,
 11-55% “intermediate risk” merits EUS; and
 > 55% “high risk” merits ERCP.

Sahai et al. GIE 1999; 49(3 Pt 1):334-343.

EUS role acute biliary pancreatitis
 Prat et al suggested that rate of morbidity and
mortality could be reduced by using systemically
EUS in case of acute pancreatitis followed by
ERC with sphincterotomy when EUS has
demonstrated CBD stones.
 When compared the relative costs and
outcomes of EUS and MRC to ERC in patients
with acute biliary pancreatitis Romagnuolo found
 EUS significantly less costly than both ERC and MRC
with fewer complications than ERC.

Prat et al. GIE 2001; 54(6):724-729.

Romagnuolo et al GIE 2005; 61(1):86-97.
 CONCLUSIONS

 EUS combines the best

performance and almost zero
morbidity.
 EUS may be considered in lieu of
ERCP as a diagnostic test for
patients felt to have a low to
intermediate risk of CBD stones.
 The main advantage of EUS over
MRC its sensitivity and specificity
for stones less than 5mm in size.
 CONCLUSIONS

 The EUS learning curve is relatively short

for CBD stones.
 Finally when EUS chosen as the imaging
modality to identify CBD stones,
 it safe & logical to do ERCP during the same
session.