Endoscopy 2005; 37(8): 715-721
DOI: 10.1055/s-2005-870132
Original Article
© Georg Thieme Verlag KG Stuttgart · New York

Intraductal Ultrasound for the Evaluation of Patients with Biliary Strictures and No Abdominal Mass on Computed Tomography

S.  Stavropoulos1 , A.  Larghi1 , E.  Verna1 , P.  Battezzati2 , P.  Stevens1
  • 1Dept. of Medicine, Division of Liver and Digestive Diseases, Columbia University Medical Center, New York, USA
  • 2Dept. of Medicine, Division of Internal Medicine, San Paolo Hospital School of Medicine, University of Milan, Milan, Italy
Further Information

Publication History

Submitted 22 November 2004

Accepted after Revision 18 March 2005

Publication Date:
20 July 2005 (online)

Background and Study Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic procedure of choice in patients with biliary strictures and no culprit mass lesion on abdominal imaging, but it is limited in its diagnostic accuracy. The aim of this prospective study was to determine the value of intraductal ultrasound (IDUS) in distinguishing between benign and malignant biliary strictures in this clinical setting.
Patients and Methods: Sixty-one patients with painless jaundice and no mass lesion on abdominal computed tomography, who were found to have a biliary stricture at ERCP, underwent IDUS with a high-frequency (20-MHz) wire-guided probe. Histopathological confirmation or clinical follow-up was used to establish the final diagnosis. The diagnostic performances of IDUS, ERCP, and IDUS plus ERCP in the identification of malignant strictures were evaluated.
Results: Forty-three patients had malignant strictures and 18 had benign strictures. ERCP produced 25 false-negative diagnoses, 22 of which were identified as malignant by IDUS. IDUS provided seven false-negative and three false-positive diagnoses. The proportion of patients with malignant strictures who tested positive with IDUS was 2.06 times that of ERCP (95 % CI, 1.37 - 3.10; 83.3 % vs. 40.5 %, P = 0.0004). When used in conjunction, IDUS increased the accuracy of ERCP from 58 % to 90 %. Patients with operable lesions on IDUS and no contraindication to surgery underwent resection; most patients with pancreatic parenchymal invasion on IDUS underwent EUS, which identified a pancreatic mass in more than 50 % of cases. Patients with negative IDUS and a low clinical suspicion for malignancy were treated endoscopically, while a more aggressive work-up was performed in all patients with high pretest probability, regardless of the IDUS results.
Conclusions: IDUS is a valuable adjunct to ERCP in the characterization of biliary strictures in patients who present with painless jaundice in the absence of a culprit mass on abdominal imaging.

References

  • 1 Stevens P D, Lightdale C J. Endoscopic ultrasound of the biliary tract. In: Gress FG, Bhattacharya I, (eds.) Endoscopic ultrasonography. Maiden (MA). Blackwell Science 2000: 103-110
  • 2 Strasberg S M. ERCP and surgical intervention in pancreatic and biliary malignancies.  Gastrointest Endosc. 2002;  56 (Suppl) S213-217
  • 3 Shah S K, Mutignani M, Costamagna G. Therapeutic biliary endoscopy.  Endoscopy. 2002;  34 43-53
  • 4 Fogel E L, Sherman S, Park S H. et al . Therapeutic biliary endoscopy.  Endoscopy. 2003;  35 156-163
  • 5 Fogel E L, Sherman S. How to improve the accuracy of diagnosis of malignant biliary strictures.  Endoscopy. 1999;  31 758-760
  • 6 De Bellis M, Sherman S, Fogel E L. et al . Tissue sampling at ERCP in suspected malignant biliary strictures (part 1).  Gastrointest Endosc. 2002;  56 552-561
  • 7 De Bellis M, Sherman S, Fogel E L. et al . Tissue sampling at ERCP in suspected malignant biliary strictures (part 2).  Gastrointest Endosc. 2002;  56 720-730
  • 8 Menzel J, Domschke W. Intraductal ultrasonography (IDUS) of the pancreato-biliary duct system: personal experience and review of literature.  Eur J Ultrasound. 1999;  10 105-115
  • 9 Tamada K, Inui K, Menzel J. Intraductal ultrasonography of the bile duct system.  Endoscopy. 2001;  33 878-885
  • 10 Levy M J, Vazquez-Sequeiros E, Wiersema M J. Evaluation of the pancreaticobiliary ductal systems by intraductal US.  Gastrointest Endosc. 2002;  55 397-408
  • 11 Tamada K, Ido K, Ueno N. et al . Preoperative staging of extrahepatic bile duct cancer with intraductal ultrasonography.  Am J Gastroenterol. 1995;  90 239-246
  • 12 Tamada K, Ido K, Ueno N. et al . Assessment of portal vein invasion by bile duct cancer using intraductal ultrasonography.  Endoscopy. 1995;  27 573-578
  • 13 Tamada K, Ido K, Ueno N. et al . Assessment of hepatic artery invasion by bile duct cancer using intraductal ultrasonography.  Endoscopy. 1995;  27 579-583
  • 14 Tamada K, Ido K, Ueno N. et al . Assessment of the course and variations of the hepatic artery in bile duct cancer by intraductal ultrasonography.  Gastrointest Endosc. 1996;  44 249-256
  • 15 Tamada K, Ueno N, Ichiyama M. et al . Assessment of pancreatic parenchymal invasion by bile duct cancer using intraductal ultrasonography.  Endoscopy. 1996;  28 492-496
  • 16 Tamada K, Nagai H, Yasuda Y. et al . Transpapillary intraductal US prior to biliary drainage in the assessment of longitudinal spread of extrahepatic bile duct carcinoma.  Gastrointest Endosc. 2001;  53 300-307
  • 17 Gress F, Chen Y K, Sherman S. et al . Experience with a catheter-based ultrasound probe in the bile duct and pancreas.  Endoscopy. 1995;  27 178-184
  • 18 Tamada K, Ueno N, Tomiyama T. et al . Characterization of biliary strictures using intraductal ultrasonography: comparison with percutaneous cholangioscopic biopsy.  Gastrointest Endosc. 1998;  47 341-349
  • 19 Riemann B, Menzel J, Schiemann U. et al . Ultrasound-guided biopsies of abdominal organs with an automatic biopsy system: a retrospective analysis of the quality of biopsies and of hemorrhagic complications.  Scand J Gastroenterol. 2000;  35 102-107
  • 20 Chak A, Isenberg G, Kobayashi K. et al . Prospective evaluation of an over-the-wire catheter US probe.  Gastrointest Endosc. 2000;  51 202-205
  • 21 Vazquez-Sequeiros E, Baron T H, Clain J E. et al . Evaluation of indeterminate bile duct strictures by intraductal US.  Gastrointest Endosc. 2002;  56 372-379
  • 22 Farrell R J, Agarwal B, Brandwein S L. et al . Intraductal US is a useful adjunct to ERCP for distinguishing malignant from benign biliary strictures.  Gastrointest Endosc. 2002;  56 681-687
  • 23 Tamada K, Tomiyama T, Wada S. et al . Endoscopic transpapillary bile duct biopsy with the combination of intraductal ultrasonography in the diagnosis of biliary strictures.  Gut. 2002;  50 326-331
  • 24 Domagk D, Poremba C, Dietl K H. et al . Endoscopic transpapillary biopsies and intraductal ultrasonography in the diagnostics of bile duct strictures: a prospective study.  Gut. 2002;  51 240-244
  • 25 Duda S H, Huppert P E, Schott U. et al . Percutaneous transhepatic intraductal biliary sonography for lymph node staging at 12.5 MHz in malignant bile duct obstruction: work in progress.  Cardiovasc Intervent Radiol. 1997;  20 133-138
  • 26 Sullivan-Pepe M. The statistical evaluation of medical tests for classification and prediction. New York; Oxford University Press 2003: 70-105
  • 27 NIH . State-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy.  NIH Consens State Sci Statements. 2002;  19 1-26
  • 28 Hawes R H. Diagnostic and therapeutic uses of ERCP in pancreatic and biliary malignancy.  Gastrointest Endosc. 2002;  56 (Suppl) S201-205
  • 29 Smith C D, Behms K B, van Heerden J A. et al . Radical pancreatoduodenectomy for misdiagnosed pancreatic mass.  Br J Surg. 1994;  81 585-589
  • 30 Kozarek R A. Analog diagnosis in a digital world: the quest to improve endoscopic tissue acquisition and diagnostic sensitivity in malignant biliary stricture.  Clin Gastoenterol Hepatol. 2004;  2 207-208
  • 31 Legmann P, Vignaux O, Dousset B. et al . Pancreatic tumors: comparison of dual-phase helical CT and endoscopic sonography.  AJR Am J Roentgenol. 1998;  170 1315-1322
  • 32 Levy M J, Wiersema M J. Endoscopic ultrasound in the diagnosis and staging of pancreatic cancer.  Oncology. 2002;  16 29-38
  • 33 Agarwal B, Abu-Hamda E, Molke K L. et al . Endoscopic ultrasound and fine-needle aspiration of unexplained bile duct strictures.  Am J Gastroenterol. 2004;  99 1069-1073
  • 34 DeWitt J, Devereaux B, Chriswell M, et . Comparison of endoscopic ultrasonography and multidetector computed tomography for detecting and staging pancreatic cancer.  Ann Intern Med. 2004;  141 753-63
  • 35 Fritscher-Ravens A, Broering D C, Sririam P V. et al . EUS-guided fine-needle aspiration cytodiagnosis of hilar cholangiocarcinoma: a case series.  Gastrointest Endosc. 2000;  52 534-540
  • 36 Eloubeidi M A, Chen V K, Jhala N C. et al . Endoscopic ultrasound-guided fine needle aspiration biopsy of suspected cholangiocarcinoma.  Clin Gastroenterol Hepatol. 2004;  2 209-213
  • 37 Rösch T, Hofrichter K, Frimberger E. ERCP or EUS for tissue diagnosis of biliary strictures? A prospective comparative study.  Gastrointest Endosc. 2004;  60 390-396

S. N. Stavropoulos, M. D.

Dept. of Medicine, Division of Digestive and Liver Diseases

Columbia University College of Physicians and Surgeons · 630 West 168th Street, P & S 10-508 · New York, NY 10032 · USA

Fax: +1-212-305-6443

Email: sns10@columbia.edu