Endoscopy 2006; 38: 35-40
DOI: 10.1055/s-2006-946649
Invited papers
Pancreatitis and cholelithiasis
© Georg Thieme Verlag KG Stuttgart · New York

State of the art lecture: Lithiasis and pancreatitis

B. Napoléon1 , 2 , C. Lefort1 , 2 , R. Gincoul2
  • 1Clinique Sainte-Anne Lumière, 85 Cours Albert Thomas 69003 Lyon
  • 2Fédération des maladies de l’appareil digestif, Hôpital Ed Herriot, 69008 Lyon
Further Information

Publication History

Publication Date:
26 June 2006 (online)

Bile duct stones

Endoscopic retrograde cholangio-pancreaticography (ERCP) has long been used as the best diagnostic method for common bile duct stones (CBDS). Moreover, it was possible to combine stone removal with endoscopic sphincterotomy (ES) during the same endoscopic session. Nevertheless it remains an invasive method, associated with complications in 5 % of patients, and with a mortality rate of 0.1-0.2 % [1] [2] for ERCP, reaching 2.2 % for ES [3] [4] [5]. As transabdominal ultrasound (US) or computed tomography are not particularly sensitive for the diagnosis of choledocholithiasis [6] [7] an accurate diagnostic minimally invasive tool was awaited, to replace ERCP and to reserve ES for patients with CBDS.

In the past decade, helical computed tomodensitometry (hCT), endoscopic ultrasonography (EUS), and magnetic resonance cholangiopancreatography (MRCP) have improved the diagnosis of CBDS. More recently intraductal ultrasound (IDUS) has also been tested. Nevertheless ERCP is needed for this procedure and only ES should be avoided in patients without CBDS. Currently, what is the respective place of these modalities?

MRCP and hCT are non-invasive procedure. hCT is generally considered as inferior than MRCP, with a sensitivity of 85-88 %, specificity of 88-97 %, and diagnostic accuracy of 86-94 % [8] [9], for CBDS. Nevertheless in the first comparative study [10] the results were the same with an accuracy of 86 %, a sensitivity of 88 % and a specificity of 75 % for the two procedures. The main drawback of these two techniques is the limited spatial resolution. In the first series, stones not diagnosed by MRCP were always smaller than 10 mm [11] [12] [13]. Imaging improvements permit now the detection of calculi smaller than 5 mm [14] but the sensitivity remains low (67 %) for stones < 5 mm as for MRCP than for hCT [10]. Moreover, MRCP is contraindicated in patients with a permanent pacemaker or metallic clips, and claustrophobic patients cannot undergo the examination, when hCT is not applicable to patients allergic to contrast medium.

EUS offers higher resolution than MRCP or hCT (0.1 versus 1 mm). The accuracy of EUS is excellent with sensitivity, specificity and accuracy ranging from 81 to 98 %, 93 to 100 % and 93 to 99 % respectively [15] [16] [17] [18] [19] [20] [21] [22] [23]. It is a minimally invasive method [20] [24] with a lower failure rate than ERCP16. The specificity of EUS in ruling out the presence of CBDS is very high, until 98 % [25]. Detection of bile duct sludge as well as minilithiasis, often missed by the other imaging techniques [26], is possible with EUS. The type of echoendoscope seems of no importance. Results are as good with radial echoendoscopes as with linear scopes [21] or with extraductal catheter probe EUS [27].

The accuracy of IDUS for the diagnosis of CBDS is also very high, reaching 100 % [28] [29]. The size of the probe (2 mm) allows an insertion inside the bile duct during an ERCP. The high frequency (20MHz) provides higher resolution than conventional EUS. Moon et al in 2005 compared the sensitivity of IDUS and MRCP to the results of ERCP + ES and stone removal [28]. For the detection of CBDS the sensitivity of IDUS and ERCP was 95 % and 80 % respectively. The clinical utility of IDUS was evaluated by Catanzaro et al [29]. The performance was compared with results of ERCP. IDUS found CBDS in 8 out of 21 patients with normal cholangiogram. ES confirmed the diagnosis in 7 patients. IDUS also avoided unnecessary ES as no lithiasis was found in 36 % of patients with a positive finding on ERCP. The main drawback of IDUS remains the morbidity of ERCP which must be performed at the same time.

Very good comparative studies between these procedures are rare. In fact, to compare the performance of each technique, some parameters have to be considered. Spontaneous stone migration between the two examinations can lead to false-positive results. Stone migration has been found to have occurred in 21 % of patients within 1 month [30]. Ideally, the ‘gold standard’ examination should be performed as soon as possible (at least during the following 2 days) after the evaluated technique. Second, ERCP (or peroperative cholangiography) is not the best ‘gold standard’ as its sensitivity to diagnose CBDS is around 90 % [18]. Two different approaches should be considered as the most sensitive and specific : - systematic ERCP, ES and instrumental exploration of the CBD (with a Dormia basket or balloon) [18]; - depending of the result of the diagnostic tool : association of ERCP, ES, and bile duct exploration when a stone is evidenced or 6 months clinical follow-up when a stone has been excluded [20] [22] [23] [31]. More recently the excellent results of ERCP with IDUS [10] should also lead to a third ‘gold standard’.

In the first comparative studies, EUS was found to be superior to MRCP [10] [32] [33] or hCT [9] [10] [19] to detect CBDS. Improvements in imaging modalities may modify these findings: in the most recent series, the specificity of EUS and MRCP were found to be equal (97 %) when sensitivity was slightly greater with EUS than with MRCP (94 % versus 88 %, respectively) [14]. These good results need to be confirmed in largest series. At present, EUS can be considered to be more accurate than hCT or MRCP, especially for smaller stones.

A considerable reduction in the number of inappropriate ERCP is obtained with the use of alternative imaging procedures [22] [23]. Given that the accuracy of EUS is greater than that of MRCP or hCT, at least in patients with microlithiasis [13] [32] [33] EUS should replace diagnostic ERCP. Whenever EUS is contraindicated (total or Billroth II gastrectomy, digestive stenosis...), MRCP or hCT might be proposed. ERCP should be used in patients already known to have CBDS (shown by US, for example) or in patients with previous ES. IDUS cannot be proposed as a first step procedure because of the ERCP morbidity. It might be reserved to patients in whom CBDS have been found at EUS or MRCP, but not at ERCP.

Is it necessary to perform a systematic minimally invasive diagnostic procedure before ERCP?

Patients suspected of having CBDS on clinical and laboratory criteria and/or US findings can be ranged into risk classes from low to high [34] [35]. Less than 30 % of patients classified as being at moderate risk have CBDS [20] [31] whereas the proportion of high-risk patients that actually have CBDS is around 70 % [18] [19] [31] [36]. For moderate- and low-risk patients, the general consensus is to perform a first-line diagnostic (after US). Thus, EUS could be the ideal alternative, selecting only those patients with bile duct stones for ERCP/ES. In high-risk patients ERCP is generally proposed as the first-line approach [20] [22] [31] [35] [37]. Nevertheless, as it is impossible completely to avoid unnecessary ERCP investigations on clinical or biochemical criteria, some authors support EUS as a first-line approach [23] [38] [39]. In the recent series of Liu et al [38] 140 patients presenting acute pancreatitis suspected to be of biliary origin were prospectively randomized. In the first group, EUS was followed by ERCP when needed, and in the second group, ERCP was performed immediately. EUS had a higher successful examination rate and a higher sensitivity in the detection of cholelithiasis. The morbidity was higher in the ERCP group (14 % of complications) than in the EUS group (7 %) but it was not significant. Then the best choice, also in high risk patients, should be to perform EUS followed, during the same endoscopic procedure, with ERCP and ES when a stone is evidenced.

Regard to cost-effectiveness, first line EUS vs first line ERCP has been studied in two situations [23] [40]. In the context of laparoscopic cholecystectomy [23] EUS was performed for all patients with suspected CBDS followed by ERCP and ES when stone was evidenced. The cost of this approach was compared with the cost of a strategy proposing ERCP as first step. The mean cost for patients managed by the EUS-based strategy was significantly less than the theoretical mean cost for patients undergoing ERCP approach. In the context of acute biliary pancreatitis, Romagnuolo et al. [40] constructed a modeling standard care for non severe (selective ERCP) and severe pancreatitis (ERCP with sphincterotomy and balloon sweep). EUS was dominant in severe pancreatitis whereas it was slightly more costly in non severe (but associated with fewer ERCPs and ERCP-related complications). So, even if the estimation of cost is different depending of the countries and healthcare systems, EUS as first diagnostic tool seems to be the most effective not only for clinical impact but also for economic target. Further studies are necessary to confirm that the EUS-based strategy is also cost-effectiveness in the sub-group of high risk patients.

References

  • 1 Davis W Z, Cotton P B, Arias A. ERCP and sphincterotomy in the context of laparoscopic cholecystectomy: academic and community practice patterns and results.  Am J Gastroenterol. 1997;  92 597-601
  • 2 Loperfido S, Angelini G, Benedetti G. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study.  Endoscopy. 1999;  31 125-130
  • 3 Freeman M L, Nelson D B, Sherman S. et al . Complications of endoscopic biliary sphincterotomy.  N Engl J Med. 1996;  335 908-918
  • 4 Sherman S, Ruffolo T A, Hawes R H. et al . Complications of endoscopic sphincterotomy.  Gastroenterology. 1991;  101 1068-1072
  • 5 Lambert M E, Betts C D, Hill J. et al . Endoscopic sphincterotomy: the whole truth.  Br J Surg. 1991;  78 473-476
  • 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 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
  • 9 Polkowski M, Palucki J, Regula J. et al . Helical computed tomographic cholangiography versus endosonography for suspected bile duct stones: a prospective blinded study in non-jaundiced patients.  Gut. 1999;  45 744-749
  • 10 Kondo S, Isayama H, Akahane M. et al . Detection of common bile duct stones: comparison between endoscopic ultrasonography, magnetic resonance cholangiography, and helical-computed-tomographic cholangiography.  Eur J Radiol. 2005;  54 271-275
  • 11 Chan W L, Chan A C, Lam W W. et al . Choledocholithiasis: comparison of MR cholangiography and endoscopic retrograde cholangiography.  Radiology. 1996;  200 85-89
  • 12 Mendler M H, Bouillet P, Sautereau P. 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
  • 13 Zidi S H, Prat F, Le Guen O. et al . Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis: prospective comparison with the reference imaging method.  Gut. 1999;  44 118-122
  • 14 Aubé C, Delorme B, Yzet T. et al . MR cholangiopancreatography versus endoscopic sonography in suspected common bile duct lithiasis: a prospective, comparative study.  AJR Am J Roentgenol. 2005;  184 55-62
  • 15 Amouyal P, Amouyal G, Levy P. et al . Diagnosis of choledocholithiasis by endoscopic ultrasonography.  Gastroenterology. 1994;  106 1062-1067
  • 16 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
  • 17 Shim C S, Joo J H, Park C W. et al . Effectiveness of endoscopic ultrasonography in the diagnosis of choledocolithiasis prior to laparoscopic cholecystectomy.  Endoscopy. 1995;  27 428-432
  • 18 Prat F, Amouyal G, Amouyal P. et al . Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected bile duct lithiasis.  Lancet. 1996;  347 75-79
  • 19 Sugiyama M, Atomi Y. Endoscopic ultrasonography for diagnosing choledocholithiasis: a prospective comparative study with ultrasonography and computed tomography.  Gastrointest Endosc. 1997;  45 143-146
  • 20 Canto M IF, Chak A, Stellato T. et al . Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis.  Gastrointest Endosc. 1998;  47 439-448
  • 21 Kohut M, Nowakowska-Dulawa E, Marek T. et al . Accuracy of linear endoscopic ultrasonography in the evaluation of patients with suspected common bile duct stones.  Endoscopy. 2002;  34 299-303
  • 22 Napoléon B, Dumortier J, Keriven-Souquet O. et al . 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 of 238 patients.  Endoscopy. 2003;  35 411-415
  • 23 Buscarini E, Tansini P, Vallisa D. et al . EUS for suspected choledocholithiasis: do benefits outweigh costs? A prospective, controlled study.  Gastrointest Endosc. 2003;  57 510-518
  • 24 Lightdale C J. Indications, contraindications and complications of endoscopic ultrasonography.  Gastrointest Endosc. 1996;  43 15-19
  • 25 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
  • 26 Frossard J L, Sosa-Valencia L, Amouyal G. et al . Usefulness of endoscopic ultrasonography in patients with ‘idiopathic’ acute pancreatitis.  Am J Med. 2000;  109 196-200
  • 27 Seifert H, Wehrmann T, Hilgers R. et al . Catheter probe extraductal EUS reliably detects distal common bile duct abnormalities.  Gastrointest Endosc. 2004;  60 61-67
  • 28 Moon J H,  C hoYD,  C haSW. et al . The detection of bile duct stones in suspected biliary pancreatitis: comparison of MRCP, ERCP, and intraductal US.  . 2005;  100 1051-1057
  • 29 Catanzarro A, Pfau P, Isenberg G A. et al . Clinical utility of intraductal EUS for evaluation of choledocholithiasis.  Gastrointest Endosc. 2003;  57 712-714
  • 30 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
  • 31 Berdah S V, Orsoni P, Berge 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
  • 32 Scheiman J M, Carlos R C, Barnett J L. et al . Can endoscopic ultrasound or magnetic resonance cholangiopancreatography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis.  Am J Gastroenterol. 2001;  96 2900-2904
  • 33 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
  • 34 Cotton P B, Baillie J, Pappas T N. et al . Laparoscopic cholecystectomy and the biliary endoscopist (editorial).  Gastrointest Endosc. 1991;  37 94-97
  • 35 Cotton P B. Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy.  Am J Surg. 1993;  165 474-478
  • 36 Abboud P A, Malet P F, Berlin J A. et al . Predictors of bile duct stones prior to cholecystectomy: a meta-analysis.  Gastrointest Endosc. 1996;  44 450-459
  • 37 Sahai A V, Mauldin P D, Marsi V. et al . Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholangiography, EUS and ERCP.  Gastrointest Endosc. 1999;  49 334-343
  • 38 Liu C L,  F anST,  L oCM. et al . Comparison of early endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the management of acute biliary pancreatitis: a prospective randomized study.  Clin Gastroenterol Hepatol. 2005;  3 1238-1244
  • 39 Rocca R, De Angelis C, Castellino F. et al . EUS diagnosis and simultaneous endoscopic retrograde cholangiography treatment of common bile duct stones by using an oblique-viewing echoendoscope.  Gastrointest Endosc. 2006;  63 479-484
  • 40 Romagnuolo J, Currie G. Non invasive vs. selective invasive biliary imaging for acute biliary pancreatitis: an economic evaluation by using decision tree analysis.  Gatrointest Endosc. 2005 Jan;  61 86-97
  • 41 Shea J A, Berlin J A, Escarce J J. et al . Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease.  Arch Intern Med. 1994;  154 2573-2581
  • 42 Ko C, Sekijima J, Lee S. Biliary sludge.  Ann Intern Med. 1999;  130 301-311
  • 43 Dill J E, Hill S, Callis J. et al . Combined endoscopic ultrasound and stimulated biliary drainage in cholecystitis and microlithiasis - diagnoses and outcomes.  Endoscopy. 1995;  27 424-427
  • 44 Dahan P, Andant C, Levy P. et al . Prospective evaluation of endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis in 45 patients with normal conventional ultrasonography.  Gut. 1996;  38 277-281
  • 45 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
  • 46 Liu C L, Lo C M, Chan L K. et al . Detection of choledocholithiasis by EUS in acute pancreatitis: a prospective evaluation in 100 consecutive patients.  Gastrointest Endosc. 2001;  54 325-330
  • 47 Yusoff I F,  R aymondG,  S ahaiAV. A prospective comparison of the yield of EUS in primary vs.  recurrent idiopathic acute pancreatitis. 2004 Nov;  60 (5) 673-678
  • 48 Wiersema M J, Hawes R H, Lehman G A. et al . Prospective evaluation of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in patients with chronic abdominal pain of suspected pancreatic origin.  Endoscopy. 1993;  25 555-564
  • 49 Wallace M B, Hawes R H, Durkalski V. et al . The reliability of EUS for the diagnosis of chronic pancreatitis: interobserver agreement among experienced endosonographers.  Gastrointest Endosc. 2001;  53 294-299
  • 50 Irisawa A, Mishra G, Hernandez L V. et al . Quantitative analysis of endosonographic parenchymal echogenicity in patients with chronic pancreatitis.  J Gastroenterol Hepatol. 2004;  19 1199-205
  • 51 Rajan E, Clain J E, Levy M J. et al . Age-related changes in the pancreas identified by EUS: a prospective evaluation.  . 2005;  61 401-406
  • 52 Bhutani M S. Endoscopic ultrasonography: changes of chronic pancreatitis in asymptomatic and symptomatic alcoholic patients.  J Ultrasound Med. 1999;  18 455-462
  • 53 Sahai A V, Mishra G, Penman I D. et al . EUS to detect evidence of pancreatic disease in patients with persistent or nonspecific dyspepsia.  Gastrointest Endosc. 2000;  52 153-159
  • 54 Hastier P, Buckley M J, Francois E. et al . A prospective study of pancreatic disease in patients with alcoholic cirrhosis: comparative diagnostic value of ERCP and EUS and long-term significance of isolated parenchymal abnormalities.  Gastrointest Endosc. 1999;  49 705-709
  • 55 Yang D H, Kim K W, Kim T K. et al . Autoimmune pancreatitis: radiologic findings in 20 patients.  Abdom Imaging. 2006;  31 (1) 94-102
  • 56 Farrell J J, Garber J, Sahani D. et al . EUS findings in patients with autoimmune pancreatitis.  Endosc. 2004;  60 927-936
  • 57 Catalano M F, Lahoti S, Geenen J E, Hogan W J. Prospective evaluation of endoscopic ultrasonography, endoscopic retrograde pancreatography, and secretin test in the diagnosis of chronic pancreatitis.  Gastrointest Endosc. 1998;  48 11-17
  • 58 Sahai A V, Zimmerman M, Aabakken L. et al . Prospective assessment of the ability of endoscopic ultrasound to diagnose, exclude, or establish the severity of chronic pancreatitis found by endoscopic retrograde cholangiopancreatography.  Gastrointest Endosc. 1998;  48 18-25
  • 59 Buscail L, Escourrou J, Moreau J. et al . Endoscopic ultrasonography in chronic pancreatitis: a comparative prospective study with conventional ultrasonography, computed tomography, and ERCP.  Pancreas. 1995;  10 251-257
  • 60 Chowdhury R, Bhutani M S, Mishra G. et al . Comparative analysis of direct pancreatic function testing versus morphological assessment by endoscopic ultrasonography for the evaluation of chronic unexplained abdominal pain of presumed pancreatic origin.  . 2005;  31 63-68
  • 61 Kahl S, Glasbrenner B, Leodolter A. et al . EUS in the diagnosis of early chronic pancreatitis: a prospective follow-up study.  Gastrointest Endosc. 2002;  55 507-511
  • 62 Hollerbach S, Klamann A, Topalidis T, Schmiegel W H. Endoscopic ultrasonography (EUS) and fine-needle aspiration (FNA) cytology for diagnosis of chronic pancreatitis.  Endoscopy. 2001;  33 824-831
  • 63 De Witt J, McGreevy K, LeBlanc J. et al . EUS-guided Trucut biopsy of suspected nonfocal chronic pancreatitis.  . 2005;  62 76-84
  • 64 Deshpande V, Mino-Kenudson M, Brugge W R. et al . Endoscopic ultrasound guided fine needle aspiration biopsy of autoimmune pancreatitis: diagnostic criteria and pitfalls.  . 2005;  29 1464-1471
  • 65 Levy M J, Reddy R P, Wiersema M J. et al . EUS-guided trucut biopsy in establishing autoimmune pancreatitis as the cause of obstructive jaundice.  . 2005 Mar;  61 (3) 467-472

Bertrand Napoleon

35 Rue Bataille 69008 LYON

Phone: 0033478781051

Fax: 0033478740792

Email: bertrand.napoleon@libertysurf.fr