Comparision of linear EUS and ERCP for patients with clinically suspicious bile duct stones that not detected in the Abdominal CT

Backgrounds/Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is being replaced by endoscopic ultrasonography (EUS) for diagnostic purposes in the pancreatobiliary disease, and it should be reserved for therapeutic indication. We investigated diagnostic accuracy, complications and benefits of an EUS-guided approach versus an ERCP-guided approach in patients with suspicious bile duct stones who were not diagnosed by CT scan.

Methods: We enrolled patients with suspicious bile duct stones, in whom a multi-detector abdominal CT scan is not diagnostic at Wonkwang university hospital from May 2007 to March 2009. These patients were prospectively randomized to either a linear EUS first, ERCP-second (n=54) or ERCP-only (n=52) procedure. ERCP were perfomed within 2 days if the common bile duct (CBD) stones were detected by a linear EUS. Patients without stones who underwent EUS were followed up over 6 months.

Results: There were no significant differences in clinical features, Barkun score and demographic characteristics. All EUS and ERCP were successful. 21 (38.8%) patients in the EUS group were found to have CBD stones that were all treated by ERCP with endoscopic sphincterotomy. In the ERCP group, 18 (34.6%) patients had CBD stones that were removed in the same method. The sensitivity and specificity of ERC in the ERCP group were 72.2% and 97.1%, respectively. The sensitivity and specificity of EUS were 95.2% and 97%, respectively. The post-ERCP pancreatitis rate was 5 of 52 (9.6%) in ERCP group and 1 of 54 (1.9%) in EUS group, but there was not significant difference. With EUS guided approach, diagnostic ERCP and its related complications could be spared in 67 (63.2%) patients. The independent factor predicting CBD stones was Barkun score (>67%) at the multivariable analysis.

Conclusions: In patients with suspicious bile duct stones that did not detected in the abdominal CT, EUS-guided approach may be a safe and valuable strategy to select patients for therapeutic ERCP.