ENDOSCOPIC ULTRASOUND IN BILIAR ACUTE PANCREATITIS. WHEN BEFORE ERCP

Aims:

The most frequent cause of acute pancreatitis is a biliary origin due to the passage of gallstones through the common bile duct.

Clinical guidelines have been drawn up to identify the patients with the greatest probability of retained stones depending on bilirubin levels and the dilation of the bile duct. Nevertheless, an intermediate probability group remains unclear.

Methods:

Endoscopic ultrasound was performed in patients with acute pancreatitis and probable biliary origin, from 2013 to 2016.

Inclusion criteria: first episode of pancreatitis, gallbladder “in situ” and without previous ERCP.

Exclusion criteria: choledocholithiasis already demonstrated on conventional ultrasound, clear signs of cholangitis.

The procedure was performed between 1 and 7 days after admission.

To establish which patients benefited from the procedure, four groups were established:

1. Normal bilirubin (< 2 mg/dl) and normal bile duct (< 6 mm).

2. Normal bilirubin and dilated choledochus (> or equal to 6 mm).

3. High bilirubin (> or equal to 2 mg/dl) and normal bile duct.

4. High bilirubin and dilated choledochus.

Results:

EUS was performed in 98 patients. 24 (24.5%) presented with choledocholithiasis, confirmed by ERCP in 23 (96%). Based on bilirubin levels and the presence or not of dilation of the bile duct in conventional ultrasound, the following results were obtained:

Group 1 (n: 46): with choledocholithiasis: 2 (4%); without choledocholithiasis: 44 (96%),

Group 2 (n: 20): with choledocholithiasis: 7 (35%); without choledocholithiasis: 13 (65%),

Group 3 (n: 39): with choledocholithiasis: 10 (26%); without choledocholithiasis: 29 (74%),

Group 4 (n: 14): with choledocholithiasis: 11 (79%); without choledocholithiasis: 3 (21%).

Average delay to surgery: 66 days (range 4 – 875 days) with risk of new pancreatitis if the delay exceeded 60 days.

Conclusions:

In patients at intermediate risk where choledocholithiasis can not be established with clinical or analytical methods, EUS allows an adequate diagnosis avoiding unnecessary ERCP.