1. 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

2. Overview Introduction Technique
Performance of EUS in detection of CBD stones
EUS vs ERCP
EUS vs MRCP
Conclusion

3. 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%.

4. 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.

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

6. 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.

10. 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):

11. 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 % 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...

13. EUS vs ERCP Author Design # of pts Sen Sp accuracy Amouyal Prospective62
97%
100%
98%
Napoleon 58
90%
95%
Shim
132
89%
Palazzo
Retrospective
422
96%
Prat
119
93%
Canto 64
84%
94%
Kohut
134
Buscarini
485
99%
Palazzo et al. GIE 1995; 42(3):
Prat et al. Lancet 1996; 347(8994):75-79.
Amouyal et al. Gastroenterology 1994; 106(4):
Shim et al. Endoscopy 1995; 27(6):
Buscarini et al. GIE 2003; 57(4):

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

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

17. 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

18. 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 23 1 24 3 33 36 26 34 60
Aljebreen et al. GIE. 2006; 63 (5): AB274

19. EUS Diagnostic performance
Sensitivity: 89% (95% CI: )
Specificity: 97% (95% CI: )
Diagnostic accuracy: 93% (95% CI: 87-99)

20. Learning curve First 30 EUS procedures Last 30 EUS procedures
Sensitivity
85 (95% CI: )
92 (95% CI: )
Specificity
94 (95% CI: )
100
PPV (%)
92(95% CI: )
NPV
89 (95% CI: )
94 (95% CI: )
Accuracy
90%
97%

21. 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

23. EUS VS MRCP for CBD stones
Author
Study design
# of pats
MRC Sen
MRC SP
EUS Sen
EUS Sp
Ainsworth
Prospective
163
87%
97%
90%
99%
De Ledinghen 32
100%
73%
96%
Materne 50
78%
98%
89%
95%
Scheiman 28
40%
80%
Kondo
88%
50%
performance
301
85%
93%
*Verma et al. GIE 2006; 64(2):

24. 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): **Kondo et al. Eur J Radiol 2005; 54(2):

25. 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):

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

27. 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.

28. 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.