Extrahepatic biliary obstruction

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    Extrahepatic Biliary

    Obstruction: Is EndoscopicUltrasonography Mandatory

    Prior to ERCP?

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    Obstructive Jaundice

    One of the most common problem

    Serious condition

    Thorough evaluation

    Treatment strategy depends on the specificetiology

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    ERCP has been considered gold standard for

    diagnosis and therapy of obstructive jaundice.

    Invasive procedure

    Complication in 5% of patients

    Mortality rate in 0.1- 0.2% Endoscopic sphinectrotoiy = 0.2- 2.2%.

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    Limitations:

    Visualization of indirect signs

    It is difficult to differentiate small stones

    from aerobilia.

    Small stone in the dilated common bile duct may bemissed.

    Difficult to visualized Biliary sludge and microlithiasis.

    Early ampullary tumor may be missed

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    What is the alternative procedure(s) to

    ERCP in evaluation of obstructive jaundice?

    MRCP

    EUS

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    MRCP is completely non invasive procedure

    limited resolution (0.1 versus EUS 1.5 mm )Difficult to diagnose stone

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    An accurate diagnostic tool associated with

    lower morbidity and mortality rates was awaited,

    to replace ERCP and to reserve endoscopic

    sphinectrotoiy for patients with CBD stones.

    EUS had provide as a gold standard in the

    exploration of extrahepatic obstruction due to itis low morbidity and it is accuracy.

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    Why EUS?

    The close a proximity between the probe

    and the pancreato-biliary region.

    Visualization of these hidden organs andpathology

    High resolution.

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    Role of EUS in CholedocholithiasisSensitivityEUS : (92% - 100%)

    ERCP : (79% - 90%)

    MRCP : (70% - 88%)

    Negative predictive value

    EUS : (97% - 100%)

    ERCP : (83% - 88%)

    Detection of microlothiasis

    Associated pathology

    Vipul Rathod, et al VHGOE 2004

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    Performance of EUS in detection of

    choledocholithiasis

    AccuracySpecificitySensitivityFrequency of

    cholidocholithiasis

    No.

    patients

    Author

    97%

    98

    95

    96

    97

    96

    95

    92

    92

    100%

    100

    90

    96

    100

    98

    97

    96

    95

    92%

    97

    100

    96

    89

    95

    93

    88

    84

    25 (42%)

    32 (52%)

    26 (45%)

    133 (63%)

    28 (21%)

    152 (36%)

    78 (66%)

    24 (48%)

    19 (30%)

    60

    62

    58

    211

    132

    422

    119

    50

    64

    Denis

    Amouyal

    Napoleon

    Salmeron

    Shim

    Palazzo

    Prat

    Norton

    Canto

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    Risk of presence of CBD stones in patients with

    suspected choledocholithiasis

    10 mmALP > twice UNL

    Acute ascending

    cholengitis,

    jaundice50-80%

    High risk

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    Indication of EUS prior to ERCP in

    Choledocholithiasis

    Patients with low or moderate riskCBD stones,

    EUS is recommended before ERCP

    High riskpatients?

    1. 20- 50% (Risk of unnecessary sphinctrotomy )

    2. Associated pathology

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    Role of EUS in Choledocholithiasis

    Limitations

    Poor performance in the hepatic hilum?!!!

    Tracing of CBD with linear electronic echoendoscope

    Difficulty in anatomical abnormalities?

    Scanning of CBD through body of stomach using linear electronic

    echoendoscope

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    Scanning of

    CBD through

    body ofstomach in

    gastric outlet

    obstruction

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    87 Patients

    Risk of Choledocholithiasis:

    Low : 33

    Intermediate : 20

    High : 34

    Clinical features, laboratory tests, CBD

    diameter on US

    EUS prior to ERCP

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    EUS Findings

    Follow up(1 yr)54(62%)NormalStone

    Extraction

    31(35%)CBD Stone

    Stenting2(2.2%)Cholengiocarcinoma

    Stenting +

    Surgery2(2.2%)

    CBD Stone +

    Cholengiocarcinoma

    Stenting +

    Surgery

    1(1.1%)CBD Stone +

    Ampullary tumor

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    Unnecessary (harmful) endoscopic

    sphinectrotomy were avoided in in 56/87 (64%)

    patients

    Treatment strategy were altered in 5 (6%)

    patients (either associated pathology or different

    diagnosis)

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    45 years female

    Jaundice + right hypochondrial pain

    US: Dilated CBD

    ERCP: Distal filling defect ~ Ampullarry tumor ?

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    EUS in Bile Duct Tumor

    Limitations of ERCP in evaluation of bile

    duct tumorOnly indirect signs such as stenosis or prestenotic

    dilation , or both, are visualized, and lesion itself isgenerally not seen.

    Difficult to differentiate benign from malignant stricture.

    Low sensitivity of ERCP guided brush cytology (30-40%)

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    EUS in Bile Duct Tumor

    Can EUS overcome limitations of ERCP ?

    Direct visualization of tumor

    Criteria for malignancy of stricture:Disruption of normal echo-layer pattern of CBD wall

    Hypoechoic infiltrating lesion

    Irregular margins lesion

    Heterogeneous mass invading surrounding tissue

    Local tumor stagingEUS-FNA sensitivity (60-80%)

    Byrne et al;Endoscopy2004

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    EUS in Bile Duct Tumor

    Limitation of EUS in bile duct tumor!!!!!

    Klat skin tumorElectronic linear echoendoscope

    5 MHz

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    57 years old

    Cholestatic jaundice

    Abdominal US : Merrizy syndrome?

    ERCP : CBD stone + hilar stricture

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    EUS in Bile Duct Tumor

    How to appropach a bile duct stricture

    Middle and distal bile duct strictures:EUS plus FNA followed by ERCP.

    Common hepatic duct and hilar strictures:

    MRCP or EUS ? followed by ERCP

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    45 years male

    Obstructive Jaundice

    US: Dilated CBD

    ERCP: Distal CBD Stricture?

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    60 years male

    Jaundice + Itching

    US: Dilated CBD

    ERCP: Mid CBD stone?

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    Role of EUS in Periampullary

    Tumor

    Diagnosis of tumor

    Tissue sampling.

    Staging

    Treatment strategy (Surgery Vs Endoscopic)

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    Role of EUS in Periampullary

    Tumor

    Limitations of ERCP:

    Diagnosis of ampullary tumor not always possible

    endocopically (intramural).

    Ampullary tumor Vs Odditis

    Coexistence of stone (6-38%)

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    Role of EUS in Periampullary

    TumorCan EUS overcome limitations of ERCP ?

    Ampullary tumorHypoechoic enlargementof ampulla

    Polypoid intraluminal massInvolvement of duodenal wall

    Oditis:Hyperechoic enlargement of ampulla

    No intraductal polypoid infiltration

    Duodenal wall preserved

    Keriven et al;Endoscopy 1993

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    70 years female

    Cholestatic jaundice

    US: Dilated CBD + stone

    ERCP: CBD stone

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    Role of EUS in Periampullary

    Tumor

    EUS should be performed prior to ERCP in

    all patients:

    Obstructive jaundice with negative CT Scanning

    and MRI.

    Insertion of biliary stent prior to EUS may impede

    visualization of small tumor.

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    Accuracy of Different Modalities in The

    Evaluation of periampullary tumors

    Diagnos t ic modal ity Accu racy

    Abdominal US 65%

    EUS 95 %

    ERCP 81 %

    MRI + MRCP 88 %

    CT scanning 83 %

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  • 8/22/2019 Extrahepatic bilia