Download - Extrahepatic biliary obstruction

8/22/2019 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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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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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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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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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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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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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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Clinical Approach To The Patient

With Obstructive Jaundice

US

Stone Tumor Unclear

EUS

StagingEUS

Confirming diagnosis

EUS

Associated pathology

Therapeutic decision

Endoscopic therapy Surgery

Definitive or PalliativeStone extraction or Stenting


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EUS is useful prior to ERCP

Detection of microlithiasis and

choledocholithiasis.

Detection and staging of pancreatic and

ampullary tumors.

Evaluation of benign and malignant bile duct

obstruction. Obtain tissue diagnosis of periampullary

tumors.


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Is it cost effective?

Extra cost of EUS, performed as the first

investigation, is out weighted by the lower

morbidity rate and shorter hospitalization

because of minor number of unnecessary ERCP

and/or sphincterotomy.


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Conclusion

EUS is necessary prior to ERCP in the

evaluation of obstructive jaundice.

Every endoscopist should be familiar with EUS

EUS and ERCP in the same session.


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