Extrahepatic biliary obstruction
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Transcript of 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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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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