andrea anderloni early eus per il triage della coledocolitiasi€¦ · • 5 to 15% of patients...

Autore: Andrea Anderloni

Early EUS per il triage della l d lcoledocolitiasi

Early EUS per il triage della l d li i icoledocolitiasi

1

Common bile duct stones (CBDS) are detectable in • 5 to 15% of patients with cholelithiasis, • 10 to 20% of those undergoing cholecystectomy, and • 18 to 21% of those with gallstones pancreatitis

CBDS pose a risk for abdominal pain, pancreatitis, ascending cholangitis extrahepatic cholestasis hepatic abscess(es)cholangitis, extrahepatic cholestasis, hepatic abscess(es).

When present, CBDS removal is strongly recommended.


ERCP has been considered the ‘reference standard’ for i i li i f h bil dpreoperative visualization of the bile duct:

• Sensibility 90% • Specificity 98%p y

However, the nonselective use of ERCP detects CBDS in less than 50% of the patients50% of the patients.


ERCP is associated with 5‐10% complication rate:P i i (1 3 6 7%)• Pancreatitis (1,3‐6,7%)

• Infection (0,6‐5,0%) • Bleeding (0,3‐2,0%) • Perforation (0,1‐1,1%)• Mortality (0,02‐0,5%)

The best way to minimize risks of ERCP complications is to use ERCP for therapy rather than diagnosis.

Early EUS per il triage della l d li i icoledocolitiasi2

Diagnosis of CBDS is generally based on: • clinical signs and symptoms• serum markers of cholestasis• imaging tests (abdominal US)

Diff t ti f l d l ith h bDifferent prognostic scores, formulas, and algorithms have been proposed to help predict the probability of choledocholithiasischoledocholithiasis.


Barkun et al 1994

ASGE guidelines, GIE 2010


According to clinical biochemical and radiological test, patients i h d CBDS b i d iwith suspected CBDS can be categorized into:

low (<10%) intermediate (10‐50%)h h ( )

probability of choledocholithiasishigh (>50%) choledocholithiasis


However, commonly used biochemical and radiological di f h f h l d h li hi ipredictors of the presence of choledocholithiasis are

unreliable.

Only 70% of patients classified at high risk for CBDS had choledocholithiasis. Canto et al [GIE 1998]

Ideally, an accurate and noninvasive imaging modality should document the presence of CBDS first before proceeding withdocument the presence of CBDS first, before proceeding with an ERCP.


US: US: sensitivity of 25 to 58% specificities of 68 to 91%

CT: CT: Helical over conventional CTi i i % d ifi i %sensitivity 65 to 88% and specificity 73 to 97%

Tseng CW J Gastroenterol Hepatol 2008; Anderson SW Radiology 2008

MRI: MRI: sensitivity 85% to 92% and specificity 93% to 97%Romagnuolo J. Ann Intern Med 2003; Verma D. Gastrointest Endosc 2006

EUS: EUS: sensitivity 89% to 94%, specificity 94% to 95%Tse F. Gastrointest Endosc 2008

Early EUS per il triage della l d li i i

Sistematic Review:

coledocolitiasi4

EUS vs MRCP for detection of choledocholithiasis.

Verma D. Gastrointest Endosc 2006

sens spec acc VPP VPN

EUS 97 3% 75% 93 3% 94 7% 85 7%EUS 97,3% 75% 93,3% 94,7% 85,7%

RMN 91,9% 75% 88,9% 94,4% 66,7%RMN 91,9% 75% 88,9% 94,4% 66,7%

C l i EUS d MRCP h hi h di ti fConclusions: EUS and MRCP have high diagnostic performance overall.


No statistically significant difference between EUS and MRCP for the detection of CBDS (Ia). GUT Guidelines 2008

They recommended taking into consideration other factors

such as resource availability, experience, and cost.y, p ,

Why should I choose EUS instead of MRCP

in suspected CBDS?!

I it l tt f t ?!Is it only a matter of costs?!


5

• EUS performance is not adversely affected by decreasing stonesize and has a high NPV. Kondo S. Eur J Radiol 2005; Sugiyama M Gastrointest Endosc 1999g

• Sensitivity of MRI diminish in the setting of small (<6 mm) stones in patient without CBD dilatation: 33 to 71% (Ia).

Zidi SH. Gut 1999; Sugiyama M. Am J Gastroenterol 1998

• If EUS detects CBDS, an ERCP can be performed at the samesession (time saving!)session (time saving!).

• Greater cost reduction when EUS before ERCP was compared• Greater cost reduction when EUS before ERCP was compared with either MRCP before ERCP or ERCP alone.

Arguedas MR, Am J Gastroenterol 2001g


The first publications of the usefulness of the alternative non i i EUS i di i CBDS d d 1990invasive ‐ EUS – in diagnosing CBDS appeared around 1990.

More than 25 prospective studies, incorporating more then 2500 patients have shown excellent accuracy/safety for EUSpatients, have shown excellent accuracy/safety for EUS.


EUS:a meta-analysis of test performance6

y p

Pooled sensitivity (0.94) and specificity (0.95) of EUS for the diagnosis of CBDS (27 studies included)studies included).

Tse et al. GIE 2008c


Sistematic Review of endoscopic ultrasonography versus 7

endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis. Petrov BJS 2009

In the EUS‐guided ERCP group, 67% ERCP avoided with a reduction of the risk of overall complications (RR 0.35)p ( )


AIM

• Primary aim of this study is to investigate the clinical impact of early EUS in the management of suspected acute biliary obstructive disease caused by choledocholithiasis.

• Secondary aim is to reasses the role of endoscopy in the evaluation of suspected choledocholithiasis.


METHODS

From January 2010 to January 2012

all patients presenting to the A&E department with clinical, biochemical or US suspicion of CBDS were prospectively i l d dincluded

i d i l d d hi h b bili fcategorized into low, moderate, and high probability of CBDS, according to the risk stratification previously pubblished.

(Barkun et al; Tse et al.)


All h i l d d i d EUS i hi 48 h

METHODS ‐ II

• All the included patients underwent EUS within 48 hours

• ERCP immediately afterward (if EUS +ve)

• The following predictors were investigated: age sex dilated CBD bilirubin AST ALT gGT ALP feverage, sex, dilated CBD, bilirubin, AST, ALT, gGT, ALP, fever

d f l d h• Predictors significantly associated with CBD stones (p<0.05) were entered in a multivariate logistic regressionmodel


8Frequency of detection of CBDS at EUS according

to the pre‐determined level of risk in the 179 patients

RISK of CBDS CBDS at EUSType (pts #) pts # (%)

LOW (# 46) 9 (20)LOW (# 46) 9 (20)

MODERATE (# 67) 33 (51)MODERATE (# 67) 33 (51)

HIGH (# 66) 44 (67)

Total (# 179) 86 (48)


Operative characteristics of EUS in detecting CBDS in the 179 patientsaccording to the pre‐determided level of risk

RISK of CBDS Sens Spec PPV NPV Accuracy

LOW (# 46) 90 100 100 97 98

MODERTE (# 67) 94 100 100 94 97

HIGH (# 66) 100 91 95 100 97

Overall pts (# 179) 95 98 98 96 97


CO C S O S

• Commonly used biochemical and radiological predictors of the

CONCLUSIONS ‐ I

• Commonly used biochemical and radiological predictors of thepresence of CBD stones are unreliable

• Early EUS seems to be safe and accurate in identifying CBDll i i di d i hstones allowing immediate endoscopic treatment at the same

session and avoiding unnecessary ERCP

• An early EUS could be also used to select patients who don’tAn early EUS could be also used to select patients who don tneed ERCP for an early discharge


CASO CLINICO 1CASO CLINICO 1

Donna, 52 anni.

Epigastralgia associata a movimento indici di colestasi e itteroEpigastralgia associata a movimento indici di colestasi e ittero.

E dd li i i d ll l i i dil i d ll i bili iEco addome: litiasi della colecisti; non dilatazione delle vie biliari.


CASO CLINICO 2

D 55 i• Donna, 55 anni.

• Epigastralgia associata a movimento indici di colestasi e ittero.

• Eco addome: non dilatazione delle vie biliari.

CASO CLINICO 2


CONCLUSIONS ‐ II

Although a cost analysis has not been performed in this study, the role that a triage EUS could have in deciding about a patient’sthe role that a triage EUS could have in deciding about a patient s early discharge may indirectly indicate the advantages of this approach in reducing both hospital stay and related cost(s)approach in reducing both hospital stay and related cost(s).

h l d l hFurther multicentric investigations are required to evaluate the cost‐effectiveness of using early EUS in all patients with suspected CBDSCBDS.


10

CONCLUSIONS ‐ III

On the basis of these results we suggest the role of EUS to be id d i h l i h f d CBDSreconsidered in the management algorithm of suspected CBDS.

C t id li h ld id EUS ti d fCurrent guidelines should consider EUS as a routine procedure for all those patients with suspected CBDS.

Ideally, the gastroenterologists responsible for ERCP should be trained in EUS and vice versatrained in EUS and vice‐versa.


GRAZIE PER L’ATTENZIONE


1

Common bile duct stones (CBDS) are detectable in • 5 to 15% of patients with cholelithiasis, • 10 to 20% of those undergoing cholecystectomy, and • 18 to 21% of those with gallstones pancreatitis

CBDS pose a risk for abdominal pain, pancreatitis, ascending cholangitis extrahepatic cholestasis hepatic abscess(es)cholangitis, extrahepatic cholestasis, hepatic abscess(es).

When present, CBDS removal is strongly recommended.


Diagnosis of CBDS is generally based on: • clinical signs and symptoms• serum markers of cholestasis• imaging tests (abdominal US)

Diff t ti f l d l ith h bDifferent prognostic scores, formulas, and algorithms have been proposed to help predict the probability of choledocholithiasischoledocholithiasis.

Early EUS per il triage della l d li i i

Sistematic Review:

coledocolitiasi4

EUS vs MRCP for detection of choledocholithiasis.

Verma D. Gastrointest Endosc 2006

sens spec acc VPP VPN

EUS 97 3% 75% 93 3% 94 7% 85 7%EUS 97,3% 75% 93,3% 94,7% 85,7%

RMN 91,9% 75% 88,9% 94,4% 66,7%RMN 91,9% 75% 88,9% 94,4% 66,7%

C l i EUS d MRCP h hi h di ti fConclusions: EUS and MRCP have high diagnostic performance overall.


5

• EUS performance is not adversely affected by decreasing stonesize and has a high NPV. Kondo S. Eur J Radiol 2005; Sugiyama M Gastrointest Endosc 1999g

• Sensitivity of MRI diminish in the setting of small (<6 mm) stones in patient without CBD dilatation: 33 to 71% (Ia).

Zidi SH. Gut 1999; Sugiyama M. Am J Gastroenterol 1998

• If EUS detects CBDS, an ERCP can be performed at the samesession (time saving!)session (time saving!).

• Greater cost reduction when EUS before ERCP was compared• Greater cost reduction when EUS before ERCP was compared with either MRCP before ERCP or ERCP alone.

Arguedas MR, Am J Gastroenterol 2001g


EUS:a meta-analysis of test performance6

y p

Pooled sensitivity (0.94) and specificity (0.95) of EUS for the diagnosis of CBDS (27 studies included)studies included).

Tse et al. GIE 2008c


Sistematic Review of endoscopic ultrasonography versus 7

endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis. Petrov BJS 2009

In the EUS‐guided ERCP group, 67% ERCP avoided with a reduction of the risk of overall complications (RR 0.35)p ( )


8Frequency of detection of CBDS at EUS according

to the pre‐determined level of risk in the 179 patients

RISK of CBDS CBDS at EUSType (pts #) pts # (%)

LOW (# 46) 9 (20)LOW (# 46) 9 (20)

MODERATE (# 67) 33 (51)MODERATE (# 67) 33 (51)

HIGH (# 66) 44 (67)

Total (# 179) 86 (48)


CONCLUSIONS ‐ II

Although a cost analysis has not been performed in this study, the role that a triage EUS could have in deciding about a patient’sthe role that a triage EUS could have in deciding about a patient s early discharge may indirectly indicate the advantages of this approach in reducing both hospital stay and related cost(s)approach in reducing both hospital stay and related cost(s).

h l d l hFurther multicentric investigations are required to evaluate the cost‐effectiveness of using early EUS in all patients with suspected CBDSCBDS.


10

CONCLUSIONS ‐ III

On the basis of these results we suggest the role of EUS to be id d i h l i h f d CBDSreconsidered in the management algorithm of suspected CBDS.

C t id li h ld id EUS ti d fCurrent guidelines should consider EUS as a routine procedure for all those patients with suspected CBDS.

Ideally, the gastroenterologists responsible for ERCP should be trained in EUS and vice versatrained in EUS and vice‐versa.

andrea anderloni early eus per il triage della coledocolitiasi€¦ · • 5 to 15% of patients...

Documents