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cbd dilation size

Cbd dilation size

Conflict-of-interest statement: The authors have nothing to disclose regarding funding from industries or conflict of interest with respect to this manuscript.

Examples of pathologic findings identified on endoscopic ultrasound in patients with negative prior imaging tests. A: Choledocholithiasis: Small stones in the common bile duct; B: Small pancreatic cancer; C: Small duodenal diverticulum with bile duct indentation (see arrow); D: Ampullary carcinoma with pancreas invasion; E: Inflammatory thickening of the distal common bile duct.

In an abstract published in 2009, based on a retrospective study, 30 patients with biliary dilatation and no evident causes on prior imaging underwent EUS[43]. Four patients had normal biliary system on EUS, 15 patients presented a dilatation of unknown etiology while pathology accounting for CBD dilatation was demonstrated in 11 of them (choledocholithiasis, ampullary adenoma, chronic pancreatitis or cholangiocarcinoma). Similarly to other studies, prevalence of abnormal findings during EUS examination was different between the patients with abnormal and those with normal liver chemistry tests (55% and 33% respectively). Conversely, the number of pathological findings in the latter group differed from percentages reported by other authors[2,3], probably because no details were specified in this study, about clinical presentation and previously used imaging techniques. Notably, none of the patients with unexplained CBD dilatation on EUS was found to have causative lesions after a mean follow-up of 16 mo.

First decision: October 14, 2014

ACKNOWLEDGMENTS

In the presence of CBD dilatation without symptoms or clinical and laboratory alarm signs, when non-invasive imaging test (TUS, CT or MRCP) fail to indentify the etiology, clinical suspicion for biliary pathology is low, thus making further investigations unwarranted[2,8]. In this setting, despite negative results of previous imaging tests, diagnostic EUS could have a role in the identification of the etiology of dilatation (Figure ​ (Figure1) 1 ) with a very low complication rate[37]. EUS combines endoscopy with real-time and high-resolution ultrasound providing excellent sonographic visualization of the extrahepatic biliary tree without interference of bowel gas, due to its ability to place the transducer in close proximity to the extrahepatic bile duct. Additionally, EUS permits the accurate and systematic visualization of the wall of the duodenum, including the papillary region[38].

As expected, the prevalence of biliary pathology is significantly higher in the case of elevated liver chemistry tests; however, despite the lack of pathological findings with non-invasive imaging techniques and normal liver biochemistry, biliary abnormalities may still be present and EUS is recommended for further evaluation.

In a meta-analysis published in 2008, on EUS performance in detecting choledocholithiasis, the authors proposed EUS as a less low invasive technique to be incorporated into the diagnostic algorithm of patients with suspected CBD stones, in order to confirm the pathological condition before proceeding with therapeutic ERCP, when indicated[31]. Scheiman et al[32], in a prospective study and cost analysis performed on a cohort of patients referred to ERCP, defined EUS the preferred initial diagnostic test, compared with MRCP, for the evaluation of biliary system and identification of extrahepatic disease.

CAUSES OF BILIARY DILATATION

In recent years, the description of isolated bile duct dilatation has been increasingly observed in subjects with normal liver function tests and nonspecific abdominal symptoms, probably due to the widespread use of high-resolution imaging techniques. However, there is scant literature about the evolution of this condition and the impact of endoscopic ultrasound (EUS) in the diagnostic work up. When noninvasive imaging tests (transabdominal ultrasound, computed tomography or magnetic resonance cholangiopancreatography) fail to identify the cause of dilatation and clinical or biochemical alarm signs are absent, the probability of having biliary disease is considered low. In this setting, using EUS, the presence of pathologic findings (choledocholithiasis, strictures, chronic pancreatitis, ampullary or pancreatic tumors, cholangiocarcinoma), not always with a benign course, has been observed. The aim of this review has been to evaluate the prevalence of disease among non-jaundiced patients without signs of cytolysis and/or cholestasis and the assessment of EUS yield. Data point out to a promising role of EUS in the identification of a potential biliary pathology. EUS is a low invasive technique, with high accuracy, that could play a double cost-effective role: identifying pathologic conditions with dismal prognosis, in asymptomatic patients with negative prior imaging tests, and excluding pathologic conditions and further follow-up in healthy subjects.

Several authors compared MRCP and EUS in detecting choledocholithiasis showing cost-effectiveness and higher accuracy of EUS in detecting distal small stones in non-dilated ducts[26,32,39]. De Lédinghen et al[39] reported a 100% negative predictive value of EUS in the diagnosis of lithiasis, thus excluding the needing for further investigation and limiting unnecessary surgery. In the previously mentioned study by Scheiman et al[32], EUS was the most useful test for confirming a normal biliary tree, and the initial EUS strategy had the greatest cost-utility by avoiding unnecessary ERCPs and preventing ERCP-related complications[40].

Cbd dilation size

EPLBD with a large balloon of over 15 mm with EST is an effective and safe procedure with a very low probability of severe post-procedural pancreatitis. Post-EPLBD pancreatitis was not associated with larger balloon size, but was associated with longer procedure time and smaller dilatation of the CBD.

Results

Attasaranya S, Cheon YK, Vittal H, et al. Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: a multicenter series. Gastrointest Endosc. 2008;67:1046–1052.

References

The history of previous pancreatitis and younger age (≤60 years) have also been reported as risk factors for post-EPBD hyperamylasemia [23, 24], but they were not significant in our data. These factors might have been underestimated in the present study because the number of patients with history of pancreatitis and the number of younger patients were relatively small.