4604 Accuracy and importance of endoscopic examination at the time of ercp.

Abstract

Background: Little is known about the yield of endoscopic examination with the duodenoscope following ERCP, and there appears to be no uniform standard of practice regarding endoscopic examination after ERCP. We hypothesized that important lesions may be identified with a thorough endoscopic examination in this setting. Methods: From 3/10/99 through 11/10/99, all patients undergoing ERCP had endoscopic examination with the duodenoscope of the duodenum, stomach, and esophagus at the completion of the procedure. Patients were then placed in the left lateral decubitus position and upper endoscopy performed with a standard forward viewing endoscope. The same investigator performed both endoscopic examinations. Patients were asked regarding past history of ulcer disease, upper gastrointestinal symptoms, use of anti-acid therapy as well as nonsteroidal drugs. Patients were excluded if they had undegone a prior endoscopy within three months or failed to consent for the study. Results: During the 8 month period of study, 262 patients (median age 55 years) underwent ERCP and EGD. The most common indication for ERCP was suspected choledocholithiasis. Endoscopic examination was normal in 27% and the most common endoscopic finding was hiatal hernia seen in 69 patients (26%). Lesions missed by duodenoscopy included subtle lesions at the gastroesophageal junction (mild esophagitis), antral lesions (erosions) and small gastric polyps. For some lesions, endoscopic examination documented more severe disease than was appreciated at duodenoscopy. Examination with the duodenoscope was superior to the forward viewing endoscope in identifying a Schatzki's ring. No patient with carcinoma, peptic ulcer, gastric varices, or severe esophagitis was missed with the duodenoscope. The accuracy of endoscopy with the duodenoscope was high (98%). Conclusions: 1) A suprisingly large percentage of patients undergoing routine ERCP had endoscopic lesions. 2) Endoscopic examination with a duodenoscope compares favorably to the forward viewing endoscope. 3) Given the ease of performing endoscopy with the duodenoscope, it should become standard of practice following ERCP.