Isolated Thickening of the Common Bile Duct At EUS: Is It Clinically Relevant?

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Background: A thickened wall of the common bile duct (CBD) is a relatively common finding in several pancreaticobiliary EUS; however, little is known about its clinical significance. In patients with major findings such as biliary stones, pancreatic cancer, and CBD stenting the thickening of the CBD wall is considered of secondary importance and ruled out. On the other hand, it may happen that it were the only atypical finding in the absence of clear causative lesions and in an otherwise normal EUS. Our aim was to determine the clinical significance of EUS detection of an isolated CBD wall thickening. Patients and Methods: We reviewed retrospectively our database in the period 2004-2007 searching for “thickened CBD wall” in the report of patients referred for pancreaticobiliary EUS with one of these indications: recent jaundice, biliary colic and/or acute pancreatitis. All relevant cases were contacted by telephone and pertinent medical reports were analyzed to follow up their clinical conditions up after EUS. Results: Overall, 101 patients had CBD thickening at EUS. Of these, 57 were excluded because other relevant pathological conditions were identified (CBD stones, pancreatic cancer, CBD stent, chronic pancreatitis). Also patients with previous endoscopic sphincterotomy were excluded. Other 22 patients were excluded due to the finding of stones in the gallbladder. Thus, 22 cases were left with the isolated finding of a thickened CBD wall constituting our study group (19 with previous cholecystectomy, 5 with acalcolous gallbladder in situ) (14F,8M; age 45-88, median 67). All these patients were symptomatic at the time of EUS (4/22 acute pancreatitis, 15/22 biliary colic with elevations of liver enzymes, 3/22 transient jaundice). After EUS, 19/22 patients remained symptom-free for a follow-up of 12-48 months (median 31). Only three/22 patients (14%) underwent ERCP with sphincterotomy for recurrent biliary pain with elevation of liver enzymes (n=2) or jaundice (n=1). Conclusions: The finding of a thickened CBD at pancreaticobiliary EUS is relatively common in a variety of clinical settings and can be exclusively appreciated by EUS in contrast to other imaging techniques. The isolated thickening of the CBD does not appear to prelude either to worsening of the presenting clinical conditions or to their recurrence. Due to the low number of patients who had recurrent symptoms, a clinical follow up is warranted in all the cases without the need for an immediate endoscopic sphincterotomy.