Routine endoscopic ultrasound in moderate and indeterminate risk patients of suspected choledocholithiasis to avoid unwarranted ERCP: A prospective randomized blinded study.

Abstract

Endoscopic ultrasound (EUS) is the most sensitive test for diagnosis of common bile duct stones and it may avoid unnecessary endoscopic retrograde cholangiopancreatography (ERCP). The purpose of this study was to evaluate whether EUS done initially would avoid unnecessary ERCP in patients with moderate or indeterminate risk for occurrence of choledocholithiasis. Patients with biliary colic or acute biliary pancreatitis, who were referred for suspected choledocholithiasis on the basis of alterations in liver function tests were prospectively included over 12months period in blinded randomized fashion. Endoscopic ultrasonography was performed for all patients. Patients were randomized to two groups. ERCP was done in all patients in group A irrespective of the EUS findings, while in the group B, ERCP was done only in those patients in whom EUS was suggested the presence of common bile duct stone or sludge. A total of 50 patients were randomized into each group. EUS diagnosed common bile duct stones in 24 out of 50 patients (48%) in group A, and ERCP identified common bile duct stones in 23 of those 24 patients. Twenty-eight out of 50 patients had common bile duct stones/sludge in group B, which were removed by subsequent ERCP. However, ERCP could be avoided in 22 cases (44%) of group B and none of these patients had biliary symptoms up to 6months of follow up. In patients with moderate or indeterminate risk for choledocholithiasis, prior EUS done for confirmation of choledocholithiasis avoids unnecessary ERCP in almost half of the cases.