Common Bile Duct Sludge Research Articles

Suspected common bile duct stones: reduction of unnecessary ERCP by pre-procedural imaging and timing of ERCP

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice to remove sludge/stones from the common bile duct (CBD). In a small but clinically important proportion of patients with suspected choledocholithiasis ERCP is negative. This is undesirable because of ERCP associated morbidity. We aimed to map the diagnostic pathway leading up to ERCP and evaluate ERCP outcome.MethodsWe established a prospective multicenter cohort of patients with suspected CBD stones. We assessed the determinants that were associated with CBD sludge or stone detection upon ERCP.ResultsWe established a cohort of 707 patients with suspected CBD sludge or stones (62% female, median age 59 years). ERCP was negative for CBD sludge or stones in 155 patients (22%). Patients with positive ERCPs frequently had pre-procedural endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) imaging (44% vs. 35%; P = 0.045). The likelihood of ERCP sludge and stones detection was higher when the time interval between EUS or MRCP and ERCP was less than 2 days (odds ratio 2.35; 95% CI 1.25–4.44; P = 0.008; number needed to harm 7.7).ConclusionsEven in the current era of society guidelines and use of advanced imaging CBD sludge or stones are absent in one out of five ERCPs performed for suspected CBD stones. The proportion of unnecessary ERCPs is lower in case of pre-procedural EUS or MRCP. A shorter time interval between EUS or MRCP increases the yield of ERCP for suspected CBD stones and should, therefore, preferably be performed within 2 days before ERCP.Graphical abstract

Comparison of Radial Echoendoscopy and Predictive Factors in the Evaluation of Patients with Suspected Choledocholithiasis

Objective: The aim of this study was to compare predictive factors and Radial Echoendoscopy (EUS) in the diagnosis of choledocholithiasis.Materials and Methods: Patients with suspected choledocholithiasis were recruited from April 2011 to January 2018. All patient characteristics, findings of EUS and findings of ERCP were recorded and analyzed.Results: Eighty patients were enrolled in this study. Clinical symptoms, blood chemistry and liver function test were similar in patients with and without choledocholithiasis. Using the findings of ERCP as the gold standard, Radial EUS had sensitivity and specificity for the detection of choledocholithiasis at 90.2% and 97.4%, and for choledocholithiasis and/or common bile duct sludge at 92.7% and 100%, respectively. For patients with intermediate likelihood and high likelihood from predictive factors (33 and 45), Radial EUS was positive for choledocholithiasis in 51.5% (17/33) and 46.7% (21/45), and ERCP was positive for choledocholithiasis in 54.5% (18/33) and 48.9% (22/45), respectively.Conclusion: Predictive factors, for both intermediate and high likelihood groups, were not accurate to diagnose these patients. Radial EUS is a good diagnostic tool and should done in both groups of patients to avoid unnecessary ERCP.

Eosinophilic Cholecystitis presenting with Common Bile Duct Sludge and Cholangitis: A Case Report

Eosinophilic cholecystitis is a rare post-cholecystectomy inflammatory histopathological condition characterized by more than 90% eosinophilic infiltrate in the gallbladder. We present a case of 27-year female presented with abdominal pain, fever, jaundice, altered mental status, shock, leucocytosis, deranged liver function test, and peripheral blood eosinophilia. The patient underwent cholecystectomy and common bile duct exploration. She developed adult respiratory distress syndrome and hospital-acquired pneumonia. From this, we want to emphasize that eosinophilic cholecystitis and cholangiopathy should be a differential diagnosis in patients presenting with allergy, peripheral eosinophilia, obstructive jaundice that are planned to undergo cholecystectomy that will have early critical care intervention.

Single‐stage retrograde endoscopic common bile duct stone removal might be sufficient in moderate acute cholangitis with a stone size ≤12 mm: A retrospective cohort study with propensity score matching

AbstractStudies elucidating the efficacy and safety of single‐stage endoscopic treatment for acute moderate cholangitis with choledocholithiasis are limited. Therefore, we performed a retrospective analysis of single‐stage endoscopic treatment for common bile duct (CBD) stone removal in patients with moderate cholangitis to determine the rates of successful stone extraction and complications. A retrospective chart review was conducted for all consecutive patients (n = 632) undergoing endoscopic retrograde cholangiopancreatography (ERCP) for CBD stone removal between January 2010 and September 2013 at the study institution. A total of 346 patients excluded based on the following criteria: procedural failure requiring an anatomy‐modifying operation, stenosis of the pyloric ring, tumor‐related obstruction, treatment requiring only biliary drainage, failure to locate the papilla, intolerance due to inadequate sedation, CBD stone > 12 mm, CBD sludge, and non‐naïve papilla in ERCP. The remaining 286 patients were randomly matched at a 1:2 ratio using propensity score together with age and sex with the Number Cruncher Statistical System statistical software. After propensity score matching, there were 90 and 134 patients in the moderate and no/mild cholangitis groups, respectively. The baseline characteristics and endoscopic findings were comparable between the two groups. The success rate of complete stone extraction was similar between the moderate and no/mild cholangitis groups (90.0% vs 91.0%, P = .793). Additionally, the complication rates were comparable between the moderate and no/mild cholangitis groups (post‐ERCP pancreatitis, 13.3% vs 10.4%, P = .542; pneumonia, 4.4% vs 1.5%, P = .183; perforation, 0% vs 1.5%, P = .243; and mortality, 2.2% vs 0.7%, P = .350). However, there was a trend for higher bleeding rate in the moderate cholangitis group compared with the no/mild cholangitis group (2.2% vs 0%, P = .084). Single‐stage retrograde endoscopic CBD stone removal in patients with moderate cholangitis and choledocholithiasis sized ≤12 mm might be adequate based on the high success rate (90.0%) for stone removal and low complication rates.

An assessment of the yield of EUS in patients referred for dilated common bile duct and normal liver function tests.

Objective:This study aims to determine the yield of EUS in patients with common bile duct (CBD) dilation and normal liver function tests (LFTs).Materials and Methods:Between October 2000 and December 2016, all patients referred for EUS for unexplained CBD dilatation (CBD ≥7 mm), with normal aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and bilirubin and no history of sphincterotomy, were eligible. Linear-array EUS was performed by one of the two experienced endosonographers. Data were extracted from a prospectively maintained database.Results:Of 29,920 upper gastrointestinal EUS procedures performed, 840/29,920 (3%) were for unexplained CBD dilation. Of 840 patients, 199 (24%) had normal LFTs, 99% were Caucasian, 46% had biliary-type abdominal pain, and 41% were postcholecystectomy. EUS diagnosed choledocholithiasis (CDL) or sludge in 18/199 (9%) patients (7/18 had CBD sludge only). No other pathology was diagnosed. Of 18 CDL patients, 15 (83%) had an intact gallbladder, and all 15 patients had cholelithiasis. The frequency of CDL or sludge in postcholecystectomy patients was only 3.7% (3/82); none of these patients were younger than 69 years of age. Regression analyses showed no associations between EUS diagnosis of CDL or sludge and biliary-type abdominal pain, other symptoms, sex, or race. Each additional year of age was associated with an increase in the risk of CDL or sludge by a factor of 1.05 (odds ratio: 1.05; P = 0.034).Summary:In patients with CBD dilation and normal LFTs, the only significant pathology identified is CBD stones or sludge (almost exclusively in elderly patients with cholelithiasis).Conclusion:EUS should be avoided in patients with dilated bile ducts and normal LFTs, especially if under 65 years of age and postcholecystectomy.

Role of endoscopic ultrasonography in patients with first episode of idiopathic acute pancreatitis

Acute pancreatitis (AP) evades an etiological diagnosis in up to 10 % to 30 % of patients. This group, ie. idiopathic acute pancreatitis (IAP) is prone to a high recurrence (up to 70 %). Endoscopic ultrasound (EUS) is promising, but there is limited data on elucidating the cause of IAP, from India. This observational study was designed to study the role of EUS after the first episode of IAP. All patients diagnosed to have first episode of IAP were included in the study and taken up for EUS examination after 6 weeks. Patients with conditions known to predispose or precipitate AP, like alcohol binge, drugs, metabolic or autoimmune conditions, or even a positive family history, were excluded from the study. A total of 51 patients were included. EUS positivity was found in 29 (56.9 %) patients. It included common bile duct (CBD) calculus in 5 (9.8 %), CBD sludge in 4 (7.8 %), gallbladder calculus in 2 (3.9 %), gallbladder sludge in 2 (3.9 %), and chronic pancreatitis (CP) in 16 (31.4 %) patients. Fourteen patients had a normal study and eight patients had indeterminate CP. EUS is safe and has a reasonable diagnostic yield in patients with first episode of IAP. CP and biliary lithiasis are the most frequent positive findings on EUS. EUS should be included in the diagnostic protocol after the first episode of IAP, rather than waiting for recurrent episodes.

Endoscopic ultrasonography in patients with elevated carbohydrate antigen 19-9 of obscure origin

To evaluate the efficacy of endoscopic ultrasonography (EUS) in patients with elevated carbohydrate antigen (CA) 19-9 levels of obscure origin. Patients who had visited Pusan National University Hospital because of elevated serum CA 19-9 levels, between January 2007 and December 2009, were retrospectively enrolled. EUS had been performed on all subjects, in addition to routine blood tests, endoscopy, abdominal computed tomography (CT) and other clinical exams, which had not revealed any abnormal findings suggestive of the origin of the elevated CA 19-9 levels. Of the 17 patients, gallbladder sludge was detected in 16 patients (94.1%) and common bile duct sludge was observed in 3 patients (17.6%). After the administration of ursodeoxycholic acid to 12 of the patients with gallbladder sludge, CA 19-9 levels normalized in 6 of the patients after a median of 4.5 mo. EUS is a useful diagnostic method for patients with elevated CA 19-9 levels of obscure origin, even if the reason for abnormal levels of this serum marker cannot be determined through prior examinations, including abdominal CT.

Comparison of the clinical characteristics and imaging findings of acute cholangitis with and without biliary dilatation

To evaluate the causes of acute cholangitis without biliary dilatation and to compare the clinical characteristics and the imaging findings between patients with acute cholangitis with and without biliary dilatation. 93 patients diagnosed with acute cholangitis underwent contrast-enhanced CT. Among them, 17 patients were classified as not having biliary dilatation (Group 1) and 76 patients were classified as having biliary dilatation (Group 2). The causes of acute cholangitis were evaluated in both groups. Clinical characteristics and imaging findings were compared between the two groups. The causes of acute cholangitis without biliary dilatation included common bile duct (CBD) stones (n=11), CBD sludge (n=3), a passed stone (n=1) and unknown causes (n=2). The total bilirubin levels of Group 1 were significantly lower than those of Group 2 (p=0.001). By contrast, Group 1 had higher median alanine aminotransferase (ALT) levels than Group 2 (p=0.04). The length of hospital stay was significantly longer in Group 2 than in Group 1 patients (p<0.001). In the imaging findings, the extent of transient hepatic attenuation differences (THADs) (p=0.003) were significantly smaller in Group 1 than in Group 2. CBD stones and sludge were the most common causes of acute cholangitis in patients without biliary dilatation. These patients showed lower levels of bilirubin and higher levels of ALT than those with acute cholangitis with biliary dilatation, and had a shorter duration of hospital stay. The extent of THADs was the only discriminative CT finding between the two groups. Acute cholangitis can present without biliary dilatation on imaging, and the most common causes are CBD stones and sludge. The patients with acute cholangitis without biliary dilatation have different clinical characteristics and imaging findings compared with those with acute cholangitis presenting with biliary dilatation.

Findings at endoscopic retrograde cholangiopancreatography after endoscopic treatment of postcholecystectomy bile leaks

Although the endoscopic management of bile leaks after cholecystectomy (CCY) is well established, the yield of a routine endoscopic retrograde cholangiogram (ERC) with a bile duct sweep at the time of stent removal is unclear. This study aimed to describe the prevalence of abnormal findings at follow-up ERC to determine whether upper endoscopy with stent removal and without cholangiography would suffice. A retrospective cohort analysis of all patients referred for initial and follow-up ERC with post-CCY bile leak was performed. The rate of abnormal findings was measured including choledocholithiasis, biliary strictures, and persistent bile leaks at follow-up ERC. Secondarily, the study sought to define the clinical characteristics of patients who demonstrated stones or sludge at follow-up assessment. Between January, 2003 and April, 2008, 105 patients underwent initial and follow-up ERC. After a mean interval of 6.9 +/- 2.7 weeks between endoscopies, 29 (27.6%) of the 105 patients demonstrated one or more abnormalities including persistent bile leak (n = 8), common bile duct (CBD) stones (n = 12), and CBD sludge alone (n = 9). In the subgroup analysis of the patients who underwent a balloon sweep at initial and follow-up ERC, the prevalence of CBD stones or sludge at the follow-up ERC was 17.6%. Besides stones during the initial ERC, no significant clinical predictors of CBD stones were found at follow-up ERC including surgical approach, interval between endoscopies, and location of bile leak. After endoscopic treatment of a bile leak, the prevalence of abnormalities at follow-up ERC is significant. A repeat cholangiogram with a balloon sweep is preferred at the time of stent removal.

4556 Impact of biliary endoprostheses on endosonographic bile duct morphology in obstructive jaundice.

BACKGROUND: Some surgeons argue against preoperative stents for obstructive jaundice based on stent-induced inflammatory changes seen on biliary histology (Surgery 1992;111:562, J Am Coll Surg 1994;178:343). The purpose of this study was to test whether and how frequently endosonography (EUS) could demonstrate any changes in biliary morphology with the use of endoscopic biliary stents for obstructive jaundice. METHODS: Data were included from all patients undergoing upper EUS from 4/95 to 11/99 having non-stone associated obstructive jaundice from a distal common bile duct (CBD) lesion with no clinical evidence of cholangitis. Patients were divided into two groups, those having an EUS before any endoscopic stent was placed and those having EUS after a plastic stent had been placed for obstructive jaundice. Patient demographics, average CBD diameter and width and the presence of biliary sludge were ascertained in both groups. RESULTS: A total of 87 patients were studied (see table) with 22 patients in the stented group. Endoprostheses were in place for an average of 3 weeks at the time of EUS. There were no significant differences in the age or sex distribution, but malignant obstruction was more frequent in the non-stented group. Patients with stents had smaller duct diameters; however, the average duct wall thickness was almost twice that seen in non-stented ducts. Stented patients had CBD sludge more frequently. CONCLUSION: Confirming previous pathologic reports, this study demonstrates that endosonographically evident duct wall thickening and CBD sludge is indeed a frequent finding after stent placement for obstructive jaundice. Whether these changes contribute to the poorer surgical outcomes reported by some groups with preoperative stenting (Arch Surg 1998;133:149)is still unclear.

Prevalence and laparoscopic ultrasound patterns of choledocholithiasis and biliary sludge during cholecystectomy.

A prospective study of laparoscopic ultrasound (LUS) for evaluation of the common bile duct during laparoscopic cholecystectomy was started in October 1993. LUS during cholecystectomy was performed routinely to preoperatively identify unsuspected stones. Three-hundred thirty patients with symptomatic cholelithiasis were included in the study. The preoperative work-up included endoscopic retrograde cholangiopancreatography in 49 patients. Common bile duct (CBD) stones were found in 22 cases; in 19 cases the stones were removed successfully by endoscopic sphincterotomy. LUS successfully visualized the CBD in all but 10 patients (3%). CBD stones were found in 17 patients and confirmed by preoperative cholangiography and/or CBD exploration. There were two false-negative and one false-positive result for LUS. In 47 patients (14.2%) LUS detected CBD sludge as low-amplitude echoes without acoustic shadowing. The presence of CBD sludge was correlated with some biochemical and clinical variables. A significant correlation was identified between the absence or presence of CBD sludge and endoscopic retrograde cholangiopancreatography, acute pancreatitis, gallbladder sludge, age, and the levels of serum bilirubin and alkaline phosphatase. A significant difference was recorded between CBD diameter and the presence or absence of stones or sludge (p = 0.00001). In our experience, LUS allowed good diagnosis of CBD stones during laparoscopic cholecystectomy. The clinical significance of CBD sludge remains to be elucidated.