Combined use of endosonography and endoscopic retrograde cholangiopancreatography in the same session.

Background/aims: The diagnostic value of endoscopic ultrasound in common bile duct stones is high. In this investigation, we evaluated the feasibility of endoscopic ultrasound preceding endoscopic retrograde cholangiography in the same session and the potential benefits in increasing the therapeutic endoscopic retrograde cholangiography ratio in the treatment of choledocholithiasis.

Methods: One hundred and sixty-five consecutive patients who presented with elevated ALP and bilirubin levels and were referred for endoscopic retrograde cholangiography of biliary stones diagnosed with magnetic resonance cholangiopancreatography were evaluated. During the evaluation period (mean: 2 weeks), 50 patients with reductions in ALP and bilirubin by at least half relative to baseline values were enrolled into the study. Endoscopic ultrasound was performed prior to endoscopic retrograde cholangiography. Time spent to perform endoscopic ultrasound was noted. For the presence of common bile duct stone, we used retrograde cholangiography findings as the standard of reference.

Results: Median endoscopic ultrasound time was 10.66 minutes (SD±1.52). Bile duct stones were revealed with retrograde cholangiography in 34 patients (68%). Sensitivity, specificity (with 95% confidence intervals [CIs]), positive predictive value and negative predictive value of endoscopic ultrasound were calculated. In identifying common bile duct stones on endoscopic ultrasound, sensitivity, specificity, positive predictive value, and negative predictive value were statistically determined as 91.2% (95% CI), 88.3% (95% CI), 91%, and 81.3%, respectively.

Conclusions: Our results indicate that in the presence of local experience and availability of endoscopic ultrasound, it is feasible to perform endoscopic ultrasound prior to endoscopic retrograde cholangiography. The sensitivity, specificity, positive predictive value, and negative predictive value for detecting choledocholithiasis in suspected cases are high. Endoscopic ultrasound preceding endoscopic retrograde cholangiography in the same session has the potential to decrease diagnostic endoscopic retrograde cholangiography and increase therapeutic endoscopic retrograde cholangiography. Need to perform magnetic resonance cholangiopancreatography in the presence of easily accessible endoscopic ultrasound should be questioned.