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Approach to Common Bile Duct Stones

The diagnosis and management of common bile duct stones has evolved considerably in recent years. New endoscopic, radiologic and surgical techniques now provide doctors with a range of options. We present an evidence based approach which incorporates the latest technology and techniques to optimize outcomes for patients.

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Approach to Common Bile Duct Stones

  1. 1. Evidence Based Approach To Common Bile Duct (CBD) Stones Dr Jarrod Lee Gastroenterologist & Advanced Endoscopist Mount Elizabeth Novena Hospital Gastroentero-Hepatology Update 2013 @ Bandung 31st August 2013
  2. 2. Scope • Overview • Initial Assessment • Further Evaluation • Risk Stratified Diagnostic Approach 2 ASGE Guidelines 2010; BSG Guidelines 2008
  3. 3. Clinical Scenario • 45 year female, no past medical history • Presented with 2 days epigastric pain • On arrival in emergency department, pain had resolved • Physical examination unremarkable • Bilirubin 55 µmol/L; Amylase normal • Trans abdominal ultrasound: multiple gallbladder stones, CBD 9 mm but no CBD stone 3
  4. 4. What Would You Do Next? A. Computer Tomography (CT) B. Magnetic Resonance Cholangiography (MRCP) C. Endoscopy Ultrasound (EUS) D. Endoscopic Retrograde Cholangiopancreatography (ERCP) E. Laparoscopic cholecystectomy with intraoperative cholangiogram (IOC) 4
  5. 5. Common Bile Duct (CBD) Stones
  6. 6. CBD Stones • Present in 10-20% of patients with symptomatic gallstones • Most commonly results from passage of gallstones through the cystic duct 6 Complications • Biliary obstruction • Cholangitis • Pancreatitis • Biliary cirrhosis
  7. 7. When to Suspect CBD Stones? • Clinical presentation: – abdominal pain, jaundice, nausea, vomiting • Cholangitis • Acute pancreatitis • Initial investigations: – Liver Function Test (LFT) – Trans abdominal Ultrasound (US) 7
  8. 8. Liver Function Test • Completely normal: NPV > 97% • Abnormal: PPV 15% • Bilirubin is the strongest predictor for CBD stones; specificity varies according to level – Bilirubin ≥ 30 µmol/L: specificity 60% – Bilirubin ≥ 68 µmol/L: specificity 75% • Mean bilirubin in CBD stones: 25.5 – 32.3 µmol/L 8
  9. 9. Trans Abdominal Ultrasound • First line imaging modality: widely available, noninvasive, inexpensive • CBD stones – Poor sensitivity: 22-65% – Specificity: 70-98% • CBD dilatation – Good sensitivity: 77-87% – Dilated CBD: >6 mm with intact gallbladder – Normal CBD: NPV 95-96% 9
  10. 10. What is the Likelihood of CBD Stones? 10
  11. 11. Clinical Predictors • Very Strong: – CBDS on US – cholangitis – bilirubin > 68 µmol/L • Strong: – dilated CBD on US – bilirubin 30-68 µmol/L • Moderate: – other abnormal LFT – gallstone pancreatitis – age > 55 yrs Likelihood of CBD Stones: • High (>50%): – any very strong predictor – both strong predictors • Low (<10%): – no predictors • Intermediate (10- 50%): – all other patients 11
  12. 12. What to do for the Intermediate Group? 12
  13. 13. Further Investigations • Radiologic – CT: Computer Tomography – MRCP: Magnetic Resonance Cholangiography • Intraoperative: – IOC: Intraoperative Cholangiogram – Laparoscopic Ultrasound • Endoscopic – ERCP: Endoscopic Retrograde Cholangiopancreatography – EUS: Endoscopic Ultrasound – IDUS: Intraductal Ultrasound 13
  14. 14. Computer Tomography (CT) 14 • Better sensitivity than US using composite criteria • Direct visualization < 75% • Helical CT has improved performance: – Sensitivity: 71-85% – Specificity: 88-97% • Limited by expense, contrast & radiation exposure
  15. 15. MRCP • Sensitivity: 85-92% • Specificity: 93-97% • Can be used when ERCP and EUS not possible, e.g. post surgical anatomy • Decreased accuracy for small stones <5 mm or large CBD >10 mm – Sensitivity for small stones: 33 -71% • Usual limitations of MRI 15
  16. 16. Intraoperative Evaluation • Intraoperative Cholangiogram (IOC) – Successful in 88-100% – Sensitivity: 59-100% – Specificity: 93-100% – Prolongs surgical procedure; needs fluoroscopy • Laparoscopic US – Sensitivity: 71-100% – Specificity: 96-100% – Technically difficult; longer learning curve longer than IOC 16
  17. 17. Endoscopic Evaluation • ERCP – Sensitivity 89-93%; Specificity 100% – Significant risk of complications • EUS – Sensitivity 89-94%; Specificity 94-95% – Highly sensitive for small stones; detects microlithiasis – Complications rare • IDUS – Sensitivity 97-100% – Clinical impact uncertain; probes expensive 17
  18. 18. ERCP 18
  19. 19. 19
  20. 20. Endoscopic Ultrasound 20
  21. 21. 21 EUS – Mid CBD Stone
  22. 22. Stone Impacted at Ampulla 22 EUS – Stone Impacted at Ampulla
  23. 23. Microlithiasis 23 EUS – Microlithiasis
  24. 24. Which Modality to Choose? Risk Stratified Diagnostic Approach 24
  25. 25. 25 Depends on costs and local availability
  26. 26. 26 Diagnostic Approach
  27. 27. 27 Treatment Approach
  28. 28. Treatment Approach • Cochrane Meta-analysis of 13 RCTs, N = 1351 – ERCP vs open surgery: open surgery had superior stone clearance – ERCP vs laparoscopic CBD exploration: similar outcomes, morbidity & mortality – Pre vs intra op ERCP: intra op ERCP had lower morbidity • In real life, laparoscopic CBD exploration & intra op ERCP rarely practiced 28Cochrane Database Syst Rev 2006
  29. 29. 29 Endoscopic Approach
  30. 30. EUS Directed ERCP • Start with EUS. If CBD stone found, proceed to ERCP at same setting or within 1 day • 4 RCTs to date: EUS directed ERCP vs ERCP – Patients with intermediate to high risk for CBD stones – Eliminates need for 60-73% of ERCP – Overall less morbidity – More cost effective when risk of CBDS 11-55%, i.e. intermediate risk • ?? Preferred approach 30
  31. 31. Personal Audit • 200 consecutive cases of EUS directed ERCP for suspected CBD stones – 64 patients with CBD stones – 125 patients with normal CBD – Sensitivity 100%; no missed stones – Specificity 99.5%; 1 false positive • 66% avoided unnecessary biliary procedure • 11 patients with distal biliary strictures: – 4 ampullary cancers, 5 cholangiocarcinomas, 2 pancreatic head cancers 31
  32. 32. Clinical Scenario • 45 year female, no past medical history • Presents with 2 days epigastric pain • On arrival in emergency department, pain had resolved • Physical examination unremarkable • Bilirubin 55 µmol/L; Amylase normal • Trans Abdominal ultrasound: multiple gallbladder stones, CBD 9mm but no stones 32 Intermediate Probability for CBD Stones
  33. 33. What Would You Do Next? A. Computer Tomography (CT) B. Magnetic Resonance Cholangiography (MRCP) C. Endoscopy Ultrasound (EUS) D. Endoscopic Retrograde Cholangiopancreatography (ERCP) E. Laparoscopic cholecystectomy with intraoperative cholangiogram (IOC) 33 EUS Directed ERCP
  34. 34. Key Points • An evidence based risk stratified approach to suspected CBD stones balances the risk of missed stones against procedural complications • New technologies allow accurate imaging of the CBD without risk of biliary instrumentation • Management is dependent on costs, local availability & expertise 34
  35. 35. Risk Stratified Approach • Initial evaluation should include LFT & Trans- abdominal US • Subsequent management depends on the probability of CBD stones: – Low  laparoscopic cholecystectomy – High  ERCP – Intermediate  MRCP, EUS, IOC • EUS directed ERCP is a promising new approach for intermediate probability patients 35
  36. 36. 36 Thank You Questions? drjarrodlee@gmail.com
  37. 37. Special Patient Groups 37
  38. 38. Post Cholecystectomy Patients • Results from undetected migrated stone or primary CBD stone – Consider: bile leak, iatrogenic stricture, SOD • Limited data for evaluation • Incidence of CBD stone in suspected patients: 33-43% • 6 mm cutoff for CBD size not appropriate • EUS & MRCP shown to be highly accurate 38
  39. 39. Gallstone Pancreatitis 39
  40. 40. Diagnostic Evaluation • Gallstones & microlithiasis are the most common causes of acute pancreatitis • 20% of acute pancreatitis will be classified as ‘idiopathic’ after US, CT & ERCP • EUS: – Maintains high accuracy for CBD stones: 97-100% – Detects gallstones or microlithiasis in 75-80% of acute pancreatitis classified as ‘idiopathic’ • EUS vs MRCP for severe pancreatitis – EUS resulted in fewer ERCPs & complications 40
  41. 41. Role of Early ERCP (24-72H) • 3 RCTs showed trend towards benefit – Significant benefit in severe pancreatitis – Included patients with biliary obstruction & cholangitis • Other trials showed no benefit – 1 RCT showed no benefit in predicted severe pancreatitis with bilirubin <85 µmol/L – Recent meta-analysis excluding cholangitis showed no benefit in severe pancreatitis – 2 RCTs for pancreatitis with biliary obstruction but no cholangitis had conflicting results 41
  42. 42. Early ERCP in Gallstone Pancreatitis • No role for early ERCP in mild pancreatitis in absence of retained stone • Early ERCP recommended in gallstone pancreatitis with cholangitis • Conflicting data in biliary obstruction without cholangitis, or in predicted severe pancreatitis • Pre-op EUS or IOC recommended before laparoscopic cholecystectomy if cholangitis or biliary obstruction absent 42
  43. 43. EUS Directed ERCP • 2 series in acute pancreatitis patients, 1 RCT vs direct ERCP • EUS better than ERCP in detecting CBD stones in acute pancreatitis • Trend towards less morbidity with EUS • No patients with negative EUS developed recurrent symptoms in 2 year median follow up 43
  44. 44. ‘Difficult’ Stone Disease • Refers to stones > 1cm or with distal stricture • Endoscopic modalities: – ‘Conventional’ treatment – Extra-corporal shockwave lithotripsy (ESWL) – Electro-hydraulic lithotripsy (EHL) – Laser lithotripsy (LL) – > 99% successful 44
  45. 45. ‘Conventional’ Treatment • Overall successful in > 90% • Mechanical lithotripsy: – Lower success in: impacted stones, stones > 2.5 cm, distal stricture – Used for emergency ‘over the basket’ lithotripsy for a large stone impacted in a standard basket • Endoscopic papillary balloon dilation – Can be combined with sphincterotomy • Biliary stent insertion & repeat ERCP – Higher success rate at repeat ERCP 45
  46. 46. ESWL, EHL & LL • ESWL – Nasobiliary drain inserted for targeting & drainage – Adverse effects: pain, hematoma, cholangitis – Duct clearance 60-90% • EHL & LL – > 95% successful – Used with cholangioscopy – Expensive 46
  47. 47. 47 Thank You Questions? drjarrodlee@gmail.com

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The diagnosis and management of common bile duct stones has evolved considerably in recent years. New endoscopic, radiologic and surgical techniques now provide doctors with a range of options. We present an evidence based approach which incorporates the latest technology and techniques to optimize outcomes for patients.

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