dilated cbd ultrasound

Background: There is scant literature about common bile duct (CBD) dilatation with normal liver function tests (LFTs).

Methods: We retrospectively reviewed our EUS database for patients referred for evaluation of CBD dilatation, normal LFTs, and prior inconclusive imaging. We excluded patients with a prior endoscopic retrograde cholangiopancreatography or a history of biliary obstruction, pancreatitis, or jaundice. Follow-up data were retrieved from medical records or by calling the general practitioners, referring specialists, patients, or their closest relatives.

Aims: The aims of this study were to assess the diagnostic yield of endoscopic ultrasound (EUS) in patients with CBD dilatation, normal LFTs, and prior inconclusive imaging tests, and to assess the natural history of these subjects.

Her initial presentation was during a consultation made by her
husband. Her symptoms seem relatively minor yet the biochemistry results
are quite abnormal indicating a pattern of obstructive jaundice. Her
ultrasound findings are dramatic with stones seen in the gallbladder and
in the lower common bile duct (CBD). Ultrasound is the first-line
investigation for the gallbladder and biliary tree. The ultrasound scan
should be available with only a short wait for more urgent cases. This
patient should be prioritised for an urgent scan appointment.

Her pancreas was seen to be swollen. The enlargement of the pancreas
may have various causes and if a biliary stone is lodged in the distal
CBD then the patient may develop pancreatitis. With aging, the pancreas
becomes more echogenic and atrophic on ultrasound.

The appearances of the liver are unexplained. Ultrasound is good for
assessing focal liver disease. A common abnormal pattern is the
geographical echogenic appearance seen in fatty change of the liver.

Dilated cbd ultrasound

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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Conflict-of-interest statement: The authors have nothing to disclose regarding funding from industries or conflict of interest with respect to this manuscript.

Finally, Oppong et al[46] presented data retrospectively collected from a cohort of patients referred for EUS evaluation to a tertiary center. By excluding subjects with jaundice, liver function tests abnormalities, evidence of mass, stricture or ductal filling defect on pre-EUS imaging or symptoms suggestive of sphincter of Oddi dysfunction or chronic pancreatitis, they selected 40 patients with isolated dilatation of CBD. New findings on EUS were identified in 8 patients (20%). In 7 the following was considered as cause of dilatation: 3 had biliary polyps (not confirmed in 2 patients who later underwent ERCP), 3 had biliary stones and 1 had portal vein compression on the CBD. Microlithiasis, identified in the eighth subject, was assessed as a secondary event. Prior cholecystectomy was significantly more frequent in patients with no new findings on EUS, although CBD diameter did not differ among patients with prior surgery or not.

Changes in bile duct anatomy and adaptation of biliary system to normal or pathological processes, impose an accurate analysis of the patient anamnesis, liver biochemical parameters, clinical context in order to differentiate subjects with higher probability of biliary pathology from those with low index of suspicion. In recent years, the availability of a low-invasive modality, without post-procedural risk of pancreatitis, led to an increasing use of EUS in the investigation of biliary dilatation, even when symptoms or signs typically suggestive of obstruction were absent. On the other hand, the use of high-resolution cross-sectional imaging to investigate abdominal symptoms commonly results in increasing findings of dilatated biliary ducts in patients with normal liver tests. Currently, EUS program presents an increasing number of referrals in this setting and evidences in literature suggest a promising role for this technique in the identification of a potential biliary pathology, despite a low pre-test clinical suspicion. Firstly, in a small subset of patients, although asymptomatic or with vague symptoms, it can underlie pathologic conditions with dismal prognosis even with negative prior imaging tests. Secondly, according to the known high negative predictive value of EUS[47,48], if EUS evaluation does not identify the cause of biliary dilatation, the patient should be reassured and no further follow-up is recommended, since no pathologic conditions emerged during follow-up period in the aforementioned studies.

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ACKNOWLEDGMENTS

Pathologic conditions are also able to induce isolated bile duct dilatations with non-specific symptoms or biochemical abnormalities. Choledocholithiasis, which develops in about 10%-20% of patients with gallbladder stones, may be asymptomatic in half of cases and CBD stones cannot always be identified by traditional non invasive imaging techniques[22]. Reported sensitivity in detection of CBD stones is 18%-74% for TUS and 50%-90% for CT[23-25]. Recently developed imaging modalities, such as MRCP and helical computed tomographic cholangiography (HCT-C) have shown higher sensitivity than TUS and conventional CT, and remain less invasive than ERCP[26]. However, EUS is considered more accurate in detecting CBD stones, especially if smaller than 5 mm in diameter, which are sometimes not identified by MRCP and HCT-C[26]. When choledocholithiasis is suspected, sensitivity of EUS reaches 90% for the detection of CBD stones[27-29]. In a prospective study, performed by Fernández-Esparrach et al[30] on patients with dilatated biliary tree, EUS increased the pretest probability of accurately diagnosing choledocholithiasis as the cause of obstruction from 49% to 84%. On the contrary, this probability decreased from 49% to 0% if EUS ruled out lithiasis as the cause of obstruction[30].

In 2007, Malik et al[3] retrospectively evaluated a cohort of patients with CBD dilatation and non-diagnostic imaging (TUS, CT or MRCP), previously performed for abdominal pain, weight loss or elevated liver enzymes in serum. These patients underwent EUS, being divided into two groups based on the level of clinical suspicion for biliary pathology (32 patients with normal liver chemistry tests and 15 patients with elevated enzymes)[3]. In the first group, the authors identified two findings on EUS (6%) potentially causative of biliary dilatation, a 7-mm stone of the CBD and a periampullary diverticulum. In the second group, 8 significant findings (53%) were observed: 4 periampullary diverticula, 3 choledocholithiasis and 1 ampullary tumor, not previously detected by TUS and CT.

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In an abstract published in 2009, based on a retrospective study, 30 patients with biliary dilatation and no evident causes on prior imaging underwent EUS[43]. Four patients had normal biliary system on EUS, 15 patients presented a dilatation of unknown etiology while pathology accounting for CBD dilatation was demonstrated in 11 of them (choledocholithiasis, ampullary adenoma, chronic pancreatitis or cholangiocarcinoma). Similarly to other studies, prevalence of abnormal findings during EUS examination was different between the patients with abnormal and those with normal liver chemistry tests (55% and 33% respectively). Conversely, the number of pathological findings in the latter group differed from percentages reported by other authors[2,3], probably because no details were specified in this study, about clinical presentation and previously used imaging techniques. Notably, none of the patients with unexplained CBD dilatation on EUS was found to have causative lesions after a mean follow-up of 16 mo.

CONCLUSION

First decision: October 14, 2014

In a meta-analysis published in 2008, on EUS performance in detecting choledocholithiasis, the authors proposed EUS as a less low invasive technique to be incorporated into the diagnostic algorithm of patients with suspected CBD stones, in order to confirm the pathological condition before proceeding with therapeutic ERCP, when indicated[31]. Scheiman et al[32], in a prospective study and cost analysis performed on a cohort of patients referred to ERCP, defined EUS the preferred initial diagnostic test, compared with MRCP, for the evaluation of biliary system and identification of extrahepatic disease.