Академический Документы
Профессиональный Документы
Культура Документы
Obstructive Jaundice
One of the most common problem Serious condition
Thorough evaluation
Treatment strategy depends on the specific etiology
ERCP has been considered gold standard for diagnosis and therapy of obstructive jaundice. Invasive procedure
Complication in 5% of patients Mortality rate in 0.1- 0.2% Endoscopic sphinectrotoiy = 0.2- 2.2%.
Limitations:
Visualization of indirect signs It is difficult to differentiate small stones from aerobilia.
MRCP
EUS
An accurate diagnostic tool associated with lower morbidity and mortality rates was awaited, to replace ERCP and to reserve endoscopic sphinectrotoiy for patients with CBD stones.
EUS had provide as a gold standard in the exploration of extrahepatic obstruction due to it is low morbidity and it is accuracy.
Why EUS?
The close a proximity between the probe and the pancreato-biliary region. Visualization of these hidden organs and pathology
High resolution.
Low risk
2- 3%
Intermediate risk
8-10 mm
High risk
87 Patients Risk of Choledocholithiasis: Low : 33 Intermediate : 20 High : 34 Clinical features, laboratory tests, CBD diameter on US EUS prior to ERCP
EUS Findings
Normal
CBD Stone
54(62%)
31(35%)
Cholengiocarcinoma
CBD Stone + Cholengiocarcinoma CBD Stone +
Ampullary tumor
2(2.2%)
2(2.2%) 1(1.1%)
Stenting
Stenting + Surgery Stenting + Surgery
Treatment strategy were altered in 5 (6%) patients (either associated pathology or different diagnosis)
57 years old Cholestatic jaundice Abdominal US : Merrizy syndrome? ERCP : CBD stone + hilar stricture
45 years male Obstructive Jaundice US: Dilated CBD ERCP: Distal CBD Stricture?
60 years male Jaundice + Itching US: Dilated CBD ERCP: Mid CBD stone?
Oditis:
Hyperechoic enlargement of ampulla No intraductal polypoid infiltration Duodenal wall preserved
Keriven et al;Endoscopy 1993
70 years female Cholestatic jaundice US: Dilated CBD + stone ERCP: CBD stone
Accuracy 65% 95 % 81 % 88 % 83 %
Stone
EUS Associated pathology
Tumor
EUS Staging
Unclear
EUS Confirming diagnosis
Definitive or Palliative
Detection of microlithiasis and choledocholithiasis. Detection and staging of pancreatic and ampullary tumors. Evaluation of benign and malignant bile duct obstruction. Obtain tissue diagnosis of periampullary tumors.
Is it cost effective?
Extra cost of EUS, performed as the first
investigation, is out weighted by the lower morbidity rate and shorter hospitalization because of minor number of unnecessary ERCP and/or sphincterotomy.
Conclusion
EUS is necessary prior to ERCP in the evaluation of obstructive jaundice. Every endoscopist should be familiar with EUS EUS and ERCP in the same session.