Original Article
Initial experience of direct-to-test endoscopic ultrasonography for suspected choledocholithiasis
Scottish Medical Journal 2015, Vol. 60(2) 85–89 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933015572276 scm.sagepub.com
Paul Lochhead1 and Perminder Phull2
Abstract Background and aims: Endoscopic ultrasound has become an invaluable tool in the investigation of patients with suspected pancreatobiliary disease. We set out to determine whether a ‘‘direct-to-test’’ endoscopic ultrasound procedure could be offered to selected patients with suspected choledocholithiasis. Methods and results: We included patients referred to our general gastroenterology service with clinical history, symptomatology and/or laboratory results compatible with choledocholithiais. Almost all patients had already had a transabdominal ultrasound performed at the request of their general practitioner. All patients underwent direct-to-test day-case endoscopic ultrasound under conscious sedation. Procedures were performed by a single practitioner using an oblique-viewing radial echoendoscope. The diagnostic yield and frequencies of discharge, onward referral and follow-up were determined. Overall diagnostic yield of direct-to-test endoscopic ultrasound was 61%. The most common diagnoses were cholelithiasis (18%) and choledocholithiasis (11%); one periampullary cancer was also detected. A definitive outcome (discharge or referral for a therapeutic procedure) occurred in 14 of 28 patients (50%). The remaining 14 patients underwent further out-patient evaluation. Eventual diagnoses in this group included autoimmune hepatitis, primary biliary cirrhosis and drug-induced hepatitis. Conclusions: For patients with suspected biliary disease, direct-to-test endoscopic ultrasound has a high diagnostic yield, and may be an appropriate mode of investigation.
Keywords Endosonography, referral and consultation, gallbladder diseases, biliary tract
Introduction Endoscopic ultrasound (EUS) has become an invaluable investigation in the assessment of pancreatobiliary disease.1,2 EUS is superior to transabdominal ultrasound (TUS) in the detection of choledocholithiasis, possessing a high positive predictive value,3,4 comparable with that of magnetic resonance cholangiopancreatography (MRCP).5 Compared to TUS, EUS affords superior visualisation of the pancreas permitting the detection of early neoplastic lesions.6–8 EUS is also a sensitive imaging modality for ampullary lesions.9,10 Unlike MRCP, computed tomography (CT), TUS and EUS with modern echoendoscopes offer the added advantage of direct visualisation of the upper gastrointestinal (GI) mucosa.
In our institution (as, we suspect, is the case in most other centres), patients usually undergo EUS only after specialist evaluation, ordinarily in the out-patient clinic. Open access and direct-to-test endoscopy services have become commonplace in the United Kingdom, and elsewhere,11–15 particularly with the implementation of referral pathways for suspected GI 1
Clinical Lecturer, Gastrointestinal Research Group, Institute of Medical Sciences, University of Aberdeen, UK; Gastrointestinal and Liver Service, Aberdeen Royal Infirmary, UK 2 Consultant Gastroenterologist, Gastrointestinal and Liver Service, Aberdeen Royal Infirmary, UK Corresponding author: Perminder S Phull, Consultant Gastroenterologist, Gastrointestinal and Liver Service, Room 2.58, Ashgrove House, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK. Email: [email protected]
Downloaded from scm.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 17, 2015
86
Scottish Medical Journal 60(2)
malignancy.16 Experience from direct and open access endoscopy services suggest that these services are efficient and offer a high degree of patient satisfaction.11,13,14,16 Endoscopic ultrasonography is safe, constituting minimal additional risk beyond that associated with standard upper GI endoscopy,17 and is acceptable and well tolerated by patients.18,19 We are not aware, however, of any reports of direct-to-test EUS for patients with suspected choledocholithiasis, who have been referred by a primary care physician. We hypothesised that, in selected patients with suspected biliary pathology, direct-to-test EUS would be a valuable first-line investigation, would be safe, and would avoid specialist clinic review and the attendant delay, expense and patient inconvenience. Here, we present our initial data on direct-to-test EUS in a teaching hospital setting.
Methods and patient characteristics Twenty-eight patients, who had been referred for gastroenterology clinic evaluation at our institution between February 2005 and October 2010, were instead selected to be offered direct-to-test EUS. All referrals came from general practitioners (GPs), not from other hospital specialties. The referrals were reviewed by a single gastroenterologist, who also performed all subsequent direct-totest EUS procedures. Patients were selected on the basis of clinical history, symptomatology, and/or liver chemistry compatible with biliary pathology. For all but one patient, a TUS had already been performed at the request of the referring GP.
A standard EUS patient information leaflet accompanied the appointment letter for the procedure, which was sent by mail. All patients provided written informed consent and underwent day-case EUS under conscious sedation using an oblique-viewing radial echoendoscope (GFUM2000; Olympus KeyMed, Southend-on-Sea, UK). The median patient age was 52 years (range 21–83); 18 out of 28 patients were female (64%). In all cases, the indication for EUS was exclusion of choledocholithiasis. The clinical details available at the time of referral were: biliary-type pain with abnormal liver chemistry but no duct dilatation on TUS (n ¼ 14); abnormal liver chemistry with duct dilatation but no stones identified on TUS (n ¼ 5); biliary-type pain, normal liver chemistry and duct dilatation but no stones on TUS (n ¼ 3); isolated biliary-type pain (n ¼ 3); progressive cholestatic liver chemistry postcholecystectomy with no duct dilatation on ultrasound (n ¼ 2); unexplained recent pancreatitis with a normal TUS (n ¼ 1). Eight out of 28 patients (29%) had a history of previous cholecystectomy.
Results All patients accepted the direct-to-test EUS appointment, and a complete examination was possible in all cases. Seventeen (61%) of patients had abnormal EUS findings (Figure 1). The EUS findings were: choledocholithiasis (n ¼ 3); cholelithiasis (n ¼ 5); hepatic steatosis (n ¼ 2); hilar or coeliac lymphadenopathy (n ¼ 2); periampullary tumour (n ¼ 1). In addition, gastritis and/or duodenitis were noted on endoscopic examination in four (14%) patients with normal endoultrasonographic examinations.
Cholelithiasis 5 (18% ) Choledocholithiasis 3 (11% )
Normal 11 (39% )
Hepatic steatosis 2 (7% ) Gastroduodenitis 4 (14% )
Lymphadenopathy 2 Periampullary tumour (7% ) 1 (4% )
Figure 1. EUS findings in direct-to-test patients with suspected choledocholithiasis (n ¼ 28).
Downloaded from scm.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 17, 2015
Lochhead and Phull
87
Eleven patients (39%) had normal endoscopic and endoultrasonographic examinations. Three of the five cases of cholelithiasis had not been detected by TUS. Similarly, neither of the two cases of hepatic steatosis had been reported by TUS. The overall yield for novel pathology (i.e. findings not apparent from TUS) was therefore 54%. There were no noted complications in any of the 28 cases. On the basis of the EUS examination, seven patients were discharged directly back to the referring GP, three patients were referred for ERCP, three for cholecystectomy and one for surgical resection of a periampullary tumour (Figure 2). This equates to 14 of 28 (50%) patients being discharged or referred for a therapeutic procedure on the basis of the direct-to-test EUS findings. In the remaining 14 cases (50%), where EUS did not lead to discharge or definitive treatment, further out-patient investigation or follow up was arranged. Eventual diagnoses in this group included autoimmune hepatitis, primary biliary cirrhosis, drug-induced hepatitis, sphincter of Oddi dysfunction and non-ulcer dyspepsia.
Of the two cases of lymphadenopathy detected at EUS, one case of hepatic hilar lymphadenopathy was associated with PBC whilst the coeliac lymphadenopathy (which was borderline by size criteria) had resolved on follow-up EUS. Of the four patients with mucosal pathology identified on endoscopic examination, three were followed up at clinic and all reported an improvement in pain in response to treatment with a proton-pump inhibitor.
Discussion Our initial findings support the hypothesis that directto-test EUS for selected patients with suspected biliary disease is a safe investigation, with a high yield for significant pathology. For a large proportion of patients (50%), the EUS examination led to a definitive outcome without additional investigations or intervening clinic review. Mucosal pathology, that may have accounted for the pain reported at presentation, was identified in 14% of cases by endoscopic examination, and may help justify the choice of EUS as the mode
Direct-to-test EUS patients (n=28)
Normal examination (n=11)
Gastritis +/duodenitis (n=4)
Periampullary tumour (n=1)
Cholelithiasis (n=5)
Lymphadenopathy (n=2)
Hepatic steatosis (n=2)
Choledocholithiasis (n=3)
n=6 n=1 Discharged to primary care physician (n=7)
Whipple’s procedure (n=1)
Cholecystectomy (n=3)
n=2 n=3 n=5
Out patient follow-up (n=14)
Additional diagnoses included: • Autoimmune hepatitis • Primary biliary cirrhosis • Drug-induced hepatitis • Sphincter of Oddi dysfunction •Non-ulcer dyspepsia
Figure 2. Outcomes of patients who underwent direct-to-test EUS for suspected choledocholithiasis.
Downloaded from scm.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 17, 2015
ERCP (n=3)
88
Scottish Medical Journal 60(2)
investigation in this patient group over, for example, MRCP. Limitations of our study include the limited number of cases, and the lack of cost analysis with reference to the standard pathway, comprising initial review in the clinic or direct-to-test upper GI endoscopy. Considering that the majority of pathology was detected on the basis of the ultrasonic examination, however, one would anticipate that, following clinic review and/or upper GI endoscopy, a definitive diagnosis would only have been reached in many of these patients by additional imaging investigations. A further caveat is that consideration for direct-to-test EUS was selective, having been at the discretion of a single clinician. Our cohort contained a high proportion of individuals who had already demonstrated their predisposition to biliary disease, as evidenced by the significant number of cases with a history of cholecystectomy. This may account for the relatively high frequency (11%) of choledocholithiasis. Owing to these potential sources of selection bias, we do not know whether our findings are generalisable to a department-wide service, where all gastroenterologists within an institution could select cases for direct-totest EUS from primary care referrals. Our findings do, however, compare favourably with the diagnostic yield for EUS as the initial investigation for upper abdominal pain.20 In a series of 172 patients with upper abdominal pain, Chang et al.20 reported that, in cases where the aetiology of pain was eventually established (38%), the diagnostic rate of EUS was 62%, and equivalent to parallel upper GI endoscopy and TUS. As with our study, no cost effectiveness analysis was performed. Similarly, in a randomized study of 240 patients with upper or right-sided abdominal pain, initial EUS appeared to be a valuable diagnostic modality compared to standard endoscopy combined with TUS.21 These two studies, with less exclusive selection criteria than our own, suggest that EUS has a yield sufficient to justify its use a first-line investigation (ahead of TUS) for upper abdominal pain. Given that a proportion of patients in our study went on to have eventual diagnoses of hepatic parenchymal disease (e.g. autoimmune hepatitis), it would be reasonable, in patients with abnormal liver chemistry being considered for direct-to-test EUS, that a liver disease screen first be performed in primary care, in an attempt to exclude other potential aetiologies. In conclusion, our experience suggests that direct-totest EUS may have a role in the initial assessment of patients with suspected biliary pathology. By avoiding an initial out-patient clinic appointment, this approach has the potential to provide a faster patient journey to a definitive diagnostic test. The generalisability of our findings and cost-effectiveness of the direct-to-test approach merit further study.
Declaration of conflicting interests The authors declare that there are no conflicts of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Varadarajulu S and Eloubeidi MA. The role of endoscopic ultrasonography in the evaluation of pancreatico-biliary cancer. Surg Clin North Am 2010; 90: 251–263. 2. Shetty D, Bhatnagar G, Sidhu HS, et al. The increasing role of endoscopic ultrasound (EUS) in the management of pancreatic and biliary disease. Clin Radiol 2013; 68: 323–335. 3. Mirbagheri SA, Mohamadnejad M, Nasiri J, et al. Prospective evaluation of endoscopic ultrasonography in the diagnosis of biliary microlithiasis in patients with normal transabdominal ultrasonography. J Gastrointest Surg 2005; 9: 961–964. 4. Aljebreen A, Azzam N and Eloubeidi MA. Prospective study of endoscopic ultrasound performance in suspected choledocholithiasis. J Gastroenterol Hepatol 2008; 23: 741–745. 5. Verma D, Kapadia A, Eisen GM, et al. EUS vs MRCP for detection of choledocholithiasis. Gastrointest Endosc 2006; 64: 248–254. 6. Helmstaedter L and Riemann JF. Pancreatic cancer—EUS and early diagnosis. Langenbecks Arch Surg 2008; 393: 923–927. 7. Yasuda I, Iwashita T, Doi S, et al. Role of EUS in the early detection of small pancreatic cancer. Dig Endosc 2011; 23(Suppl 1): 22–25. 8. Munroe CA, Fehmi SM and Savides TJ. Endoscopic ultrasound in the diagnosis of pancreatic cancer. Expert Opin Med Diagn 2013; 7: 25–35. 9. Castillo C. Endoscopic ultrasound in the papilla and the periampullary region. World J Gastrointest Endosc 2010; 2: 278–287. 10. Azih LC, Broussard BL, Phadnis MA, et al. Endoscopic ultrasound evaluation in the surgical treatment of duodenal and peri-ampullary adenomas. World J Gastroenterol 2013; 19: 511–515. 11. Cann PA, Corbett WA, Bramble MG, et al. Open access gastroscopy. Service is efficient and effective. BMJ 1993; 306: 1750. 12. Marshall JB. Open access endoscopy in Britain: a service in evolution. Gastrointest Endosc 1998; 48: 653–658. 13. Charles RJ, Cooper GS, Wong RC, et al. Effectiveness of open-access endoscopy in routine primary-care practice. Gastrointest Endosc 2003; 57: 183–186. 14. Delaney BC, Wilson S, Roalfe A, et al. Cost effectiveness of initial endoscopy for dyspepsia in patients over age 50 years: a randomised controlled trial in primary care. Lancet 2000; 356: 1965–1969.
Downloaded from scm.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 17, 2015
Lochhead and Phull
89
15. Keren D, Rainis T, Stermer E, et al. A nine-year audit of open-access upper gastrointestinal endoscopic procedures: results and experience of a single centre. Can J Gastroenterol 2011; 25: 83–88. 16. Maruthachalam K, Stoker E, Chaudhri S, et al. Evolution of the two-week rule pathway—direct access colonoscopy vs outpatient appointments: one year’s experience and patient satisfaction survey. Colorectal Dis 2005; 7: 480–485. 17. Eloubeidi MA, Tamhane A, Lopes TL, et al. Cervical esophageal perforations at the time of endoscopic ultrasound: a prospective evaluation of frequency, outcomes, and patient management. Am J Gastroenterol 2009; 104: 53–56. 18. Allescher HD, Rosch T, Willkomm G, et al. Performance, patient acceptance, appropriateness of
indications and potential influence on outcome of EUS: a prospective study in 397 consecutive patients. Gastrointest Endosc 1999; 50: 737–745. 19. Mortensen MB, Fristrup C, Holm FS, et al. Prospective evaluation of patient tolerability, satisfaction with patient information, and complications in endoscopic ultrasonography. Endoscopy 2005; 37: 146–153. 20. Chang KJ, Erickson RA, Chak A, et al. EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain. Gastrointest Endosc 2010; 72: 967–974. 21. Jung A, Schlag C, Becker V, et al. Endosonography for right-sided and acute upper intestinal misery: the EFRAIM study: a prospective, randomized, controlled, blinded study. United European Gastroenterol J 2013; 1: 329–334.
Downloaded from scm.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 17, 2015
Initial experience of direct-to-test endoscopic ultrasonography for suspected choledocholithiasis
Scottish Medical Journal 2015, Vol. 60(2) 85–89 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933015572276 scm.sagepub.com
Paul Lochhead1 and Perminder Phull2
Abstract Background and aims: Endoscopic ultrasound has become an invaluable tool in the investigation of patients with suspected pancreatobiliary disease. We set out to determine whether a ‘‘direct-to-test’’ endoscopic ultrasound procedure could be offered to selected patients with suspected choledocholithiasis. Methods and results: We included patients referred to our general gastroenterology service with clinical history, symptomatology and/or laboratory results compatible with choledocholithiais. Almost all patients had already had a transabdominal ultrasound performed at the request of their general practitioner. All patients underwent direct-to-test day-case endoscopic ultrasound under conscious sedation. Procedures were performed by a single practitioner using an oblique-viewing radial echoendoscope. The diagnostic yield and frequencies of discharge, onward referral and follow-up were determined. Overall diagnostic yield of direct-to-test endoscopic ultrasound was 61%. The most common diagnoses were cholelithiasis (18%) and choledocholithiasis (11%); one periampullary cancer was also detected. A definitive outcome (discharge or referral for a therapeutic procedure) occurred in 14 of 28 patients (50%). The remaining 14 patients underwent further out-patient evaluation. Eventual diagnoses in this group included autoimmune hepatitis, primary biliary cirrhosis and drug-induced hepatitis. Conclusions: For patients with suspected biliary disease, direct-to-test endoscopic ultrasound has a high diagnostic yield, and may be an appropriate mode of investigation.
Keywords Endosonography, referral and consultation, gallbladder diseases, biliary tract
Introduction Endoscopic ultrasound (EUS) has become an invaluable investigation in the assessment of pancreatobiliary disease.1,2 EUS is superior to transabdominal ultrasound (TUS) in the detection of choledocholithiasis, possessing a high positive predictive value,3,4 comparable with that of magnetic resonance cholangiopancreatography (MRCP).5 Compared to TUS, EUS affords superior visualisation of the pancreas permitting the detection of early neoplastic lesions.6–8 EUS is also a sensitive imaging modality for ampullary lesions.9,10 Unlike MRCP, computed tomography (CT), TUS and EUS with modern echoendoscopes offer the added advantage of direct visualisation of the upper gastrointestinal (GI) mucosa.
In our institution (as, we suspect, is the case in most other centres), patients usually undergo EUS only after specialist evaluation, ordinarily in the out-patient clinic. Open access and direct-to-test endoscopy services have become commonplace in the United Kingdom, and elsewhere,11–15 particularly with the implementation of referral pathways for suspected GI 1
Clinical Lecturer, Gastrointestinal Research Group, Institute of Medical Sciences, University of Aberdeen, UK; Gastrointestinal and Liver Service, Aberdeen Royal Infirmary, UK 2 Consultant Gastroenterologist, Gastrointestinal and Liver Service, Aberdeen Royal Infirmary, UK Corresponding author: Perminder S Phull, Consultant Gastroenterologist, Gastrointestinal and Liver Service, Room 2.58, Ashgrove House, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK. Email: [email protected]
Downloaded from scm.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 17, 2015
86
Scottish Medical Journal 60(2)
malignancy.16 Experience from direct and open access endoscopy services suggest that these services are efficient and offer a high degree of patient satisfaction.11,13,14,16 Endoscopic ultrasonography is safe, constituting minimal additional risk beyond that associated with standard upper GI endoscopy,17 and is acceptable and well tolerated by patients.18,19 We are not aware, however, of any reports of direct-to-test EUS for patients with suspected choledocholithiasis, who have been referred by a primary care physician. We hypothesised that, in selected patients with suspected biliary pathology, direct-to-test EUS would be a valuable first-line investigation, would be safe, and would avoid specialist clinic review and the attendant delay, expense and patient inconvenience. Here, we present our initial data on direct-to-test EUS in a teaching hospital setting.
Methods and patient characteristics Twenty-eight patients, who had been referred for gastroenterology clinic evaluation at our institution between February 2005 and October 2010, were instead selected to be offered direct-to-test EUS. All referrals came from general practitioners (GPs), not from other hospital specialties. The referrals were reviewed by a single gastroenterologist, who also performed all subsequent direct-totest EUS procedures. Patients were selected on the basis of clinical history, symptomatology, and/or liver chemistry compatible with biliary pathology. For all but one patient, a TUS had already been performed at the request of the referring GP.
A standard EUS patient information leaflet accompanied the appointment letter for the procedure, which was sent by mail. All patients provided written informed consent and underwent day-case EUS under conscious sedation using an oblique-viewing radial echoendoscope (GFUM2000; Olympus KeyMed, Southend-on-Sea, UK). The median patient age was 52 years (range 21–83); 18 out of 28 patients were female (64%). In all cases, the indication for EUS was exclusion of choledocholithiasis. The clinical details available at the time of referral were: biliary-type pain with abnormal liver chemistry but no duct dilatation on TUS (n ¼ 14); abnormal liver chemistry with duct dilatation but no stones identified on TUS (n ¼ 5); biliary-type pain, normal liver chemistry and duct dilatation but no stones on TUS (n ¼ 3); isolated biliary-type pain (n ¼ 3); progressive cholestatic liver chemistry postcholecystectomy with no duct dilatation on ultrasound (n ¼ 2); unexplained recent pancreatitis with a normal TUS (n ¼ 1). Eight out of 28 patients (29%) had a history of previous cholecystectomy.
Results All patients accepted the direct-to-test EUS appointment, and a complete examination was possible in all cases. Seventeen (61%) of patients had abnormal EUS findings (Figure 1). The EUS findings were: choledocholithiasis (n ¼ 3); cholelithiasis (n ¼ 5); hepatic steatosis (n ¼ 2); hilar or coeliac lymphadenopathy (n ¼ 2); periampullary tumour (n ¼ 1). In addition, gastritis and/or duodenitis were noted on endoscopic examination in four (14%) patients with normal endoultrasonographic examinations.
Cholelithiasis 5 (18% ) Choledocholithiasis 3 (11% )
Normal 11 (39% )
Hepatic steatosis 2 (7% ) Gastroduodenitis 4 (14% )
Lymphadenopathy 2 Periampullary tumour (7% ) 1 (4% )
Figure 1. EUS findings in direct-to-test patients with suspected choledocholithiasis (n ¼ 28).
Downloaded from scm.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 17, 2015
Lochhead and Phull
87
Eleven patients (39%) had normal endoscopic and endoultrasonographic examinations. Three of the five cases of cholelithiasis had not been detected by TUS. Similarly, neither of the two cases of hepatic steatosis had been reported by TUS. The overall yield for novel pathology (i.e. findings not apparent from TUS) was therefore 54%. There were no noted complications in any of the 28 cases. On the basis of the EUS examination, seven patients were discharged directly back to the referring GP, three patients were referred for ERCP, three for cholecystectomy and one for surgical resection of a periampullary tumour (Figure 2). This equates to 14 of 28 (50%) patients being discharged or referred for a therapeutic procedure on the basis of the direct-to-test EUS findings. In the remaining 14 cases (50%), where EUS did not lead to discharge or definitive treatment, further out-patient investigation or follow up was arranged. Eventual diagnoses in this group included autoimmune hepatitis, primary biliary cirrhosis, drug-induced hepatitis, sphincter of Oddi dysfunction and non-ulcer dyspepsia.
Of the two cases of lymphadenopathy detected at EUS, one case of hepatic hilar lymphadenopathy was associated with PBC whilst the coeliac lymphadenopathy (which was borderline by size criteria) had resolved on follow-up EUS. Of the four patients with mucosal pathology identified on endoscopic examination, three were followed up at clinic and all reported an improvement in pain in response to treatment with a proton-pump inhibitor.
Discussion Our initial findings support the hypothesis that directto-test EUS for selected patients with suspected biliary disease is a safe investigation, with a high yield for significant pathology. For a large proportion of patients (50%), the EUS examination led to a definitive outcome without additional investigations or intervening clinic review. Mucosal pathology, that may have accounted for the pain reported at presentation, was identified in 14% of cases by endoscopic examination, and may help justify the choice of EUS as the mode
Direct-to-test EUS patients (n=28)
Normal examination (n=11)
Gastritis +/duodenitis (n=4)
Periampullary tumour (n=1)
Cholelithiasis (n=5)
Lymphadenopathy (n=2)
Hepatic steatosis (n=2)
Choledocholithiasis (n=3)
n=6 n=1 Discharged to primary care physician (n=7)
Whipple’s procedure (n=1)
Cholecystectomy (n=3)
n=2 n=3 n=5
Out patient follow-up (n=14)
Additional diagnoses included: • Autoimmune hepatitis • Primary biliary cirrhosis • Drug-induced hepatitis • Sphincter of Oddi dysfunction •Non-ulcer dyspepsia
Figure 2. Outcomes of patients who underwent direct-to-test EUS for suspected choledocholithiasis.
Downloaded from scm.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 17, 2015
ERCP (n=3)
88
Scottish Medical Journal 60(2)
investigation in this patient group over, for example, MRCP. Limitations of our study include the limited number of cases, and the lack of cost analysis with reference to the standard pathway, comprising initial review in the clinic or direct-to-test upper GI endoscopy. Considering that the majority of pathology was detected on the basis of the ultrasonic examination, however, one would anticipate that, following clinic review and/or upper GI endoscopy, a definitive diagnosis would only have been reached in many of these patients by additional imaging investigations. A further caveat is that consideration for direct-to-test EUS was selective, having been at the discretion of a single clinician. Our cohort contained a high proportion of individuals who had already demonstrated their predisposition to biliary disease, as evidenced by the significant number of cases with a history of cholecystectomy. This may account for the relatively high frequency (11%) of choledocholithiasis. Owing to these potential sources of selection bias, we do not know whether our findings are generalisable to a department-wide service, where all gastroenterologists within an institution could select cases for direct-totest EUS from primary care referrals. Our findings do, however, compare favourably with the diagnostic yield for EUS as the initial investigation for upper abdominal pain.20 In a series of 172 patients with upper abdominal pain, Chang et al.20 reported that, in cases where the aetiology of pain was eventually established (38%), the diagnostic rate of EUS was 62%, and equivalent to parallel upper GI endoscopy and TUS. As with our study, no cost effectiveness analysis was performed. Similarly, in a randomized study of 240 patients with upper or right-sided abdominal pain, initial EUS appeared to be a valuable diagnostic modality compared to standard endoscopy combined with TUS.21 These two studies, with less exclusive selection criteria than our own, suggest that EUS has a yield sufficient to justify its use a first-line investigation (ahead of TUS) for upper abdominal pain. Given that a proportion of patients in our study went on to have eventual diagnoses of hepatic parenchymal disease (e.g. autoimmune hepatitis), it would be reasonable, in patients with abnormal liver chemistry being considered for direct-to-test EUS, that a liver disease screen first be performed in primary care, in an attempt to exclude other potential aetiologies. In conclusion, our experience suggests that direct-totest EUS may have a role in the initial assessment of patients with suspected biliary pathology. By avoiding an initial out-patient clinic appointment, this approach has the potential to provide a faster patient journey to a definitive diagnostic test. The generalisability of our findings and cost-effectiveness of the direct-to-test approach merit further study.
Declaration of conflicting interests The authors declare that there are no conflicts of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Varadarajulu S and Eloubeidi MA. The role of endoscopic ultrasonography in the evaluation of pancreatico-biliary cancer. Surg Clin North Am 2010; 90: 251–263. 2. Shetty D, Bhatnagar G, Sidhu HS, et al. The increasing role of endoscopic ultrasound (EUS) in the management of pancreatic and biliary disease. Clin Radiol 2013; 68: 323–335. 3. Mirbagheri SA, Mohamadnejad M, Nasiri J, et al. Prospective evaluation of endoscopic ultrasonography in the diagnosis of biliary microlithiasis in patients with normal transabdominal ultrasonography. J Gastrointest Surg 2005; 9: 961–964. 4. Aljebreen A, Azzam N and Eloubeidi MA. Prospective study of endoscopic ultrasound performance in suspected choledocholithiasis. J Gastroenterol Hepatol 2008; 23: 741–745. 5. Verma D, Kapadia A, Eisen GM, et al. EUS vs MRCP for detection of choledocholithiasis. Gastrointest Endosc 2006; 64: 248–254. 6. Helmstaedter L and Riemann JF. Pancreatic cancer—EUS and early diagnosis. Langenbecks Arch Surg 2008; 393: 923–927. 7. Yasuda I, Iwashita T, Doi S, et al. Role of EUS in the early detection of small pancreatic cancer. Dig Endosc 2011; 23(Suppl 1): 22–25. 8. Munroe CA, Fehmi SM and Savides TJ. Endoscopic ultrasound in the diagnosis of pancreatic cancer. Expert Opin Med Diagn 2013; 7: 25–35. 9. Castillo C. Endoscopic ultrasound in the papilla and the periampullary region. World J Gastrointest Endosc 2010; 2: 278–287. 10. Azih LC, Broussard BL, Phadnis MA, et al. Endoscopic ultrasound evaluation in the surgical treatment of duodenal and peri-ampullary adenomas. World J Gastroenterol 2013; 19: 511–515. 11. Cann PA, Corbett WA, Bramble MG, et al. Open access gastroscopy. Service is efficient and effective. BMJ 1993; 306: 1750. 12. Marshall JB. Open access endoscopy in Britain: a service in evolution. Gastrointest Endosc 1998; 48: 653–658. 13. Charles RJ, Cooper GS, Wong RC, et al. Effectiveness of open-access endoscopy in routine primary-care practice. Gastrointest Endosc 2003; 57: 183–186. 14. Delaney BC, Wilson S, Roalfe A, et al. Cost effectiveness of initial endoscopy for dyspepsia in patients over age 50 years: a randomised controlled trial in primary care. Lancet 2000; 356: 1965–1969.
Downloaded from scm.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 17, 2015
Lochhead and Phull
89
15. Keren D, Rainis T, Stermer E, et al. A nine-year audit of open-access upper gastrointestinal endoscopic procedures: results and experience of a single centre. Can J Gastroenterol 2011; 25: 83–88. 16. Maruthachalam K, Stoker E, Chaudhri S, et al. Evolution of the two-week rule pathway—direct access colonoscopy vs outpatient appointments: one year’s experience and patient satisfaction survey. Colorectal Dis 2005; 7: 480–485. 17. Eloubeidi MA, Tamhane A, Lopes TL, et al. Cervical esophageal perforations at the time of endoscopic ultrasound: a prospective evaluation of frequency, outcomes, and patient management. Am J Gastroenterol 2009; 104: 53–56. 18. Allescher HD, Rosch T, Willkomm G, et al. Performance, patient acceptance, appropriateness of
indications and potential influence on outcome of EUS: a prospective study in 397 consecutive patients. Gastrointest Endosc 1999; 50: 737–745. 19. Mortensen MB, Fristrup C, Holm FS, et al. Prospective evaluation of patient tolerability, satisfaction with patient information, and complications in endoscopic ultrasonography. Endoscopy 2005; 37: 146–153. 20. Chang KJ, Erickson RA, Chak A, et al. EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain. Gastrointest Endosc 2010; 72: 967–974. 21. Jung A, Schlag C, Becker V, et al. Endosonography for right-sided and acute upper intestinal misery: the EFRAIM study: a prospective, randomized, controlled, blinded study. United European Gastroenterol J 2013; 1: 329–334.
Downloaded from scm.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 17, 2015
