Clinical Impact of the Endoscopic Ultrasound in Patients with Intermediate Probability of Choledocholithiasis: Prospective and Comparative Study of 2 Treatment Strategies

Introduction: Due to the complications with ERCP (5-10%), its indication in patients with intermediate pre-test of choledocholithiasis (CL) should be backed up by less invasive and more sensitive methods such as the EUS. In several published studies, the EUS showed to be very effective at avoiding the performance of ERCP (30-73.3%) in patients with intermediate risk of CL. This is the first study made in Argentina that assesses the clinical impact that the EUS has as a “filtering” method to avoid unnecessary ERCPs. Objective: to determine the clinical impact of the EUS in the treatment of patients with intermediate probability of CL and the amount of ERCPs that could be avoided. Methods: Prospective study of patients with intermediate risk of CL (according to the ASGE criteria) in which two strategies are compared: a) Group with EUS: EUS was performed as a filter. ERCP was performed immediately in the cases in which CL is detected, while in the negative cases there was a clinical control; b) Group without EUS: ERCP was performed directly. The group was selected according to the availability of the physician performing the study. We consecutively included patients derived to our hospital to perform ERCP with suspicion of CL from January 2016 to April 2017. Results: 44 patients were included in the EUS group (average age: 37, 37 females) and 27 in the group without EUS (average age: 38, 21 females). In the first group, the results were negative for CL in 29 cases (66%); CL was detected in 15 patients (34%) to whom we performed ERCP and confirmed the diagnosis in 12 of them (80%). There was only one complication: post-ERCP low-grade pancreatitis. In the second group, the one without EUS, the ERCP was normal in 15 patients (56%), we found presence of CL in 10 cases (37%), biliary stenosis in 1 patient (3.7%) and cannulation failure in 1 case (self-limited hemorrhage after the infundibulotomy). There was one case of post-ERCP moderate pancreatitis. Conclusion: The EUS has shown to be very useful as a “filtering” method in the diagnostic algorithm of patients with intermediate risk of CL. In the EUS group, ERCP could be avoided in 2/3 of the patients, reducing the number of normal ERCPs and the risk of complications. We recommend the indication of EUS in the group of patients with intermediate suspicion of CL as previous instance for the performance of the ERCP.