Role of endoscopic ultrasonography in patients with intermediate probability of choledocholithiasis but a negative CT scan

BACKGROUND/GOALS:: Despite the increased role of endoscopic ultrasonography (EUS) in diagnosis, few studies have evaluated its impact on the management of choledocholithiasis in a clinical setting for patients for whom computed tomography (CT) was conducted initially. Our aim in this study was to evaluate the role of EUS in patients with a diagnosis of intermediate probability of choledocholithiasis with a negative CT scan result. STUDY:: A total of 98 patients who were diagnosed with symptomatic cholelithiasis with intermediate probability of choledocholithiasis were evaluated prospectively. Twenty-six of the 98 patients (26.5%) were diagnosed with choledocholithiasis by CT scans. The remaining 72 patients underwent EUS. RESULTS:: Twenty-five of the 72 patients were shown to have choledocholithiasis (n=20/72, 27.8%) or papillitis with biliary outflow obstruction (n=5/72, 6.9%) on EUS. These 25 patients with positive EUS findings underwent endoscopic sphincterotomy, and choledocholithiasis was endoscopically confirmed in 23 of the 25 patients (92.0%). Postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis occurred in 3 patients (12.0% of the 25 patients who received ERCP, 4.2% of all 72 patients). Forty-seven patients with no evidence of choledocholithiasis on EUS were followed-up for a median period of 340 days (range, 185 to 755 d), and no recurrent biliary events occurred in these patients during this period. The sensitivity and specificity of EUS for choledocholithiasis was 87.0% and 100%, respectively. CONCLUSIONS:: An EUS-first strategy in patients with intermediate probability of choledocholithiasis but a negative CT scan is very useful and can reduce the need to perform invasive ERCP.