Transcript Dia 1 - stichting BG

13 & 14 December 2010, Fourth Annual Course
Hotel Okura Amsterdam, the Netherlands
Baltahasar Geeraerts Symposium 2010
What is the role of
EUS in cholelithiasis?
Paul Fockens, MD PhD
Professor of Gastrointestinal Endoscopy,
Academic Medical Center, University of Amsterdam
EUS in cholelithiasis
• History
• Instruments
• EUS for cholecystolithiasis
• EUS for choledocholithiasis
• Conclusions and future of EUS in gallstones
History of EUS in clinical practice
• Started as a technique to image organs outside
GI-tract (US, start of ERCP, no CT, no MR)
• Staging of luminal tumors quickly followed
(esophagus, stomach, colorectum)
• Next major breakthrough: EUS-guided FNA
• 2009: non-invasive staging by excellent CT & MR
• 2010+: EUS for early diagnosis and guided Rx
EUS in cholelithiasis
• History
• Instruments
• EUS for cholecystolithiasis
• EUS for choledocholithiasis
• Conclusions and future of EUS in gallstones
Instruments & Accesories
High-end US processors (Aloka, Hitachi. ...)
• Elastography
• Tissue Harmonic Imaging
• Contrast Enhanced EUS
• .......
Instruments & Accesories
• 360° Radial array
vs. Linear array
EUS in choledocholithiasis
EUS in cholelithiasis
• History
• Instruments
• EUS for cholecystolithiasis
• EUS for choledocholithiasis
• Conclusions and future of EUS in gallstones
EUS in cholecystolithiasis
• Transabdominal US is standard for
galbladder stones
• EUS may be useful in case of:
– Multiple very small stones (sludge)
– Poor imaging because of obesity
• Indication for EUS in cholecystolithiasis
– Strong suspicion of gallbladder stones with
negative non-invasive imaging
EUS in cholecystolithiasis
• 35 pts with biliary type pain and negative US
• EUS showed suspicion of stones in 18pts (52%)
• 15/17 proven during surgery
• 13/15 symptomfree at one year FU
EUS in cholecystolithiasis
EUS in cholelithiasis
• History
• Instruments
• EUS for cholecystolithiasis
• EUS for choledocholithiasis
• Conclusions and future of EUS in gallstones
EUS in choledocholithiasis
• Imaging of CBD is not so difficult anymore
with excellent new equipment
• Experience is important (50-100/year)
• EUS only in low-probablility for CBD-stones?
• Should every ERCP for stones be preceded
by EUS?
• How about acute pancreatitis?
EUS in choledocholithiasis
EUS in choledocholithiasis
EUS in choledocholithiasis
• ERCP vs. EUS +/- ERCP
• 65pts with elevated LFT’s or dilated CBD (8 or
10mm)
• ERCP: 7/32 pts (22%) with CBD-stones
• EUS +/- ERCP: 9/33pts (27%) CBD-stones
• 1pt in each group recurrent symtoms
EUS in choledocholithiasis
• 4 trials selected (423pts)
• In EUS group, ERCP was avoided in 74%
• EUS significantly reduced risk of ERCP
associated complications
EUS in choledocholithiasis
risk of acute pancreatitis
EUS in cholelithiasis
• History
• Instruments
• EUS for cholecystolithiasis
• EUS for choledocholithiasis
• Conclusions and future of EUS in gallstones
Conclusions & future use
• EUS is most sensitive technique for CBDstones, more sensitive than MRCP
• EUS is invasive and requires expertise
• Restriction of ERCP to (very) experienced
seems imminent (raise req/yr from 40100)
• Combine EUS with ERCP in:
– Unexplained obstrcutive jaundice
– All pts referred for treatment of CBD-stones
13 & 14 December 2010, Fourth Annual Course
Hotel Okura Amsterdam, the Netherlands