ASGE Annual GI Advanced Practice Provider Course (On-Demand) - Onboarding (Day One) | March 2024-Radiology Studies Case 2 Common Bile Duct Stone

Pdf Summary

A 32-year-old woman presented with epigastric pain, nausea, and vomiting for a week, denying typical symptoms like fevers or diarrhea but showing abnormal liver enzyme levels. Abdominal ultrasound revealed cholelithiasis and dilated common bile duct (CBD), suggestive of choledocholithiasis. Different imaging modalities were discussed, highlighting ultrasound's limited sensitivity, CT's potential, and MRCP's benefits of no radiation or contrast. Endoscopic ultrasound (EUS) was recommended for intermediate-risk patients, showing high sensitivity for stones. EUS was compared favorably to MRCP in terms of sensitivity and cost-effectiveness, with the potential for avoiding the need for ERCP. Risk assessment for choledocholithiasis included factors like CBD dilation and liver test abnormalities. High-risk cases required ERCP, while intermediate-risk patients could undergo MRCP, EUS, or cholecystectomy with intraoperative cholangiography (IOC). Low-risk patients could proceed with cholecystectomy without further testing. ERCP was discussed as having high sensitivity but elevated complication risks, including pancreatitis and infection. EUS-directed ERCP was proposed for intermediate-to-high risk patients, showing potential in reducing unnecessary ERCP procedures. The 2019 ASGE guideline emphasized the importance of using total bilirubin levels and CBD dilation sizes as high-risk criteria. The document outlined the different management approaches based on risk levels and provided details on ERCP-related complications, highlighting the potential benefits of EUS-directed ERCP in selected patient populations.

Asset Subtitle

Janelle DeFilippis, APN-BC and Sumeet Tewani MD, FASGE

Keywords

epigastric pain

nausea

vomiting

abnormal liver enzyme levels

cholelithiasis

dilated common bile duct

choledocholithiasis

imaging modalities

endoscopic ultrasound

ERCP