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News

Can EUS or MRCP replace ERCP in patients with suspected biliary disease?

Initial EUS strategy in patients with suspected biliary disease has the greatest cost-utility by avoiding unnecessary ERCP examinations, according to a study in October's American Journal of Gastroenterology.

News image

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A team from Ann Arbor, Michigan, USA, compared the performance of endoscopic ultrasound (EUS) with magnetic resonance cholangiopancreatography (MRCP) and ERCP in the same patients with suspected extrahepatic biliary disease.

The economic outcomes of EUS-, MRCP-, and ERCP-based diagnostic strategies were evaluated.

A total of 30 patients referred for ERCP with suspected biliary disease were included in the prospective study.

MRCP and EUS were performed within 24 hours before ERCP.

The investigators were blinded to the results of the alternative imaging studies.

ERCP cholangiogram failed in 1 patient, and another patient did not complete MRCP because of claustrophobia.

The final diagnoses (n = 28) were CBD stone (mean = 4 mm) in 5 patients, biliary stricture in 3 patients, and normal biliary tree in 20.

Of the patients, 2 had pancreatitis after therapeutic ERCP, 1 after precut sphincterotomy followed by a normal cholangiogram.

Cost per person:
ERCP: $1346
MRCP: $1145
EUS: $1111
American Journal Of Gastroenterology

The researchers found that EUS was more sensitive than MRCP in the detection of choledocolithiasis (80% vs 40%), with similar specificity.

In addition, MRCP had a poor specificity and positive predictive value for the diagnosis of biliary stricture (76%/25%) compared to EUS (100%/100%), with similar sensitivity.

The overall accuracy of MRCP for any abnormality was 61%, compared to 89% for EUS.

Among those patients with a normal biliary tree, the proportion correctly identified with each test was 95% for EUS and 65% for MRCP.

The cost for each strategy per patient evaluated was found to be $1346 for ERCP, $1111 for EUS, and $1145 for MRCP.

Author J. M. Scheiman, of the University of Michigan Medical Center, Ann Arbor, said on behalf of colleagues, "In this patient population with a low disease prevalence, EUS was superior to MRCP for choledocholithiasis.

"EUS was most useful for confirming a normal biliary tree and should be considered a low-risk alternative to ERCP."

"Although MRCP had the lowest procedural reimbursement, the initial EUS strategy had the greatest cost-utility by avoiding unnecessary ERCP examinations," it was concluded.

Am J Gastroenterol 2001; 96(10): 2900-4
09 November 2001

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