Clinical Gastroenterology and Hepatology
Volume 7, Issue 11 , Page 1256, November 2009

Reply

published online 23 September 2009.

Article Outline

 

The following reply refers to a letter to the editor (Reiss G, Ramrakhiani S. Right upper-quadrant pain and a normal abdominal ultrasound. Clin Gastroenterol Hepatol 2009;7:603) published in the May 2009 issue of Clinical Gastroenterology and Hepatology.

We would like to thank Drs Reiss and Ramrakhiani for their comments regarding the utility of endoscopic ultrasound (EUS) in this difficult group of patients. We agree that EUS is an excellent test for the evaluation of small gallbladder stones or sludge missed on other imaging studies, with a reported sensitivity of 96%.1 However, with the recent advances in abdominal imaging, transabdominal ultrasound (TUS) now has a sensitivity and specificity of at least 95% for cholelithiasis.2 Indeed, some radiologists suggest that clinicians should now expect 100% accuracy in the diagnosis of gallbladder stones with TUS in fasting patients3 (K. Sandrasegaran, personal communication, January 2009). Older series have much lower rates of detection.4 Given the high prevalence of disease and the excellent performance characteristics of TUS, we agree with John Baillie when he states that “… it is unlikely that EUS will ever play a major role in diagnosing cholelithiasis.”5 Although a few small studies have demonstrated symptom relief or resolution after cholecystectomy when biliary sludge or microlithiasis has been missed by TUS but detected by EUS, these studies have been criticized for their flawed scientific design.5, 6

Reiss and Ramrakhiani suggest that TUS reliability might be compromised in patients with altered anatomy and obesity, and it is operator-dependent. We agree that obesity might decrease the sensitivity of TUS in obese patients.7 However, altered anatomy might actually impact performance of EUS more than TUS. In patients with Billroth-II anatomy, for example, gallbladder visualization from the gastric remnant might be significantly reduced. We would also suggest that performance of EUS and interpretation of findings follow a learning curve.8

The patient described in our scenario illustrates a well-known fact: the practice of medicine is as much an art as it is a science. At our tertiary level pancreatobiliary clinic, this patient might undergo biliary scintigraphy, endoscopic retrograde cholangiopancreatography with manometry, or perhaps might be referred for empiric cholecystectomy. Others might undergo evaluation for subtle small bowel pathology; whereas still others might begin medication trials aimed at a functional etiology. We believe that the points raised by Reiss and Ramrakhiani simply confirm that this is a controversial and challenging patient population. We maintain that EUS will be useful in only a subset of these patients. Furthermore, EUS has not yet become universally available (as is cholescintigraphy), is costly, and referral to larger centers remains necessary in many areas. The precise role of EUS in these patients requires prospective trials with cost-effective analyses.

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References 

  1. Liu CL, Lo CM, Chan JK, et al. EUS for detection of occult cholelithiasis in patients with idiopathic pancreatitis. Gastrointest Endosc. 2000;51:28–32
  2. Amouyal G, Amouyal P. Endoscopic ultrasonography in gallbladder stones. Gastrointest Endosc Clin N Am. 1995;5:825–830
  3. Lees W. Percutaneous ultrasound. In:  Weinstein WM,  Hawkey CJ,  Bosch J editor. Clinical gastroenterology and hepatology: the modern clinician's guide. London: Elsevier Health Sciences; 2005;p. 921–927
  4. Gandolfi L, Torresan F, Solmi L, et al. The role of ultrasound in biliary and pancreatic disease. Eur J Ultrasound. 2003;16:141–159
  5. Baillie J. Biliary tract diseases. In:  Classen M,  Tytgat GNJ,  Lightdale CJ editor. Gastrointestinal endoscopy. New York: Thieme; 2002;p. 614–633
  6. Coyle WJ, Lawson JM. Combined endoscopic ultrasound and stimulated biliary drainage in cholecystitis and microlithiasis: diagnosis and outcomes. Gastrointest Endosc. 1996;44:102–103
  7. Pieken SR, Feld R, Kasterberg D. Role of endosonography in the diagnosis of gallstone disease in obese subjects (abstract). Gastroenterology. 1992;104:A328
  8. Rösch T. State of the art lecture: endoscopic ultrasonography: training and competence. Endoscopy. 2006;38(Suppl 1):S69–S72

 Conflicts of interest The authors disclose no conflicts.

PII: S1542-3565(09)00908-2

doi:10.1016/j.cgh.2009.09.015

Refers to article:

  • Right Upper-Quadrant Pain and a Normal Abdominal Ultrasound , 15 December 2008

    Gary Reiss, Sanjay Ramrakhiani
    Clinical Gastroenterology and Hepatology May 2009 (Vol. 7, Issue 5, Page 603)

Clinical Gastroenterology and Hepatology
Volume 7, Issue 11 , Page 1256, November 2009