A 46 yrs male was referred to us for the favor of EUS sos ERCP in view of suspected CBD obstruction. All the imaging studies including MRCP showed a normal CBD and did not reveal any pathology that can explain mildly abnormal LFT in the setting of multiple small stones in the gall bladder seen on USG abdomen. EUS revealed normal sized CBD with an small (4.0 mm)impacted stone in the prepapillary portion of the CBD. EUS showed distended Gall bladder with multiple small stones and imaging microliths. Pancreas and MPD appeared normal on EUS. In view of these findings ERCP was considered in the same sedation after EUS. After selective cannulation of CBD cholangiogram showed normal sized CBD, a biliary sphincterotomy was then performed and the stone that was seen on EUS was extracted with a dormia basket and CBD was cleared. Patient was sent home the same evening on an OPD basis.

Expert comments:

As seen in this case when there is a LFT abnormality in the setting of gall stones and even when an MRCP is normal, one should consider EUS sos ERCP to be sure prior to laparoscopic cholecystectomy. It is our practice for over a decade now that any patient who has suspected CBD stone referred to us will be first subjected to EUS and only after a definitive diagnosis of the pathology, then an ERC will be considered only as a therapeutic invtervention in the same sedation.

For a suspected CBD stone, ERCP cannot be justified for diagnostic purpose and should be avoided when we have other more reliable and less hazardous procedures such as MRCP or EUS are available for an accurate diagnosis. At our institute it’s a policy that whenever any pathology is suspected in the lower CBD and if there is no definitive diagnosis is made on Trans-abdominal ultrasound then we would consider EUS straight away without any other imaging modalities as the diagnostic accuracy of EUS at Endoscopy Asia is in the range of 98-99%.

1. EUS showed normal CBD with multiple stones in the Gall bladder

2. A small 4.0 mm stone was seen in the prepapillary portion of CBD

3. Selective cannulation of CBD was achieved

4. Cholangiogram revealed normal sized CBD

4. Cholangiogram revealed normal sized CBD

5. Biliary sphincterotomy was performed

5. Biliary sphincterotomy was performed

 

 

6. A 4.0 mm stone seen on EUS was then extracted with dormia basket.

6. A 4.0 mm stone seen on EUS was then extracted with dormia basket.

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