Intraductal Ultrasound For Evaluating The Pancreaticobiliary Ductal System

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Intraductal ultrasound for evaluating the

pancreaticobiliary ductal system
AUTHOR: Maurits J Wiersema, MD
SECTION EDITOR: Douglas G Adler, MD, FACG, AGAF, FASGE
DEPUTY EDITOR: Kristen M Robson, MD, MBA, FACG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2024.

This topic last updated: Apr 12, 2023.
INTRODUCTION
Intraductal ultrasound (IDUS) of the pancreaticobiliary ductal system utilizes a small caliber
ultrasound catheter (also referred to as a mini-catheter). Because the ultrasound catheter
ranges in size from 2 to 3 mm, it can be passed through the accessory channel of a
duodenoscope and into the pancreatic or bile duct. The ultrasound catheter's small caliber,
wire-guided design, flexibility, and high resolution imaging facilitate the evaluation of biliary,
pancreatic, and ampullary disorders ( table 1).
This topic will discuss the imaging principles, procedure technique, and clinical applications
of IDUS. We generally use IDUS to complement endoscopic and radiographic imaging during
endoscopic retrograde cholangiopancreatography (ERCP), which has evolved into mostly a
therapeutic procedure. An overview of ERCP is discussed separately. (See "Overview of
endoscopic retrograde cholangiopancreatography (ERCP) in adults".)
The role of small caliber ultrasound catheters for evaluating other parts of the
gastrointestinal tract is discussed elsewhere. (See "Endoscopic ultrasound (EUS): Use of
miniprobes for evaluating gastrointestinal lesions".)
PROCEDURE
Patient preparation — The preprocedure preparation for patients undergoing IDUS is

similar to the preparation for patients undergoing ERCP, and these issues are discussed
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separately. (See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in

adults", section on 'Patient preparation'.)
Imaging principles — IDUS produces higher resolution images than standard endoscopic
ultrasound (EUS) [1]. Close proximity of the ultrasound transducer to the duct wall permits
the use of high frequency, high resolution sound waves. The pancreatic and bile ducts have a
tubular anatomy, are fluid filled, and are only slightly larger in caliber than the IDUS catheter.
In addition, the IDUS catheter operates at higher frequencies (12 to 20 MHz) than standard
EUS imaging [1,2]. The use of high frequencies produces high resolution images and detailed
examination of ductal and periductal tissues. However, the limited depth of penetration
prevents detailed examination of the surrounding tissue and more distant sites.
Equipment — Commercially-available systems for performing IDUS are listed in the table
( table 2).
Mechanical ultrasound catheters include the following components:
● A single transducer mounted on the tip of a wire that allows the transducer to rotate
and produce a 360-degree image
● A cable that excites the transducer and transfers signals to the image processor
● A flexible protective housing
Some ultrasound catheters provide biplane imaging by allowing the transducer to move in
both radial and linear planes.
Design variations exist for IDUS systems, and some systems incorporate the use of a
guidewire ( picture 1 and picture 2). Mechanical catheters with a guidewire port permit
mechanical rotating sector scanning and linear scanning with three-dimensional
reconstruction.
Technique
Evaluating the biliary tract — The procedural technique for IDUS in the biliary tract is
summarized as follows:
● Accessing the bile duct – We typically perform IDUS by inserting the ultrasound
catheter through the ampulla of Vater during endoscopic retrograde
cholangiopancreatography (ERCP), but IDUS can also be performed using a
percutaneous approach. The small caliber of the wire-guided ultrasound catheter (ie, 2
to 3 mm in diameter) facilitates cannulating an intact biliary sphincter [3-5]. If
endoscopic sphincterotomy is planned for patients with biliary obstruction, we perform
IDUS prior to sphincterotomy to help retain fluid and minimize insufflation of the biliary
tree. An intact biliary sphincter optimizes acoustic coupling and image quality. Patients
with tight biliary strictures may require balloon or catheter dilation to facilitate
inserting the ultrasound catheter. However, we target a post-dilation diameter that will
allow catheter insertion but avoid excessive tissue disruption because it may impact
bile duct wall thickness and overall appearance.
The total time for performing IDUS, including catheter insertion and imaging time, is
approximately 5 to 10 minutes [1,6]. This does not include time required to perform
ERCP. (See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in
adults".)
● Imaging technique – All IDUS catheters are mechanical. We usually perform IDUS
using a pullback imaging technique. We maintain the elevator of the duodenoscope in
the down (relaxed) position while the catheter is being withdrawn. In our experience,
this minimal elevator technique reduces tension on the rotating cable of the catheter
and extends the lifespan of the catheter. In some settings, using a stiffer guidewire (ie,
0.035 inches in diameter) may facilitate this technique. As an example, we use a stiffer
guidewire to help advance the catheter in patients with proximal biliary strictures. (See
"Endoscopic biliary sphincterotomy", section on 'Guidewires'.)
IDUS produces high quality imaging of the biliary system and surrounding structures,
such as the right hepatic artery, portal vein, and the hepatoduodenal ligament
( image 1 and image 2). Examination of more distant tissues is hindered by its
limited depth of penetration [7-10]. IDUS may also have limited value in evaluating
lymph nodes, and unlike EUS, IDUS provides diagnostic assessment only and cannot be
used to perform fine needle aspiration. (See "Endoscopic ultrasound-guided fine needle
aspiration in the gastrointestinal tract".)
● Imaging appearance – The normal bile duct appears as either two or three layers,
which is similar to that seen during EUS [2,11,12]. The normal bile duct wall is 0.31 to
0.79 mm thick, with smooth inner and outer surfaces and homogeneous internal
echoes [13]. When visualized as a two-layer structure, an internal hypoechoic layer is
seen, which represents the mucosa, muscularis propria (fibromuscular layer), and
fibrous layer of the subserosa [14,15]. An outer hyperechoic layer represents the
adipose layer of the subserosa, the serosa, and the interface echo between the serosa
and surrounding organs. A third inner hyperechoic layer, representing an interface, will
occasionally be identified. It may not be possible to differentiate the fibromuscular
layer from the perimuscular connective tissue in some patients in whom they appear as
a single hypoechoic layer.
Evaluating the pancreatic ducts — The technique for performing IDUS of the pancreatic
duct is similar to the technique for examination of the bile duct (see 'Evaluating the biliary
tract' above):
● Accessing the pancreatic duct – We typically perform IDUS by inserting the

ultrasound catheter into the pancreatic duct, although the proximal portion of the
pancreatic duct may be tortuous [6,16]. However, cannulating the pancreatic duct does
not typically require pancreatic sphincterotomy. In a study including 153 patients who
underwent ERCP, the IDUS catheter was successfully passed into the pancreatic head,
body, and tail in 94, 89, and 55 percent of patients, respectively [6].
● Imaging appearance – The ultrasound appearance of the wall of the main pancreatic
duct varies from a single hyperechoic layer to three layers. When three layers are
present, the inner and outer layers are hyperechoic, with an intervening hypoechoic
layer [12].
Adverse events — Adverse events attributed to IDUS are uncommon but may include
pancreatitis and catheter fracture [3,6,17-19]. However, most studies do not typically
distinguish adverse events related specifically to IDUS from events due to the ERCP itself.
(See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults",
section on 'Adverse events'.)
Limited data suggested that performing IDUS during ERCP was not associated with
increased risk of post-ERCP pancreatitis. In two studies including 443 patients who
underwent IDUS, four patients (0.9 percent) developed mild pancreatitis [6,16]. The
incidence, risk factors, and prevention of post-ERCP pancreatitis are discussed separately.
(See "Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis".)
Post-procedure care — After the procedure, patients are recovered from sedation or
anesthesia. (See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in
adults", section on 'Post-procedure care'.)
The equipment is cleaned per procedural protocol. (See "Preventing infection transmitted by
gastrointestinal endoscopy".)
CONTRAINDICATIONS AND LIMITATIONS
Contraindications to IDUS are similar to those for ERCP and include (see "Overview of
endoscopic retrograde cholangiopancreatography (ERCP) in adults", section on
'Contraindications'):
● Patients who cannot tolerate moderate sedation, monitored anesthesia care, or general
anesthesia. (See "Anesthesia for gastrointestinal endoscopy in adults".)
● Patients who are hemodynamically unstable.
Limitations of IDUS include that it is invasive, uses specialized equipment, requires expertise
in advanced endoscopy, increases overall cost, and may not be widely available.
CLINICAL APPLICATIONS
Diagnostic role of IDUS — IDUS can assist in the evaluation of patients with a variety of
pancreaticobiliary disorders ( table 1). The most common indications for IDUS of the biliary
tract are obstructive jaundice and evaluating indeterminate biliary strictures. IDUS is useful
for determining the cause of biliary obstruction and can also assist in local tumor staging.
Biliary disease
Bile duct strictures — We may use IDUS to evaluate biliary strictures by assessing for the
following sonographic features that are suggestive of malignancy ( image 3) [4,7,19-25]:
● A hypoechoic mass, especially if infiltrating surrounding tissues or >7 mm in thickness

● Heterogeneity of the internal echo
● Notching or irregularity of the outer border
● A papillary surface
● Disruption of the normal bile duct structure
● Suspicious lymph nodes (hypoechoic, round and smooth bordered)
Malignant biliary strictures may be related to tumors such as cholangiocarcinoma or

pancreatic cancer, and the diagnostic evaluation and staging of these tumors is discussed in
detail separately. (See "Clinical manifestations and diagnosis of cholangiocarcinoma" and
"Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer".)
Biliary strictures that do not have sonographic characteristics of malignancy may be related
to a variety of nonmalignant conditions:
● Post-surgical biliary complications (eg, cholecystectomy) (see "Complications of

laparoscopic cholecystectomy" and "Liver transplantation in adults: Long-term
management of transplant recipients", section on 'Biliary complications')
● Primary sclerosing cholangitis (see "Primary sclerosing cholangitis in adults: Clinical

manifestations and diagnosis")
● Autoimmune pancreatitis (see "Autoimmune pancreatitis: Clinical manifestations and

diagnosis")
● Chronic pancreatitis (see "Overview of the complications of chronic pancreatitis",

section on 'Biliary obstruction')
● Infectious or ischemic cholangiopathy, including chronic bacterial cholangitis, recurrent

pyogenic cholangitis, and biliary parasitosis (see "Recurrent pyogenic cholangitis")
Studies suggested that IDUS demonstrated better overall test performance than other
methods for distinguishing malignant from nonmalignant strictures [4,19,20,24,25]. In a
study including 234 patients with indeterminate bile duct strictures who underwent
endoscopic retrograde cholangiopancreatography (ERCP) with IDUS in addition to
endoscopic ultrasound (EUS), computed tomography (CT), and endoscopic transpapillary
biopsy, 136 patients (58 percent) had a malignant stricture that was confirmed by surgical
histology or median follow-up of 34 months [24]. IDUS had a higher accuracy (ie, ability to
correctly differentiate malignant from nonmalignant strictures) compared with EUS, CT, or
transpapillary biopsy (91 versus 74, 73, and 59 percent, respectively). For 55 patients who
were diagnosed with pancreatic adenocarcinoma, IDUS had higher accuracy compared with
EUS or CT (90 versus 81 and 76 percent, respectively) [24]. In another study including 193
patients with indeterminate biliary strictures, 97 patients were diagnosed with malignancy
(confirmed by tissue sampling, surgery, and/or long-term follow up) [19]. The sensitivity and
specificity of IDUS were 97 and 79 percent, respectively. The accuracy of IDUS (ie, ability to
correctly differentiate malignant from nonmalignant strictures) was higher for proximal
compared with distal biliary strictures (98 versus 83 percent). Malignant strictures were
longer (20 versus 14 mm) and had greater wall thickness (7 versus 3 mm) compared with
nonmalignant strictures.
Other potential applications of IDUS in patients with indeterminate bile duct strictures but
negative or nondiagnostic tissue sampling include:
● Surveillance – IDUS may be useful for surveillance of indeterminate biliary strictures

with negative tissue sampling. In a study including 86 patients with indeterminate bile
duct strictures who had multiple tests including cholangiography, brush cytology,
intraductal biopsy, digital image analysis (DIA), and fluorescence in situ hybridization
(FISH), 21 patients (24 percent) with initially negative tissue sampling were later
diagnosed with malignant stricture [25]. IDUS had higher sensitivity for diagnosing
malignancy compared with combined FISH/DIA, FISH alone, or DIA alone (86 versus 67,
62, and 14 percent, respectively).
● Providing US guidance for tissue sampling – We may use IDUS to target sampling of
polypoid or localized bile duct lesions in the setting of an otherwise normal bile duct
wall [26].
● Identifying possible indications for surgery – Preliminary studies suggested that

some lesion characteristics (eg, a lesion involving and disrupting the bile duct wall) may
be an indication for surgical exploration, even in patients with negative tissue sampling
[26-28]. Additional studies are needed to confirm these findings before using these
IDUS-related lesion characteristics as indications for surgery.
Primary sclerosing cholangitis — For patients with primary sclerosing cholangitis (PSC),
we use IDUS to assess biliary strictures for features of malignancy (eg, irregular foci) and
facilitate targeted tissue sampling [22,25]. In a study of 40 patients with a PSC-related
dominant biliary stricture who underwent ERCP, tissue sampling, and IDUS, eight patients (20
percent) had cholangiocarcinoma [22]. Compared with cholangiography, IDUS had higher
sensitivity and specificity for diagnosing malignancy (88 versus 63 percent and 91 versus 53
percent, respectively). However, studies suggested that overall accuracy of IDUS (ie, ability to
correctly differentiate malignant from nonmalignant strictures) is lower for PSC-related
strictures compared with non-PSC-related strictures (62 versus 82 percent) [25]. (See
"Primary sclerosing cholangitis in adults: Clinical manifestations and diagnosis", section on
'Dominant biliary strictures' and 'Bile duct strictures' above.)
Cholangiocarcinoma — IDUS is useful for characterizing malignant bile duct strictures and
for local tumor staging of cholangiocarcinoma. IDUS detects early lesions, determines the
longitudinal tumor extent, and identifies tumor extension into adjacent organs (eg,
pancreas) and major blood vessels (eg, portal vein, hepatic artery) [8,9,29-31]. The use of
IDUS for local staging and preoperative planning is discussed separately. (See "Clinical
manifestations and diagnosis of cholangiocarcinoma", section on 'Intraductal ultrasound'.)
Distinguishing tumor spread from peritumoral bile duct wall inflammation is challenging
with IDUS and other noninvasive imaging techniques. Studies suggested that the following
factors may facilitate detailed visualization using IDUS [3,19,31-33]:
● Procedure timing – For patients with malignant biliary obstruction, we perform IDUS
ideally prior to or within a few days of biliary stent placement [3,26]. The evaluation of
bile duct wall thickening may be impacted by stent-induced inflammation and epithelial
hyperplasia that may lead to overestimation of the longitudinal extent of the tumor
[26].
● Thresholds for bile duct thickness – Assessing bile duct wall thickness with IDUS may be
helpful in distinguishing inflammatory from malignant conditions. In a study
comparing IDUS findings in 23 patients with IgG4-related sclerosing cholangitis (IgG4-
SC) with 11 patients with cholangiocarcinoma, bile duct wall thickness >0.8 mm in non-
strictured areas on cholangiography was highly suggestive of IgG4-SC, with sensitivity
and specificity of 95 and 91 percent, respectively [31,33].
Choledocholithiasis — The use of IDUS for evaluating patients with suspected

choledocholithiasis is generally reserved for those with nondiagnostic imaging (eg, magnetic
resonance cholangiopancreatography [MRCP]) and as an option for confirming bile duct
clearance following endoscopic stone removal [18,34-39]. The evaluation of suspected

choledocholithiasis is discussed in detail separately. (See "Choledocholithiasis: Clinical
manifestations, diagnosis, and management".)
● Suspected choledocholithiasis in patients with nondiagnostic studies – Both larger

caliber bile ducts (>10 mm) and smaller stones (<3 mm) reduce the sensitivity of both
MRCP and ERCP [18,36,37]. However, IDUS maintains high sensitivity and specificity in
both conditions [18,36,37]. In a study including 92 patients with suspected biliary
pancreatitis and negative cholangiogram, IDUS demonstrated bile duct stones (mean
stone size, 1.9 mm) in 33 patients (36 percent), and the diagnosis was confirmed with
endoscopic stone extraction [37]. During mean follow-up of 24 months, two patients (2
percent) had recurrent biliary pancreatitis. However, both patients had stones on IDUS
but did not undergo cholecystectomy. In a study including 95 patients with jaundice
and suspected choledocholithiasis who had negative cholangiography, bile duct stones
were detected by IDUS in 31 patients (33 percent), and stones were confirmed by
endoscopic stone removal in all patients [34]. Stone diameter ranged from 1 to 7 mm
(mean stone size, 2.9 mm). In addition, IDUS showed biliary sludge in 24 patients (25
percent), which was confirmed by sludge extraction in 21 patients (88 percent). In a
study including 32 patients with suspected biliary pancreatitis who had radiologic
imaging (transabdominal US, CT, and MRCP) that was followed by ERCP with IDUS,
choledocholithiasis was confirmed in 20 patients by stone extraction [18]. The
sensitivity of US, CT, MRCP, ERCP and IDUS for identifying choledocholithiasis was 20,
40, 80, 90, and 95 percent, respectively, and specificity was 83, 92, 83, 92, and 92
percent, respectively. Of note, the sensitivity of MRCP decreased with bile duct dilation
(bile duct diameter >10 mm, 73 versus 89 percent).
● Confirming duct clearance – Using IDUS to confirm stone clearance has been
associated with lower rates of stone recurrence. Although IDUS adds time to ERCP (ie,
an additional 5 to 10 minutes), it facilitates achieving complete duct clearance during
the index procedure [38,39]. In a study comparing 59 patients who underwent IDUS
after ERCP-guided biliary stone removal with 129 patients who had ERCP with stone
removal only, rates of stone recurrence after three years were lower in the IDUS group
(3 versus 13 percent) [38]. During the index procedure, 14 patients (24 percent) in the
IDUS group had residual common bile duct stones (mean stone size, 4.9 mm). In a
study of 70 patients with choledocholithiasis based on radiologic imaging (eg, US,
MRCP) who underwent ERCP with sphincterotomy and stone extraction followed by
IDUS, 28 patients (40 percent) had residual bile duct stones (mean size, 2.2 mm) that
were addressed during the index procedure [39]. Although randomized trials are
lacking, these data support the use of IDUS for confirming bile duct clearance after
endoscopic removal.
Pancreatic disease — Technical advances, test performance, and safety of other methods
for pancreatic imaging (eg, CT, magnetic resonance imaging [MRI], EUS) have essentially
eliminated the need for ERCP with diagnostic invasive pancreatography. Thus, the role of
IDUS of the pancreatic duct is limited to selected patients [5,17,40]:
● Pancreatic cystic neoplasms – For patients with suspected pancreatic cystic

neoplasms ( table 3), IDUS has been studied for detecting small lesions, determining
the extent of intraductal disease, and assessing for parenchymal invasion. Evaluation
with IDUS may help guide surgical planning for patients with mucin-producing tumors
involving the main pancreatic duct or for patients with side-branch disease by
identifying papillary tumor projections into the main pancreatic duct.
However, other imaging studies provide accurate diagnostic and presurgical

assessment such that IDUS is not performed in most patients with pancreatic cystic
neoplasms. The diagnosis, classification, and management of pancreatic cystic
neoplasms is discussed in detail separately. (See "Classification of pancreatic cysts" and
"Pancreatic cystic neoplasms: Clinical manifestations, diagnosis, and management".)
Data from randomized trials and observation studies suggested that IDUS was useful
for surgical planning in patients with intraductal papillary mucinous neoplasm (IPMN)
of the pancreas ( picture 3 and image 4) [5,17,40,41]. In a trial including 40
patients with IPMN who underwent preoperative testing followed by surgical resection,
assessment with IDUS resulted in lower rates of surgical modifications based on
intraoperative frozen sections compared with no IDUS (15 versus 50 percent) [5].
Preoperative IDUS also resulted in lower rates of recurrent disease after mean follow-
up of 50 months (5 versus 20 percent). In a study including 24 patients with branch duct
IPMN who underwent IDUS prior to surgical resection, the sensitivity and specificity of
IDUS for detecting lateral tumor spread into the main pancreas duct was 92 and 91
percent, respectively [40]. One false negative occurred in a patient with flat atypia in the
main pancreas duct, and one false positive arose in a patient with fibrosis and
inflammation in the wall of the main duct.
Management of IPMN of the pancreas is discussed in more detail separately. (See

"Intraductal papillary mucinous neoplasm of the pancreas (IPMN): Evaluation and
management".)
● Other pancreatic disorders – IDUS may be used for evaluating indeterminate

pancreatic strictures when the diagnosis is uncertain despite advanced imaging and
when ERCP is planned for tissue sampling or therapeutic intervention [16]. The
diagnostic evaluation of suspected pancreatic cancer is discussed separately. (See
"Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer".)
Ampullary lesions — We use IDUS for evaluating the size and extent of ampullary lesions in
selected patients (eg, patients with an adenoma in whom the extent of pancreas or biliary
ductal infiltration requires clarification prior to endoscopic resection or in whom ampullary
carcinoma cannot be excluded). This approach is consistent with society guidelines [42].
However, we do not use IDUS to evaluate all patients with ampullary lesions because of the
potential risk of pancreatitis, additional procedure time, and cost. IDUS provides detailed
visualization of the papilla and can reliably differentiate the sphincter of Oddi musculature
from the papillary orifice [10,42].
Studies suggested that accuracy of IDUS for T-staging of ampullary lesions ranged from 87 to
95 percent [10,43]. In a meta-analysis including five studies, the pooled sensitivity and
specificity of IDUS for T1 tumors was 90 and 88 percent, respectively; for T2 tumors, 73 and
91 percent, respectively, and for T3 tumors, 79 and 97 percent, respectively [10]. However,
the pooled sensitivity for N-staging was 61 percent. In a study including 48 patients with
ampullary lesions who underwent surgical or endoscopic resection, IDUS had higher
sensitivity for detecting bile duct infiltration compared with EUS (71 versus 43 percent), while
both techniques had good specificity (90 versus 98 percent) [43].
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Endoscopic
retrograde cholangiopancreatography (ERCP)".)
SUMMARY AND RECOMMENDATIONS
● Background – Intraductal ultrasound (IDUS) of the pancreaticobiliary system utilizes a

small caliber ultrasound catheter that can be passed through the accessory channel of
a duodenoscope and into the pancreatic or bile duct. The ultrasound catheter's small
caliber, wire-guided design, flexibility, and high resolution imaging are beneficial for
evaluating a variety of biliary, pancreatic, and ampullary disorders ( table 1). The use
of high frequencies allows for detailed examination of ductal and periductal tissues
( image 1 and image 2). However, the limited depth of penetration prevents
examination of more distant sites. (See 'Introduction' above.)
● Procedure – IDUS is typically performed by inserting the ultrasound catheter through

the ampulla of Vater during endoscopic retrograde cholangiopancreatography (ERCP):
• Pre- and post-procedure care – Pre- and post-procedure care is similar to that for
patients who undergo ERCP alone. (See "Overview of endoscopic retrograde
https://www-uptodate-com.bibliotecavirtual.udla.edu.ec/contents/intraductal-ultrasound-for-evaluating-the-pancreaticobiliary-ductal-system/print… 10/26
cholangiopancreatography (ERCP) in adults", section on 'Patient preparation'.)
• Contraindications – There are few contraindications that are mainly related to ERCP
itself, including inability to tolerate anesthesia/sedation and/or hemodynamic
instability. (See 'Contraindications and limitations' above and "Endoscopic
ultrasound (EUS): Use of miniprobes for evaluating gastrointestinal lesions", section
on 'Contraindications'.)
• Adverse events – Adverse events associated with IDUS are uncommon. Limited
data suggested that performing IDUS during ERCP was not associated with
increased risk of post-ERCP pancreatitis. (See 'Adverse events' above.)
Limitations of IDUS include that it is invasive, uses specialized equipment, requires

expertise in advanced endoscopy, and may not be widely available.
● Clinical applications – Clinical applications of IDUS include (see 'Clinical applications'

above):
• Indeterminate biliary strictures – IDUS can help differentiate malignant from

nonmalignant biliary strictures based on sonographic features such as hypoechoic
mass, heterogeneity of the internal echo, and irregularity of the outer border
( image 3). (See 'Bile duct strictures' above.)
• Cholangiocarcinoma – IDUS detects early lesions, determines the longitudinal tumor

extent, and identifies tumor extension into adjacent organs (eg, pancreas) and
major blood vessels (eg, portal vein, hepatic artery). (See 'Cholangiocarcinoma'
above and "Clinical manifestations and diagnosis of cholangiocarcinoma", section
on 'Intraductal ultrasound'.)
• Suspected but unconfirmed choledocholithiasis – IDUS may be useful for

demonstrating choledocholithiasis when other imaging studies (eg, magnetic
resonance cholangiopancreatography [MRCP] and/or cholangiography) are
nondiagnostic. (See 'Choledocholithiasis' above.)
• Pancreatic disease – For patients with intraductal papillary mucinous neoplasm

(IPMN), IDUS may distinguish main duct disease from branch duct disease and
determine the extent of tumor spread and parenchymal invasion. (See 'Pancreatic
disease' above.)
ACKNOWLEDGMENT
The UpToDate editorial staff acknowledges Michael J Levy, MD (deceased), who contributed
to earlier versions of this topic review.
Use of UpToDate is subject to the Terms of Use.
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23. Tringali A, Lemmers A, Meves V, et al. Intraductal biliopancreatic imaging: European

Society of Gastrointestinal Endoscopy (ESGE) technology review. Endoscopy 2015;
47:739.
24. Heinzow HS, Kammerer S, Rammes C, et al. Comparative analysis of ERCP, IDUS, EUS and
CT in predicting malignant bile duct strictures. World J Gastroenterol 2014; 20:10495.
25. Levy MJ, Baron TH, Clayton AC, et al. Prospective evaluation of advanced molecular
markers and imaging techniques in patients with indeterminate bile duct strictures. Am
J Gastroenterol 2008; 103:1263.
26. Tamada K, Tomiyama T, Ichiyama M, et al. Influence of biliary drainage catheter on bile
duct wall thickness as measured by intraductal ultrasonography. Gastrointest Endosc
1998; 47:28.
27. Tamada K, Ueno N, Tomiyama T, et al. Characterization of biliary strictures using
intraductal ultrasonography: comparison with percutaneous cholangioscopic biopsy.
Gastrointest Endosc 1998; 47:341.

28. Gress F, Chen YK, Sherman S, et al. Experience with a catheter-based ultrasound probe
in the bile duct and pancreas. Endoscopy 1995; 27:178.
29. Kuroiwa M, Tsukamoto Y, Naitoh Y, et al. New technique using intraductal
ultrasonography for the diagnosis of bile duct cancer. J Ultrasound Med 1994; 13:189.
30. Tamada K, Ido K, Ueno N, et al. Assessment of the course and variations of the hepatic
artery in bile duct cancer by intraductal ultrasonography. Gastrointest Endosc 1996;
44:249.
31. Choi ER, Chung YH, Lee JK, et al. Preoperative evaluation of the longitudinal extent of
borderline resectable hilar cholangiocarcinoma by intraductal ultrasonography. J
Gastroenterol Hepatol 2011; 26:1804.
32. Kuroiwa M, Goto H, Hirooka Y, et al. Intraductal ultrasonography for the diagnosis of
proximal invasion in extrahepatic bile duct cancer. J Gastroenterol Hepatol 1998; 13:715.
33. Naitoh I, Nakazawa T, Ohara H, et al. Endoscopic transpapillary intraductal
ultrasonography and biopsy in the diagnosis of IgG4-related sclerosing cholangitis. J
Gastroenterol 2009; 44:1147.
34. Kim DC, Moon JH, Choi HJ, et al. Usefulness of intraductal ultrasonography in icteric
patients with highly suspected choledocholithiasis showing normal endoscopic
retrograde cholangiopancreatography. Dig Dis Sci 2014; 59:1902.
35. Fusaroli P, Caletti G. Intraductal ultrasound for high-risk patients: when will the last be
first? Dig Dis Sci 2014; 59:1676.
36. Endo T, Ito K, Fujita N, et al. Intraductal ultrasonography in the diagnosis of bile duct
stones: when and whom? Dig Endosc 2011; 23:173.
37. Yoon LY, Moon JH, Choi HJ, et al. Clinical usefulness of intraductal ultrasonography for
the management of acute biliary pancreatitis. J Gastroenterol Hepatol 2015; 30:952.
38. Tsuchiya S, Tsuyuguchi T, Sakai Y, et al. Clinical utility of intraductal US to decrease early
recurrence rate of common bile duct stones after endoscopic papillotomy. J
Gastroenterol Hepatol 2008; 23:1590.
39. Ang TL, Teo EK, Fock KM, Lyn Tan JY. Are there roles for intraductal US and saline solution
irrigation in ensuring complete clearance of common bile duct stones? Gastrointest
Endosc 2009; 69:1276.
40. Kobayashi G, Fujita N, Noda Y, et al. Lateral spread along the main pancreatic duct in
branch-duct intraductal papillary-mucinous neoplasms of the pancreas: usefulness of
intraductal ultrasonography for its evaluation. Dig Endosc 2011; 23:62.
41. Sho M, Nakajima Y, Kanehiro H, et al. Pattern of recurrence after resection for
intraductal papillary mucinous tumors of the pancreas. World J Surg 1998; 22:874.
42. Vanbiervliet G, Strijker M, Arvanitakis M, et al. Endoscopic management of ampullary

tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy
2021; 53:429.
43. Okano N, Igarashi Y, Hara S, et al. Endosonographic preoperative evaluation for tumors
of the ampulla of vater using endoscopic ultrasonography and intraductal
ultrasonography. Clin Endosc 2014; 47:174.
Topic 2664 Version 24.0
GRAPHICS
Indications for intraductal ultrasound
Biliary tract
Suspected but undetected choledocholithiasis
Identify residual choledocholithiasis during ERCP-guided stone removal
Distinguish malignant from nonmalignant bile duct strictures
Local tumor staging
Pancreas
Distinguish malignant from nonmalignant pancreatic duct strictures
Characterize pancreatic cystic neoplasm
Ampullary lesions
Staging ampullary neoplasms
ERCP: endoscopic retrograde cholangiopancreatography.
Graphic 74332 Version 2.0
Available intraductal ultrasound systems
Catheter for mechanical sector

Catheter for mechanical sector
and combined sector/linear
scanner (Fujifilm)
scanner (Olympus)
Scanning Mechanical/radial/radial-linear (biplane) Mechanical/radial

method
Frequency (MHz) 12-20/20 20
Transducer 1/1 1
elements
Working length 205 215

(cm)
Diameter (mm) 2.5/2.9-3.1 2
Wire guided Yes No

option
Biplane/3D Yes No
reconstruction
Wire-guided intraductal ultrasound catheter
The wire-guided intraductal ultrasound catheter can be passed through a standard side-viewing
duodenoscope.
Courtesy of Micheal J Levy, MD, Enrique Vazquez-Sequeiros, MD, and Maurits J Wiersema, MD.
Intraductal ultrasound catheter
Intraductal ultrasound catheter positioned over a guidewire seen at the tip of an duodenoscope.
Courtesy of Micheal J Levy, MD, Enrique Vazquez-Sequeiros, MD, and Maurits J Wiersema, MD.
Intraductal ultrasound demonstrating a normal common bile duct and

pancreatic duct
Normal intraductal ultrasound examination demonstrating the common bile duct (CBD) and
pancreatic duct (PD).
Courtesy of Drs. Michael J Levy, Enrique Vazquez-Sequeiros, and Maurits J Wiersema.
Intraductal ultrasound showing a normal common hepatic duct, cystic duct,

portal vein, and hepatic artery
Normal intraductal ultrasound demonstrating the common hepatic duct (CHD), cystic duct, portal vein
(PV), and hepatic artery (HA).
Courtesy of Drs. Micheal J Levy, Enrique Vazquez-Sequeiros, and Maurits J Wiersema.
Polypoid mass in the common bile duct evaluated with EUS and with IDUS
(A) EUS image shows a polypoid mass in the distal common bile duct.
(B) For this patient, IDUS was performed to further characterize the polypoid mass.
EUS: endoscopic ultrasound; IDUS: intraductal ultrasound.
Courtesy of Michael J Levy, MD, Enrique Vazquez-Sequeiros, MD, and Maurits J Wiersema, MD.
World Health Organization classification of pancreatic cystic neoplasms
Serous neoplasms
Serous cystadenoma
Microcystic serous cystadenoma
Macrocystic (oligocystic) serous cystadenoma
Solid serous adenoma
Von Hippel-Lindau syndrome-associated serous cystic neoplasm
Mixed serous-neuroendocrine neoplasm
Serous cystadenocarcinoma
Mucinous cystic neoplasm

Mucinous cystic neoplasm with low-grade dysplasia
Mucinous cystic neoplasm with high-grade dysplasia
Mucinous cystic neoplasm with associated invasive carcinoma
Intraductal papillary mucinous neoplasm

Intraductal papillary mucinous neoplasm with low-grade dysplasia
Intraductal papillary mucinous neoplasm with high-grade dysplasia
Intraductal papillary mucinous neoplasm with associated invasive carcinoma
Solid pseudopapillary neoplasm

Solid pseudopapillary neoplasm
Solid pseudopapillary neoplasm with high-grade carcinoma
Data from: Zamboni G, Kloeppel G, Hruban RH, et al. Mucinous cystic neoplasms. Tumours of the pancreas. In: World Health
Organization Classification of Tumours. Pathology and Genetics of Tumours of the Digestive System, 5th ed, Aaltonen LA,
Hamilton SR (Eds), IARC Press, Lyon 2019.
Guidewire placement for intraductal ultrasound
Placement of a guidewire, for intraductal ultrasound, into the pancreatic duct in a patient with a
widely patent papilla that is extruding mucus as a result of an intraductal papillary mucinous
neoplasm.
Intraductal ultrasound showing papillary projections in the pancreatic duct
In this patient with intraductal papillary mucinous neoplasm, two papillary projections (arrows) were
identified during intraductal ultrasound of the pancreas.

Intraductal Ultrasound For Evaluating The Pancreaticobiliary Ductal System

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21/2/24, 19:49 Intraductal ultrasound for evaluating the pancreaticobiliary ductal system - UpToDate

Official reprint from UpToDate®

Intraductal ultrasound for evaluating the

Literature review current through: Jan 2024.

Patient preparation — The preprocedure preparation for patients undergoing IDUS is

separately. (See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in

Mechanical ultrasound catheters include the following components:

● Accessing the pancreatic duct – We typically perform IDUS by inserting the

CONTRAINDICATIONS AND LIMITATIONS

● Patients who are hemodynamically unstable.

● A hypoechoic mass, especially if infiltrating surrounding tissues or >7 mm in thickness

Malignant biliary strictures may be related to tumors such as cholangiocarcinoma or

● Post-surgical biliary complications (eg, cholecystectomy) (see "Complications of

● Primary sclerosing cholangitis (see "Primary sclerosing cholangitis in adults: Clinical

● Autoimmune pancreatitis (see "Autoimmune pancreatitis: Clinical manifestations and

● Chronic pancreatitis (see "Overview of the complications of chronic pancreatitis",

● Infectious or ischemic cholangiopathy, including chronic bacterial cholangitis, recurrent

● Surveillance – IDUS may be useful for surveillance of indeterminate biliary strictures

● Identifying possible indications for surgery – Preliminary studies suggested that

Choledocholithiasis — The use of IDUS for evaluating patients with suspected

clearance following endoscopic stone removal [18,34-39]. The evaluation of suspected

● Suspected choledocholithiasis in patients with nondiagnostic studies – Both larger

● Pancreatic cystic neoplasms – For patients with suspected pancreatic cystic

However, other imaging studies provide accurate diagnostic and presurgical

Management of IPMN of the pancreas is discussed in more detail separately. (See

● Other pancreatic disorders – IDUS may be used for evaluating indeterminate

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● Background – Intraductal ultrasound (IDUS) of the pancreaticobiliary system utilizes a

● Procedure – IDUS is typically performed by inserting the ultrasound catheter through

cholangiopancreatography (ERCP) in adults", section on 'Patient preparation'.)

Limitations of IDUS include that it is invasive, uses specialized equipment, requires

● Clinical applications – Clinical applications of IDUS include (see 'Clinical applications'

• Indeterminate biliary strictures – IDUS can help differentiate malignant from

• Cholangiocarcinoma – IDUS detects early lesions, determines the longitudinal tumor

• Suspected but unconfirmed choledocholithiasis – IDUS may be useful for

• Pancreatic disease – For patients with intraductal papillary mucinous neoplasm

Use of UpToDate is subject to the Terms of Use.

1. Sun B, Hu B. The role of intraductal ultrasonography in pancreatobiliary diseases.

6. Menzel J, Domschke W. Intraductal ultrasonography (IDUS) of the pancreato-biliary duct

12. Furukawa T, Naitoh Y, Tsukamoto Y, et al. New technique using intraductal

15. Noda Y, Fujita N, Kobayashi G, et al. [Comparison of echograms by a microscanner and

23. Tringali A, Lemmers A, Meves V, et al. Intraductal biliopancreatic imaging: European

Gastrointest Endosc 1998; 47:341.

42. Vanbiervliet G, Strijker M, Arvanitakis M, et al. Endoscopic management of ampullary

Indications for intraductal ultrasound

Identify residual choledocholithiasis during ERCP-guided stone removal

Distinguish malignant from nonmalignant bile duct strictures

Local tumor staging

Characterize pancreatic cystic neoplasm

ERCP: endoscopic retrograde cholangiopancreatography.

Graphic 74332 Version 2.0

Available intraductal ultrasound systems

Catheter for mechanical sector

Scanning Mechanical/radial/radial-linear (biplane) Mechanical/radial

Frequency (MHz) 12-20/20 20

Working length 205 215

Diameter (mm) 2.5/2.9-3.1 2

Wire guided Yes No

Graphic 70245 Version 2.0

Wire-guided intraductal ultrasound catheter

Graphic 79640 Version 2.0