Evidence Based Medicine

Jordan Coulston
UCSD Medical Center
March 30, 2010
 Assess
61 y/o male admitted with painless jaundice
(Tbili 15, Dbili 11.5) and high suspicion of
malignancy. Ultrasound showed borderline
common bile duct (7mm) without stones.
MRCP did not lead to diagnosis.

Should this patient undergo ERCP?

 Background
 ERCP frequently used for diagnosis and
treatment of biliary disease
 High risk procedure:
 Pancreatitis
 Hemorrhage
 Perforation
 Cholangitis
 Lower risk diagnostic options include MRCP
and EUS
 Ask

P Obstructive jaundice
I MRCP
C ERCP
O Diagnosis of biliary disease
 Acquire
Comparison of endoscopic ultrasonography and
magnetic resonance cholangiopancreatography
in the diagnosis of pancreatobiliary diseases: a
prospective study.

Gloria Fernandez-Esparrach, M.D., Ph.D et al.

Am J Gastroenterol 2007;102:1632–1639.
 Appraise
 Prospective, Randomized, Double-Blinded
 159 participants underwent both MRCP and EUS within 24
hours
 Two study groups:
 1) Unexplained biliary dilation (>7mm) after traditional
ultrasound (63)
 2) Non-dilated biliary tree with high pre-test probability
of cholelithiasis (72)
 Exclusions (24): contraindication to MRI, severe
pancreatitis, inability to perform EUS
 Gold standard: ERCP with sphincterotomy, EUS-FNA,
intraoperative cholangiogram, or surgery.
Results
Results
 Apply
 EUS and MRCP are lower-risk alternatives to
ERCP for excluding malignancy as a cause of
biliary obstruction.
 Risk of malignancy with negative MRCP is
2.6% (perhaps less with EUS).
 Concordance between EUS and MRCP is very
high.
 Our patient did not undergo ERCP…until
today (new GI attending).
Questions?