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CC BY-NC-ND 4.0 · Endosc Int Open 2021; 09(06): E911-E917
DOI: 10.1055/a-1452-8919
Original article

Do endosonographers agree on the presence of bile duct sludge and the subsequent need for intervention?

Rutger Quispel‡
1   Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, Netherlands
,
Hannah M. Schutz‡
1   Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, Netherlands
,
Nora D. Hallensleben
2   Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
,
Abha Bhalla
3   Department of Gastroenterology and Hepatology, HAGA Hospital, Den Haag, Netherlands
,
Robin Timmer
4   Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Netherlands
,
Jeanin E. van Hooft
5   Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
6   Department of Gastroenterology and Hepatology, Leiden University Medical Center Leiden, Netherlands
,
Niels G. Venneman
7   Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, Netherlands
,
Nicole S. Erler
8   Department of Biostatistics, Erasmus University Medical Center, Rotterdam, Netherlands
,
Bart J. Veldt
1   Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, Netherlands
,
Lydi M.J.W. van Driel
9   Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
,
Marco J. Bruno
9   Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
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Abstract

Background and study aims Endoscopic ultrasonography (EUS) is a tool widely used to diagnose bile duct lithiasis. In approximately one out of five patients with positive findings at EUS, sludge is detected in the bile duct instead of stones. The objective of this study was to establish the agreement among endosonographers regarding: 1. presence of common bile duct (CBD) stones, microlithiasis and sludge; and 2. the need for subsequent treatment.

Patients and methods 30 EUS videos of patients with an intermediate probability of CBD stones were evaluated by 41 endosonographers. Experience in EUS and endoscopic retrograde cholangiopancreatography, and the endosonographers’ type of practices were recorded. Fleiss’ kappa statistics were used to quantify the agreement. Associations between levels of experience and both EUS ratings and treatment decisions were investigated using mixed effects models.

Results A total of 1230 ratings and treatment decisions were evaluated. The overall agreement on EUS findings was fair (Fleiss’ κ 0.32). The agreement on presence of stones was moderate (κ 0.46). For microlithiasis it was fair (κ 0.25) and for sludge it was slight (κ 0.16). In cases with CBD stones there was an almost perfect agreement for the decision to subsequently perform an ERC + ES. In case of presumed microlithiasis or sludge an ERC was opted for in 78 % and 51 % of cases, respectively. Differences in experience and types of practice appear unrelated to the agreement on both EUS findings and the decision for subsequent treatment.

Conclusions There is only slight agreement among endosonographers regarding the presence of bile duct sludge. Regarding the need for subsequent treatment of bile duct sludge there is no consensus.

Supplementary material



Publication History

Received: 25 September 2020

Accepted: 20 January 2021

Article published online:
27 May 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Georg Thieme Verlag KG
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Comment to this article:

Endoscopy International Open – recently publishedEndoscopy 2021; 53(07): 769-769
DOI: 10.1055/a-1469-4558

 

  • References

  • 1 Petrov MS, Savides TJ. Systematic review of endoscopic ultrasonography versus endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis. Br J Surg 2009; 96: 967-974
    CrossrefPubMedGoogle Scholar
  • 2 Tse F, Liu L, Barkun AN. et al. EUS: a meta-analysis of test performance in suspected choledocholithiasis. Gastrointest Endosc 2008; 67: 235-244
    CrossrefPubMedGoogle Scholar
  • 3 Manes G, Paspatis G, Aabakken L. et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2019; 51: 472-491
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Fusaroli P, Lisotti A, Syguda A. et al. Reliability of endoscopic ultrasound in predicting the number and size of common bile duct stones before endoscopic retrograde cholangiopancreatography. Dig Liver Dis 2016; 48: 277-282
    CrossrefPubMedGoogle Scholar
  • 5 Quispel R, van Driel LM, Veldt BJ. et al. The utility and yield of endoscopic ultrasonography for suspected choledocholithiasis in common gastroenterology practice. Eur J Gastroenterol Hepatol 2016; 28: 1473-1476
    CrossrefPubMedGoogle Scholar
  • 6 Lee SP. Pathogenesis of biliary sludge. Hepatology 1990; 12: 200S-203S ; discussion 203S–205S
    PubMedGoogle Scholar
  • 7 Lee SP, Maher K, Nicholls JF. Origin and fate of biliary sludge. Gastroenterology 1988; 94: 170-176
    CrossrefPubMedGoogle Scholar
  • 8 Dahan P, Andant C, Levy P. et al. Prospective evaluation of endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis in 45 patients with normal conventional ultrasonography. Gut 1996; 38: 277-281
    CrossrefPubMedGoogle Scholar
  • 9 Dill JE, Hill S, Callis J. et al. Combined endoscopic ultrasound and stimulated biliary drainage in the diagnosis of cholecystitis and microlithiasis. Endoscopy 1995; 27: 218
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Keizman D, Ish-Shalom M, Konikoff FM. The clinical significance of bile duct sludge: is it different from bile duct stones?. Surg Endosc 2007; 21: 769-773
    CrossrefPubMedGoogle Scholar
  • 11 Ko CW, Sekijima JH, Lee SP. Biliary sludge. Ann Intern Med 1999; 130: 301-311
    CrossrefPubMedGoogle Scholar
  • 12 Collins C, Maguire D, Ireland A. et al. A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg 2004; 239: 28-33
    CrossrefPubMedGoogle Scholar
  • 13 Frossard JL, Hadengue A, Amouyal G. et al. Choledocholithiasis: a prospective study of spontaneous common bile duct stone migration. Gastrointest Endosc 2000; 51: 175-179
    CrossrefPubMedGoogle Scholar
  • 14 Hauer-Jensen M, Karesen R, Nygaard K. et al. Prospective randomized study of routine intraoperative cholangiography during open cholecystectomy: long-term follow-up and multivariate analysis of predictors of choledocholithiasis. Surgery 1993; 113: 318-323
    PubMedGoogle Scholar
  • 15 Khan OA, Balaji S, Branagan G. et al. Randomized clinical trial of routine on-table cholangiography during laparoscopic cholecystectomy. Br J Surg 2011; 98: 362-367
    CrossrefPubMedGoogle Scholar
  • 16 Murison MS, Gartell PC, McGinn FP. Does selective peroperative cholangiography result in missed common bile duct stones?. J R Coll Surg Edinb 1993; 38: 220-224
    PubMedGoogle Scholar
  • 17 Nies C, Bauknecht F, Groth C. et al. [Intraoperative cholangiography as a routine method? A prospective, controlled, randomized study]. . Chirurg 1997; 68: 892-897
    CrossrefPubMedGoogle Scholar
  • 18 Diehl AK, Holleman Jr DR, Chapman JB. et al. Gallstone size and risk of pancreatitis. Arch Intern Med 1997; 157: 1674-1678
    CrossrefPubMedGoogle Scholar
  • 19 Venneman NG, Buskens E, Besselink MG. et al. Small gallstones are associated with increased risk of acute pancreatitis: potential benefits of prophylactic cholecystectomy?. Am J Gastroenterol 2005; 100: 2540-2550
    CrossrefPubMedGoogle Scholar
  • 20 Wani S, Keswani R, Hall M. et al. A Prospective multicenter study evaluating learning curves and competence in endoscopic ultrasound and endoscopic retrograde cholangiopancreatography among advanced endoscopy trainees: the rapid assessment of trainee endoscopy skills study. Clin Gastroenterol Hepatol 2017; 15: 1758-1767 e1711
    CrossrefPubMedGoogle Scholar
  • 21 Maple JT, Ben-Menachem T. ASGE Standards of Practice Committee. et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc 2010; 71: 1-9
    CrossrefPubMedGoogle Scholar
  • 22 Al-Haddad MA. EUS in Bile Duct, Galbladder, and Ampullary Lesions. In: Hawes RH FP, Varadarajulu S. Endosonography 3rd edition. Elsevier Saunders; 2015: 226-255
    Google Scholar
  • 23 Jungst C, Kullak-Ublick GA, Jungst D. Gallstone disease: Microlithiasis and sludge. Best Pract Res Clin Gastroenterol 2006; 20: 1053-1062
    CrossrefPubMedGoogle Scholar
  • 24 Shaffer EA. Gallbladder sludge: what is its clinical significance?. Curr Gastroenterol Rep 2001; 3: 166-173
    CrossrefPubMedGoogle Scholar
  • 25 Gwet KL. Testing the difference of correlated agreement coefficients for statistical significance. Educ Psychol Meas 2016; 76: 609-637
    CrossrefPubMedGoogle Scholar
  • 26 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159-174
    CrossrefPubMedGoogle Scholar
  • 27 Molenberghs GVG. Models for Discrete Longitudinal Data. 2006
    PubMedGoogle Scholar
  • 28 Hedeker D, du Toit SHC, Demirtas H. et al. A note on marginalization of regression parameters from mixed models of binary outcomes. Biometrics 2018; 74: 354-361
    CrossrefPubMedGoogle Scholar
  • 29 Rizopoulos D. GLMMadaptive: Generalized Linear Mixed Models Using Adaptive Gaussian Quadrature. 2020
    PubMedGoogle Scholar
  • 30 Somani P, Sunkara T, Sharma M. Role of endoscopic ultrasound in idiopathic pancreatitis. World J Gastroenterol 2017; 23: 6952-6961
    CrossrefPubMedGoogle Scholar
  • 31 Lee SP, Nicholls JF, Park HZ. Biliary sludge as a cause of acute pancreatitis. N Engl J Med 1992; 326: 589-593
    CrossrefPubMedGoogle Scholar
  • 32 Raty S, Pulkkinen J, Nordback I. et al. Can laparoscopic cholecystectomy prevent recurrent idiopathic acute pancreatitis? A prospective randomized multicenter trial.. Ann Surg 2015; 262: 736-741
    CrossrefPubMedGoogle Scholar
  • 33 de Jong K, Verlaan T, Dijkgraaf MG. et al. Interobserver agreement for endosonography in the diagnosis of pancreatic cysts. Endoscopy 2011; 43: 579-584
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Stevens T, Lopez R, Adler DG. et al. Multicenter comparison of the interobserver agreement of standard EUS scoring and Rosemont classification scoring for diagnosis of chronic pancreatitis. Gastrointest Endosc 2010; 71: 519-526
    CrossrefPubMedGoogle Scholar
  • 35 Topazian M, Enders F, Kimmey M. et al. Interobserver agreement for EUS findings in familial pancreatic-cancer kindreds. Gastrointest Endosc 2007; 66: 62-67
    CrossrefPubMedGoogle Scholar
  • 36 Wallace MB, Hawes RH, Durkalski V. et al. The reliability of EUS for the diagnosis of chronic pancreatitis: interobserver agreement among experienced endosonographers. Gastrointest Endosc 2001; 53: 294-299
    CrossrefPubMedGoogle Scholar
  • 37 Buxbaum JL, Abbas Fehmi SM. ASGE Standards of Pracitce Committee,. et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc 2019; 89: 1075-1105 e1015
    CrossrefPubMedGoogle Scholar
  • 38 Wani S, Cote GA, Keswani R. et al. Learning curves for EUS by using cumulative sum analysis: implications for American Society for Gastrointestinal Endoscopy recommendations for training. Gastrointest Endosc 2013; 77: 558-565
    CrossrefPubMedGoogle Scholar
  • 39 Wani S, Han S, Simon V. et al. Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees. Gastrointest Endosc 2019; 89: 1160-1168 e1169
    CrossrefPubMedGoogle Scholar
  • 40 Hwang JH KT, Kimmey MB. Principles of Ultrasound. In: Endosonography. Elsevier; 2015
    Google Scholar
  • 41 Moller M, Gustafsson U, Rasmussen F. et al. Natural course vs interventions to clear common bile duct stones: data from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). JAMA Surg 2014; 149: 1008-1013
    CrossrefPubMedGoogle Scholar