Management of Pancreatico-Biliary Disease: Endoscopic Ultrasound (EUS)

  • Robert D. Fanelli
  • Stephanie M. Fanelli
  • Josephine A. Fanelli


Biliary stone disease, pancreaticobiliary inflammation, pancreaticobiliary neoplasia, and incidental radiographic findings are among the most common indications for performing EUS. EUS routinely is used to investigate laboratory abnormalities and lesions identified on cross-sectional imaging and provides both additional diagnostic and therapeutic value, sparing some patients operative intervention. Clinical presentation, physical findings, biochemical analyses, TUS, CT, MRI, and ERCP all play important roles in the diagnosis and treatment of CBDS and other pancreaticobiliary disorders. None, however, is as effective as EUS for diagnosis of the various benign and malignant conditions impacting the biliary tree and pancreas.

EUS is a superior diagnostic tool for identifying CBDS and other biliopancreatic pathology. Using EUS to direct the application of ERCP renders the latter solely a therapeutic procedure, which limits the risks and costs of unnecessary interventions. The development of adjunctive devices, like lumen apposing metal stents (LAMS), has fueled the development of novel EUS-based approaches to CBDS in patients with surgically altered anatomy, drainage of pancreatic fluid collections and walled off pancreatic necrosis (WOPN), and extra-anatomic decompression of the obstructed biliary tree. These procedures, now becoming routine, benefit patients through increasingly less invasive therapy.


EUS LAMS SEMS Choledocholithiasis Laparoscopic cholecystectomy Gallstones ERCP Endoscopic ultrasound Pancreatitis Jaundice Cholangitis Pancreatic pseudocyst Pancreatic cancer 


  1. 1.
    ASGE Standards of Practice Committee, Maple JT, Ben-Menachem T, Anderson MA, Appalaneni V, Banerjee S, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010;71(1):1–9.CrossRefGoogle Scholar
  2. 2.
    Schmidt S, Chevallier P, Novellas S, Gelsi E, Vanbiervliet G, Tran A, et al. Choledocholithiasis: repetitive thick-slab single-shot projection magnetic resonance cholangiopancreaticography versus endoscopic ultrasonography. Eur Radiol. 2007;17(1):241–50.CrossRefGoogle Scholar
  3. 3.
    Aljebreen A, Azzam N, Eloubeidi MA. Prospective study of endoscopic ultrasound performance in suspected choledocholithiasis. J Gastroenterol Hepatol. 2008;23(5):741–5.CrossRefGoogle Scholar
  4. 4.
    Petrov MS, Savides TJ. Systematic review of endoscopic ultrasonography versus endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis. Br J Surg. 2009;96(9):967–74.CrossRefGoogle Scholar
  5. 5.
    Ang TL, Teo EK, Fock KM. Endosonography- vs. endoscopic retrograde cholangiopancreatography-based strategies in the evaluation of suspected common bile duct stones in patients with normal transabdominal imaging. Aliment Pharmacol Ther. 2007;26(8):1163–70.CrossRefGoogle Scholar
  6. 6.
    Lee YT, Chan FKL, Leung WK, Chan HLY, Wu JCY, Yung MY, et al. Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study. Gastrointest Endosc. 2008;67(4):660–8.CrossRefGoogle Scholar
  7. 7.
    Turner BG, Cizginer S, Agarwal D, Yang J, Pitman MB, Brugge WR. Diagnosis of pancreatic neoplasia with EUS and FNA: a report of accuracy. Gastrointest Endosc. 2010;71(1):91–8.CrossRefGoogle Scholar
  8. 8.
    Borie F, Fingerhut A, Millat B. Acute biliary pancreatitis, endoscopy, and laparoscopy. Surg Endosc. 2003;17(8):1175–80.CrossRefGoogle Scholar
  9. 9.
    Videhult P, Sandblom G, Rudberg C, Rasmussen IC. Are liver function tests, pancreatitis and cholecystitis predictors of common bile duct stones? Results of a prospective, population-based, cohort study of 1171 patients undergoing cholecystectomy. HPB (Oxford). 2011;13(8):519–27.CrossRefGoogle Scholar
  10. 10.
    Sheen AJ, Asthana S, Al-Mukhtar A, Attia M, Toogood GJ. Preoperative determinants of common bile duct stones during laparoscopic cholecystectomy. Int J Clin Pract. 2008;62(11):1715–9.CrossRefGoogle Scholar
  11. 11.
    ASGE Standards of Practice Committee, Maple JT, Ben-Menachem T, Anderson MA, Appalaneni V, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010;71(1):1–9.CrossRefGoogle Scholar
  12. 12.
    Einstein DM, Lapin SA, Ralls PW, Halls JM. The insensitivity of sonography in the detection of choledocholithiasis. AJR Am J Roentgenol. 1984;142:725.CrossRefGoogle Scholar
  13. 13.
    Nebiker CA, Baierlein SA, Beck S, von Flue M, Ackermann C, Peterli R. Is routine MR cholangiopancreatography (MRCP) justified prior to cholecystectomy? Langenbeck’s Arch Surg. 2009;394(6):1005–10.CrossRefGoogle Scholar
  14. 14.
    Almadi M, Barkun JS, Barkun AN. Management of suspected stones in the common bile duct. CMAJ. 2012;184(8):884–92.CrossRefGoogle Scholar
  15. 15.
    Sakai Y, Tsuyuguchi T, Yukisawa S, Tsuchiya S, Sugiyama H, Miyakawa K, et al. Diagnostic value of magnetic resonance cholangiopancreatography for clinically suspicious spontaneous passage of bile duct stones. J Gastroenterol Hepatol. 2008;23(5):736–40.CrossRefGoogle Scholar
  16. 16.
    Desai R, Shokouhi BN. Common bile duct stones – their presentation, diagnosis and management. Indian J Surg. 2009;71(5):229–37.CrossRefGoogle Scholar
  17. 17.
    Peng WK, Sheikh Z, Paterson-Brown S, Nixon SJ. Role of liver function tests in predicting common bile duct stones in acute calculous cholecystitis. Br J Surg. 2005;92(10):1241–7.CrossRefGoogle Scholar
  18. 18.
    Yang M-H, Chen T-H, Wang S-E, Tsai Y-F, Su C-H, Wu C-W, et al. Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy. Surg Endosc. 2008;22(7):1620–4.CrossRefGoogle Scholar
  19. 19.
    Rickes S, Treiber G, Monkemuller K, Peitz U, Csepregi A, Kahl S, et al. Impact of the operator’s experience on value of high-resolution transabdominal ultrasound in the diagnosis of choledocholithiasis: a prospective comparison using endoscopic retrograde cholangiography as the gold standard. Scand J Gastroenterol. 2006;41(7):838–43.CrossRefGoogle Scholar
  20. 20.
    Grönroos JM, Haapamäki MM, Gullichsen R. Effect of the diameter of the common bile duct on the incidence of bile duct stones in patients with recurrent attacks of right epigastric pain after cholecystectomy. Eur J Surg. 2001;167(10):767–9.CrossRefGoogle Scholar
  21. 21.
    Al-Jiffry BO, Elfateh A, Chundrigar T, Othman B, Almalki O, Rayza F, et al. Non-invasive assessment of choledocholithiasis in patients with gallstones and abnormal liver function. World J Gastroenterol. 2013;19(35):5877–82.CrossRefGoogle Scholar
  22. 22.
    Tseng CW, Chen CC, Chen TS, Chang FY, Lin HC, Lee SD. Can computed tomography with coronal reconstruction improve the diagnosis of choledocholithiasis? J Gastroenterol Hepatol. 2008;23(10):1586–9.CrossRefGoogle Scholar
  23. 23.
    Lee JK, Kim TK, Byun JH, Kim AY, Ha HK, Kim PN, et al. Diagnosis of intrahepatic and common duct stones: combined unenhanced and contrast-enhanced helical CT in 1090 patients. Abdom Imaging. 2006;31(4):425–32.CrossRefGoogle Scholar
  24. 24.
    Topal B, Van de Moortel M, Fieuws S, Vanbeckevoort D, Van Steenbergen W, Aerts R, et al. The value of magnetic resonance cholangiopancreatography in predicting common bile duct stones in patients with gallstone disease. Br J Surg. 2003;90(1):42–7.CrossRefGoogle Scholar
  25. 25.
    Boraschi P, Gigoni R, Braccini G, Lamacchia M, Rossi M, Falaschi F. Detection of common bile duct stones before laparoscopic cholecystectomy. Acta Radiol. 2002;43(6):593–8.CrossRefGoogle Scholar
  26. 26.
    Raval B, Kramer L. Advances in the imaging of common duct stones using magnetic resonance cholangiography, endoscopic ultrasonography, and laparoscopic ultrasonography. Semin Laparosc Surg. 2000;7(4):232–6.CrossRefGoogle Scholar
  27. 27.
    Stiris MG, Tennøe B, Aadland E, Lunde OC. MR cholangiopancreaticography and endoscopic retrograde cholangiopancreaticography in patients with suspected common bile duct stones. Acta Radiol. 2000;41(3):269–72.CrossRefGoogle Scholar
  28. 28.
    Kejriwal R, Liang J, Andrewson G, Hill A. Magnetic resonance imaging of the common bile duct to exclude choledocholithiasis. ANZ J Surg. 2004;74(8):619–21.CrossRefGoogle Scholar
  29. 29.
    Mendler MH, Bouillet P, Sautereau D, Chaumerliac P, Cessot F, Le Sidaner A, et al. Value of MR cholangiography in the diagnosis of obstructive diseases of the biliary tree: a study of 58 cases. Am J Gastroenterol. 1998;93(12):2482–90.CrossRefGoogle Scholar
  30. 30.
    Sharma SK, Larson KA, Adler Z, Goldfarb MA. Role of endoscopic retrograde cholangiopancreatography in the management of suspected choledocholithiasis. Surg Endosc. 2003;17(6):868–71.CrossRefGoogle Scholar
  31. 31.
    Kubota Y, Takaoka M, Yamamoto S, Shibatani N, Shimatani M, Takamido S, et al. Diagnosis of common bile duct calculi with intraductal ultrasonography during endoscopic biliary cannulation. J Gastroenterol Hepatol. 2002;17(6):708–12.CrossRefGoogle Scholar
  32. 32.
    Urbach DR, Khajanchee YS, Jobe BA, Standage BA, Hansen PD, Swanstrom LL. Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration. Surg Endosc. 2001;15(1):4–13.CrossRefGoogle Scholar
  33. 33.
    Mukai S, Itoi T, Tsuchiya T, Tanaka R, Tonozuka R. EUS-guided intrahepatic bile duct stone extraction via choledochoduodenostomy created by a lumen-apposing metal stent. Gastrointest Endosc. 2016;83(4):832–3.CrossRefGoogle Scholar
  34. 34.
    Overby DW, Richardson W, Fanelli R. Choledocholithiasis after gastric bypass: a growing problem. Surg Obes Relat Dis. 2014;10(4):652–3.CrossRefGoogle Scholar
  35. 35.
    Menon S. EUS in biliary stone disease. Gastrointest Endosc. 2008;68(4):810; author reply -1.CrossRefGoogle Scholar
  36. 36.
    Tsuchiya T, Itoi T, Sofuni A, Tonozuka R, Mukai S. Endoscopic ultrasonography-guided rendezvous technique. Dig Endosc. 2016;28 Suppl 1:96–101.CrossRefGoogle Scholar
  37. 37.
    Tyberg A, Desai AP, Kumta NA, Brown E, Gaidhane M, Sharaiha RZ, et al. EUS-guided biliary drainage after failed ERCP: a novel algorithm individualized based on patient anatomy. Gastrointest Endosc. 2016;84(6):941–6.CrossRefGoogle Scholar
  38. 38.
    Tyberg A, Nieto J, Salgado S, Weaver K, Kedia P, Sharaiha RZ, et al. Endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography or EUS: mid-term analysis of an emerging procedure. Clin Endosc. 2017;50(2):185–90.CrossRefGoogle Scholar
  39. 39.
    Siripun A, Sripongpun P, Ovartlarnporn B. Endoscopic ultrasound-guided biliary intervention in patients with surgically altered anatomy. World J Gastrointest Endosc. 2015;7(3):283–9.CrossRefGoogle Scholar
  40. 40.
    Baron TH, Topazian MD. Endoscopic transduodenal drainage of the gallbladder: implications for endoluminal treatment of gallbladder disease. Gastrointest Endosc. 2007;65(4):735–7.CrossRefGoogle Scholar
  41. 41.
    Baron TH, Grimm IS, Swanstrom LL. Interventional approaches to gallbladder disease. N Engl J Med. 2015;373(4):357–65.CrossRefGoogle Scholar
  42. 42.
    Irani S, Baron TH, Grimm IS, Khashab MA. EUS-guided gallbladder drainage with a lumen-apposing metal stent (with video). Gastrointest Endosc. 2015;82(6):1110–5.CrossRefGoogle Scholar
  43. 43.
    Law R, Grimm IS, Stavas JM, Baron TH. Conversion of percutaneous cholecystostomy to internal transmural gallbladder drainage using an endoscopic ultrasound-guided, lumen-apposing metal stent. Clin Gastroenterol Hepatol. 2016;14(3):476–80.CrossRefGoogle Scholar
  44. 44.
    Varadarajulu S, Christein JD, Tamhane A, Drelichman ER, Wilcox CM. Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts (with videos). Gastrointest Endosc. 2008;68(6):1102–11.CrossRefGoogle Scholar
  45. 45.
    Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology. 2013;145(3):583–90.e1.CrossRefGoogle Scholar
  46. 46.
    Siddiqui AA, Kowalski TE, Loren DE, Khalid A, Soomro A, Mazhar SM, et al. Fully covered self-expanding metal stents versus lumen-apposing fully covered self-expanding metal stent versus plastic stents for endoscopic drainage of pancreatic walled-off necrosis: clinical outcomes and success. Gastrointest Endosc. 2017;85(4):758–65.CrossRefGoogle Scholar
  47. 47.
    Sharaiha RZ, Tyberg A, Khashab MA, Kumta NA, Karia K, Nieto J, et al. Endoscopic therapy with lumen-apposing metal stents is safe and effective for patients with pancreatic walled-off necrosis. Clin Gastroenterol Hepatol. 2016;14(12):1797–803.CrossRefGoogle Scholar
  48. 48.
    Fanelli RD, Andrew BD. Making the diagnosis: surgery, a rational approach to the patient with suspected CBD stones. In: Hazey JW, Conwell DL, Guy GE, editors. Management of common bile duct stones: an interdisciplinary textbook. Cham: Springer International Publishing Company; 2016. p. 37–48.CrossRefGoogle Scholar

Copyright information

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

Authors and Affiliations

  • Robert D. Fanelli
    • 1
  • Stephanie M. Fanelli
    • 2
  • Josephine A. Fanelli
    • 3
  1. 1.The Guthrie Clinic, Department of Surgery, Geisinger Commonwealth School of MedicineSayreUSA
  2. 2.The Ohio State University College of Medicine, School of Health and Rehabilitation SciencesColumbusUSA
  3. 3.The Guthrie Clinic, Division of Endocrinology and Metabolism, Department of MedicineSayreUSA

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