Stavropoulos S, Larghi A, Verna E, Battezzati P, Stevens P
Dept. of Medicine, Division of Liver and Digestive Diseases, Columbia University Medical Center, New York 10032, USA.
Endoscopy. 2005 Aug;37(8):715-21. doi: 10.1055/s-2005-870132.
Endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic procedure of choice in patients with biliary strictures and no culprit mass lesion on abdominal imaging, but it is limited in its diagnostic accuracy. The aim of this prospective study was to determine the value of intraductal ultrasound (IDUS) in distinguishing between benign and malignant biliary strictures in this clinical setting.
Sixty-one patients with painless jaundice and no mass lesion on abdominal computed tomography, who were found to have a biliary stricture at ERCP, underwent IDUS with a high-frequency (20-MHz) wire-guided probe. Histopathological confirmation or clinical follow-up was used to establish the final diagnosis. The diagnostic performances of IDUS, ERCP, and IDUS plus ERCP in the identification of malignant strictures were evaluated.
Forty-three patients had malignant strictures and 18 had benign strictures. ERCP produced 25 false-negative diagnoses, 22 of which were identified as malignant by IDUS. IDUS provided seven false-negative and three false-positive diagnoses. The proportion of patients with malignant strictures who tested positive with IDUS was 2.06 times that of ERCP (95 % CI, 1.37 - 3.10; 83.3 % vs. 40.5 %, P = 0.0004). When used in conjunction, IDUS increased the accuracy of ERCP from 58 % to 90 %. Patients with operable lesions on IDUS and no contraindication to surgery underwent resection; most patients with pancreatic parenchymal invasion on IDUS underwent EUS, which identified a pancreatic mass in more than 50 % of cases. Patients with negative IDUS and a low clinical suspicion for malignancy were treated endoscopically, while a more aggressive work-up was performed in all patients with high pretest probability, regardless of the IDUS results.
IDUS is a valuable adjunct to ERCP in the characterization of biliary strictures in patients who present with painless jaundice in the absence of a culprit mass on abdominal imaging.
对于腹部影像学检查未发现明确占位性病变的胆管狭窄患者，内镜逆行胰胆管造影（ERCP）是首选的诊断方法，但它的诊断准确性有限。这项前瞻性研究的目的是确定在这种临床情况下，导管内超声（IDUS）在鉴别良性和恶性胆管狭窄方面的价值。
61例腹部计算机断层扫描显示无痛性黄疸且无占位性病变、ERCP检查发现胆管狭窄的患者，接受了高频（20MHz）线阵探头的IDUS检查。通过组织病理学确诊或临床随访来确定最终诊断。评估了IDUS、ERCP以及IDUS联合ERCP在识别恶性狭窄方面的诊断性能。
43例患者为恶性狭窄，18例为良性狭窄。ERCP出现了25例假阴性诊断，其中22例经IDUS检查被诊断为恶性。IDUS出现了7例假阴性和3例假阳性诊断。IDUS检查呈阳性的恶性狭窄患者比例是ERCP检查的2.06倍（95%CI，1.37 - 3.10；83.3%对40.5%，P = 0.0004）。联合使用时，IDUS将ERCP的准确性从58%提高到了90%。IDUS检查显示可手术切除且无手术禁忌证的患者接受了手术切除；IDUS检查发现胰腺实质受侵犯的大多数患者接受了超声内镜检查（EUS），其中超过50%的病例发现了胰腺肿块。IDUS检查结果为阴性且临床怀疑恶性可能性低的患者接受了内镜治疗，而所有预测试验概率高的患者，无论IDUS检查结果如何，均进行了更积极的检查。
对于腹部影像学检查未发现明确占位性病变的无痛性黄疸患者，IDUS是ERCP鉴别胆管狭窄性质的一种有价值的辅助手段。
