The additional value of the combined use of EUS and ERCP for the evaluation of unclear biliary strictures

Figures & data

Figure 1. Patient selection in a flow diagram.

BC: brush cytology, EUS: endoscopic ultrasound, ERCP: endoscopic retrograde cholangiopancreatography, FNA: fine needle aspiration.

Table 1. The study’s baseline characteristics.

	Study cases (n = 78)
Patient characteristics
Age, median (range, years)	59 (15-80)
Male gender, n (%)	51 (65)
Previous biliary disorder, n (%)
None	53 (68)
Primary sclerosing cholangitis	24 (31)
Cholelithiasis	1 (1)
Distal strictures	10
Work-up characteristics Imaging before EUS-ERCP n (%)
CT	55 (71)
MRI	68 (87)
CT and MRI	46 (59)
CT/MRI with strong suspicion of malignancy	28 (36)
ERCP before EUS-ERCP	39 (53)
Reference standard n (%)
Pathology	30 (38)
Clinical follow-up 48(18-92) months (median (range))	48 (62)

Table 2. The final diagnoses.

	Study cases (n = 78)
Benign, n (%)	48 (62)
Benign stricture not related to PSC/stone/pancreatitis	8 (10)
PSC-related stricture without dysplasia	18 (23)
Stricture related to choledocholithiasis	6 (8)
Stricture related to chronic pancreatitis	4 (5)
IgG4-associated pancreatitis/cholangitis	3 (4)
Other benign strictures	6 (8)
Stricture related to a benign polyp in the CBD^a	3 (4)
Malignant, n (%)	30 (38)
Cholangiocarcinoma (CCA)	16 (20)
Malignancy other than CCA^b	13 (17)
Metastasis to the biliary tract^c	1 (1)

^aCBD = common bile duct; ^bpancreas malignancy (adenocc., NET), duodenal GIST, papilladenoma with high-grade dysplasia; ^ccolon cancer metastasis.

Table 3. The Laboratory results in relation to the final diagnosis.

Diagnosis	CCA	PSC + CCA	Pancreas cancer	Other malignancy	Benign PSC	Other benign diagnosis
n = 78	10	6	11	3	18	30
	Median (range)
CA 19-9 Ref < 37 (kU/l)	92	30.5	63.5	43	32	34
	(5–3800)	(6–912)	(2–2383)	(2–3800)	(2–188)	(2–65)
ALP Ref < 1.9 (ukat/l)	5.6	3.8	12.55	1,4	5.3	1,5
	(1–29)	(1–36)	(2–25)	(1–2)	(1–19)	(1–9)
Bilirubin Ref < 25 (umol/l)	21	3.25	87	7.75	9.95	9.3
	(4–200)	(1–170)	(8–510)	(3–11)	(0–77)	(1–180)
ALAT Ref < 0.75 (ukat/l)	1.75	0.82	2.25	0.43	1.7	0.5
	(1–4)	(1–2)	(1–9)	(0–1)	(0–10)	(0–8)
ASAT Ref < 0.6 (ukat/l)	1.15	8.5	1.85	0.44	2.1	0.5
	(1–18)	(1–20)	(1–8)	(0–1)	(0–34)	(0–12)
Albumin Ref < 35(g/l)	33.5	35	34.5	32.5	37.5	36
	(1–38)	(30–45)	(19–41)	(24–41)	(22–43)	(6–48)

Figure 2. Sensitivity, specificity, NPV, PPV, and accuracy of the different diagnostic modalities in patients undergoing combined EUS-ERCP (n = 73). This is the per-protocol analysis.

Figure 3. Sensitivity, specificity, NPV, PPV, and accuracy of the different diagnostic modalities in all the included patients referred for EUS-ERCP (n = 78). This is the intention-to-diagnose analysis (ITD analysis).

Figure 4. A comparison of the diagnostic performance in PSC patients undergoing EUS-ERCP (n = 24). Brush cytology (BC); tissue sampling (TS).

Figure 5. Results of different types of tissue sampling in patients undergoing EUS-ERCP with both FNA and brush cytology (BC) (n = 22).