Re: inflammed liver

Which diagnostic tests should be used to detect CBDS? And in what order should they be performed?

All patients in whom choledocholithiasis is suspected should have a thorough history, physical examination, and serum chemistry evaluation. The most appropriate initial procedure is transabdominal ultrasound. Although this procedure may miss up to 40% of CBDS, it is nonetheless a useful screening test because it is noninvasive, inexpensive, and widely available. Even if stones are not detected by ultrasound, a dilated CBD may be found, which is suggestive of choledocholithiasis in the appropriate clinical context. In addition, ultrasound may reveal other biliary, liver, or pancreatic pathology.

How is endoscopic ultrasound (EUS) used in the detection of CBDS?

Transabdominal ultrasound is not particularly sensitive for detection of CBDS because of interference from bowel gas in the duodenum. This is not a problem with EUS, however, because the transducer is placed directly in the duodenal bulb. Several studies confirm that EUS and ERCP are equally sensitive in detecting CBDS—in the range of 90% and higher. Based on these findings, and the fact that EUS is less costly than ERCP and carries minimal risk of pancreatitis, EUS may be preferable as a screening test for patients with a low to intermediate risk for choledocholithiasis, while ERCP remains the preferred procedure for patients at high risk.

In addition, EUS has been compared directly with MRCP in the detection of CBDS. One study reported a sensitivity for both tests of 100%, but a specificity of 95% for EUS and only 73% for MRCP. However, the advantage of MRCP is that it is noninvasive. Intraductal ultrasound is also under investigation as a diagnostic tool. Interestingly, in a study of patients who had had an endoscopic papillary dilation and stone extraction, intraductal ultrasound detected small residual stones in 27 of the total 81 patients with "normal" cholangiograms. There is as yet no consensus regarding which imaging modality should be used in patients with suspected choledocholithiasis.

Found here: http://mdchoice.com/emed/main.asp?template=0&page=detail&type=3&id=989