EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain

Chang, Kenneth J.; Erickson, Richard A.; Chak, Amitabh; Lightdale, Charles; Chen, Yang K.; Binmoeller, Kenneth F.; Albers, Gregory C.; Chen, Wen-Pin; McLaren, Christine E.; Sivak, Michael V.; Lee, John G.; Isenberg, Gerard A.; Wong, Richard C.K.

doi:10.1016/j.gie.2010.04.007

« Previous Next »Gastrointestinal Endoscopy
Volume 72, Issue 5 , Pages 967-974, November 2010

EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain

Current affiliations: Division of Gastroenterology, Department of Medicine (K.J.C., G.C.A., J.G.L.), H. H. Chao Comprehensive Digestive Disease Center, University of California, Irvine, Orange, California; Scott and White Hospital and Clinic (R.A.E.), Texas A&M University, Temple, Texas; University Hospitals Case Medical Center (A.C., M.V.S., G.A.I., R.C.K.W.), Case Western Reserve University, Cleveland, Ohio; Columbia University Medical Center (C.L.), New York, New York; University of Colorado Health Sciences Center (Y.K.C.), Aurora, Colorado; California Pacific Medical Center (K.F.B.), San Francisco, California; Chao Family Comprehensive Cancer Center (W.-P.C.), Orange, California; Epidemiology Division, Department of Epidemiology (C.E.M.), University of California, Irvine, California, U.S.A.

Received 13 April 2009; accepted 7 April 2010. published online 23 July 2010.

Background

Primary upper endoscopy (EGD) and transabdominal US (TUS) are often performed in patients with upper abdominal pain.

Objective

Primary: Determine whether the combination of EGD and EUS was equivalent to EGD plus TUS in the diagnostic evaluation of upper abdominal pain. Secondary: Compare EUS versus TUS in detecting abdominal lesions, and compare EGD by using an oblique-viewing echoendoscope versus the standard, forward-viewing endoscope in detecting mucosal lesions.

Design

Prospective, paired design.

Setting

Six academic endoscopy centers.

Patients

This study involved patients with upper abdominal pain referred for endoscopy.

Intervention

All patients had EGD, EUS, and TUS. The EGD was done using both an oblique-viewing echoendoscope and the standard, forward-viewing endoscope (randomized order) by two separate endoscopists in a blinded fashion, followed by EUS. TUS was performed within 4 weeks of EGD/EUS, also in a blinded fashion. Follow-up: telephone interviews and chart reviews.

Main Outcome Measurements

Diagnose possible etiology of upper abdominal pain and detect clinically significant lesions.

Results

A diagnosis of the etiology of upper abdominal pain was made in 66 of 172 patients (38%). The diagnostic rate was 42 of 66 patients (64%) for EGD plus EUS versus 41 of 66 patients (62%) for EGD plus TUS, which was statistically equivalent (McNemar test; P = .27). One hundred ninety-eight lesions were diagnosed with either EUS or TUS. EUS was superior to TUS for visualizing the pancreas (P < .0001) and for diagnosing chronic pancreatitis (P = .03). Two biliary stones were detected only by EUS. Two hundred fifty-one mucosal lesions were similarly diagnosed with EGD with either the standard, forward-viewing endoscope or the oblique-viewing echoendoscope (kappa = 0.48 [95% CI, .43-.54]). EGD with the standard, forward-viewing endoscope was preferred for biopsies.

Limitations

No cost analysis.

Conclusion

The combination of EGD with EUS is equivalent to EGD plus TUS for diagnosing a potential etiology of upper abdominal pain. EUS is superior to TUS for detecting chronic pancreatitis. EGD combined with EUS should be considered in the first-line diagnostic evaluation of patients with upper abdominal pain.

Abbreviations: CBD, common bile duct, HIDA, Hepatobiliary Imino-Diacetic Acid, MRI, magnetic resonance imaging, oEGD, oblique-viewing radial echoendoscope EGD, TUS, transabdominal US, UAP, upper abdominal pain