BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is the initial therapy recommended for patients with high likelihood of choledocholithiasis. To determine whether endoscopic ultrasonography (EUS) can prevent diagnostic ERCPs in patients with high probability of choledocholithiasis and inconclusive ultrasonography (US). METHODS: All patients with high likelihood of choledocholithiasis and negative US underwent EUS. ERCP was performed for the patients who showed a definite stone/sludge on EUS. Patients without choledocholithiasis were followed up for 3 months. The primary outcome was avoidance of diagnostic ERCP. RESULTS: We included 78 patients (51 women; 27 men). Of these, 25 and 7 (total 41%) were diagnosed with choledocholithiasis and sludge, respectively; stone/sludge was removed in 96.9% of the patients. EUS ruled out choledocholithiasis in 38 patients (48.7%). Two of them were found to have choledocholithiasis on follow-up. The sensitivity, specificity, positive and negative predictive value of EUS for detecting choledocholithiasis were 93.9%, 97.3%, 96.9%, and 94.7%, respectively. Unnecessary ERCP was avoided in 57.7% of the patients by using the EUS-first approach. CONCLUSIONS: EUS is a highly accurate and safe procedure. EUS can replace ERCP as the initial investigation in patients with a high probability of choledocholithiasis. It avoids unnecessary ERCP; hence, decreasing related costs and complications.
Cholangiopancreatography, Endoscopic Retrograde* ; Choledocholithiasis* ; Endosonography* ; Female ; Follow-Up Studies ; Humans ; Prospective Studies* ; Sensitivity and Specificity ; Sewage ; Ultrasonography*

BACKGROUND/AIMS: This study aimed to compare tolerance to air, carbon dioxide, or water insufflation in patients with anticipated difficult colonoscopy (young, thin, obese individuals, and patients with prior abdominal surgery or irradiation). METHODS: Patients with body mass index (BMI) less than 18 kg/m2 or more than 30 kg/m2, or who had undergone previous abdominal or pelvic surgeries were randomized to air, carbon dioxide, or water insufflation during colonoscopy. The primary endpoint was cecal intubation with mild pain (less than 5 on visual analogue scale [VAS]), without use of sedation. RESULTS: The primary end point was achieved in 32.7%, 43.8%, and 84.9% of cases with air, carbon dioxide and water insufflation (P < 0.001). The mean pain scores were 5.17, 4.72, and 3.93 on the VAS for air, carbon dioxide, and water insufflation (P < 0.001). The cecal intubation rate or procedure time did not differ significantly between the 3 groups. CONCLUSIONS: Water insufflation was superior to air or carbon dioxide for pain tolerance. This was seen in the subgroups with BMI < 18 kg/m2 and the post-surgical group, but not in the group with BMI >30 kg/m2.
Body Mass Index ; Carbon Dioxide* ; Carbon* ; Colonoscopy* ; Humans ; Insufflation* ; Intubation ; Water*