Diagnostic performance of the current risk-stratified approach with computed tomography for suspected choledocholithiasis and its options when negative finding

Background:Several studies evaluated the current guideline of the American Society for Gastrointestinal Endoscopy(ASGE)and reported only suboptimal accuracy.This study evaluated the diagnostic performance of the ASGE guideline based on computed tomography(CT)and role of endoscopic ultrasonography(EUS)and magnetic resonance cholangiopancreatography(MRCP)in patients with suspected choledocholithiasis but negative CT finding.Methods:Patients with suspected choledocholithiasis undergoing ERCP between January 2016 and January 2017 were retrospectively analyzed.All patients underwent CT to detect choledocholithiasis.EUS or MRCP was performed when the CT scan showed negative findings.Patients were classified into the high and intermediate-risk groups,based on predictors from the ASGE criteria.Results:Of 583 patients with suspected choledocholithiasis,340(58.3%)had stones on ERCP(65.9%in the high-risk group and 40.6%in the intermediate-risk group).The accuracy of ASGE guideline for CT was 63.98%(79.12%sensitivity,42.80%specificity)and 36.02%(20.88%sensitivity,57.20%specificity)in the high-risk and intermediate-risk groups,respectively.In 103 patients in the high-risk group underwent both CT and US,the accuracy of CT was higher than that of US for detecting choledocholithiasis(78.64%vs.53.40%),with a significant difference in area under the curve(AUC)(0.78 vs.0.59,P<0.001).Of 339 with negative CT finding,the accuracy of EUS was higher than that of MRCP(90.91%vs.82.76%),but with no significant difference in AUC(0.91 vs.0.83,P=0.347).Conclusions:CT-based ASGE guideline showed superior diagnostic performance than US for predicting choledocholithiasis.The diagnostic options,EUS or MRCP,with negative CT finding showed comparable performance.Therefore,the diagnostic modality should be selected based on availability,experience,cost,and contraindications.

Randomized clinical trial comparing fixed-time split dosing and split dosing of oral Picosulfate regimen for bowel preparation

AIM To compare the efficacy of fixed-time split dose and split dose of an oral sodium picosulfate for bowel preparation.METHODS This is study was prospective, randomized controlled study performed at a single Institution(2013-058). A total of 204 subjects were assigned to receive one of two sodium picosulfate regimens(i.e., fixed-time split or split) prior to colonoscopy. Main outcome measurements were bowel preparation quality and subject tolerability.RESULTS There was no statistical difference between the fixedtime split dose regimen group and the split dose regimen group(Ottawa score mean 2.57 ± 1.91 vs 2.80 ± 2.51, P = 0.457). Cecal intubation time and physician's satisfaction of inspection were not significantly different between the two groups(P = 0.428, P = 0.489). On subgroup analysis, for afternoon procedures, the fixed-time split dose regimen was equally effective as compared with the split dose regimen(Ottawa score mean 2.56 ± 1.78 vs 2.59 ± 2.27, P = 0.932). There was no difference in tolerability or compliance between the two groups. Nausea was 21.2% in the fixed-time split dose group and 14.3% in the split dose group(P = 0.136). Vomiting was 7.1% and 2.9%(P = 0.164), abdominal discomfort 7.1% and 4.8%(P = 0.484), dizziness 1% and 4.8%(P = 0.113), cold sweating 1% and 0%(P = 0.302) and palpitation 0% and 1%(P = 0.330), respectively. Sleep disturbance was two(2%) patients in the fixed-time split dose group and zero(0%) patient in the split dose preparation(P = 0.143) group.CONCLUSION A fixed-time split dose regimen with sodium picosulfate is not inferior to a split dose regimen for bowel preparation and equally effective for afternoon colonoscopy.