ERCP has been the accepted gold standard for evaluation of the biliary tract. However, given the potential complications of this relatively invasive procedure, most importantly pancreatitis and cholangitis, it would be useful to find less invasive diagnostic alternative. The two most important alternative imaging modalities are Endoscopic Ultrasound (EUS) and Magnetic Resonance Cholangiopancreatography (MRCP) and both have been individually compared with ERCP for detection of biliary disease. Variable results were found with MRCP, with sensitivities ranging from 85% to >90%. These results were dependent on radiologic experience in interpretation of images and emerging technology for imaging resolution. EUS, in studies outside the United States, has been found to have >90% sensitivity in detecting choledocholithiasis in highly experienced hands. However, no North American trails have confirmed these results. With the published data individually comparing ERCP to EUS and MRCP, we hypothesize that EUS and MRCP will be equivalent to diagnostic ERCP in detecting extrahepatic biliary disease and will be associated with fewer complications. Furthermore, the use of EUS in patients with suspected extrahepatic biliary disease will lead to the lowest overall cost per patient. Thus, in this prospective, blinded study, EUS and MRCP will be compared with ERCP in patients with suspected extrahepatic biliary disease. The accuracy and complication rates will be compared between the three methods. A cost analysis of the potential impact of each precedure on patient management will be performed.
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