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Canadian Journal of Gastroenterology and Hepatology
Volume 28, Issue 7, Pages 385-390
http://dx.doi.org/10.1155/2014/797960
Original Article

Poor ‘Real-Life’ Negative Predictive Value of Cross-Sectional Imaging in Obstructive Jaundice

Brian A Brunson,1 Robert Hawes,2 Brenda Hoffman,3 Stacie Vela,4 and Joseph Romagnuolo5

1Gastroenterology Associates, Birmingham, Alabama, USA
2Florida Hospital, Orlando, Florida, USA
3Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
4Baylor Medical College, Houston, Texas, USA
5Palmetto Health and Columbia Gastroenterology Associates, Columbia, South Carolina, USA

Received 3 April 2014; Accepted 19 April 2014

Copyright © 2014 Hindawi Publishing Corporation. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

BACKGROUND: Cross-sectional imaging remains the first-line test for obstructive jaundice despite high miss rates for pancreatobiliary tumours. Improvements in resolution and slice thickness of spiral computed tomography/magnetic resonance imaging/magnetic resonance cholangiopancreatography promised to increase accuracy.

OBJECTIVE: To assess whether the post-test probability of neoplasm is truly altered by the presence or absence of a mass on computed tomography/magnetic resonance imaging in obstructive jaundice.

METHODS: The institutional endoscopic ultrasound (EUS) database was retrospectively reviewed to stratify patients presenting to EUS over a two-year period for obstructive jaundice (suspicious for malignancy) according to their pre-EUS imaging results. The primary analysis involved the calculation of the positive predictive value and negative predictive value (NPV) of imaging with 95% binomial CIs. Test performance of EUS/fine-needle aspiration (FNA) was also calculated. Final diagnosis was determined by positive cytology/histology; negative EUS was supplemented by clinical follow-up.

RESULTS: The positive predictive value (n=51) and NPV (n=53) of pre-EUS imaging was 98% (95% CI 90% to 100%) and 9% (95% CI 3% to 21%), respectively (accuracy 53%), with post-test suspicion of malignancy similar between imaging-positive and -negative groups. EUS demonstrated a mass in 96% of imaging-positive cases versus 85% in imaging-negative cases (exact P=0.09). Malignant or suspicious FNA cytology was obtained with EUS in 92% of the imaging-positive group, and 62% of the imaging-negative group (75% of subgroup with FNA) (P<0.001).

CONCLUSION: Lack of a definite mass on pre-EUS imaging had low NPV, and was clearly not sufficiently accurate or reassuring in this clinical setting. In suspicious obstructive jaundice, EUS with FNA has a high diagnostic yield regardless of the findings of pre-EUS cross-sectional imaging and, as such, EUS may be a more reasonable first-line test in this high-suspicion setting.