Diagnosis of intraductal papillary mucinous neoplasm using endoscopic ultrasound guided microbiopsies:A case report

Pancreatic cysts are increasingly diagnosed due to expanding use of cross-sectional imaging,but current diagnostic modalities have limited diagnostic accuracy.Recently,a novel through-the-needle microbiopsy forceps has become available,offering the possibility of obtaining cyst-wall biopsies.We present a case of 41-year-old male with chronic pancreatitis and a 2-cm pancreatic cyst,initially considered a pseudocyst.Subsequently,endoscopic ultrasou-nd guided microbiopsies were successfully obtained,which surprisingly revealed an intraductal papillary mucinous neoplasm of mixed subtype with low grade dysplasia.In conclusion,obtaining biopsies from the wall of the pancreatic cystic lesions with this novel instrument is feasible and,as demonstrated in this case,can possibly alter the clinical outcome.Microbiopsies offered enough cellular material,allowing supplemental gene mutation analysis,which combined with other modalities could lead to a more individual approach when treating pancreatic cysts.However,prospective studies are warranted before routine clinical implementation.     

Diagnosis of ectopic pancreas by endoscopic ultrasound with fine-needle aspiration

AIM:To study the clinical,endoscopic,sonographic,and cytologic features of ectopic pancreas(EP).METHODS:This was a retrospective study performedat an academic referral center including two hospitals.Institutional review board approval was obtained.Patients referred to the University Hospital or Denver Health Medical Center Gastrointestinal Endoscopy Lab for gastroduodenal subepithelial lesions(SEL)with a final diagnosis of EP between January 2009and December 2013 were identified.Patients in this group were selected for the study if they underwent endoscopic ultrasound(EUS)with fine-needle aspiration(FNA)or deep biopsy.A review of the medical record was performed specifically to review the following information:presenting symptoms,endoscopic and EUS findings,computed tomography or magnetic resonance imaging findings,pathology results,procedure-related adverse events,and subsequent treatments after EUSFNA.EUS with FNA or deep submucosal biopsy was performed in all patients on an outpatient basais by one of two physicians(Attwell A,Fukami N).Review of all subsequent clinic notes and operative reports was performed in order to determine follow-up and final diagnoses.RESULTS:Between July 2009 and December 2013,10patients[3 males,7 females,median age 52(26-64)years]underwent EUS for a gastroduodenal SEL and were diagnosed with EP.One patient was symptomatic.Six(60%)lesions were in the antrum,3(30%)in the body,and 1(10%)in the duodenum.A mucosal dimple was noted in 6(60%).Mean lesion size was 17(8-25)mm.Gastrointestinal wall involvement:muscularis mucosae,10%;submucosa,70%;muscularis propria,60%;and serosa,10%.Nine(90%)lesions were hypoechoic and 5(50%)were homogenous.A duct was seen in 5(50%).FNA was attempted in 9(90%)and successful in 8(80%)patients after 4(2-6)passes.Cytology showed acini or ducts in 7 of 8(88%).Superficial biopsies in 7 patients(70%)showed normal gastric mucosa.Deep endoscopic biopsies were taken in 2 patients and diagnostic in one.One patient(10%)developed pancreatitis after EUS-FNA.Two patients(20%)underwent surgery to relieve symptoms or confirm the diagnosis.The main limitation of the study was the fact that it was retrospective and performed at a single medical center.CONCLUSION:EUS features of EP include antral location,mucosal dimple,location in layers 3-4,and lesional duct,and FNA or biopsy is accurate and effective.     

Differential diagnosis of pancreatic lesions using endoscopic ultrasound

The most common pancreatic tumour is the ductal adenocarcinoma. Many other benign and malignant pancreatic neoplasms have to be recognised and now account for more than 50 % of the pancreatic lesions seen in our daily routine. An improved differential diagnosis is, therefore, mandatory and will be discussed in this review.     

Diagnosis of autoimmune pancreatitis using endoscopic ultrasonography

Background  Revised clinical criteria for autoimmune pancreatitis (AIP) have been proposed by the Research Committee of Intractable Disease of the Pancreas and the Japan Pancreas Society. These criteria require distinguishing AIP from neoplastic lesions. However, this can be difficult, and patients often undergo surgery on the basis of suspected pancreatic cancer (PC). Methods  AIP was diagnosed in 25 patients at the Aichi Cancer Center Hospital (ACCH) according to the revised AIP criteria. In each patient, endoscopic ultrasonography (EUS) was used to describe the conventional pancreatic parenchymal and ductal features of chronic pancreatitis (Sahai criteria), and other abnormal features, namely, diffuse hypoechoic areas (DHAs), diffuse enlargement (DE), focal hypoechoic areas (FHAs), focal enlargement, bile duct wall thickening (BWT), lymphadenopathy, and peripancreatic hypoechoic margins (PHMs). We compared these features between 25 patients with AIP and 30 patients with pancreatic cancer resected at ACCH. Results  Few conventional EUS features of chronic pancreatitis (CP) were seen in patients with AIP (mean, 2.0 features). Frequencies of DHA, DE, BWT, and PHM were significantly higher in AIP than in PC. DHAs, DE, and FHAs resolved after steroid treatment. Conclusions  Novel EUS features of AIP are useful in distinguishing AIP from PC and for following the effects of steroid therapy.     

Clinical effects of eosinophilic esophagitis observed using endoscopic ultrasound

A 50-year-old woman was referred to our hospital for dysphagia and several episodes of esophageal food impaction during the prior three months. Complete blood count and basic biochemical tests were normal. No eosinophilia was found. Esophagogastroduodenoscopy (EGD) revealed the presence of concentric rings (esophageal “trachealization”) and stenosis along the middle and distal esophagus. Endoscopic ultrasound (EUS) showed circumferential thickening of all layers in the same part. Cytopathologic evaluation of a specimen obtained by endoscopic biopsy of the thickened area in the distal esophagus showed eosinophilic infiltration (20 eosinophils per high-powered field). She was diagnosed as having eosinophilic esophagitis (EoE). Topical steroid therapy was started. A tendency of dysphagia for relief and improvement of characteristic EGD findings began early, but wall thickening in EUS remained. Past reports of the related literature have described that thickness of submucosa and muscularis propria remained after therapy, although significant reduction in the mucosal thickness was provided by short-term steroid therapy. One explanation for early relapse is insufficient reduction in the submucosa and muscularis propria. Consequently, our patient was given steroids until thickness on EUS improved. EUS is regarded as useful for evaluating the curative effect in patients with EoE.     

Diagnosis of deep-vein thrombosis using duplex ultrasound

PURPOSE: To critically evaluate the accuracy, advantages, and drawbacks of duplex ultrasound as a diagnostic test for proximal deep-vein thrombosis. DATA IDENTIFICATION: An English-language search using MEDLINE (1980 to 1988) and bibliographies from articles, and a hand search of pertinent radiology and ultrasound journals from 1988. STUDY SELECTION: All series comparing duplex ultrasound to the reference standard, contrast venography, were reviewed and classified into levels based on the quality of study design. DATA EXTRACTION: Results of duplex ultrasound compared with venography in the proximal deep venous system, technical problems encountered, frequency of diagnosis of other causes of leg swelling, and frequency of unsuccessful or inconclusive studies were collated. RESULTS OF DATA SYNTHESIS: Four well-designed studies reported similar results. The sensitivity of duplex ultrasound in detecting proximal thrombi ranged from 92% to 95% with a combined sensitivity of 93% (CI, 88% to 98%), and the specificity ranged from 97% to 100% with a combined sensitivity of 98% (CI, 96% to 100%). Similar findings were noted in nine other studies that had minor methodologic flaws. Four studies reported that ultrasound was able to identify a nonthrombotic cause of leg swelling in 5% to 15% of cases. Four studies found that duplex ultrasound was inconclusive in 1% to 6% of cases, with a combined frequency of 2%. CONCLUSIONS: Duplex ultrasound appears to be very accurate in the detection of acute proximal deep-vein thrombosis. This test has major advantages as well as certain limitations compared with other diagnostic methods.     

超声内镜诊断腹膜后淋巴管瘤1例(含视频)

腹膜后淋巴管瘤是腹膜后肿瘤中的一种, 多数是先天性的, 呈单房或多房的囊性形态, 当体积较大时会出现压迫及浸润周围器官组织的特征, CT和(或)磁共振等传统影像学检查很难将其与腹膜后其他肿瘤进行鉴别, 较难进行外科术前精准诊断评估。本文介绍了1例腹膜后淋巴管瘤术前借助超声内镜精准诊断评估的病例, 并结合既往国内外文献对该病进行系统性分析, 以提高临床医师对该病的认识及治疗水平。     

Diagnosis of recurrent upper gastrointestinal cancer at the surgical anastomosis by endoscopic ultrasound

Endoscopic ultrasonography (EUS) with a 7.5 MHz transducer was used to examine the upper gastrointestinal tract in 40 patients who had resection of esophageal or gastric cancer, and symptoms suggesting recurrence. There were 24 patients with recurrent cancer in the area of the surgical anastomosis (based on endoscopic biopsy in 16, repeat endoscopy in 2, and surgery after negative endoscopy in 6), and 16 patients without anastomotic recurrence. With EUS, locally recurrent cancer was correctly identified by nodular hypoechoic thickening at the anastomosis in 23 of 24 patients with one false negative; absence of anastomotic recurrence was correctly diagnosed in 13 of 16 with three false positives (sensitivity, 95%; specificity, 80%; positive predictive accuracy, 88%; and negative predictive accuracy, 92%). High frequency EUS with limited depth of penetration is not effective for evaluation of distant metastases, but is ideally suited for diagnosis of locally recurrent esophageal and gastric cancer.     

Evidence based endoscopic ultrasound

In this overview the variety of current evidence based diagnostic options of EUS are discussed.     

Current state of endohepatology: Diagnosis and treatment of portal hypertension and its complications with endoscopic ultrasound

The diagnosis and management of cirrhosis and portal hypertension (PH) with its complications including variceal hemorrhage, ascites, and hepatic encephalopathy continues to evolve. Although there are established “standards of care” in liver biopsy and measurement of PH, gastric varices remain an area without a universally accepted therapeutic approach. The concept of “Endo Hepatology” has been used to describe of the applications of endoscopic ultrasound (EUS) to these challenges. EUS-liver biopsy (EUS-LB) offers an alternative to percutaneous and transjuglar liver biopsy without compromising safety or efficacy, and with added advantages including the potential to reduce sampling error by allowing biopsies in both hepatic lobes. Furthermore, EUS-LB can be performed during the same procedure as EUS-guided portal pressure gradient (PPG) measurements, allowing for the collection of valuable diagnostic and prognostic data. EUS-guided PPG measurements provide an appealing alternative to the transjugular approach, with proposed advantages including the ability to directly measure portal vein pressure. In addition, EUS-guided treatment of gastric varices (GV) offers several possible advantages to current therapies. EUS-guided treatment of GV allows detailed assessment of the vascular anatomy, similar efficacy and safety to current therapies, and allows the evaluation of treatment effect through doppler ultrasound visualization. The appropriate selection of patients for these procedures is paramount to ensuring generation of useful clinical data and patient safety.     

Impact of endoscopic ultrasound quality assessment on improving endoscopic ultrasound reports and procedures

AIM: To evaluate the impact of endoscopic ultrasonography (EUS) quality assessment on EUS procedures by comparing the most recent 2013-2014 local EUS procedural reports against relevant corresponding data from a 2009 survey of EUS using standardized quality indicators (QIs).METHODS: Per EUS exam, 27 QIs were assessed individually and by grouping pre-, intra-, and post-procedural parameters. The recorded QI frequencies from 200 reports (2013-2014) were compared to corresponding data of 100 reports from the quality control study of EUS in 2009. Data for QIs added after 2009 to professional guidelines (added after 2010) were also tabulated.RESULTS: Significant differences (P-value < 0.05) were found for 13 of 20 of the relevant QIs examined. 4 of 5 pre-procedural QIs, 6 of 10 intra-procedural QIs, and 3 of 5 post-procedural QIs all demonstrated significant upgrading with a P-value < 0.05.CONCLUSION: Significant improvements were demonstrated in QI adherence and thus EUS reporting and delivery quality when the 2013-2014 reports were compared to 2009 results. QI implementation facilitates effective high-quality EUS exams by ensuring comprehensive documentation while limiting error.     

Diagnosis of valvular heart disease using transcutaneous Doppler ultrasound

An ultrasonic Doppler instrument capable of measuring mean and maximum velocities inside a small sample volume is presented. The instrument has been used for determining velocities in normal and diseased heart valves. A method is described for identifying the different heart valves, based on their relation to one another as well as the form of the velocity curve. The pressure drop across the mitral valve can be determined from the maximum velocity and the mean velocity can be used to determine the degree of aortic insufficiency. Recordings of mean and maximum velocities can give an indication of the form of the whole spectrum, thus making complete frequency analysis unnecessary for most purposes.