EUS findings in patients with autoimmune pancreatitis

BACKGROUND: Autoimmune pancreatitis is an increasingly recognized benign condition with a presentation similar to pancreatic neoplasia but responds to corticosteroid therapy. Clinical features, ERCP, and CT findings have been described. This study assessed the EUS and EUS-guided FNA features of proven autoimmune pancreatitis. METHODS: The diagnosis of autoimmune pancreatitis was based on examination of surgical resection specimens or typical clinical findings (elevated immunoglobulin G level, no evidence of malignancy, characteristic non-EUS imaging studies, and clinical improvement, especially in response to treatment with a corticosteroid). RESULTS: Presenting manifestations in 14 patients included obstructive jaundice, abdominal pain, and weight loss. Ten patients underwent surgery (including exploratory surgery). Six were successfully treated with corticosteroid. EUS revealed diffuse hypoechoic pancreatic enlargement (8/14) or a focal irregular hypoechoic mass (6/14). Features of chronic pancreatitis were not noted. EUS-guided FNA of the pancreas was suggestive of chronic inflammatory pancreatitis in 9 of 12 patients. Celiac and peripancreatic lymphadenopathy (up to 3 cm in diameter) was present in 6 patients. EUS-guided FNA of lymph nodes (3/4) did not reveal evidence of malignancy. Vascular involvement was noted in 3 patients. CONCLUSIONS: The EUS features of autoimmune pancreatitis are easily mistaken for malignancy. However, a diffusely hypoechoic, enlarged pancreas, together with chronic inflammatory cells in aspirated cytologic specimens, is supportive of the diagnosis of autoimmune pancreatitis. When combined with clinical data, EUS and EUS-guided FNA may support a diagnosis of autoimmune pancreatitis, may warrant a trial of corticosteroid, and thereby may prevent unnecessary surgery.     

Limitations of screening for occult cancer in patients with idiopathic venous thromboembolism

Background: Idiopathic venous thrombosis (IVT) is associated with occult malignancy in 10% of patients. The Trousseau study investigated whether extensive screening using abdominal and chest computed tomography (CT) scans and mammography in women would decrease mortality, compared with limited screening. Here, the costs and test characteristics of these screening strategies are presented, including true- and false-positive findings, sensitivity and specificity. Methods: All investigations performed because of a suspicion of malignancy in the limited or extensive screening groups were collected. Costs were calculated using Dutch healthcare tariffs. Results: A total of 342 and 288 patients with IVT were included in the extensive and the limited screening group, respectively. The prevalences of malignancy and mortality were comparable between these two groups, as were the abnormal findings during routine screening. In 30% of the extensively screened patients, the CT scans or mammography showed abnormalities necessitating further diagnostic work-up; this yielded six malignancies and resulted in a positive predictive value of 6.6%, sensitivity of 33% and specificity of 70%. Mean costs per patient were v 165.17 for the routine and v 530.92 for the extensive screening. Conclusion: Screening using CT scans and mammography results in extra costs due to the high percentage of false-positive findings for which a further diagnostic work-up is indicated.     

Biliary microcrystals in idiopathic acute pancreatitis: clue for occult underlying biliary etiology

The main causes of pancreatic inflammation worldwide are biliary lithiasis and alcoholism. However, 10 to 30% of patients have been considered to have "idiopathic" acute pancreatitis. Recently, some studies showed that a significant rate of the so called idiopathic pancreatitis are caused by microlithiasis and/or biliary sludge, identified by the presence of cholesterol monohidrate and/or calcium bilirubinate microcrystals in the biliary sediment. In the present study, the analysis of microcrystals from bile obtained during endoscopic retrograde cholangiopancreatography was done in patients with pancreatitis (idiopathic, biliary or alcoholic--20 in each group). Patients with idiopathic pancreatitis and microcrystals in the bile underwent cholecystectomy whenever possible. Those who refused or were inapt to surgery underwent endoscopic sphincterotomy or received continuous therapy with ursodeoxycholic acid. Patients with idiopathic pancreatitis without biliary crystals did not receive any specific treatment. The prevalence of biliary microcrystals in patients with idiopathic pancreatitis (75%) and biliary pancreatitis (90%) was significantly higher than in those with alcoholic pancreatitis (15%). In the identification of the etiology of biliary pancreatitis, the presence of microcrystals had a sensitivity of 90%, specificity of 85%, positive predictive value of 85.7%, negative predictive value of 89.4% and accuracy of 87.5%. In the patients with recurrent idiopathic pancreatitis, with biliary crystals, there was an statistically significant reduction in the number of pancreatitis episodes after specific treatment. In the follow-up of this group during 23.3 +/- 4.8 months, recurrence of pancreatitis occurred only in patients with "persistent biliary factor" (choledocholithiasis and/or persistence of cholesterol monohidrate). All patients with idiopathic pancreatitis who underwent cholecystectomy had chronic cholecystitis. Moreover, cholelithiasis was present in one case. In the ultrassonographic follow-up of the patients with idiopathic acute pancreatitis with microcrystals in the bile, cholelithiasis was detected in one case. In the subgroup of five patients with idiopathic pancreatitis without biliary microcrystals recurrence occurred in one case. Ultrassonographic study during follow-up did not reveal biliary stones in any of these patients. We concluded that the detection of biliary microcrystals in "idiopathic" pancreatitis suggested an underlying biliary etiology, even if occult. What's more, early specific therapeutic procedure (cholecystectomy, endoscopic sphincterotomy or ursodeoxycholic acid) in patients with recurrent idiopathic pancreatitis with microcrystals in the bile reduced significantly the recurrence during the follow-up. Finally, acute pancreatitis (specially recurrent) should not be called idiopathic before the microscopic analysis of the bile, aiming to detect or exclude the presence of microcrystals.     

A prospective comparison of the yield of EUS in primary vs. recurrent idiopathic acute pancreatitis

BACKGROUND: It is uncertain whether EUS should be performed after a single episode of idiopathic pancreatitis vs. recurrent episodes or if clinical factors can predict positive EUS findings. METHODS: Consecutive patients with a single episode of idiopathic pancreatitis or with recurrent episodes underwent EUS (with analysis of bile for bilirubinate and cholesterol crystals, when possible). The diagnostic yield was compared for patients with a single episode of idiopathic pancreatitis and recurrent episodes (stratified by cholecystectomy status). Predictors of positive EUS findings were sought. EUS was considered "positive" if it identified any possible cause of pancreatitis other than chronic pancreatitis. RESULTS: A total of 370 patients were studied (246 no-cholecystectomy group [134 single episode of idiopathic pancreatitis, 112 recurrent episodes] and 124 post-cholecystectomy group [67 single episode of idiopathic pancreatitis, 57 recurrent episodes]). Overall, EUS yielded a positive finding in 29.2%. For patients in the no-cholecystectomy group, positive EUS findings were not significantly more frequent in those with a single episode of idiopathic pancreatitis vs. those with recurrent episodes (31.3% vs. 32.1%; p = 0.89). In the post-cholecystectomy group, the yield was not significantly different for single episode of idiopathic pancreatitis (29.9%) vs. recurrent episodes (17.5%) ( p = 0.15). Chronic pancreatitis was the only abnormality identified in 30.9% of patients in the no-cholecystectomy group vs. 26.6% of those in the post-cholecystectomy group ( p = 0.24). It was the most common abnormality found in all 4 subgroups (range 16.4%-42.0%) and was approximately twice as frequent in patients with recurrent episodes vs. a single episode of idiopathic pancreatitis (no-cholecystectomy: 42.0% vs. 21.6%, p = 0.0008; post-cholecystectomy: 38.6% vs. 16.4%, p = 0.008). Analysis of bile revealed crystals in 38/80 (47.5%) patients in whom it could be performed. Patients with positive EUS findings tended to be older. CONCLUSIONS: In patients with idiopathic pancreatitis, the yield of EUS is not significantly different after an initial attack or after recurrent attacks. Therefore, it is reasonable to perform EUS after an initial attack of idiopathic acute pancreatitis, especially in older patients.     

腹部CT和EUS检查慢性胰腺炎患者表现特点及其诊断价值分析*

目的 探讨腹部CT和超声内镜（EUS）检查对不同临床分期的慢性胰腺炎（CP）患者的诊断价值。方法 2012年5月~2017年3月我院收治的78例CP患者,均行EUS、腹部CT和胰腺组织病理学检查。应用受试者工作特征（ROC）曲线分析腹部CT和EUS检查对CP临床分期的诊断价值。结果 经组织病理学检查,本组诊断1期CP患者28例,2期24例,3期26例;EUS对1期CP诊断的AUC为0.85（95%CI：0.75~0.92）,其敏感度为85.7%,特异性为84.0%,准确性为84.6%,而腹部CT诊断1期CP的AUC为0.72（95%CI：0.61~0.82）,其敏感度为60.7%,特异性为88.0%,准确性为78.2%;EUS诊断2期CP的AUC为0.81（95%CI：0.70~0.89）,其敏感度为79.2%,特异性为81.5%,准确度为80.8%,而CT诊断2期CP的AUC为0.73（95%CI：0.62~0.82）,其敏感度为62.5%,特异性为85.2%,准确度为78.2%;EUS诊断3期CP的AUC为0.75（95%CI：0.64~0.84）,其敏感度为84.6%,特异性为85.2%,准确度为85.0%,而CT诊断3期CP的AUC为0.69（95%CI：0.57~0.79）,其敏感度为69.2%,特异性为88.9%,准确度为82.5%。结论 EUS和腹部CT检查诊断CP患者具有较高的价值,但在1期CP患者,EUS的诊断效能可能优于腹部CT检查。     

Detection of occult liver metastases during EUS for staging of malignancies

BACKGROUND: EUS is commonly used in the staging of GI, thoracic, and other malignancies. Studies suggest EUS can detect occult liver metastases, but the frequency with which this occurs is unknown. METHODS: Records were reviewed for all patients seen during a 3-year period who underwent EUS of the upper-GI tract for staging of known or suspected malignancy. Patients were included if there was histopathologic evidence of malignancy, they had undergone noninvasive liver imaging within 6 weeks of EUS, and liver surveillance was specifically mentioned in the report of the EUS procedure. RESULTS: A total of 222 patients were included. Liver lesions were seen in 27 patients, 17 of whom had an abnormal noninvasive liver imaging test. EUS-guided FNA of the liver was performed in 21 patients and was diagnostic of malignancy in 15 (6.8%), 5 of whom (2.3%) had normal noninvasive imaging. In 6 patients, the EUS-guided FNA result was benign. EUS missed liver lesions in 4 patients known to have abnormalities by other imaging modalities. CONCLUSIONS: EUS can detect occult liver metastases in patients in whom noninvasive hepatic imaging studies are normal, although the frequency at which such lesions are detected is low. Liver surveillance during EUS is worthwhile for patients in whom there is another indication for the procedure; but, at present, EUS should not replace traditional imaging modalities.     

Diagnostic performance of EUS for chronic pancreatitis: a comparison with histopathology

BACKGROUND: EUS has been proposed as a minimally invasive and accurate test to detect chronic pancreatitis (CP). OBJECTIVE: To investigate the correlation between EUS criteria and histopathology grading in patients with presumed CP. DESIGN: Retrospective study. SETTING AND PATIENTS: Patients who received pancreatic surgery according to presumed CP from the Medical University of South Carolina surgical database between 1995 and 2003 were identified and included if EUS was performed within 1 year before surgery. The number of EUS criteria for CP was compared with a histologic fibrosis score (FS). MAIN OUTCOME MEASUREMENTS: Sensitivity and specificity of number of EUS criteria compared with FS. RESULTS: Seventy-one patients were identified (38 women). Median FS was 7 (range, 0-12). Of the patients with calcifications: calcifications were detected by EUS in 30 (42%), 14 (47%) had calcifications missed by other imaging modalities, and 28 (93%) were confirmed to have abnormal histology (FS > or = 2). Of the patients without calcifications: in the 41 patients without calcifications on EUS, 36 (88%) had FS > or = 2; median FS was 5 (range, 0-12); the correlation between the number of EUS criteria and FS was low but statistically significant (r = 0.40; P = .01). Three or more EUS criteria provided the best balance of sensitivity (83.3%) and specificity (80.0%) for predicting abnormal histology. LIMITATIONS: Retrospective study. All patients were believed to need surgery. CONCLUSIONS: A threshold of 3 or more EUS criteria provides the best balance of sensitivity and specificity for histologic pancreatic fibrosis. Calcifications seen by EUS but missed by other imaging are common in this group of patients.     

Preoperative detection of occult enterovesical fistulas in patients with Crohn's disease

OBJECTIVES: Nonhazardous enteral administration of indocyanine green solution was performed to detect enterovesical occult microfistulas in patients with Crohn's disease before the fistulas had become readily apparent. METHODS: A total of 12 patients with Crohn's disease who were suspected from their clinical manifestations of having enterovesical fistulas underwent study. For detection of the fistulas after oral or rectal administration of the indocyanine green solution, urine was collected and examined using a colorimeter to check for contamination with indocyanine green. The effectiveness of the indocyanine green test and conventional x-ray study was compared. RESULTS: The indocyanine green test was positive after either oral or rectal administration in 11 of the 12 patients, providing a rate of accurate diagnosis of 92 percent (11/12 patients). In contrast, the rate of accurate diagnosis using the x-ray study was only 17 percent (2/12 patients). Furthermore, in eight patients with occult fistulas, accurate diagnosis could be made in none using the x-ray study, whereas all showed positive results with use of the indocyanine green test. CONCLUSIONS: The ability to diagnose obscure fistulas using the indocyanine green test was 92 percent. This indocyanine green test was highly diagnostic, whereas conventional examinations are often complicated and much less diagnostic.     

胆石症患者胆汁菌群分布及药敏分析

目的 比较有无胆管炎的胆石症患者胆汁细菌培养阳性率差异,以及结石数量、患者年龄对培养结果的影响,了解病原菌菌谱及药敏情况.方法 对我院2008年1月至7月行内镜逆行胰胆管造影术(ERCP)中获取的61例胆汁标本进行细菌培养和药敏试验.结果 胆汁培养阳性率为68.8%,其中G-杆菌36株(占85.7%),G+球菌5株(占11.9%),真菌1株(占2.4%).合并胆管炎患者细菌培养阳性率为76.9%明显高于单纯胆结石的阳性率50%(P＜0.05);大于或等于60岁患者,细菌培养阳性率为78.0%明显高于＜60岁的45%(P＜0.05).药敏结果显示,G-菌对三代头孢、美罗培南、阿米卡星敏感性较好.结论 胆管是否存在炎症及年龄因素对细菌培养结果有显著影响,结石数量与胆汁培养阳性率无关.胆汁细菌中以G-杆菌为主,要有针对性地合理选用抗生素.     

Pathogenesis of cholelithiasis in chronic pancreatitis]

The prevalence and the pathogenesis of gallstones in patients with chronic pancreatitis have never been studied prospectively. The aim of this study was to evaluate prospectively the prevalence of gallstones with ultrasonography and to look for markers of pigment or cholesterol stone formation in gallbladder bile. Ultrasonography was performed in 39 patients and detected gallstones in 7 patients and sludge in 3. Common bile duct and intrahepatic bile duct dilatation were observed in 16 and 13 patients, respectively. Liver biopsies were obtained in 31 patients and cirrhosis was found in 4. There were calcium bilirubinate granules in 7 of the 27 bile samples examined. Cholesterol crystals were not found in any case. The nucleation time (median: 21 days) was higher in patients with chronic pancreatitis than in patients with cholesterol stones (median: 2 days) (P < 0.001) but was not different from nucleation time in patients either free of stones (median: 21 days) or with pigment stones (median: 21 days). The cholesterol saturation index was similar in patients with chronic pancreatitis and in controls. The 2 patients with chronic pancreatitis who underwent cholecystectomy had pigment stones. Calcium bilirubinate granules were more frequent in patients with intrahepatic bile ducts dilatation (P < 0.02). In conclusion, this study demonstrates a high prevalence of cholelithiasis in chronic pancreatitis patients. Pigment stone formation could be favored by cholestasis.     

ERCP联合胆道微结石检测对明确特发性急性胰腺炎病因的价值

目的:探讨内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)联合胆道微结石检测对特发性急性胰腺炎(idiopathic pancreatitis,IAP)病因的诊断价值.方法:以2008-01/2011-01急性胰腺炎(acute pancreatitis,AP)患者105例为研究对象,选择影像学(CT、B超、MRCP)检查后不能明确病因的特发性急性胰腺炎患者42例进行诊断性ERCP检查,同时收集胆汁5mL行胆道微结石监测.以2005-01/2008-01AP患者90例为对照组,应用SPSS13.0统计软件统计,取P<0.05差异有统计学意义.结果:对照组对AP病因确诊率为55.5%(50/90),联合检查组对AP的病因确诊率为87.5%(93/105),差异有统计学意义(P<0.05),ERCP联合胆道微结石检测对IAP病因有较高的确诊率.结论:ERCP联合胆道微结石检测对明确IAP病因有重要价值.     

Endoscopic ultrasound (EUS) elastography and contrast enhanced EUS in groove pancreatitis

We report for the first time the findings on endoscopic ultrasound elastrography and contrast enhanced EUS in a patient with groove pancreatitis.     

EUS vs MRCP for detection of choledocholithiasis

BACKGROUND: Numerous published studies have shown the high diagnostic performance of both EUS and MRCP compared with ERCP for the detection of choledocholithiasis. DESIGN: We undertook a systematic review of all published randomized, prospective trials that compared EUS with MRCP with the primary aim being to compare the overall diagnostic accuracy for the detection of choledocholithiasis in patients with suspected biliary disease. METHODS: A MEDLINE review was performed. We identified 5 randomized, prospective, blinded trials comparing MRCP and EUS for the detection of choledocholithiasis, with subsequent ERCP or intraoperative cholangiography as a criterion standard. The study-specific variables for EUS and MRCP for choledocholithiasis were calculated from the data, and analyses were performed by using aggregated variables (sensitivity, specificity, positive and negative predictive values, and likelihood ratios). RESULTS: The pooled data set consisted of 301 patients. The aggregated sensitivities of EUS and MRCP for the detection of choledocholithiasis were 0.93 and 0.85, respectively, whereas their specificities were 0.96 and 0.93, respectively. The aggregated positive predictive values for EUS and MRCP were 0.93 and 0.87, respectively, with the corresponding negative predictive values of 0.96 and 0.92, respectively. Positive likelihood ratios were >10 for both tests, and corresponding negative likelihood ratios approached 0.10 for both tests. No statistically significant differences between EUS and MRCP were found in our analysis. CONCLUSIONS: EUS and MRCP have high diagnostic performance overall. Our analysis showed no statistically significant difference between the modalities. We recommend taking into consideration other factors, such as resource availability, experience, and cost considerations in deciding between these 2 tests.     

Chest radiography as a method of screening for occult cancer in patients with idiopathic deep vein thrombosis

The occurrence of neoplasms in patients with idiopathic deep vein thrombosis (DVT) may result in a significant reduction in survival rates. The aim of our study was to assess the use of chest X-rays (CXRs) as a screening method of intrathoracic neoplasms in patients who with idiopathic DVT. In observational, cross-sectional study, the medical records of 99 patients with idiopathic DVT, who were submitted to CXR (during the hospital stay or within 30 days after discharge), were investigated. Of these patients, 15.1% had images suggestive of thoracic neoplasias (single or multiple pulmonary nodules and mediastinal widening). Neoplasms were diagnosed in 4 patients in the follow-up with CXR. The CXR is an option of early screening for thoracic neoplasms and other nonmalignant diseases in patients with idiopathic DVT.     

手术治疗胆石症并发急性胰腺炎患者血清炎症和氧化应激介质的变化

目的 探讨胆石症并发急性胰腺炎（AP）患者在病情稳定后接受腹腔镜胆囊切除术（LC）治疗血清炎性和氧化应激介质的变化。 方法 150例胆石症并发AP患者,在内科治疗病情稳定后,84例接受LC术,66例接受开腹胆囊切除术。采用ELISA法检测血清白介素-6（IL-6）、IL-10和C反应蛋白（CRP）;采用ELISA法检测血清丙二醛（MDA）、氧化型低密度脂蛋白（ox-LDL）和对氧磷酶-1（PON-1）;采用高效液相色谱法检测血清8-羟基鸟嘌呤（8-OHG）。 结果 术后第5天,LC组血清IL-6水平为（42.3±4.8）μg/L,显著低于开腹组的【（57.7±5.1）μg/L,P<0.05】,IL-10水平为（64.3±5.3） pg/ml,显著高于开腹组的【（51.2±4.2） pg/ml,P<0.05】,CRP水平为（15.8±5.7）μg/L,显著低于开腹组的【（38.4±6.8） μg/L,P<0.05】;MDA水平为（3.3±0.9） nmol/mL,显著低于开腹组的【（5.4±1.8） nmol/mL,P<0.05】,ox-LDL水平为（63.2±11.7） ng/ml,显著低于开腹组的【（72.3±11.0） ng/ml,P<0.05】,PON-1水平为（116.3±10.2） U/ml,显著高于开腹组的【（104.5±11.4） U/ml,P<0.05】,8-OHG水平为（0.5±0.2）ng/ml,与开腹组的（0.6±0.2） ng/ml比,无显著性相差（P>0.05）。 结论 对于胆石症并发AP患者,在内科控制AP病情后,及时行LC手术治疗,去除结石,可以减轻患者的氧化应激反应,安全可行。     

A prospective evaluation of catheter probe EUS for the detection of ascites in patients with gastric carcinoma

BACKGROUND: Gastric carcinoma is known for its propensity to spread to the peritoneum. This study assessed the value of EUS in the detection of ascites not visible on CT in patients with gastric carcinoma. METHODS: A total of 402 consecutive patients with histopathologically confirmed gastric adenocarcinoma underwent catheter-probe EUS. The accuracy of catheter-probe EUS in the detection of ascites was compared with subsequent findings at laparoscopy or laparotomy. RESULTS: There was a slight predominance of men in the study population (M:F=1.6:1). Mean patient age was 65.4+/-0.7 years. Ascites was noted by catheter-probe EUS in 36 patients (9.0%). There was no procedure-related morbidity or mortality. Ascites and peritoneal seeding subsequently were found in, respectively, 56 (13.9%) and 66 (16.4%) patients. The finding of ascites by EUS was significantly related to the presence of peritoneal seeding (p<0.001). The sensitivity, specificity, and positive and negative predictive values of EUS in the detection of ascites were, respectively, 60.7%, 99.4%, 94.4%, and 94.0%. The positive and negative likelihood ratios were, respectively, 105.0: 95% CI[26, 425] and 0.40: 95% CI[0.29, 0.55]. CONCLUSIONS: EUS is useful for the detection of ascites in patients with gastric carcinoma.