The use of EUS to diagnose malignant portal venous system invasion by pancreatic cancer

Background: CT scanning and mesenteric angiography are insensitive tests for diagnosing vascular invasion by pancreatic cancer. Endoscopic ultrasound (EUS) has been proposed as an alternative. The sensitivity, specificity, and accuracy of specific EUS criteria for diagnosing malignant invasion of the branches of the portal venous system have not been determined. Methods: This is a prospective blinded evaluation of EUS and angiography to diagnose malignant invasion of the portal venous system by pancreatic cancer in 45 patients, 28 of whom underwent surgery. Surgical staging was used as the gold standard for determining the accuracy of EUS and angiography. Results: Four EUS criteria were studied and the overall accuracy rates were as follows: irregular venous wall (87%), loss of interface (78%), proximity of mass (73%), and size (39%). Although “irregular venous wall” was the most accurate, it suffered from a low sensitivity rate (47%) because of its relative inability to detect superior mesenteric vein invasion (sensitivity of 17%). The angiographic criteria had accuracy rates of 73% to 90% with low sensitivity rates (20% to 77%). The clean resection rate was 86% when all tests were used, 78% if EUS was used without angiography, and 60% if only angiography was used. Conclusion: EUS is highly sensitive for detecting portal and splenic vein invasion by pancreatic cancer, but may be insensitive for superior mesenteric vein involvement. (Gastrointest Endosc 1996;43:561-7.)     

A New Invasion Score for Determining the Resectability of Pancreatic Carcinomas with Contrast-Enhanced Multidetector Computed Tomography

Objective: It was the aim of this study to evaluate a new infiltration score to determine the resectability of pancreatic carcinomas in preoperative planning. Materials and Methods: Eighty patients with suspected pancreatic tumor were examined prospectively using 16-row spiral CT. The scans were evaluated for the presence of pancreatic carcinoma, peripancreatic tumor extension and vascular invasion using a standardized questionnaire. Invasion of the surgically relevant vessels was evaluated using a new invasion score. The operative and histological findings and the clinical follow-up served as the gold standard. Results: Forty patients had a pancreatic carcinoma, 5 had metastasis of a different primary tumor, and in 35 patients, there was no malignant pancreatic disease. The sensitivity for tumor detection was 100%, with a specificity of 88% for differentiating between malignant and benign pancreatic tumors. Invasion of the surrounding vessels was evaluated correctly using the invasion score, with a sensitivity of 89% and a specificity of 99%. In evaluation of resectability, a sensitivity of 94% and a specificity of 89% were achieved. Conclusion: Using 16-row spiral CT, the invasion score is a valid tool for correctly assessing invasion in relevant vessels in cases of pancreatic carcinoma and for determining resectability.     

Modification and establishment of CT criteria in preoperative assessment of portal venous invasion by hilar cholangiocarcinoma

Background

To compare the diagnostic performance of CT criteria and to establish a new model in evaluating portal venous invasion by hilar cholangiocarcinoma.

Multidetector CT Evaluation of the Course of Nonresectable Pancreatic Carcinomas with Neoadjuvant Therapy

Objective: A prospective study to determine the value of multidetector CT (MD-CT) in assessing the course of nonresectable pancreatic carcinoma during therapy. Material and Methods: 26 patients with nonresectable pancreatic carcinoma underwent MD-CT before and after therapy. The examinations were evaluated with regard to tumor size and vascular invasion using an invasion score (IS) by 2 radiologists independently (κ analysis). Diagnosis was confirmed surgically, by biopsy or clinical course. Results: Sensitivity for the assessment of irresectability was 100%. Following therapy, 54% of all the tumors were smaller (14/26), 42% had increased in volume (11/26), and one tumor remained stable (1/26). The IS (veins) during follow-up changed in 26 patients (portal vein: 5 higher (mean score 10.4/16.2), 4 lower (mean score 17.5/11.5); superior mesenteric vein: 12 higher (11/14.4), 5 lower (16.2/14.6); p = 0.026). The IS (arteries) changed in 13 patients (celiac trunk: 3 higher (3.3/10); hepatic artery: 4 higher (5.7/10.2), 3 lower (11.6/10.3); superior mesenteric artery: 2 higher (4.5/9.5), 1 lower (12/11)). The k values were calculated between 0.56 and 0.87. Conclusion: MD-CT is suitable for evaluating tumor spread during therapy for nonresectable pancreatic carcinoma. The IS is useful for assessing the degree of change in vessel invasion.     

Aberrant Hepatic Artery in Patients Undergoing Pancreaticoduodenectomy

Background: It is very important to keep the integrity of the hepatic artery blood supply in patients treated by pancreaticoduodenectomy. Knowing and identifying hepatic artery anomalies is helpful to avoid injuring them during the procedure of pancreaticoduodenectomy in patients with ampullary tumors (including cancer in the pancreatic head). Methods: Aberrant hepatic artery in patients with ampullary tumors was identified by multislice computed tomography (CT) and digital subtraction angiography (DSA) in our institute between April 2002 and June 2006. Clinical data of patients treated with pancreaticoduodenectomy were reviewed. Hepatic artery anomalies were classified by the Michels method. Results: 15 patients treated with pancreaticoduodenectomy had hepatic artery anomalies (9 males, 6 females; mean age 58.3 years, range 25–72 years). Patients were given preoperative examination consisting of contrast-enhanced CT (n = 15) and celiomesenteric angiography (n = 10). Pylorus-preserving pancreaticoduodenectomy (PPPD) was performed in 7 patients, and radical pancreaticoduodenectomy in the other 8 cases. Hepatic artery anomalies were diagnosed as Michels type II (n = 3), with a replaced left hepatic artery arising from the left gastric artery; Michels type III (n = 6), with a replaced right hepatic artery branching off the superior mesenteric artery; Michels type V (n = 2), with a dual arterial supply with an accessory left hepatic artery that arose from the left gastric artery; Michels type VI (n = 3), with a dual arterial supply with an accessory right hepatic artery that arose from the superior mesenteric artery, and Michels type IX (n = 1), with the common hepatic artery originating from the superior mesenteric artery. The aberrant hepatic arteries were correctly identified on CT scan in 10 cases, with an accuracy of 67% (10/15). The anomalies were detected by DSA in all the 10 cases, and the accuracy was 100% (10/10). All the aberrant hepatic arteries except one were successfully preserved during the operation, with no surgical mortalities and postoperative complications in 6 patients (40%). Conclusions: It is inferred that hepatic artery anomalies are not rare in patients with ampullary tumors. Preoperative CT and angiography should play a critical part in the preoperative evaluation of hepatic artery anomalies whenever and wherever available.     

Diagnosis and management of extrahepatic portal vein aneurysm:a case report

BACKGROUND: Extrahepatic portal vein aneurysm is a rare clinical entity with no more than 50 reported cases in the English literature. This study was to elucidate the procedures used in the diagnosis and management of portal vein aneurysm. METHOD: The clinical data of a patient with extrahepatic portal vein aneurysm were analyzed. RESULTS: Extrahepatic portal vein aneurysm associated with portal hypertension and splenomegaly was diagnosed by color Doppler ultrasonography (US), computed tomography (CT), magnetic resonance angiography (MRA) and angiography (indirect portography). Splenectomy and surgical shunt (splenorenal shunt) were performed. No hepatic encephalopathy and variceal bleeding occurred after the operation except mild pancreatic leakage caused by partial pancreatic tail resection. The patient recovered well. CONCLUSIONS: Extrahepatic portal vein aneurysm can be evaluated by US, CT, MRA, and angiography for optimum conservative or surgical management.     

Preoperative diagnosis and staging of pancreatic cancer by endoscopic ultrasonography (EUS)--a comparative study with other diagnostic tools]

Endoscopic ultrasonography (EUS), ultrasonography (US), computed tomography (CT), and angiography (Angio) were performed in 26 patients with pancreatic cancer which were all resected. Preoperative findings of each diagnostic tools were compared with histological findings. In order to discuss the effectiveness of each body imagings, the preoperative staging of pancreatic cancer was evaluated in direct invasion to the anterior pancreatic capsule and stomach (S), direct invasion to the duodenum (D), direct invasion to the retroperitoneal adjacent vessels (Rp), and regional lymph node metastasis (N). The overall accuracy rate was 77% with EUS (50% with US, 38% with CT, 56% with Angio) in S, 81% with EUS (44% with US, 38% with CT, 63% with Angio) in D, 77% with EUS (58% with US, 42% with CT, 73% with Angio) in Rp, and 65% with EUS (58% with US, 38% with CT) in N. EUS revealed high accuracy rates because EUS images of the whole pancreas, surrounding organs and major vessels were clearly visualized through the gastroduodenal walls. Also, the accuracy rates of Angio in Rp and US in N were almost the same as those of EUS in Rp and N. However, it was difficult for every procedure to diagnose the retroperitoneal perineural invasion. From these results, EUS is one of the most beneficial procedures for detecting of the extent of cancer. EUS is expected to be popularized in the diagnosis and staging of the pancreatic cancer.     

Power Doppler sonography for hepatocellular carcinoma: factors affecting the power Doppler signals of the tumors

Abstract: Aims/Background: A recent advancement in Doppler ultrasonography (US) is power Doppler for detecting low-velocity blood flow at the microvascular level with angle independence. The present study was performed to characterize the factors contributing to the power Doppler signals of hepatocellular carcinoma (HCC). Method: Correlation of Doppler signals of HCC in 114 patients with 178 HCC nodules was analyzed in relation to the findings of CT and angiography, tumor characteristics (size, echo pattern, and histological differentiation of tumor), viral markers and severity of liver disease. Results: The sensitivity of power Doppler US was superior to that of CT and angiography (each p<0.05; McNemar's test). The detection rate of power Doppler signal was significantly higher in tumors with diameter ≥2 cm (vs <2 cm in diameter), and with low/mixed echo pattern (vs high echo appearance), and with moderately/poorly differentiated HCC (vs well-differentiated HCC). Univariate analysis revealed that echo pattern, tumor size and histological differentiation of HCC in addition to CT and angiographic findings were significant. Multivariate analysis showed that tumor size and differentiation were significant. Conclusion: These results indicate that tumor characteristics play an important role in power Doppler signals and that these could be assessed by the presence or absence of power Doppler signals.     

Congenital arteriovenous malformation of the pancreas: its diagnostic features on images

To analyze diagnostic features on images of congenital arteriovenous malformation (AVM) of the pancreas, we analyzed the diagnostic findings in six patients with the disease, using gray-scale ultrasonography (US), color Doppler US, computed tomography, and angiography and analyzed previously reported cases. AVM characteristic findings on images were multiple, small hypoechoic nodules on US, mosaic appearance of the lesion and pulsatile wave form in the portal vein on color Doppler US, conglomerated small nodular enhancement of the lesion and early appearance of the portal vein on CT, and a racemose network and early appearance of the portal vein on angiography. Five of the six patients underwent surgery, and all resected specimens were histologically found to be AVMs of the pancreas; however, one with developed portal hypertension at surgery died of repeated bleeding from esophageal varices. From analysis of total of 35 cases including our six cases, a mosaic appearance of the lesion was found in 100% and a pulsatile wave form in the portal vein in 77.8% on color Doppler US. Color Doppler US is noninvasive and useful for detecting congenital AVM of the pancreas at an early stage, preventing the portal hypertension causing esophageal varices and their rupture.     

Assessment of internal mammary artery and saphenous vein graft patency and flow reserve using transthoracic Doppler echocardiography

OBJECTIVE—To investigate transthoracic Doppler echocardiography in the identification of coronary artery bypass graft (CABG) flow for assessing graft patency.
DESIGN—The initial study group comprised 45 consecutive patients with previous CABG undergoing elective cardiac catheterisation for recurrent ischaemia. The Doppler variables best correlated with angiographic graft patency were then tested prospectively in a further 84 patients (test group).
SETTING—Three tertiary referral centres.
INTERVENTIONS—Flow velocities in grafts were recorded at rest and during hyperaemia induced by dipyridamole (0.56 mg/kg/4 min), under the guidance of transthoracic colour Doppler flow mapping. Findings on transthoracic Doppler were compared with angiography.
MAIN OUTCOME MEASURES—Feasibility of identifying open grafts by Doppler and diagnostic accuracy for Doppler detection of significant ( 70%) graft stenosis.
RESULTS—In the test group the identification rate for mammary artery grafts was 100%, for saphenous vein grafts to left anterior descending coronary artery 91%, for vein grafts to right coronary artery 96%, and for vein grafts to circumflex artery 90%. Coronary flow reserve (the ratio between peak diastolic velocity under hyperaemia and at baseline) of < 1.9 (95% confidence interval 1.83 to 2.08) had 100% sensitivity, 98% specificity, 87.5% positive predictive value, and 100% negative predictive value for mammary artery graft stenosis. Coronary flow reserve of < 1.6 (95% CI 1.51 to 1.73) had 91% sensitivity, 87% specificity, 85.4% positive predictive value, and 92.3% negative predictive value for significant vein graft stenosis.
CONCLUSIONS—Transthoracic Doppler can provide non-invasive assessment of CABG patency.


Keywords: blood flow; coronary artery disease; coronary artery bypass graft; echocardiography     

A new approach for evaluating the resectability of pancreatic and periampullary neoplasms

ObjectiveTo establish a new standard for assessing the resectability of pancreatic and periampullary tumors by the Medical Image Three-Dimensional Visualization System (MI-3DVS).MethodsEighty cases of pancreatic and periampullary tumors were examined. The 64-slice multidetector CT (64-MDCT) images and patient data were processed by MI-3DVS. The main elements examined by MI-3DVS included tumor shape, size, and location; distribution of related vessels; luminal morphology of large vessels; distribution and morphology of the small peripancreatic veins; morphology, degree of dilation, and obstructive sites of bile and pancreatic ducts. Based on vascular characteristics of MI-3DVS findings, the cases were classified into five types. Type I and II were resectable, type III were potentially resectable or resectable with combined vascular resection and reconstruction, and type IV and V were unresectable. The outcome was then compared with corresponding CT angiography (CTA) analysis and actual surgical observations.ResultsAmong the 80 cases, MI-3DVS indicated that 60 were resectable and the remaining 20 were not. In contrast, CTA indicated 50 resectable cases and 30 unresectable cases. For 57 cases of pancreatic ductal carcinomas and all 80 cases periampullary tumors, MI-3DVS assessment yielded a positive predictive value of 100%, negative predictive value of 100%, a sensitivity of 100%, a specificity of 100%, and an accuracy of 100%. While CTA generated corresponding values of 96%, 60%, 80%, 90%, 82.5%. The overall differences between the two methods were significant (P < 0.05).ConclusionThe new classification system is able to reliably assess the resectability of pancreatic and periampullary tumors.     

Practice and Yield of Early CT Scan in Acute Pancreatitis: A Dutch Observational Multicenter Study

Background: Early computed tomography (CT) (within 4full days after symptom onset) may be performed to distinguish acute pancreatitis (AP) from other intra-abdominal conditions or to identify early pancreatic necrosis. We analyzed practice and yield of early CT in patients with an established clinical diagnosis of AP in a Dutch cohort (EARL study). Methods: Multicenter observational study. Etiology, disease course, CT timing, Balthazar CT score, and clinical management were evaluated. Results: First documented hospital admissions of 166 patients were analyzed. Etiology was biliary (42.8%), unknown (20.5%), alcoholic (18.1%), post-endoscopic retrograde cholangiopancreatography (11.4%), and miscellaneous (7.2%). In 89.2% (148/166), the disease course was mild. Out of 18 patients with severe AP, 11 eventually developed (peri)pancreatic necrosis. At least one CT (range 1–12) was performed in 47% (78/166) of all patients and in 62.8% (49/78) it was acquired within 4 full days after symptom onset. Practice, timing, and Balthazar CT score of early CTs were not significantly different between mild and severe AP. None of the early CTs showed necrosis and no alternative diagnoses were established. In 89.8% (44/49), clinical management was not altered after early CT. In 10.2% (5/49), prophylacticantibiotics were started, butin absenceof necrosis. Conclusions: A CT scan was frequently acquired early in the course of AP, but its yield was low and had no implications with regard to clinical management. It seems prudent that clinicians should be more restrictive in the use of early CT, in particular in mild AP, to prevent unnecessary radiation exposure and to save costs.     

Pancreatic Stellate Cells Increase the Invasion of Human Pancreatic Cancer Cells through the Stromal Cell-Derived Factor-1/CXCR4 Axis

Aim: Both pancreatic stellate cells (PSCs) and the stromal cell-derived factor-1(SDF-1)/CXCR4 receptor ligand system have important roles in pancreatic cancer progression. This study set out to detect if PSCs express SDF-1 and promote the invasion of pancreatic cancer through the SDF-1/CXCR4 receptor ligand axis. Methods: RT-PCR was performed to detect the expression of SDF-1 and CXCR4 in PSCs, pancreatic cancer lines and cancer tissue samples. ELISA was used to investigate the concentration of SDF-1 in PSC supernatants. An MTT assay was applied to detect the proliferation of pancreatic cancer cells. A transwell chamber migration assay was employed to detect the migration of AsPC-1 cells. An in vitro invasion assay was used to detect the invasion of AsPC-1 cells. Results: CXCR4 expression was detected in PSCs; AsPC-1, SW1990 and BxPC-3 cancer cells; and cancer tissues. SDF-1 was detected in PSCs and cancer tissues, but not in AsPC-1, SW1990 and BxPC-3 cells. SDF-1α protein was found in PSC supernatants. PSC-conditioned media can promote the proliferation, migration and invasion of pancreatic cancer cells. SDF-1 neutralizing antibody or AMD3100 can significantly inhibit these promotive effects. Conclusion: PSCs can secrete SDF-1 and increase the invasion of pancreatic cancer cells through the SDF-1/CXCR4 axis.     

Effect of power Doppler and digital subtraction techniques on the comparison of myocardial contrast echocardiography with SPECT

OBJECTIVE—To compare the accuracy and feasibility of harmonic power Doppler and digitally subtracted colour coded grey scale imaging for the assessment of perfusion defect severity by single photon emission computed tomography (SPECT) in an unselected group of patients.
DESIGN—Cohort study.
SETTING—Regional cardiothoracic unit.
PATIENTS—49 patients (mean (SD) age 61 (11) years; 27 women, 22 men) with known or suspected coronary artery disease were studied with simultaneous myocardial contrast echo (MCE) and SPECT after standard dipyridamole stress.
MAIN OUTCOME MEASURES—Regional myocardial perfusion by SPECT, performed with ^99mTc tetrafosmin, scored qualitatively and also quantitated as per cent maximum activity.
RESULTS—Normal perfusion was identified by SPECT in 225 of 270 segments (83%). Contrast echo images were interpretable in 92% of patients. The proportion of normal MCE by grey scale, subtracted, and power Doppler techniques were respectively 76%, 74%, and 88% (p < 0.05) at > 80% of maximum counts, compared with 65%, 69%, and 61% at < 60% of maximum counts. For each technique, specificity was lowest in the lateral wall, although power Doppler was the least affected. Grey scale and subtraction techniques were least accurate in the septal wall, but power Doppler showed particular problems in the apex. On a per patient analysis, the sensitivity was 67%, 75%, and 83% for detection of coronary artery disease using grey scale, colour coded, and power Doppler, respectively, with a significant difference between power Doppler and grey scale only (p < 0.05). Specificity was also the highest for power Doppler, at 55%, but not significantly different from subtracted colour coded images.
CONCLUSIONS—Myocardial contrast echo using harmonic power Doppler has greater accuracy than with grey scale imaging and digital subtraction. However, power Doppler appears to be less sensitive for mild perfusion defects.


Keywords: myocardial contrast echo; SPECT; coronary artery disease; dipyridamole stress     

Estimation of bulky lymph nodes by power Doppler ultrasound scanning in patients with Hodgkin's lymphoma: a prospective study

The accuracy of standard methods in estimating bulky lesions requires validation. We used clinical/computed tomography (CT) evaluation and power Doppler ultrasound (US) to detect bulky disease in 137 consecutive Hodgkin's lymphoma patients, and analyzed the prognostic relevance of each method. Bulky disease was detected by clinical/CT evaluation in 47% of the patients and by power Doppler US in 20%. After treatment, at multivariate analysis power Doppler US-selected bulky disease was the parameter that best correlated with freedom from treatment failure (p<0.001). Power Doppler US, a readily available imaging technique, provides a better prognostic classification by detecting true bulky disease more accurately.     

Diagnosis and treatment of hemosuccus pancreaticus during a nonbleeding episode: A case report of a patient with obscure intermittent gastrointestinal bleeding and silent chronic pancreatitis

Background: Hemorrhage from the pancreatic duct, i.e. hemosuccus pancreaticus (HP), is a rare cause of gastrointestinal bleeding. This potentially life-threatening complication of chronic pancreatitis may pose a significant diagnostic and therapeutic dilemma, especially in patients with silent forms of the disease. Methods: We report a case of a 64-year-old man with no history or symptoms but positive findings of chronic calcifying pancreatitis at computed tomography (CT) scan. Results: The patient presented with repeated episodes of gastrointestinal bleeding requiring transfusion and did not, until later in the disease, develop hyperamylasemia and epigastric pain. Repeated endoscopies could not reveal the source of bleeding. The radiological diagnosis and successful transcatheter embolization of a small splenic pseudoaneurysm were performed during an interval when the patient was asymptomatic and showed no signs of bleeding. Conclusion: We suggest that when HP is suspected, a contrast-enhanced CT angiography with reconstruction of the arteries should be performed regardless of whether the patient shows signs of active bleeding or not.     

Ukrain Affects Pancreas Cancer Cell Phenotype in vitro by Targeting MMP-9 and Intra-/Extracellular SPARC Expression

Background/Aims: We investigated whether the anticancer drug Ukrain (UK) is able to modulate the expression of some of the key markers of tumor progression in pancreatic cell carcinoma, in order to assess its potential therapeutic effect. Methods: Three cell lines (HPAF-II, PL45,HPAC) were treated with UK (5,10 and 20 μM) for 48 h, or left untreated. Secreted protein acidic and rich in cysteine (SPARC) mRNA levels were assessed by real-time PCR. Matrix metalloproteinases (MMP)-2 and -9 activity was analyzed by SDS zymography; SPARC protein levels in cell lysates and supernatants were determined by Western blot. Cell cycle was determined by flow cytometric analysis, and invasion by matrigel invasion assay. Results: UK down-regulated MMP-2 and MMP-9, suggesting that UK may decrease pancreatic cancer cell invasion, as confirmed by the matrigel invasion assay. SPARC protein down-regulation in supernatants points to an inhibition by UK of extracellular matrix remodeling in the tumor microenvironment. At the same time, SPARC mRNA and cellular protein level up-regulation suggests that UKcan affect cell proliferation by cell cycle inhibition, showing a cell cycle G2/M arrest in UK-treated cells. Conclusion: Our results suggest that UK modulates two major aspects involved in tumorigenesis of pancreatic cancer cells, such as extracellular matrix remodeling and cell proliferation.     

Identification of a Novel Kindred with Familial Pancreatitis and Pancreatic Cancer

Background/Aims: Hereditary pancreatic cancer comprises about 10% of pancreatic cancer cases. Multiple causative mutations have been identified. Here we describe a pancreatitis/pancreatic cancer (P/PC) family, which demonstrates pancreatitis and pancreatic cancer resulting from an uncharacterized mutation. Methods: Family members completed evaluations to determine signs of mutation status. Select patients were screened for mutations associated with hereditary pancreatic diseases. Results: In generation II, 12 siblings exhibit 6 cases of pancreatitis, 3 pancreatic cancer, and 2 obligate carrier status. The average age at pancreatitis diagnosis of enrolled members is 32.5 years; average age at pancreatic cancer diagnosis is 59 years. There is no association with known cancer syndromes. Those affected generally present with mild epigastric pain, and CT scans demonstrate characteristic fatty infiltration of the pancreatic body and tail with sparing of the head and neck. Full sequenceanalysis of genes associated with hereditary pancreatic disease failed to dem- onstrate known mutations or polymorphisms. Conclusion: Based upon pedigree evaluation and preliminary DNA analysis, we believe that the family members with P/PC carry a novel genetic mutation resulting in hereditary pancreatitis. This mutation is autosomal dominant, expressed with high penetrance, and is part of a unique hereditary syndrome that significantly increases pancreatic cancer risk.     

A prospective evaluation of pancreatic exocrine function in patients with acute pancreatitis: Correlation with extent of necrosis and pancreatic endocrine insufficiency

Aims: The aim of this prospective study was to assess pancreatic exocrine function in patients recovering from a first attack of acute pancreatitis, and to evaluate its relationship to severity of attack, extent of pancreatic necrosis and severity of pancreatic endocrine insufficiency. Methods: Between December 2000 and November 2001, 23 patients were prospectively evaluated. Pancreatic exocrine function was measured by the faecal elastase-1 test and insufficiency was classified as moderately impaired or severely impaired. Pancreatic necrosis was determined by contrast-enhanced CT scan, and its extent was categorised according to Balthazar's classification. The severity of pancreatic endocrine insufficiency was categorised according to insulin dependence. Attacks were classified as mild (n = 16) or severe (n = 7) according to the Atlanta criteria. Results: Pancreatic exocrine insufficiency was significantly more frequent in patients recovering from severe attacks than mild (n = 6, 86% vs. n = 2, 13%; p = 0.002), and in those who developed pancreatic necrosis or pseudocyst than those who did not (6 of 7 patients vs. 2 of 16 patients, and 5 of 5 patients vs. 3 of 18 patients respectively; p = 0.002). The development of exocrine insufficiency correlated strongly with the extent of pancreatic necrosis (r = −0.754, p < 0.001), and the severity of pancreatic endocrine insufficiency (n = 4, r = −0.453, p = 0.03). Conclusion: Pancreatic exocrine insufficiency is a common occurrence in patients recovering from severe acute pancreatitis, and its severity correlates with the extent of pancreatic necrosis and the severity of concomitant pancreatic endocrine insufficiency.     

Endoscopic Ultrasound and IL-8 in Pancreatic Juice to Diagnose Chronic Pancreatitis

Background/Aim: Pancreatic juice (PJ) [IL-8] has been proposed as a marker for pancreatic diseases. We compared the accuracy of PJ [IL-8] and endoscopic ultrasound (EUS) to diagnose chronic pancreatitis (CP). Methods: 79 patients with symptoms suspicious for CP were enrolled. PJ emptied into the duodenum was collected during an upper endoscopy with IV secretin and [IL-8] was measured. CP was diagnosed when PJ [IL-8] was >20 pg/ml. CP was diagnosed at EUS when ≥4 of the 9 established criteria were present. CP was diagnosed by using composite gold standard: ERCP, histology, CT or MRI, and clinical follow-up (mean 20 months). Results: 38 patients had CP, whereas 41 patients had no pancreatic disease. To diagnose CP, PJ [IL-8] was significantly less sensitive compared to EUS (47 vs. 71%), but equally accurate (71 vs. 80%) and specific (93 vs. 88%). By combining PJ [IL-8] and EUS, sensitivity and specificity significantly increased to 82% (either IL-8 or EUS positive) and 100% (both IL-8 and EUS positive). Conclusions: Both PJ [IL-8] and EUS are accurate diagnostic modalities for CP. PJ collection can be performed at the time of EUS. PJ [IL-8] and EUS are complementary with higher sensitivity and specificity when used together.