Role of endoscopy in the diagnosis of autoimmune pancreatitis and immunoglobulin G4‐related sclerosing cholangitis

Autoimmune pancreatitis (AIP) must be differentiated from pancreatic carcinoma, and immunoglobulin (Ig)G4‐related sclerosing cholangitis (SC) from cholangiocarcinoma and primary sclerosing cholangitis (PSC). Pancreatographic findings such as a long narrowing of the main pancreatic duct, lack of upstream dilatation, skipped narrowed lesions, and side branches arising from the narrowed portion suggest AIP rather than pancreatic carcinoma. Cholangiographic findings for PSC, including band‐like stricture, beaded or pruned‐tree appearance, or diverticulum‐like outpouching are rarely observed in IgG4‐SC patients, whereas dilatation after a long stricture of the bile duct is common in IgG4‐SC. Transpapillary biopsy for bile duct stricture is useful to rule out cholangiocarcinoma and to support the diagnosis of IgG4‐SC with IgG4‐immunostaining. IgG4‐immunostaining of biopsy specimens from the major papilla advances a diagnosis of AIP. Contrast‐enhanced endoscopic ultrasonography (EUS) and EUS elastography have the potential to predict the histological nature of the lesions. Intraductal ultrasonographic finding of wall thickening in the non‐stenotic bile duct on cholangiography is useful for distinguishing IgG4‐SC from cholangiocarcinoma. Endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) is widely used to exclude pancreatic carcinoma. To obtain adequate tissue samples for the histological diagnosis of AIP, EUS‐Tru‐cut biopsy or EUS‐FNA using a 19‐gauge needle is recommended, but EUS‐FNA with a 22‐gauge needle can also provide sufficient histological samples with careful sample processing after collection and rapid motion of the FNA needles within the pancreas. Validation of endoscopic imaging criteria and new techniques or devices to increase the diagnostic yield of endoscopic tissue sampling should be developed.     

Factors affecting the diagnostic accuracy of endoscopic ultrasonography‐guided fine‐needle aspiration (EUS‐FNA) for upper gastrointestinal submucosal or extraluminal solid mass lesions

Aim: A number of potential variables are associated with the diagnostic accuracy of endoscopic ultrasonography‐guided fine‐needle aspiration (EUS‐FNA). The aim of this study was to evaluate factors affecting the diagnostic accuracy of EUS‐FNA for upper gastrointestinal submucosal or extraluminal solid lesions. Methods: Patients with such lesions who underwent EUS‐FNA between January 2009 and December 2010 were studied retrospectively. Needles of 22, 25 and 19 gauge were used. The associations between the EUS‐FNA results and factors such as mass location, mass size, needle size, number of needle passes, combined histologic‐cytologic analysis and final diagnosis were analyzed. Results: A total of 170 EUS‐FNA procedures were performed in 158 patients with upper gastrointestinal submucosal or extraluminal solid lesions. The overall accuracy of EUS‐FNA was 86.5% (147/170). The diagnostic accuracy with three or more needle passes was higher than with less than 3.0 needle passes (90.0%, 108/120 vs 78.0%, 39/50; P < 0.05). Mass location, mass size, and final diagnosis were not associated with EUS‐FNA accuracy. Combined cytologic‐histologic analysis had significantly higher diagnostic accuracy than either cytologic or histologic analysis alone (P < 0.001). In a subgroup of 90 patients, both 22 and 25 gauge needles were used for EUS‐FNA. The overall diagnostic accuracy was similar for 25 gauge needles and 22 gauge needles (80.0% vs 78.9% P = 1.000) in this subgroup. Conclusion: Overall, 25 and 22 gauge needles have a similar diagnostic accuracy. Our results suggest that 3.0 or more needle passes and combined cytologic‐histologic analysis enhance the diagnostic accuracy of EUS‐FNA.     

Prospective evaluation of the optimal number of 25‐gauge needle passes for endoscopic ultrasound‐guided fine‐needle aspiration biopsy of solid pancreatic lesions in the absence of an onsite cytopathologist

Introduction: A prior study with 22‐gauge needles recommended more than seven needle passes for endoscopic ultrasound‐guided fine‐needle aspiration biopsy (EUS‐FNA) of solid pancreatic lesions (SPL) without onsite cytopathology for optimal acquisition of cytopathological diagnosis. The feasibility of this recommendation should be re‐evaluated considering the later development and popularity of 25‐gauge EUS‐FNA needles. We aimed to determine the optimal number of needle passes for cytopathological specimen acquisition with 25‐gauge needles for EUS‐FNA of SPL. Methods: A preliminary prospective study of 22 patients with an onsite cytopathology technician showed a sensitivity of 93.3% and a specificity of 100% with four needle passes that was not statistically different from five needle passes. Based on our preliminary study, we fixed the number of needle passes to four (Group A). As a control group, we carried out sampling in consecutive patients using 25‐gauge needles with an onsite cytopathologist (Group B). Sampling rate, diagnostic value and complications were evaluated. Results: We enrolled 20 patients in each group. Sampling rate was higher in Group B (20/20, 100%) than in Group A (19/20, 95%), but there was no statistical difference between them (P‐value = 0.31). In Group A, sensitivity, specificity and accuracy were 100% among 19. In Group B, sensitivity was 94.1%, specificity 100%, accuracy 95%. There were also no statistical differences between the groups. No complications were seen. Conclusion: Our study suggests that four needle passes using a 25‐gauge needle may be sufficient for EUS‐FNA of SPL where onsite cytology is not available.     

ENDOSCOPIC ULTRASOUND‐GUIDED CHOLEDOCHODUODENOSTOMY

Endoscopic biliary drainage (EBD) may be unsuccessful in some patients, because of failed biliary cannulation or tumor infiltration, limiting endoscopic access to major papilla. The alternative method of percutaneous transhepatic biliary drainage carries a risk of complications, such as bleeding, portal vein thrombus, portal vein occlusion and intra‐ or extra‐abdominal bile leakage. Recently, endoscopic ultrasonography (EUS)‐guided biliary stent placement has been described in patients with malignant biliary obstruction. Technically, EUS‐guided biliary drainage is possible via transgastric or transduodenal routes or through the small intestine using a direct access or rendezvous technique. We describe herein a technique for direct stent insertion from the duodenal bulb for the management of patients with jaundice caused by malignant obstruction of the lower extrahepatic bile duct. We think transduodenal direct access is the best treatment in patients with jaundice caused by inoperable malignant obstruction of the lower extrahepatic bile duct when EBD fails.     

A prospective multicenter evaluation of a new side‐port endoscopic ultrasound‐fine‐needle aspiration in solid upper gastrointestinal lesions

Background and Study Aims: Diagnostic yield of endoscopic ultrasound (EUS)‐fine‐needle aspiration (FNA) varies depending on the equipment used and the site targeted. Multiple needle passes are usually required to obtain a diagnosis. A new needle incorporating a side‐port carries a theoretical advantage regarding acquisition of cytological material. The aim of the study was to demonstrate the safety and efficacy of the Olympus side‐port needle in solid upper gastrointestinal indications. Patients and Methods: A prospective multicenter evaluation of patients referred for EUS‐FNA for solid lesions was performed across six tertiary gastroenterology referral centers in four capital cities in Australia. The main outcome measures include cytological diagnosis, number of needle passes required for diagnosis and complication rates. Results: Thirty patients (17 men; 13 women) with a mean age of 67.5 years were studied. Indications included pancreatic or biliary mass in 24 patients, retroperitoneal or periduodenal mass in 2, enlarged lymph node in 2, a gastric submucosal tumor in 1 and a subcarinal mass in 1. The mean size of the lesions was 3.47 cm (range, 0.5–8 cm). All but one case had a diagnosis made (96.7%). The mean number of passes required to reach a diagnosis was 1.7. In neoplastic lesions the diagnosis was made with a mean of 1.6 passes. No complications were encountered. Conclusions: The new EUS‐FNA needle with side port appears effective and safe in solid upper gastrointestinal EUS‐FNA indications.     

Endoscopic ultrasound‐guided fine‐needle aspiration of solid lesions on clopidogrel may not be a high‐risk procedure for bleeding: A case series

The major gastrointestinal endoscopy society guidelines list endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) as a high‐risk procedure for bleeding. However, there are no studies evaluating the risk of bleeding for EUS‐FNA of solid organs while patients continue to take clopidogrel. The aim of the present case series was to evaluate the rate of bleeding in a cohort of patients who underwent EUS‐FNA for solid lesions while on clopidogrel. Bleeding was measured at the time of the procedure by bleeding seen on EUS, endoscopic visualization of blood, or drop in hemoglobin after the procedure. From 2013 to 2015, 10 patients were identified for this case series. Lesions that underwent EUS‐FNA included gastric and rectal subepithelial lesions, pancreas masses, and liver masses. No immediate or delayed bleeding was observed in any of the patients. EUS‐FNA of solid lesions on clopidogrel may not be a high‐risk procedure for bleeding. Larger studies are needed to confirm this finding.     

ENDOSONOGRAPHY‐GUIDED BILIARY DRAINAGE IN CASES WITH DIFFICULT TRANSPAPILLARY ENDOSCOPIC BILIARY DRAINAGE

Background: Recently, reports on a new endoscopic biliary drainage technique utilizing endosonographic guidance (endosonography‐guided biliary drainage [ESBD]) have been increasing. The aim of this study was to evaluate the efficacy of ESBD in cases with difficult transpapillary endoscopic biliary drainage (EBD). Patients and Methods: Sixteen patients with obstructive jaundice who underwent ESBD because of difficult EBD between January 2007 and September 2008 were included. The technical success, complications, and clinical efficacy of ESBD were prospectively evaluated. Results: ESBD was performed via the duodenum, stomach, and esophagus in eight, six and two patients, respectively. Stent placement was successful in all cases and excellent biliary decompression was achieved in all but one patient. One patient developed localized peritonitis following guidewire migration and re‐puncture of the bile duct. In another patient, stent migration was observed one week after ESBD and re‐ESBD was carried out. Three patients underwent surgery for their primary diseases, and stent exchange was carried out in 10 patients during the course. Conclusions: ESBD is an effective treatment for obstructive jaundice that will replace percutaneous transhepatic biliary drainage in cases of difficult EBD and is a possible alternative to EBD in selected cases.     

SUCCESSFUL ENDOSCOPIC ULTRASOUND‐GUIDED FINE‐NEEDLE ASPIRATION OF THE PELVIC LESION THROUGH THE SIGMOID COLON

Endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) is a useful modality when the target is a lymph node located in the mediastinum, perigastric area or perirectum. Although it is difficult to carry out EUS‐FNA of the colon using an oblique view linear scope, we report two cases of successful EUS‐FNA of the lesions via the proximal sigmoid colon using a recently available new convex type EUS scope. Case 1 was a 77‐year‐old Japanese woman noted to have multiple lymph node swelling in the para‐aortic area and in the pelvis. Case 2 was a 60‐year‐old Japanese woman noted to have a large mass in the left lower abdomen. In case 1, oral EUS showed no lymph node swelling. In both cases, EUS with forward‐viewing radial echoendoscope was carried out via the anus, and multiple lymph‐node swelling or a large mass was observed near the proximal sigmoid colon. In the EUS‐FNA for these cases, we used a new convex‐type EUS scope that has an oblique view, but with a wide‐angled optical device giving a view similar to a forward one. EUS‐FNA was successfully carried out on the lesions. The pathological specimen revealed diffuse large B‐cell lymphoma in case 1 and gastrointestinal stromal tumor (GIST) in case 2.