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  • 4628 Intraductal ultrasound combined with ercp: is there a diagnostic advantage in pancreato-biliary disease?

    Aim: Intraductal ultrasound (IDUS) is a new diagnostic technique for lesions of the pancreato-biliary tract. The benefit over the gold standard ERCP has yet to be defined. The present study reports our preliminary results. Methods: Two EUS-experienced endoscopists performed IDUS of the biliary tract in selected patients with expected diagnostic benefit from ultrasonography. IDUS was performed as co-examination with ERCP after opacification of the common bile duct (CBD) with contrast media as acoustical interface. A 20MHz Miniprobe (Olympus UM-G20-29R) was inserted through the working channel of a duodenoscope (Olympus JF 1T20). We focused on technical feasibility as well as on diagnostic information of IDUS. All patients records were reviewed and classified based on their clinical impact on further examinations. Results: Between March and October 1999 IDUS was performed in addition to ERCP in sixteen patients (5 male, median age 62y [32-79]). The average time of examination for IDUS was 14,2 minutes [7-24]. In eleven patients (69%) IDUS had a direct impact on clinical decisions: In five patients either sludge or gallstones could be localized, which were not detected by ERCP and papillotomy was performed. In two patients with a history of symptomatic cholelithiasis and normal MP-EUS without sludge, papillotomy was definitely not performed and the patients were referred to cholecystectomy. Three benign and one malignant CBD-stenosis could be identified: Twice a papillitis stenosans was suspected and confirmed by cytology. In one patient with history of acute pancreatitis sludge or gallstones could be excluded and no papillotomy was performed. Once a suspected cystic duct stone could be excluded due to an irregular wall structure which proved to be a cholangiocarcinoma. Of the remaining five patients without benefit, one was because of a technical problem of the Miniprobe. In four patients the results of ERCP could be confirmed but no additional information was achieved. In one of these, a cystic lesion in the head of the pancreas was better visualized but IDUS had no further advantage. Conclusion: Intraductal ultrasound (IDUS) is a new diagnostic imaging technique for intra- and extraluminal lesions of the pancreato-biliary tract. Our results suggest that IDUS is a valuable tool and is complementary to ERCP allowing to obtain relevant supplementary information in selected clinical situations.
  • T1453: Utility of EGD Prior to EUS in Patients Undergoing EUS for Pancreato-Biliary and Mediastinal Indications

    Endoscopic Ultrasound (EUS) has an important role in evaluating pancreatic and mediastinal diseases. Echoendoscopes used for EUS provide oblique and limited views of the upper gastrointestinal (GI) tract and may result in missed luminal lesions. There is no consensus among endosonographers regarding the need for performing a routine Esophagogastroduodenuoscopy (EGD) prior to EUS.

    Objective

    Prospectively assess the utility of EGD to detect luminal abnormalities prior to EUS for pancreatic or mediastinal evaluation.

    Methods

    Patients presenting to two tertiary referral centers for EUS evaluation were prospectively enrolled. The patients completed a survey regarding any GI symptoms. The patient's age, gender and indication for the EUS were recorded. At the time of the procedure, the endoscopist completed a questionnaire regarding the level of difficulty of the procedure, any luminal abnormality noted during EGD or EUS, and the timing of the two procedures. Information regarding biopsies taken, any complications, and recommendations made based on the EGD portion of the study were also recorded.

  • Imaging Characteristics of Autoimmune Pancreato-Cholangitis - Results of a Multicenter Study Group

    Background: An autoimmune process causing pancreato-cholangitis (APC) has recently been proposed in Europe. The frequency of this entity, which presents with an enlarged pancreatic head, pancreatic and bile duct strictures and lympho-plasmocytic inflammation, fibrosis and good response to cortiosteroid therapy is yet unknown. As the awareness of this disease is not widespread in Europe correct diagnosis is rarely made at the onset of symptoms and many patients are treated surgically. Immunosuppressive treatment is often only started some years after presentation, when the diagnosis is finally made, and symptoms are evident. The aim of this study was to explore whether there are symptoms or laboratory tests that may suggest this diagnosis and avoid unnecessary surgery prior to correct treatment. Materials and Methods: 40 cases with APC were collected in a multicenter approach and reviewed. The diagnostic criteria were evaluated retrospectively. Results: Initial CT imaging was available in 37/40 patients, which showed abnormalities within the head of the pancreas suspicious of either pancreatic malignancy or focal pancreatitis in all but no initial calcifications or cysts. 15 patients had initial magnetic resonance imaging (MRI) showing dilated bile and pancreatic ducts in all. In 4 cases an unusual hypodense rim or corona around the pancreas was noted. 35/40 had ERCP. Abnormalities were seen in the pancreatic duct (PD) (narrowing or calibre changes) in 32/35 available pancreatograms, a normal duct was described in only 3 of these patients. ERC showed distal stenosis of varying length in 32/36 patients. Hilar stenosis suspicious of Klatskin tumor was seen in 13 cases and 18 patients developed intrahepatic bile duct strictures within 6 years of follow-up. Conclusion: Patients with APC always present with hypodense pancreatic head/body on CT, which provides suspicion of pancreatic cancer or chronic pancreatitis. This may be supported by double duct sign (combined stenosis of the distal CBD and PD) in the majority of cases on ERCP. These mimics may lead to the wrong conclusion of the etiology of the disease and consequently to futile surgery. Consecutive or simultaneous proximal or intrahepatic biliary stenosis may occur and may mimick malignancy or PSC. To exclude patients with potential autoimmune APC from true malignancies or PSC imaging alone may not be sufficient. Appropriate studies including serum IGG/IGG4 may be warranted in every patient with unproven malignancy of the pancreas or bile ducts