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92 Utilization of EUS-FNA in Diagnosing Pancreatic Neoplasms Without Definitive Masses on CT Scans
AGA Abstracts
order for other 50 cases, the other 2 investigators were provided with the same anonymized cases switching the order of the examinations. The evaluations included a rating of inflammation , the presence of a clinically significant stricture, fistula and abscess, and therapeutic recommendations for the use of steroids, immunosuppressants, anti-TNF therapy and surgery. Results: Information of the first examination was considered sufficient for management in 65% of cases for MRI and only 34% of cases for colonoscopy (p<0.005). Indications for anti-TNF therapy (41% vs 27%, p<0.005), and surgery (14.5 vs 4.5%, p<0.001) were more frequent after MRI as first examination than after colonoscopy as first examination. Adding MRI to the information of colonoscopy led to a change in the clinicians' confidence grade in a higher proportion of patients than adding colonoscopy to information of MRI for the suspicion of stenosis (16.5% vs 9%, p<0.005), fistula (8% vs 2%, p<0.001), and internal abscess (8.5% vs 1%, p<0.001%), but not for disease activity (4.5% vs 3%, p:n.s.). The information of MRI as a second examination led also to a change in global therapy in a higher proportion of patients than colonoscopy as second examination (28% vs 7.5%, p<0.001). The impact of MRI on treatment was higher for patients with incomplete colonoscopy compared to those with complete examinations (36.5% vs. 20.2%). Conclusion: In CD information provided by MRI has a higher impact on patient management than colonoscopy and may be considered as a first line examination for assessment of CD, although examination costs might have an influence in examination preference.
tumors (8), metastatic disease (4), and cystic neoplasm (4). Forty of 116 patients had nonmalignant findings: normal pancreas (21), chronic pancreatitis (9), autoimmune pancreatitis (5), mucinous cystadenoma (1), adenomyoma of the bile duct (1), primary sclerosing cholangitis (1), choledocholithiasis (1), and atypical cytology without confirmation of malignancy (1). Excluding one patient who died of pancreatitis at 3 months, patients with benign conditions had mean follow-up of 3 years (range 1-9 years). Initial EUS-FNA had a sensitivity, specificity, positive predictive value (PPV) and accuracy of 88%, 95.1%, 97.1% and 90.5% respectively. When repeat EUS-FNAs were included, the sensitivity, specificity, PPV and accuracy were 87.3%, 98.3%, 98.5%, and 92.1% respectively. Factors significantly associated with EUS detection of pancreatic lesions are shown in Table 1. Multivariate analysis (Table 2) identified the following independent factors of diagnosing PanCa: age (OR 1.059, 95%CI 1.005-1.117, p=0.032), total bilirubin (OR 4.380, 95%CI 1.7-11.283, p=0.002), PD dilation on CT (OR 4.377, 95%CI 1.363-14.049, p=0.013). The mean size of the PanCa (2.43±0.82cm) was significantly larger (p=0.002) than that of non-PanCa lesions (1.97±0.91cm). Conclusions: When CT is inconclusive for patients with clinical presentation of possible pancreatic malignancy, EUS is a highly sensitive and accurate modality for detection of neoplasm; EUS is more sensitive than CT when the tumor size is smaller than 2.4cm. EUS finding of a mass, total bilirubin >6.9 mg/dl, presence of PD dilation, age >66 years are significantly associated with presence of malignancy. Table 1. Univariate analysis on variables associated with all neoplastic pancreatic lesions and pancreatico-biliary adenocarcinoma
91 Small Intestine Contrast Ultrasonography (SICUS) and CT-Enteroclysis in the Assessment of Crohn's Disease Lesions Emma Calabrese, Francesca Zorzi, Sara Onali, Elisa Stasi, Simonetta Prencipe, Giovanna Condino, Francesco Pallone, Livia Biancone Background. CT enteroclysis (CTE) is an imaging technique with the highest diagnostic accuracy for the detection of intestinal involvement of Crohn's disease (CD) including extramural complications. Several studies demonstrated that Small intestine contrast ultrasonography (SICUS) has emerged as a valuable and radiation-free technique in the detection of intestinal damage in CD. Our aim was to evaluate the diagnostic accuracy of SICUS for location, disease extent and complications in CD using CTE as gold standard. Methods. Between January 2007 and September 2011, CD pts who underwent SICUS and CTE in a 6-month interval were retrospectively identified. A total of 53 pts were included (30 males; median age 42; disease duration: median 156 mos; CD behavior: non-penetrating in 37 pts, penetrating in 16 pts; CD location: ileo-colonic in 20 pts, ileal in 28 pts, jejuno-ileal in 3 pts, colonic disease in 2 pts; previous ileocolonic resection in 17 pts). SICUS was performed after PEG ingestion (375 mL). CTE was performed using 1500 mL of PEG administrated using an 8F naso-jejunal catheter and administration of intravenous iodinated contrast material using a 64-slice multi detector. Disease location in terms of bowel wall thickness (>3 mm) and lesion extent (cm), presence of complications (stenosis, pre-stenostic dilation, abscess, fistula) were considered using CTE as gold standard. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and diagnostic accuracy were calculated. Correlation (Spearman's test: r) between SICUS and CTE in the small bowel CD was calculated for maximum wall thickness and disease extent. Results. Sensitivity, specificity, PPV, NPV and diagnostic accuracy of SICUS are shown in the Table 1. SICUS and CTE showed a high correlations for bowel wall thickness (r=0.796) and disease extent (r=0.888) (p=0.0001 for both). Conclusions. SICUS showed a high sensitivity, specificity and accuracy in the assessment of CD lesion and complications compared to CTE. SICUS may represent an alternative, radiation-free imaging modality for detection and monitoring CD lesions. Table 1
Fisher's exact test or chi-square test were used to analyze categorical varibles. Independent samples t test was used to analyze continous variables. Logistic regression was used to calculate odds ratios. Table 2. Multivariate analysis on variables associated with all neoplastic pancreatic lesions and pancreatico-biliary adenocarcinoma
93 MRI is a Valuable Tool for Identification of Fibrosis in Patients With Crohn's Disease Jordi Rimola, Montserrat Aceituno, Ingrid Ordás, Aranzazu Jáuregui, Marta Gallego, Sonia Rodríguez, Miriam Cuatrecasas, Julian Panes
92 Utilization of EUS-FNA in Diagnosing Pancreatic Neoplasms Without Definitive Masses on CT Scans Wei Wang, Alexander Shpaner, Somashekar G. Krishna, William A. Ross, Manoop S. Bhutani, Eric P. Tamm, Gottumukkala S. Raju, Lianchun Xiao, Jeffrey H. Lee
Background: Measurement of the component of fibrosis in Crohn's disease (CD) lesions may have important therapeutic implications, and cannot be made by endoscopy. The aim of this study was to characterize the MRI findings that are differentially associated with the presence of fibrosis and those associated with inflammatory activity, using the histological analysis of surgically resected intestinal lesions as reference standard. Material and methods: 41 CD patients who were to undergo elective resection surgery of the bowel were prospectively studied, performing an MRI study within 3 months prior to surgery. MRI findings evaluated were: wall thickening, edema, signal intensity (SI) at submucosa (at 70 seconds, and 7 minutes after gadolinium injection), relative contrast enhancement between SI 70 seconds and 7 minutes, presence of stenosis and pre-stenotic dilatation, presence of ulcers, pattern of enhancement in each phase of the dynamic study and changes on this pattern over time. The CD pathological inflammatory score of the segments was classified into three grades of severity (1, 2, 3); fibrosis was also classified into three grades (0, 1, 2) as proposed Chiorean, and in addition fibrosis was precisely quantified by the intensity of Masson-trichrome staining. Vascularization was evaluated qualitatively and quantitatively after specific staining of endothelium with CD31. Results: A total of 45 segments were available for the study. The pathological score of activity was grade 1 (16 segments), grade 2 (15 segments) and grade 3 (14 segments), and the score for fibrosis was grade 0 (3 segments), grade 1 (29 segments) and grade 2 (13 segments). MRI findings that were significantly associated with pathological
Background: When abdominal CT is inconclusive, establishing a diagnosis of pancreatic neoplasm is challenging. Objective: To determine the diagnostic accuracy for pancreatic neoplasm by endoscopic ultrasound (EUS) with fine needle aspiration (FNA) in this setting. Methods: Retrospective chart review of patients who underwent pancreatic EUS from January 2002 to December 2010 at a tertiary referral hospital. The inclusion criteria are clinical findings suspicious for pancreatic malignancy, inconclusive abdominal CT, and having undergone EUS. Results: A total of 1131 pancreatic EUS were performed in 1046 patients. Among them, 116 patients (69 men, mean age 63.3years, range 24-85 years) met the inclusion criteria and underwent 139 EUS-FNAs; 15 patients had the examination more than once. The most common indications for initial CT were jaundice (57), abdominal pain (50), weight loss (40), nausea and vomiting (21), and/or diarrhea (16). The most common findings of CT were ill-defined parenchymal irregularities in pancreas (83), dilated bile duct (73), and/or dilated pancreatic duct (PD, 48). EUS-FNA established diagnoses of pancreatic neoplasm in 76 cases: pancreatico-biliary adenocarcinoma (PanCa, 60), neuroendoscrine
AGA Abstracts
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order for other 50 cases, the other 2 investigators were provided with the same anonymized cases switching the order of the examinations. The evaluations included a rating of inflammation , the presence of a clinically significant stricture, fistula and abscess, and therapeutic recommendations for the use of steroids, immunosuppressants, anti-TNF therapy and surgery. Results: Information of the first examination was considered sufficient for management in 65% of cases for MRI and only 34% of cases for colonoscopy (p<0.005). Indications for anti-TNF therapy (41% vs 27%, p<0.005), and surgery (14.5 vs 4.5%, p<0.001) were more frequent after MRI as first examination than after colonoscopy as first examination. Adding MRI to the information of colonoscopy led to a change in the clinicians' confidence grade in a higher proportion of patients than adding colonoscopy to information of MRI for the suspicion of stenosis (16.5% vs 9%, p<0.005), fistula (8% vs 2%, p<0.001), and internal abscess (8.5% vs 1%, p<0.001%), but not for disease activity (4.5% vs 3%, p:n.s.). The information of MRI as a second examination led also to a change in global therapy in a higher proportion of patients than colonoscopy as second examination (28% vs 7.5%, p<0.001). The impact of MRI on treatment was higher for patients with incomplete colonoscopy compared to those with complete examinations (36.5% vs. 20.2%). Conclusion: In CD information provided by MRI has a higher impact on patient management than colonoscopy and may be considered as a first line examination for assessment of CD, although examination costs might have an influence in examination preference.
tumors (8), metastatic disease (4), and cystic neoplasm (4). Forty of 116 patients had nonmalignant findings: normal pancreas (21), chronic pancreatitis (9), autoimmune pancreatitis (5), mucinous cystadenoma (1), adenomyoma of the bile duct (1), primary sclerosing cholangitis (1), choledocholithiasis (1), and atypical cytology without confirmation of malignancy (1). Excluding one patient who died of pancreatitis at 3 months, patients with benign conditions had mean follow-up of 3 years (range 1-9 years). Initial EUS-FNA had a sensitivity, specificity, positive predictive value (PPV) and accuracy of 88%, 95.1%, 97.1% and 90.5% respectively. When repeat EUS-FNAs were included, the sensitivity, specificity, PPV and accuracy were 87.3%, 98.3%, 98.5%, and 92.1% respectively. Factors significantly associated with EUS detection of pancreatic lesions are shown in Table 1. Multivariate analysis (Table 2) identified the following independent factors of diagnosing PanCa: age (OR 1.059, 95%CI 1.005-1.117, p=0.032), total bilirubin (OR 4.380, 95%CI 1.7-11.283, p=0.002), PD dilation on CT (OR 4.377, 95%CI 1.363-14.049, p=0.013). The mean size of the PanCa (2.43±0.82cm) was significantly larger (p=0.002) than that of non-PanCa lesions (1.97±0.91cm). Conclusions: When CT is inconclusive for patients with clinical presentation of possible pancreatic malignancy, EUS is a highly sensitive and accurate modality for detection of neoplasm; EUS is more sensitive than CT when the tumor size is smaller than 2.4cm. EUS finding of a mass, total bilirubin >6.9 mg/dl, presence of PD dilation, age >66 years are significantly associated with presence of malignancy. Table 1. Univariate analysis on variables associated with all neoplastic pancreatic lesions and pancreatico-biliary adenocarcinoma
91 Small Intestine Contrast Ultrasonography (SICUS) and CT-Enteroclysis in the Assessment of Crohn's Disease Lesions Emma Calabrese, Francesca Zorzi, Sara Onali, Elisa Stasi, Simonetta Prencipe, Giovanna Condino, Francesco Pallone, Livia Biancone Background. CT enteroclysis (CTE) is an imaging technique with the highest diagnostic accuracy for the detection of intestinal involvement of Crohn's disease (CD) including extramural complications. Several studies demonstrated that Small intestine contrast ultrasonography (SICUS) has emerged as a valuable and radiation-free technique in the detection of intestinal damage in CD. Our aim was to evaluate the diagnostic accuracy of SICUS for location, disease extent and complications in CD using CTE as gold standard. Methods. Between January 2007 and September 2011, CD pts who underwent SICUS and CTE in a 6-month interval were retrospectively identified. A total of 53 pts were included (30 males; median age 42; disease duration: median 156 mos; CD behavior: non-penetrating in 37 pts, penetrating in 16 pts; CD location: ileo-colonic in 20 pts, ileal in 28 pts, jejuno-ileal in 3 pts, colonic disease in 2 pts; previous ileocolonic resection in 17 pts). SICUS was performed after PEG ingestion (375 mL). CTE was performed using 1500 mL of PEG administrated using an 8F naso-jejunal catheter and administration of intravenous iodinated contrast material using a 64-slice multi detector. Disease location in terms of bowel wall thickness (>3 mm) and lesion extent (cm), presence of complications (stenosis, pre-stenostic dilation, abscess, fistula) were considered using CTE as gold standard. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and diagnostic accuracy were calculated. Correlation (Spearman's test: r) between SICUS and CTE in the small bowel CD was calculated for maximum wall thickness and disease extent. Results. Sensitivity, specificity, PPV, NPV and diagnostic accuracy of SICUS are shown in the Table 1. SICUS and CTE showed a high correlations for bowel wall thickness (r=0.796) and disease extent (r=0.888) (p=0.0001 for both). Conclusions. SICUS showed a high sensitivity, specificity and accuracy in the assessment of CD lesion and complications compared to CTE. SICUS may represent an alternative, radiation-free imaging modality for detection and monitoring CD lesions. Table 1
Fisher's exact test or chi-square test were used to analyze categorical varibles. Independent samples t test was used to analyze continous variables. Logistic regression was used to calculate odds ratios. Table 2. Multivariate analysis on variables associated with all neoplastic pancreatic lesions and pancreatico-biliary adenocarcinoma
93 MRI is a Valuable Tool for Identification of Fibrosis in Patients With Crohn's Disease Jordi Rimola, Montserrat Aceituno, Ingrid Ordás, Aranzazu Jáuregui, Marta Gallego, Sonia Rodríguez, Miriam Cuatrecasas, Julian Panes
92 Utilization of EUS-FNA in Diagnosing Pancreatic Neoplasms Without Definitive Masses on CT Scans Wei Wang, Alexander Shpaner, Somashekar G. Krishna, William A. Ross, Manoop S. Bhutani, Eric P. Tamm, Gottumukkala S. Raju, Lianchun Xiao, Jeffrey H. Lee
Background: Measurement of the component of fibrosis in Crohn's disease (CD) lesions may have important therapeutic implications, and cannot be made by endoscopy. The aim of this study was to characterize the MRI findings that are differentially associated with the presence of fibrosis and those associated with inflammatory activity, using the histological analysis of surgically resected intestinal lesions as reference standard. Material and methods: 41 CD patients who were to undergo elective resection surgery of the bowel were prospectively studied, performing an MRI study within 3 months prior to surgery. MRI findings evaluated were: wall thickening, edema, signal intensity (SI) at submucosa (at 70 seconds, and 7 minutes after gadolinium injection), relative contrast enhancement between SI 70 seconds and 7 minutes, presence of stenosis and pre-stenotic dilatation, presence of ulcers, pattern of enhancement in each phase of the dynamic study and changes on this pattern over time. The CD pathological inflammatory score of the segments was classified into three grades of severity (1, 2, 3); fibrosis was also classified into three grades (0, 1, 2) as proposed Chiorean, and in addition fibrosis was precisely quantified by the intensity of Masson-trichrome staining. Vascularization was evaluated qualitatively and quantitatively after specific staining of endothelium with CD31. Results: A total of 45 segments were available for the study. The pathological score of activity was grade 1 (16 segments), grade 2 (15 segments) and grade 3 (14 segments), and the score for fibrosis was grade 0 (3 segments), grade 1 (29 segments) and grade 2 (13 segments). MRI findings that were significantly associated with pathological
Background: When abdominal CT is inconclusive, establishing a diagnosis of pancreatic neoplasm is challenging. Objective: To determine the diagnostic accuracy for pancreatic neoplasm by endoscopic ultrasound (EUS) with fine needle aspiration (FNA) in this setting. Methods: Retrospective chart review of patients who underwent pancreatic EUS from January 2002 to December 2010 at a tertiary referral hospital. The inclusion criteria are clinical findings suspicious for pancreatic malignancy, inconclusive abdominal CT, and having undergone EUS. Results: A total of 1131 pancreatic EUS were performed in 1046 patients. Among them, 116 patients (69 men, mean age 63.3years, range 24-85 years) met the inclusion criteria and underwent 139 EUS-FNAs; 15 patients had the examination more than once. The most common indications for initial CT were jaundice (57), abdominal pain (50), weight loss (40), nausea and vomiting (21), and/or diarrhea (16). The most common findings of CT were ill-defined parenchymal irregularities in pancreas (83), dilated bile duct (73), and/or dilated pancreatic duct (PD, 48). EUS-FNA established diagnoses of pancreatic neoplasm in 76 cases: pancreatico-biliary adenocarcinoma (PanCa, 60), neuroendoscrine
AGA Abstracts
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