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Crystals in “black” and “white” bile from malignant bile duct obstruction
E R CP--BILIAR Y t437
t439
TISSUE DIAGNOSIS F O R NEOPLASTIC B m Z A R Y S T ~ C ~ S 0VBS): A PROSPECTIVE S T U D Y C O M P A R I N G FORCEPS BIOPSY AND CYTOLOGY. SK Lo, S French, L Chang, R Venegas, J Chen, E Doe, D Juarez. Departments of Medicine and Pathology. HarborUCLA Medical Center, University of California, Los Angeles, CA. Aim: To evaluate the relative utility of forceps biopsy and cytology in diagnosingNBS. Methods: We standardize,d our techniques of forceps biopsy, bile collection and stricture brushing. All sampling were done by the same endoseopist. The pathologist was blinded to all clinical information and did not communicate with the cytopathologist. All patients with newly presented biliary strictures (BS), except obvious post-operative lesions, were enrolled. Specimens were collected in the following order: obstructed bile aspiration, brushing, forceps biopsy. Results: 92 patients underwent ERCP for new BS. 18 were excluded from analysis (failed access-5; unsafe to : )le-2; duodenal obstructionBile Bn~h F. Biopsy Combined gpecificity(n) 100% (47) 100% (49) 100% (49) 100% (49) gemitivity (n) 8% 14% 71% 73% -Included "suspicious" 17% 22% 73% 76% values, versus F. Biopsy <0.000l <0.0001 ->0.05 3; broken instrument-2; diagnosis could not be/has not been established3/3), 25 were benin;n, and 49 were neoplastic
EARLY EXPERIENCE WITH A CATHETER BASED ULTRASOUND P R O B E TO E X A M I N E THE RIGHT UPPER QUADRANT DURING ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP). DF Lum, RB Goldstein, PW Callen, RA Filly and JW Ostroff. Depamnents of Medicine and Radiology. University of California, San Francisco, San Francisco, CA. Evaluation of the right upper quadrant is difficult with endoscopic ultrasound. We describe our early experience using Intraductal Ultrasonography (IDUS) during routine ERCP. Methods: After approval by the Committee on Human Research, 15 pts (F:7, M:8, mean age 56 + 18) underwent ERCP with IDUS. The diagnosis were 3-anastomotic stricture after orthotopic liver transplant (OLT), 3-choledocholithiasis, 2pancreatic cancer, 2-cholangitis, l-ampullary tumor, l-pancreatitis, 1cirrhosis, l-pseudocyst, 1-normal. Following diagnostic ERCP the ultrasound probe [6.2 Fr, 12.5 MHz and giving real time 360~ images] (Microvasive, Watertown, MA) was inserted through the working channel of the Pentax ED-3410 duodenoscope (Pentax Precision Instrument Co, Orangeburg, NY). We used a guidewire assisted probe and the non-guidewire round tip probe. The probes were driven by a Hewlett-Packard console (Pale Alto, CA). Results: Cannulation was successful in all 15 cases (none had prior sphincterotomies). A 0.025 inch guidewire allowed for easier cannulation of the bile duct, although we successfully used 0.035 inch guidewires in 2 cases. In the proximal bile duct, the hepatic artery and portal vein were visualized in all cases. The portal vein was less well seen distally. The cystic duct take off, gallbladder, and pancreatic duct were easily visualized. Anastomotic strictures was noted in 2/3 OLT, choledocbolithiasis in 2/3 cases, pancreatic carcinoma with biliary stricture in 2/2, and pancreatic pseudocyst in 1/1. The superior mesenteric artery/vein and the splenic vein were visualized and there were no complications. The probes could be sterilized and reused 3 times. Binding of the probe occurred which required repositioning of the catheter. A sphincterotomy introduced air into the biliary tree which attenuates the image. C o n c l u s i o n s : Cannulation of common bile duct was successful in all cases and use of a guidewire made cannulation easier. Identification of vascular structures was easily obtained with no obvious difference between benign and malignant strictures with the 12.5 MHz probe which best visualized vascular structures near the pancreato-biliary system. As the probes are modified with balloon stabilization and higher frequencies, it may be possible to distinguish benign from malignant strictures.
~
438 CRYSTALS IN "BLACK" AND "WHITE" BILE FROM MALIGNANT BILE DUCT OBSTRUCTION. W B Long,S L Kadish, B Mochan, Division of Gastroenterology and Department of Pathology, University of Pennsylvania Medical Center, Philadelphia,PA. We noted that bile flowing immediately after placement of endoscopic stents to relieve malignant biliary obstruction seemed to have minute particles and we examined it for crystals. Obstructed bile had either an oily black color ("black bile") or a clear, near-colorless mucoid appearance ("white bile"). We collected bile from the common hepatic duct during ERCP in patients with jaundice from pancreatic carcinoma (Tpts) or ampuUary carcinoma (lpt). Two of the patients had white bile and the others "black bile". Bile was examined for cholesterol and calcium bilirubinate crystals with polarized light microscopy. The number of crystals was estimated as numerous (25), rare (1+) or none (O).Two pancreatic carcinoma patients were post cholecystectemy and none of the patients had gallstones or cholangitis. Control bile from patients without biliary obstruction or gallstones was also examined for crystals. "Black bile" contained numerous cholesterol and bilirubinate crystals in all patients. In contrast, "white bile" contained rare cholesterol or bilirubinate crystals (p
V O L U M E 41, NO. 4, 1995
t440 CYTOLOGIC BRUSHINGS OF DUCTAL LESIONS AT ERCP E. Macken, M. Drijkoningen*, E. Van Aken, W. Van Steenbergen. Depts of Internal Medicine and of Pathology*, U.Z. Gasthuisberg, Leuven, Belgium The aim of the present study is to report on our experience with the use of endoscopic brushing cytology (EBC) as a technique for diagnosis of malignancy in cases of biliary (n=146) or pancreatic (n=8) stricture, in whom radiologic imaging was insufficient to make a clear diagnosis. Between January 1988 and August 1994, 154 brushings have been performed in 132 pts. q n 132 brushing specimens obtained from 116 pts, cell yield was satisfactory for cytologic interpretation (86%). All samples were examined by a single experienced pathologist. Nine pts were excluded because of inadequate follow-up. Of the remaining 107 pts, 63 finally proved to have a malignant stricture: cholangioca (n=28), pancreatic ca (n=19), ampulloma (n=10), gallbladder ca (n=3), metastatic ca (n=2), nonhodgkin lymphoma (n=l). EBC had an overall sensitivity of 62% and a specificity of 98%. One false positive result was obtained in a p t with a biliary infection by Fasciola hepatica. The sensitivity of EBC in m a l i g n a n t ampullary (9/12;75%) and pancreatic (3/3;100%) strictures was higher than for malignant CBD-strictures (29/51;57%). "Atypical" cells were found in 4 cases, 2 of whom proved to have a malignant stricture. In 13 out of the 63 pts, EBC was the only method to establish the diagnosis o~ malignancy. EBC confirmed the diagnosis of malignancy based on ERCP alone in 6 pts. Since EBC is a simple technique with a high specificity, we conclude that it should be performed in all strictures of unknown etiology in the biliary and, if possible, in the pancreatic duct systela.
GASTROINTESTINAL
ENDOSCOPY
405
t439
TISSUE DIAGNOSIS F O R NEOPLASTIC B m Z A R Y S T ~ C ~ S 0VBS): A PROSPECTIVE S T U D Y C O M P A R I N G FORCEPS BIOPSY AND CYTOLOGY. SK Lo, S French, L Chang, R Venegas, J Chen, E Doe, D Juarez. Departments of Medicine and Pathology. HarborUCLA Medical Center, University of California, Los Angeles, CA. Aim: To evaluate the relative utility of forceps biopsy and cytology in diagnosingNBS. Methods: We standardize,d our techniques of forceps biopsy, bile collection and stricture brushing. All sampling were done by the same endoseopist. The pathologist was blinded to all clinical information and did not communicate with the cytopathologist. All patients with newly presented biliary strictures (BS), except obvious post-operative lesions, were enrolled. Specimens were collected in the following order: obstructed bile aspiration, brushing, forceps biopsy. Results: 92 patients underwent ERCP for new BS. 18 were excluded from analysis (failed access-5; unsafe to : )le-2; duodenal obstructionBile Bn~h F. Biopsy Combined gpecificity(n) 100% (47) 100% (49) 100% (49) 100% (49) gemitivity (n) 8% 14% 71% 73% -Included "suspicious" 17% 22% 73% 76% values, versus F. Biopsy <0.000l <0.0001 ->0.05 3; broken instrument-2; diagnosis could not be/has not been established3/3), 25 were benin;n, and 49 were neoplastic
EARLY EXPERIENCE WITH A CATHETER BASED ULTRASOUND P R O B E TO E X A M I N E THE RIGHT UPPER QUADRANT DURING ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP). DF Lum, RB Goldstein, PW Callen, RA Filly and JW Ostroff. Depamnents of Medicine and Radiology. University of California, San Francisco, San Francisco, CA. Evaluation of the right upper quadrant is difficult with endoscopic ultrasound. We describe our early experience using Intraductal Ultrasonography (IDUS) during routine ERCP. Methods: After approval by the Committee on Human Research, 15 pts (F:7, M:8, mean age 56 + 18) underwent ERCP with IDUS. The diagnosis were 3-anastomotic stricture after orthotopic liver transplant (OLT), 3-choledocholithiasis, 2pancreatic cancer, 2-cholangitis, l-ampullary tumor, l-pancreatitis, 1cirrhosis, l-pseudocyst, 1-normal. Following diagnostic ERCP the ultrasound probe [6.2 Fr, 12.5 MHz and giving real time 360~ images] (Microvasive, Watertown, MA) was inserted through the working channel of the Pentax ED-3410 duodenoscope (Pentax Precision Instrument Co, Orangeburg, NY). We used a guidewire assisted probe and the non-guidewire round tip probe. The probes were driven by a Hewlett-Packard console (Pale Alto, CA). Results: Cannulation was successful in all 15 cases (none had prior sphincterotomies). A 0.025 inch guidewire allowed for easier cannulation of the bile duct, although we successfully used 0.035 inch guidewires in 2 cases. In the proximal bile duct, the hepatic artery and portal vein were visualized in all cases. The portal vein was less well seen distally. The cystic duct take off, gallbladder, and pancreatic duct were easily visualized. Anastomotic strictures was noted in 2/3 OLT, choledocbolithiasis in 2/3 cases, pancreatic carcinoma with biliary stricture in 2/2, and pancreatic pseudocyst in 1/1. The superior mesenteric artery/vein and the splenic vein were visualized and there were no complications. The probes could be sterilized and reused 3 times. Binding of the probe occurred which required repositioning of the catheter. A sphincterotomy introduced air into the biliary tree which attenuates the image. C o n c l u s i o n s : Cannulation of common bile duct was successful in all cases and use of a guidewire made cannulation easier. Identification of vascular structures was easily obtained with no obvious difference between benign and malignant strictures with the 12.5 MHz probe which best visualized vascular structures near the pancreato-biliary system. As the probes are modified with balloon stabilization and higher frequencies, it may be possible to distinguish benign from malignant strictures.
~
438 CRYSTALS IN "BLACK" AND "WHITE" BILE FROM MALIGNANT BILE DUCT OBSTRUCTION. W B Long,S L Kadish, B Mochan, Division of Gastroenterology and Department of Pathology, University of Pennsylvania Medical Center, Philadelphia,PA. We noted that bile flowing immediately after placement of endoscopic stents to relieve malignant biliary obstruction seemed to have minute particles and we examined it for crystals. Obstructed bile had either an oily black color ("black bile") or a clear, near-colorless mucoid appearance ("white bile"). We collected bile from the common hepatic duct during ERCP in patients with jaundice from pancreatic carcinoma (Tpts) or ampuUary carcinoma (lpt). Two of the patients had white bile and the others "black bile". Bile was examined for cholesterol and calcium bilirubinate crystals with polarized light microscopy. The number of crystals was estimated as numerous (25), rare (1+) or none (O).Two pancreatic carcinoma patients were post cholecystectemy and none of the patients had gallstones or cholangitis. Control bile from patients without biliary obstruction or gallstones was also examined for crystals. "Black bile" contained numerous cholesterol and bilirubinate crystals in all patients. In contrast, "white bile" contained rare cholesterol or bilirubinate crystals (p
V O L U M E 41, NO. 4, 1995
t440 CYTOLOGIC BRUSHINGS OF DUCTAL LESIONS AT ERCP E. Macken, M. Drijkoningen*, E. Van Aken, W. Van Steenbergen. Depts of Internal Medicine and of Pathology*, U.Z. Gasthuisberg, Leuven, Belgium The aim of the present study is to report on our experience with the use of endoscopic brushing cytology (EBC) as a technique for diagnosis of malignancy in cases of biliary (n=146) or pancreatic (n=8) stricture, in whom radiologic imaging was insufficient to make a clear diagnosis. Between January 1988 and August 1994, 154 brushings have been performed in 132 pts. q n 132 brushing specimens obtained from 116 pts, cell yield was satisfactory for cytologic interpretation (86%). All samples were examined by a single experienced pathologist. Nine pts were excluded because of inadequate follow-up. Of the remaining 107 pts, 63 finally proved to have a malignant stricture: cholangioca (n=28), pancreatic ca (n=19), ampulloma (n=10), gallbladder ca (n=3), metastatic ca (n=2), nonhodgkin lymphoma (n=l). EBC had an overall sensitivity of 62% and a specificity of 98%. One false positive result was obtained in a p t with a biliary infection by Fasciola hepatica. The sensitivity of EBC in m a l i g n a n t ampullary (9/12;75%) and pancreatic (3/3;100%) strictures was higher than for malignant CBD-strictures (29/51;57%). "Atypical" cells were found in 4 cases, 2 of whom proved to have a malignant stricture. In 13 out of the 63 pts, EBC was the only method to establish the diagnosis o~ malignancy. EBC confirmed the diagnosis of malignancy based on ERCP alone in 6 pts. Since EBC is a simple technique with a high specificity, we conclude that it should be performed in all strictures of unknown etiology in the biliary and, if possible, in the pancreatic duct systela.
GASTROINTESTINAL
ENDOSCOPY
405