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Echo-Endoscopic Analysis of Variceal Hemodynamics in Patient with Isolated Gastric Varices
Abstracts
W1302 Echo-Endoscopic Analysis of Variceal Hemodynamics in Patient with Isolated Gastric Varices Hidemichi Imamura, Atsushi Irisawa, Takuto Hikichi, Goro Shibukawa, Tadayuki J. Takagi, Takeru Wakatsuki, Yuuta Takahashi, Ai Sato, Masaki Sato, Katsutoshi Obara
W1304 The Diagnostic Utility of Endoscopic Ultrasound (EUS) and ERCP in Evaluating Patients with Idiopathic Acute Recurrent Pancreatitis (IARP): An Update Rahul A. Shimpi, Sammy Ho, Malcolm S. Branch, Paul S. Jowell, John Baillie, Frank G. Gress
Background/Aim: Massive hemorrhage of isolated gastric varices (GV) is a lifethreatening event in patients with portal hypertension. To stanch the gastric variceal bleeding, endoscopic injection sclerotherapy (EIS) using immediate tissueadhesive substances, super glue, is considered effective treatment. Until now, we have performed EIS using 62.5%/75% cyanoacrylate mixed contrast medium to 150 or more patients. However, leakage of injected CA to systemic circulation through the gastro-renal shunt was occurred in some patients with large GV. Although it was thought that large GV had high blood flow volume (BFV), there was no data of relationship between GV diameter and BFV. The aim of this study was to investigate BFV of GV in variety of GV size using echo-endoscope. Patients/Methods: Eleven patients who had isolated GV in the period from Nov. 2004 to Oct. 2005 were enrolled in this study. We had used echo-endoscope with curved linear array (GFUCT240-AL5, Tokyo, Olympus, Japan) or with electronic radial array (GF-UE260AL5, Olympus, Japan). The variceal diameter and BFV were measured five times in each patient, definite data was fixed with the use of average excluding the maximum/minimum diameter and FV. Assessment of variceal form (F1: small varix, F2: medium varix, F3: large/tumorous varix) was according to Japanese society of portal hypertention. EIS was performed using cyanoacrylate in all cases. Results: 1) Form and the diameter of GV: F1 was 3.9 mm, F2 was 5.3 mm, and F3 was 9.0 mm in mean diameter of EV. 2) BFV and diameter of GV: BFV was in range of 104-420 ml/min (4.4-7.1 mm in diameter), 791.7 ml/min (9 mm in diameter). BFV was interrelated with GV diameter in the curve of the expression of the second order. 3) therapeutic results: GV was completely eradicated in all cases. However, in a case that diameter was 9 mm, injected cyanoacrylate flowed out the systemic circulation. Conclusions: BFV of isolated GV was correlated with its size. Our results suggested that the estimation of BFV by endoscopic findings would be possible in isolated GV case. In addition, care should be exercised in the case of 9 mm in diameter and/or more than 700 ml/min in BFV, in performing EIS for GVs using super glue.
Background: Standard evaluation of patients with recurrent acute pancreatitis may fail to determine an etiology. Accurately determining cause helps direct therapy, limits unnecessary diagnostic tests, and may improve a patient’s long-term prognosis. The aim of this study was to determine the diagnostic yield of EUS and ERCP in evaluating patients with IARP. Methods: All patients referred to our institution for evaluation of IARP between 2000 and 2005 were reviewed. IARP was defined as two or more episodes of pancreatitis without a definitive etiology found after standard work-up. Only patients who underwent both EUS and ERCP were included. Results: 63 patients (22M/41F, mean age 49, range 18-82) underwent EUS and ERCP for evaluation of IARP between 2000 and 2005. 63% (40/63) had prior cholecystectomy. ERCP was successful in 90% (57/63). 42% (24/57) had manometry performed during ERCP. The combination of EUS and ERCP identified a cause of IARP in 84% (53/63) of patients: sphincter of Oddi dysfunction in 32% (17/53), chronic pancreatitis in 26% (14/53), pancreas divisum in 19% (10/53), papillary stenosis in 11% (6/53), pancreatic malignancy in 6% (3/53), microlithiasis in 4% (2/ 53), and IPMT in 2% (1/53). In 16% (10/63), no etiology was found. EUS revealed a diagnosis in 44% (28/63) of patients, while ERCP was diagnostic in 71% (45/63). The rate of post-ERCP pancreatitis was 17% (11/63), with 7 of these 11 patients (64%) having a manometry study. There were no EUS-related complications. EUS-guided fine needle aspiration diagnosed two patients with pancreatic adenocarcinoma. Endoscopic therapy during ERCP (biliary and/or pancreatic sphincterotomy) was performed in 67% (38/57) of patients. Four of these patients sustained another episode of pancreatitis during a median follow-up period of 21 months. Of the 10 patients whose etiology remained unknown after EUS and ERCP, none have had recurrent attacks. Conclusions: 1. These updated data demonstrate that the etiology of IARP can be established in the majority of patients undergoing combined EUS and ERCP. 2. ERCP was diagnostic in more patients than EUS, but was associated with a higher risk of procedure-related pancreatitis. 3. Endoscopic therapy during ERCP was effective in preventing further attacks. 4. Given the lower complication rate, EUS should continue to have an early role in the evaluation of IARP. When the etiology remains unknown, ERCP with or without manometry study may establish a diagnosis, direct therapy, and potentially improve a patient’s long-term prognosis.
W1303 Is Endoscopic Ultrasonography More Useful Than Naked Eyes for Discrimination of Gastric Mucosal Cancer from Deeper Invasion? Kyungsik Park, Byoungkuk Jang, Woojin Chung, Kwangbum Cho, Jaeseok Hwang, Sunghoon Ahn, Seongyeol Kim, Hongsug Lee, Yeongseok Lee, Junyoung Hwang Background/Aims: Recently, endoscopic ultrasonography (EUS) has been used widely for diagnosing tumor depth. But accuracy of EUS for diagnosing tumor depth is variously reported according to centers. Furthermore some expert endoscopists may well discriminate mucosal cancer from deeper invasion with naked eyes by morphology. Thus the aims of this study are first to find accuracy of EUS for diagnosing tumor depth and second to compare the accuracy of EUS with that of naked eyes of variously experienced endoscopists. Methods: EUS and pathologic reports of gastric cancer patients whose staging had been confirmed pathologically by surgery or ESD were analyzed retrospectively. Endoscopic images extracted from picture archiving communication system (PACS) were reviewed by 3 endoscopists whose clinical experiences are 1 (Dr1), 3 (Dr2), and 5 (Dr3) years, respectively, and they were requested to guess tumor depth. Any clinical informations about the patients were not presented to them. Tumor depth was presented as follows (T1m: confined to mucosal layer, T1sm; invasion to submucosal layer or deeper). Accuracies of EUS and each doctor’s naked eyes were analyzed by comparing the values of them with those of pathologic finding. Cohen’s kappa was used for statistical analysis. Accuracies of EUS during first and second year were also analyzed separately to find out relationship between accuracy and examiner’s experience. Results: From November 2003 to October 2005, 94 patients (54 men and 38 wemes) were involved and mean age was 60.1 G 11.1 years. There were 52 (55.3%) T1m and 42 (44.7%) T1sm patients. The kappa values of EUS, Dr1, Dr2, D3 were 0.508 (p ! 0.001), 0.175 (p Z 0.002), 0.480 (p ! 0.001), 0.407 (p ! 0.001), respectively. Of 52 T1m patients, only 29 (55.8%) patients were diagnosed as T1m with EUS. But of 42 T1sm patients, 41 (97.6%) patients were diagnosed accurately. So overall accuracy of EUS was 74.5%. Dr2’s naked eyes whose accuracy was highest of 3 endoscopists showed accuracy of 61.5%, 88.1%, and 73.4% for T1m, T1sm, and overall, respectively. There were one (1.1%) and 5 (11.9%) cases of understaging with EUS and naked eyes, respectively. The overall accuracy and kappa value of EUS for first a year were 69.8%, 0.403, and for second year were 78.4%, 0.582. Conclusions: Overall accuracy of EUS for differentiating gastric mucosal cancer from deeper invasion is 74.5%. But this accuracy can rise with examiner’s experience. Overstaing of mucosal cancer is main cause of this discordance. Though accuracy of 3 year experienced endoscopist’s naked eye may be nearly as high as that of EUS, relatively understaging of deeper cancer should be considered.
AB262 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
W1305 Utility of Presenting Symptoms and Endoscopic Ultrasound Morphology Characteristics in the Diagnosis of Intraductal Papillary Mucinous Tumors: Correlation with Histopathology in 74 Patients Shireen A. Pais, Siriboon Attasaranya, Julia K. Leblanc, Lee Mc Henry, Stuart Sherman, Max Schmidt, John Dewitt Introduction: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are precancerous cystic tumors usually characterized by dilation of the main pancreatic duct (IPMN-M) alone, side branches alone (IPMN-Br) or both. The aim of this study is to identify the EUS features and presenting symptoms in these patients and to identify any variables predictive of malignancy. Methods: Utilizing endoscopy, surgery and pathology databases, patients who underwent EUS followed by surgery for IPMNs between July 1996 and November 2005 were retrospectively identified. EUS was performed by 7 experienced endosonographers with on-site cytopathologists. The surgical specimen was considered as the diagnostic gold standard. The tumor was considered as benign if classified as any of the following: IPMN adenoma, low grade, borderline or high-grade dysplasia. Only invasive carcinoma was considered as malignant. Results: 74 patients (38 male; mean age: 65 G 10 yrs) were identified with 21 (28%) malignant and 53 (72%) benign IPMNs. The tumors were located in the pancreatic head alone, body alone, tail alone or were multifocal in 39 (53%), 17 (23%), 5 (6%) and 9 (12%) respectively. The tumors were classified as IPMN-M, IPMN-Br or both in 21 (28%), 18 (25%) and 35 (47%) respectively. The most common presenting symptoms included abdominal pain in 31 (42%), weight loss in 23 (32%), back pain in 10 (14%), jaundice in 9 (13%) and diarrhea in 8 (11%). 29 patients (39%) previously had acute pancreatitis and 7 (10%) were asymptomatic. Compared with benign tumors, patients with malignancy were more likely to be older (mean age 70 yrs versus 63 yrs (p Z 0.011)), and present with jaundice (p Z 0.03) or weight loss (p Z 0.03). Patients with malignancy had a larger mean main pancreatic duct diameter (8.8 mm versus 4.3 mm (p Z 0.0001)) or were more likely to have EUS evidence of a solid lesion (p Z 0.0001), filling defects within the main duct (p Z 0.03) or thickened septae within any cyst (p Z 0.02). Between the two groups, there was no difference in gender, presence of abdominal pain, diarrhea or back pain, tumor location, size of largest cyst or visible sidebranches (p O 0.05 for all comparisions). Conclusions: For IPMNs, older age, jaundice, weight loss at presentation are predictive of invasive cancer. EUS features of malignancy include: a solid lesion, marked dilation of the main pancreatic duct, filling defects within the main duct and thickened septae within the cyst. Knowledge of these features may help endosonographers identify which IPMNs should undergo EUS-FNA.
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W1302 Echo-Endoscopic Analysis of Variceal Hemodynamics in Patient with Isolated Gastric Varices Hidemichi Imamura, Atsushi Irisawa, Takuto Hikichi, Goro Shibukawa, Tadayuki J. Takagi, Takeru Wakatsuki, Yuuta Takahashi, Ai Sato, Masaki Sato, Katsutoshi Obara
W1304 The Diagnostic Utility of Endoscopic Ultrasound (EUS) and ERCP in Evaluating Patients with Idiopathic Acute Recurrent Pancreatitis (IARP): An Update Rahul A. Shimpi, Sammy Ho, Malcolm S. Branch, Paul S. Jowell, John Baillie, Frank G. Gress
Background/Aim: Massive hemorrhage of isolated gastric varices (GV) is a lifethreatening event in patients with portal hypertension. To stanch the gastric variceal bleeding, endoscopic injection sclerotherapy (EIS) using immediate tissueadhesive substances, super glue, is considered effective treatment. Until now, we have performed EIS using 62.5%/75% cyanoacrylate mixed contrast medium to 150 or more patients. However, leakage of injected CA to systemic circulation through the gastro-renal shunt was occurred in some patients with large GV. Although it was thought that large GV had high blood flow volume (BFV), there was no data of relationship between GV diameter and BFV. The aim of this study was to investigate BFV of GV in variety of GV size using echo-endoscope. Patients/Methods: Eleven patients who had isolated GV in the period from Nov. 2004 to Oct. 2005 were enrolled in this study. We had used echo-endoscope with curved linear array (GFUCT240-AL5, Tokyo, Olympus, Japan) or with electronic radial array (GF-UE260AL5, Olympus, Japan). The variceal diameter and BFV were measured five times in each patient, definite data was fixed with the use of average excluding the maximum/minimum diameter and FV. Assessment of variceal form (F1: small varix, F2: medium varix, F3: large/tumorous varix) was according to Japanese society of portal hypertention. EIS was performed using cyanoacrylate in all cases. Results: 1) Form and the diameter of GV: F1 was 3.9 mm, F2 was 5.3 mm, and F3 was 9.0 mm in mean diameter of EV. 2) BFV and diameter of GV: BFV was in range of 104-420 ml/min (4.4-7.1 mm in diameter), 791.7 ml/min (9 mm in diameter). BFV was interrelated with GV diameter in the curve of the expression of the second order. 3) therapeutic results: GV was completely eradicated in all cases. However, in a case that diameter was 9 mm, injected cyanoacrylate flowed out the systemic circulation. Conclusions: BFV of isolated GV was correlated with its size. Our results suggested that the estimation of BFV by endoscopic findings would be possible in isolated GV case. In addition, care should be exercised in the case of 9 mm in diameter and/or more than 700 ml/min in BFV, in performing EIS for GVs using super glue.
Background: Standard evaluation of patients with recurrent acute pancreatitis may fail to determine an etiology. Accurately determining cause helps direct therapy, limits unnecessary diagnostic tests, and may improve a patient’s long-term prognosis. The aim of this study was to determine the diagnostic yield of EUS and ERCP in evaluating patients with IARP. Methods: All patients referred to our institution for evaluation of IARP between 2000 and 2005 were reviewed. IARP was defined as two or more episodes of pancreatitis without a definitive etiology found after standard work-up. Only patients who underwent both EUS and ERCP were included. Results: 63 patients (22M/41F, mean age 49, range 18-82) underwent EUS and ERCP for evaluation of IARP between 2000 and 2005. 63% (40/63) had prior cholecystectomy. ERCP was successful in 90% (57/63). 42% (24/57) had manometry performed during ERCP. The combination of EUS and ERCP identified a cause of IARP in 84% (53/63) of patients: sphincter of Oddi dysfunction in 32% (17/53), chronic pancreatitis in 26% (14/53), pancreas divisum in 19% (10/53), papillary stenosis in 11% (6/53), pancreatic malignancy in 6% (3/53), microlithiasis in 4% (2/ 53), and IPMT in 2% (1/53). In 16% (10/63), no etiology was found. EUS revealed a diagnosis in 44% (28/63) of patients, while ERCP was diagnostic in 71% (45/63). The rate of post-ERCP pancreatitis was 17% (11/63), with 7 of these 11 patients (64%) having a manometry study. There were no EUS-related complications. EUS-guided fine needle aspiration diagnosed two patients with pancreatic adenocarcinoma. Endoscopic therapy during ERCP (biliary and/or pancreatic sphincterotomy) was performed in 67% (38/57) of patients. Four of these patients sustained another episode of pancreatitis during a median follow-up period of 21 months. Of the 10 patients whose etiology remained unknown after EUS and ERCP, none have had recurrent attacks. Conclusions: 1. These updated data demonstrate that the etiology of IARP can be established in the majority of patients undergoing combined EUS and ERCP. 2. ERCP was diagnostic in more patients than EUS, but was associated with a higher risk of procedure-related pancreatitis. 3. Endoscopic therapy during ERCP was effective in preventing further attacks. 4. Given the lower complication rate, EUS should continue to have an early role in the evaluation of IARP. When the etiology remains unknown, ERCP with or without manometry study may establish a diagnosis, direct therapy, and potentially improve a patient’s long-term prognosis.
W1303 Is Endoscopic Ultrasonography More Useful Than Naked Eyes for Discrimination of Gastric Mucosal Cancer from Deeper Invasion? Kyungsik Park, Byoungkuk Jang, Woojin Chung, Kwangbum Cho, Jaeseok Hwang, Sunghoon Ahn, Seongyeol Kim, Hongsug Lee, Yeongseok Lee, Junyoung Hwang Background/Aims: Recently, endoscopic ultrasonography (EUS) has been used widely for diagnosing tumor depth. But accuracy of EUS for diagnosing tumor depth is variously reported according to centers. Furthermore some expert endoscopists may well discriminate mucosal cancer from deeper invasion with naked eyes by morphology. Thus the aims of this study are first to find accuracy of EUS for diagnosing tumor depth and second to compare the accuracy of EUS with that of naked eyes of variously experienced endoscopists. Methods: EUS and pathologic reports of gastric cancer patients whose staging had been confirmed pathologically by surgery or ESD were analyzed retrospectively. Endoscopic images extracted from picture archiving communication system (PACS) were reviewed by 3 endoscopists whose clinical experiences are 1 (Dr1), 3 (Dr2), and 5 (Dr3) years, respectively, and they were requested to guess tumor depth. Any clinical informations about the patients were not presented to them. Tumor depth was presented as follows (T1m: confined to mucosal layer, T1sm; invasion to submucosal layer or deeper). Accuracies of EUS and each doctor’s naked eyes were analyzed by comparing the values of them with those of pathologic finding. Cohen’s kappa was used for statistical analysis. Accuracies of EUS during first and second year were also analyzed separately to find out relationship between accuracy and examiner’s experience. Results: From November 2003 to October 2005, 94 patients (54 men and 38 wemes) were involved and mean age was 60.1 G 11.1 years. There were 52 (55.3%) T1m and 42 (44.7%) T1sm patients. The kappa values of EUS, Dr1, Dr2, D3 were 0.508 (p ! 0.001), 0.175 (p Z 0.002), 0.480 (p ! 0.001), 0.407 (p ! 0.001), respectively. Of 52 T1m patients, only 29 (55.8%) patients were diagnosed as T1m with EUS. But of 42 T1sm patients, 41 (97.6%) patients were diagnosed accurately. So overall accuracy of EUS was 74.5%. Dr2’s naked eyes whose accuracy was highest of 3 endoscopists showed accuracy of 61.5%, 88.1%, and 73.4% for T1m, T1sm, and overall, respectively. There were one (1.1%) and 5 (11.9%) cases of understaging with EUS and naked eyes, respectively. The overall accuracy and kappa value of EUS for first a year were 69.8%, 0.403, and for second year were 78.4%, 0.582. Conclusions: Overall accuracy of EUS for differentiating gastric mucosal cancer from deeper invasion is 74.5%. But this accuracy can rise with examiner’s experience. Overstaing of mucosal cancer is main cause of this discordance. Though accuracy of 3 year experienced endoscopist’s naked eye may be nearly as high as that of EUS, relatively understaging of deeper cancer should be considered.
AB262 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
W1305 Utility of Presenting Symptoms and Endoscopic Ultrasound Morphology Characteristics in the Diagnosis of Intraductal Papillary Mucinous Tumors: Correlation with Histopathology in 74 Patients Shireen A. Pais, Siriboon Attasaranya, Julia K. Leblanc, Lee Mc Henry, Stuart Sherman, Max Schmidt, John Dewitt Introduction: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are precancerous cystic tumors usually characterized by dilation of the main pancreatic duct (IPMN-M) alone, side branches alone (IPMN-Br) or both. The aim of this study is to identify the EUS features and presenting symptoms in these patients and to identify any variables predictive of malignancy. Methods: Utilizing endoscopy, surgery and pathology databases, patients who underwent EUS followed by surgery for IPMNs between July 1996 and November 2005 were retrospectively identified. EUS was performed by 7 experienced endosonographers with on-site cytopathologists. The surgical specimen was considered as the diagnostic gold standard. The tumor was considered as benign if classified as any of the following: IPMN adenoma, low grade, borderline or high-grade dysplasia. Only invasive carcinoma was considered as malignant. Results: 74 patients (38 male; mean age: 65 G 10 yrs) were identified with 21 (28%) malignant and 53 (72%) benign IPMNs. The tumors were located in the pancreatic head alone, body alone, tail alone or were multifocal in 39 (53%), 17 (23%), 5 (6%) and 9 (12%) respectively. The tumors were classified as IPMN-M, IPMN-Br or both in 21 (28%), 18 (25%) and 35 (47%) respectively. The most common presenting symptoms included abdominal pain in 31 (42%), weight loss in 23 (32%), back pain in 10 (14%), jaundice in 9 (13%) and diarrhea in 8 (11%). 29 patients (39%) previously had acute pancreatitis and 7 (10%) were asymptomatic. Compared with benign tumors, patients with malignancy were more likely to be older (mean age 70 yrs versus 63 yrs (p Z 0.011)), and present with jaundice (p Z 0.03) or weight loss (p Z 0.03). Patients with malignancy had a larger mean main pancreatic duct diameter (8.8 mm versus 4.3 mm (p Z 0.0001)) or were more likely to have EUS evidence of a solid lesion (p Z 0.0001), filling defects within the main duct (p Z 0.03) or thickened septae within any cyst (p Z 0.02). Between the two groups, there was no difference in gender, presence of abdominal pain, diarrhea or back pain, tumor location, size of largest cyst or visible sidebranches (p O 0.05 for all comparisions). Conclusions: For IPMNs, older age, jaundice, weight loss at presentation are predictive of invasive cancer. EUS features of malignancy include: a solid lesion, marked dilation of the main pancreatic duct, filling defects within the main duct and thickened septae within the cyst. Knowledge of these features may help endosonographers identify which IPMNs should undergo EUS-FNA.
www.giejournal.org