- Email: [email protected]
Endoscopic transpapillary biopsies and intraductal ultrasonography in the diagnostics of biliary ductal strictures
A204 AGA ABSTRACTS
GASTROENTEROLOGY Vol. 118, No.4
1267 ASSESSMENT OF GALLBLADDER MOTOR FUNCTION IN HUMAN SUBJECTS: CHOLESCINTIGRAPHY COMPARED WITH DIRECT MEASUREMENTS OF INTRA-GALLBLADDER COMPLIANCE. Adnan Ahmad, Salam F. Zakko, Cecile F. Guttermuth, Mozafareddin K. Karimeddini, Gale R. Ramsby, UConn Health Ctr, Farmington. CT. Cholescintigraphy (HIDA) is classically used to quantify gallbladder (GB) motor function by calculating the percent change of GB volume in response to sincalide (CCK) as an indirect measure of GB ejection fraction. We previously described a direct method to assess GB compliance in patients with percutaneous GB access. In this study we compare HIDA against this technique. To our knowledge, the accuracy of HIDA in quantifying GB contractility has not been validated against direct measurements in humans. METHODS: Five patients who were enrolled in a percutaneous gallstone dissolution protocol and who had functioning GBs by oral cholecystography were studied. Each patient had CCK stimulated HIDA and direct GB compliance assessment in the fasting state within one week of each other. HIDA was performed by gamma camera imaging after an IV infusion of 5 mCi of Tc-99m. A baseline image was obtained followed by a slow IV infusion of sincalide 0.02 ug/kg over 30 minutes. GB imaging was repeated every 5 minutes. Direct GB compliance measurements were carried out utilizing the multilumen gallstone dissolution catheter that was already in place. All bile was evacuated from the GB then dilute contrast material was injected at a constant rate of 12 mUmin. Intra-GB pressure was measured through an independent catheter lumen and plotted in real time on an X-V chart recorder against the cumulative infused volume. The infusion was stopped when contrast was observed fluoroscopically to pass through the cystic duct. This pressure-volume curve was repeated every 5 minutes after an IV infusion of CCK at the same dose above. The % reduction in GB volume in response to CCK as detected by HIDA is compared to the reduction in GB volume at the cystic duct pressure on the compliance curve. RESULTS: Both techniques detected a maximal steady state GB response 20 minutes after CCK. Values of GB ejection fraction obtained using these two methods correlated very closely, r=0.997(see Fig). CONCLUSION: GB response to CCK by HIDA strongly correlates with direct intra-GB compliance measurements in patients who have a patent cystic duct by oral cholecystography. Studies are underway to determine if this correlation exists in patients with partial GB outlet obstruction where HIDA may underestimate GB ejection fraction since it only measures change in volume and not compliance.
90
%
80
REDUCll0t~ m GB VOLUM: III RESPO t~SE TO CCK
maximal coning employed to minimize skin dose. The films were subsequently evaluated for dose distribution. Results: Calibration curves were determined for all three films. From 30 cases studied, the procedure fluoro times 2.5 to 20 min (median 7), and the max anterior skin doses 10 to 110 cGy (median 58) were well within the acceptable range for minimal radiation damage. Conclusion: The present work demonstrates a simple, rapid and accurate means of measuring patient dose, providing immediate identification of cases exceeding set dose levels and allowing initiation of patient care measures. The protocol makes it simple to evaluate whether steps taken for dose reduction during the procedure are effective. With this cost-effective method, it is hoped that consistently monitoring all procedures would soon become a routine that helps reducing excessive exposure to radiation.
1269 QUALITY OF LIFE OUTCOMES FOLLOWING ENDOSCOPIC ULTRASOUND FOR DYSPEPSIA / UNEXPLAINED UPPER ABDOMINAL PAIN. 1. Dill, B. Dill, Carilion Roanoke Community Hosp, Roanoke, VA. Many patients with severe upper abdominal pain have negative conventional testing, including transabdominal ultrasound (TUS). Studies of Endoscopic Ultrasound (EUS) with and without Stimulated Biliary Drainage (SBD) demonstrated significant findings such as biliary sludge, microlithiasis and otherwise occult pancreatitis. The present study aimed to determine Quality of Life (QOL) outcomes post EUS/SBD with or without Cholecystectomy. PATIENTSIMETHODS: A 2 yr. prospective Andy with 64 pts. undergoing EUS/SBD for dyspepsia/unexplained upper abdominal pain after (-)TUS. Pts. with abnormal gallbladder (GB) EUS and/or microlithiasis on SBD were considered for poss. Cholecystectomy. Abnormal GB EUS was defined as GB sludge or stones, or wall thickening (>3mm). At avo 21 mo. post EUS/SBD without surgery or avo 19 mo. post surgery, SF-36 questionnaires & pain relief questions were mailed to all 64 pts. (34 return responses). U.S. Mean QOL summary scores on SF-36 are PCS 50, MCS 50. RESULTS: 34 pts. post EUS/SBD (female 29 (85%), male 5 (15%) Post Cholecystectomy- 27 pts.; pain relief - 24 (89%)/QOL Scores: PCS 47.57 MCS 49.48, unimproved - 3 (II %)/QOL Scores: PCS 26.09 MCS 38.15. No surgery -7 pts.; pain relief - 3 (43%)/QOL Scores: PCS 47.14 MCS 49.56, unimproved - 4 (57%)lQOL Scores: PCS 27.40 MCS 40.30. Positive Predictive Value: EUS/SBD for abnormal GB histopathology or GB microlithiasis = 100% CONCLUSION I. Av. 19mo. post Cholecyglectomy, 89% of pts. with dyspepsia/unexplained upper abdominal pain after (+) EUS and/or SBD had pain relief. Av. SF-36 QOL summary scores: PCS 47.57 MCS 49.48. -2. 4 pts. (57%) without surgery were unimproved. Av. SF-36 QOL summary scores: PCS 27.40 MCS 40.30. 3. EUS/SBD demonstrated 100% Positive Predictive Value for abnormal GB histopathology or GB microlithiasis.
w 70
1270
z 60 ce
ENDOSCOPIC TRANSPAPILLARY BIOPSIES AND INTRADUCTAL ULTRASONOGRAPHY IN THE DIAGNOSTICS OF BILIARY DUCTAL STRICTURES. Dirk Domagk, Christopher Poremba, Karlheinz Dietl, Norbert Senninger, Wolfram Domschke, Josef Menzel, Univ of Muenster, Muenster, Germany. Introduction: The use of intraductal Ultrasonography (lDUS) performed during endoscopic retrograde cholangio-pancreatography (ERCP) has become a valuable technique for the assessment of bile duct strictures. Methods: We examined 60 patients with biliary ductal strictures of unknown etiology by ERCP including transpapillary biopsies and intraductal ultrasonography. All patients underwent laparotomy. Results: Final diagnosis revealed 30 pancreatic carcinomas, 17 bile duct cancers, 3 gallbladder cancers and 10 benign bile duct strictures. Using endoscopic transpapillary forceps biopsies, a correct preoperative diagnosis was achieved in 27 out of 60 patients (45% of the cases) resulting in a sensitivity of 55.7% and a specificity of 100%. IDUS showed higher values for bile duct cancer than transpapillary biopsies with a sensitivity of 88.2% and a specificity of 86%. For neoplastic pancreatic lesions, IDUS had a sensitivity of 86.6% and a specificity of 80%. ERCP supplemented with transpapillary forceps biopsy and IDUS allows a correct preoperative diagnosis in 78.3% of the cases (47 out of 60 patients), which is significantly higher than transpapillary biopsies alone (p<0.05). Conclusion: Because of low accuracy, endoscopic transpapillary biospy for itself is not a reliable diagnostic tool for definite preoperative diagnosis of bile duct strictures. By adding IDUS and transpapillary biopsy to ERCP, however, an improvement of preoperative diagnosic capacity is guaranteed. Accurate preoperative diagnosis of bile duct strictures is essential for planning therapy strategies.
u
:J 50 Q. ~40
o
u 30
~ 20
~=O.994, P=O.01
10
o
o
10 20 30 40 50 60 70 80 90 BY CHOLE SCmTIGRAPHY
1268 AN ACCURATE SIMPLE MEASURE OF PATffiNT RADIATION EXPOSURE DURING ERCP BY PORTAL FILM DOSIMETRY. H. M. Kuan, J. A. Ferretti, J. W. Birk. S. F. Amanullah, K. I. Ashraf, B. J. Pollack, Univ Hosp and Med Ctr, SUNY, Stony Brook, NY. Purpose: The radiation dose patients receive during diagnostic-therapeutic ERCP procedures(ERCPs) is of importance yet often poorly quantified. Our protocol piloting the use of film dosimetry was developed for measuring/mapping skin doses during ERCPs. Dose distribution, calculated range and median dermal doses were recorded. Variations as to type of procedure, extent of disease, specifics in the use of equipment and patientrelated factors were examined. Materials and Methods: Three 14" x17" portal films, progressively calibrated for a continuum of radiation dose (Kodak X-Omat V, calibrated for doses up to 50 cGy, EC film, calibrated to 150 cGy, and a new ISP Radiochromic film XXRF-I0404, calibrated to 800 cGy and beyond) were stacked together and exposed during the entire procedure by being placed between the x-ray table top and the patient who was in prone position throughout. The undertable x-ray tube was of a fixed 19" SSD, fluoro and spot films taken in auto mode with max kV of 110, and
1271 VIRTUAL CHOLANGIOSCOPY USING TRANSABDOMINAL THREE-DIMENSIONAL ULTRASONOGRAPHY. Senju Hashimoto, Hidemi Goto, Yoshiki Hirooka, Akihiro Ito, Yoshihiro Ishiguro, Shinya Kojima, Takanori Hirai, Tetsuo Hayakawa, Yasuo Naitoh, Nagoya Univ Sch of medicine, Nagoya, Japan. Three-dimensional (3D) images of bilialy diseases have made rapid progress recently. Here we evaluated clinical usefulness of virtual cholangioscopy (VC) obtained with transabdominal three-dimensional ultrasonography for bilialy tract diseases. Subjects and Methods Six persons
GASTROENTEROLOGY Vol. 118, No.4
1267 ASSESSMENT OF GALLBLADDER MOTOR FUNCTION IN HUMAN SUBJECTS: CHOLESCINTIGRAPHY COMPARED WITH DIRECT MEASUREMENTS OF INTRA-GALLBLADDER COMPLIANCE. Adnan Ahmad, Salam F. Zakko, Cecile F. Guttermuth, Mozafareddin K. Karimeddini, Gale R. Ramsby, UConn Health Ctr, Farmington. CT. Cholescintigraphy (HIDA) is classically used to quantify gallbladder (GB) motor function by calculating the percent change of GB volume in response to sincalide (CCK) as an indirect measure of GB ejection fraction. We previously described a direct method to assess GB compliance in patients with percutaneous GB access. In this study we compare HIDA against this technique. To our knowledge, the accuracy of HIDA in quantifying GB contractility has not been validated against direct measurements in humans. METHODS: Five patients who were enrolled in a percutaneous gallstone dissolution protocol and who had functioning GBs by oral cholecystography were studied. Each patient had CCK stimulated HIDA and direct GB compliance assessment in the fasting state within one week of each other. HIDA was performed by gamma camera imaging after an IV infusion of 5 mCi of Tc-99m. A baseline image was obtained followed by a slow IV infusion of sincalide 0.02 ug/kg over 30 minutes. GB imaging was repeated every 5 minutes. Direct GB compliance measurements were carried out utilizing the multilumen gallstone dissolution catheter that was already in place. All bile was evacuated from the GB then dilute contrast material was injected at a constant rate of 12 mUmin. Intra-GB pressure was measured through an independent catheter lumen and plotted in real time on an X-V chart recorder against the cumulative infused volume. The infusion was stopped when contrast was observed fluoroscopically to pass through the cystic duct. This pressure-volume curve was repeated every 5 minutes after an IV infusion of CCK at the same dose above. The % reduction in GB volume in response to CCK as detected by HIDA is compared to the reduction in GB volume at the cystic duct pressure on the compliance curve. RESULTS: Both techniques detected a maximal steady state GB response 20 minutes after CCK. Values of GB ejection fraction obtained using these two methods correlated very closely, r=0.997(see Fig). CONCLUSION: GB response to CCK by HIDA strongly correlates with direct intra-GB compliance measurements in patients who have a patent cystic duct by oral cholecystography. Studies are underway to determine if this correlation exists in patients with partial GB outlet obstruction where HIDA may underestimate GB ejection fraction since it only measures change in volume and not compliance.
90
%
80
REDUCll0t~ m GB VOLUM: III RESPO t~SE TO CCK
maximal coning employed to minimize skin dose. The films were subsequently evaluated for dose distribution. Results: Calibration curves were determined for all three films. From 30 cases studied, the procedure fluoro times 2.5 to 20 min (median 7), and the max anterior skin doses 10 to 110 cGy (median 58) were well within the acceptable range for minimal radiation damage. Conclusion: The present work demonstrates a simple, rapid and accurate means of measuring patient dose, providing immediate identification of cases exceeding set dose levels and allowing initiation of patient care measures. The protocol makes it simple to evaluate whether steps taken for dose reduction during the procedure are effective. With this cost-effective method, it is hoped that consistently monitoring all procedures would soon become a routine that helps reducing excessive exposure to radiation.
1269 QUALITY OF LIFE OUTCOMES FOLLOWING ENDOSCOPIC ULTRASOUND FOR DYSPEPSIA / UNEXPLAINED UPPER ABDOMINAL PAIN. 1. Dill, B. Dill, Carilion Roanoke Community Hosp, Roanoke, VA. Many patients with severe upper abdominal pain have negative conventional testing, including transabdominal ultrasound (TUS). Studies of Endoscopic Ultrasound (EUS) with and without Stimulated Biliary Drainage (SBD) demonstrated significant findings such as biliary sludge, microlithiasis and otherwise occult pancreatitis. The present study aimed to determine Quality of Life (QOL) outcomes post EUS/SBD with or without Cholecystectomy. PATIENTSIMETHODS: A 2 yr. prospective Andy with 64 pts. undergoing EUS/SBD for dyspepsia/unexplained upper abdominal pain after (-)TUS. Pts. with abnormal gallbladder (GB) EUS and/or microlithiasis on SBD were considered for poss. Cholecystectomy. Abnormal GB EUS was defined as GB sludge or stones, or wall thickening (>3mm). At avo 21 mo. post EUS/SBD without surgery or avo 19 mo. post surgery, SF-36 questionnaires & pain relief questions were mailed to all 64 pts. (34 return responses). U.S. Mean QOL summary scores on SF-36 are PCS 50, MCS 50. RESULTS: 34 pts. post EUS/SBD (female 29 (85%), male 5 (15%) Post Cholecystectomy- 27 pts.; pain relief - 24 (89%)/QOL Scores: PCS 47.57 MCS 49.48, unimproved - 3 (II %)/QOL Scores: PCS 26.09 MCS 38.15. No surgery -7 pts.; pain relief - 3 (43%)/QOL Scores: PCS 47.14 MCS 49.56, unimproved - 4 (57%)lQOL Scores: PCS 27.40 MCS 40.30. Positive Predictive Value: EUS/SBD for abnormal GB histopathology or GB microlithiasis = 100% CONCLUSION I. Av. 19mo. post Cholecyglectomy, 89% of pts. with dyspepsia/unexplained upper abdominal pain after (+) EUS and/or SBD had pain relief. Av. SF-36 QOL summary scores: PCS 47.57 MCS 49.48. -2. 4 pts. (57%) without surgery were unimproved. Av. SF-36 QOL summary scores: PCS 27.40 MCS 40.30. 3. EUS/SBD demonstrated 100% Positive Predictive Value for abnormal GB histopathology or GB microlithiasis.
w 70
1270
z 60 ce
ENDOSCOPIC TRANSPAPILLARY BIOPSIES AND INTRADUCTAL ULTRASONOGRAPHY IN THE DIAGNOSTICS OF BILIARY DUCTAL STRICTURES. Dirk Domagk, Christopher Poremba, Karlheinz Dietl, Norbert Senninger, Wolfram Domschke, Josef Menzel, Univ of Muenster, Muenster, Germany. Introduction: The use of intraductal Ultrasonography (lDUS) performed during endoscopic retrograde cholangio-pancreatography (ERCP) has become a valuable technique for the assessment of bile duct strictures. Methods: We examined 60 patients with biliary ductal strictures of unknown etiology by ERCP including transpapillary biopsies and intraductal ultrasonography. All patients underwent laparotomy. Results: Final diagnosis revealed 30 pancreatic carcinomas, 17 bile duct cancers, 3 gallbladder cancers and 10 benign bile duct strictures. Using endoscopic transpapillary forceps biopsies, a correct preoperative diagnosis was achieved in 27 out of 60 patients (45% of the cases) resulting in a sensitivity of 55.7% and a specificity of 100%. IDUS showed higher values for bile duct cancer than transpapillary biopsies with a sensitivity of 88.2% and a specificity of 86%. For neoplastic pancreatic lesions, IDUS had a sensitivity of 86.6% and a specificity of 80%. ERCP supplemented with transpapillary forceps biopsy and IDUS allows a correct preoperative diagnosis in 78.3% of the cases (47 out of 60 patients), which is significantly higher than transpapillary biopsies alone (p<0.05). Conclusion: Because of low accuracy, endoscopic transpapillary biospy for itself is not a reliable diagnostic tool for definite preoperative diagnosis of bile duct strictures. By adding IDUS and transpapillary biopsy to ERCP, however, an improvement of preoperative diagnosic capacity is guaranteed. Accurate preoperative diagnosis of bile duct strictures is essential for planning therapy strategies.
u
:J 50 Q. ~40
o
u 30
~ 20
~=O.994, P=O.01
10
o
o
10 20 30 40 50 60 70 80 90 BY CHOLE SCmTIGRAPHY
1268 AN ACCURATE SIMPLE MEASURE OF PATffiNT RADIATION EXPOSURE DURING ERCP BY PORTAL FILM DOSIMETRY. H. M. Kuan, J. A. Ferretti, J. W. Birk. S. F. Amanullah, K. I. Ashraf, B. J. Pollack, Univ Hosp and Med Ctr, SUNY, Stony Brook, NY. Purpose: The radiation dose patients receive during diagnostic-therapeutic ERCP procedures(ERCPs) is of importance yet often poorly quantified. Our protocol piloting the use of film dosimetry was developed for measuring/mapping skin doses during ERCPs. Dose distribution, calculated range and median dermal doses were recorded. Variations as to type of procedure, extent of disease, specifics in the use of equipment and patientrelated factors were examined. Materials and Methods: Three 14" x17" portal films, progressively calibrated for a continuum of radiation dose (Kodak X-Omat V, calibrated for doses up to 50 cGy, EC film, calibrated to 150 cGy, and a new ISP Radiochromic film XXRF-I0404, calibrated to 800 cGy and beyond) were stacked together and exposed during the entire procedure by being placed between the x-ray table top and the patient who was in prone position throughout. The undertable x-ray tube was of a fixed 19" SSD, fluoro and spot films taken in auto mode with max kV of 110, and
1271 VIRTUAL CHOLANGIOSCOPY USING TRANSABDOMINAL THREE-DIMENSIONAL ULTRASONOGRAPHY. Senju Hashimoto, Hidemi Goto, Yoshiki Hirooka, Akihiro Ito, Yoshihiro Ishiguro, Shinya Kojima, Takanori Hirai, Tetsuo Hayakawa, Yasuo Naitoh, Nagoya Univ Sch of medicine, Nagoya, Japan. Three-dimensional (3D) images of bilialy diseases have made rapid progress recently. Here we evaluated clinical usefulness of virtual cholangioscopy (VC) obtained with transabdominal three-dimensional ultrasonography for bilialy tract diseases. Subjects and Methods Six persons