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Endosonography (EUS) for Detection of Anomalous Union of the Pancreaticobiliary Duct (AUPBD) in Patients with Asymptomatic Gallbladder Wall Thickening
*T1603 EUS: An Ideal Initial Test for Elderly Patients with Idiopathic Pancreatitis Karin M. Rettig, Allan G. Halline, Russell D. Brown, Rama P. Venu Background: Current standard of care for patients with idiopathic pancreatitis (IP) involves an extensive evaluation including ERCP with possible sphincter manometry to identify an etiology. ERCP carries a significant risk of pancreatitis in comparison to endoscopic ultrasound (EUS). Furthermore, EUS identifies malignancy, stones, sludge, and chronic pancreatitis as well as or better than ERCP. Older patients may have a higher risk of malignancy and a lower incidence of sphincter dysfunction (SD), making EUS an attractive method for initial endoscopic evaluation in this group. Aim: To determine if EUS should be used as the initial investigation of choice in older patients with IP. Methods: Patients >55 years old referred with IP were evaluated with history, physical, amylase, lipase, triglyceride, calcium, liver enzymes, ultrasound and CT. Patients in whom the etiology was unknown after noninvasive evaluation were included in this study. Each patient had EUS, followed by helical CT and ERCP +/- sphincterotomy (ES). Radial array EUS was done first followed by linear array EUS with possible fine needle aspirate (FNA). CT, ERCP with brush cytology and/or SOM was performed in all patients. ES, stone extraction, stent placement, laparotomy, or Whipple operation was done based on ERCP results. Results: Of 20 patients, an etiology was identified in 7 (35%). Four of 20 patients had a malignancy (3 pancreas, 1 periampullary). One patient each had choledocholithiasis, pancreas divisum, SD, and early chronic pancreatitis. EUS demonstrated a mass in all 4 patients with malignancy, and FNA of each mass was positive for adenocarcinoma in 3. ERCP showed PD stricture suggestive of malignancy in 3 patients, with brush cytology positive for adenocarcinoma in one. Both EUS and ERCP identified a common bile duct stone in one patient, while SD (1) and pancreas divisum (1) were diagnosed exclusively by ERCP. EUS established a diagnosis in 6/7 (84%), while ERCP did so in 4/7 (56%). CT scanning revealed a mass in only one of four cancer patients and an enlarged pancreas due to pancreatitis in 17/20 patients. Three of four patients with cancer underwent Whipple surgery, and all three were correctly staged by EUS. One patient had metastasis to the liver and was treated with endoprosthesis. Conclusion: EUS should be considered as the initial endoscopic study of choice in older patients with IP. EUS has an overall higher yield and can accurately establish a tissue diagnosis, enable staging of malignancy, and aid in appropriate planning for therapy.
*T1604 Endosonography (EUS) for Detection of Anomalous Union of the Pancreaticobiliary Duct (AUPBD) in Patients with Asymptomatic Gallbladder Wall Thickening Bong Min Ko, Sang Woo Cha, Young Seok Kim, Jong Ho Moon, Young Deok Cho, Yun Soo Kim, Joon Seong Lee, Moon Sung Lee, Chan Sup Shim, Boo Sung Kim BACKGROUND/AIM: Early diagnosis and treatment of AUPBD are important before malignancy arises from the biliary tract. Mucosal hyperplasia of the gallbladder (GB) may be one of the earliest changes of carcinogenesis. Thickened GB wall sign has been reported as being a clue to the diagnosis of AUPBD and a useful ultrasonongraphic finding for mucosal hyperplasia of the GB. We conducted a study to assess the usefulness of EUS, as a noninvasive diagnostic imaging modality for detection of AUPBD in the patients with asymptomatic GB wall thickening. METHOD: Thirty-five patients who had asymptomatic thicken GB wall (4 mm or more) on abdominal ultrasonography (US) were evaluated. EUS criteria for AUPBD was presence of union outside the duodenal wall. AUPBD confirmed by endoscopic retrograde cholangiopancreatography (ERCP). Histologic examination of 24 patients were made. RESULT: 1) Of 35 patients with GB wall thickening, 11 had suspicious AUPBD on EUS(31%). 2) 10 patients out of 11 patients were confirmed to AUPBD on ERCP (91%). Among 4 patients with undilated type of AUPBD on ERCP, 3 patients were detected by EUS (75%). Among 6 patients with dilated AUPBD on ERCP, all patients were detected by EUS (100%). 3) Of 24 resected GB examined histopathologically, GB cancer in 4, adenomatous hyperplasia in 5, chronic inflammation in 13, adenomyomatosis in 2 and inflammatory polyp in 1 patient. CONCLUSION: EUS is a useful noninvasive imaging modality for diagnosis of AUPBD in patients with asymptomatic GB wall thickening.
*T1605 Usefulness of Endoscopic Ultrasonography in the Differentiation Between Malignant and Benign Causes of Thickened Gallbladder Wall Don Lee, Sung Koo Lee Background: The early diagnosis of possible cancer within thickened gallbladder wall is very important. This study was aimed to confirm the usefulness of endoscopic ultrasonography (EUS) in diagnosis of gallbladder cancer within
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thickened wall, and to find out the findings of EUS that favor gallbladder cancer. Methods: We reviewed 67 cases of patients who underwent cholecystectomies and who also showed thickened gallbladder wall in their preoperative EUS. According to the post-surgical pathologic diagnosis, the cases were classified into malignant and benign diseases, and then they were statistically compared with several findings of EUS of thickened gallbladder wall such as thickness, extent of wall thickening, associations of gallstones, loss or preservation of layered structure of wall, internal echo pattern within thickened wall, associations of microcyst or echogenic nodule within thickened wall, and irregularity of inner surface of thickened wall. Results: Pathologic diagnoses included 10 cancers and 57 benign gallbladder diseases. The sensitivity and specificity of EUS examination for diagnosis of the gallbladder cancer were 90% and 98% respectively, and especially in the specificity, EUS was superior to that of abdominal ultrasonography or abdominal CT scan that were also performed to enrolled patients preoperatively. Through statistical analyses, EUS findings of thickened wall such as thickness, associations of gallstones, loss or preservation of layered structure, and irregularity of inner surface of thickened wall were turned out to be the statistically significant variables in the differential diagnosis between malignant and benign causes of thickened gallbladder wall. On the multivariate analyses, loss or preservation of layered structure, and irregularity of inner surface of thickened wall were finally remained as independent variables, odds ratio (OR) 12.10: 95% CI (1.2, 137.6), OR 15.80: 95% CI (1.5, 167.0). Conclusion: EUS is useful to diagnose gallbladder cancer when gallbladder shows thickened wall and EUS findings of thicker wall, absence of gall stones, loss of normal layered structure, and irregular internal surface of thickened wall are predictive factor of gallbladder cancer.
*T1606 Predictors of Accuracy in Patients Undergoing Endoscopic Ultrasound (EUS) Guided Fine Needle Aspirate (FNA) of the Pancreas Richard Zubarik There is little data evaluating factors, which may influence the accuracy of EUS guided FNA. Aim: To determine what factors effect accuracy rates of EUS guided FNA of the pancreas in detecting malignancy. Methods: Patients undergoing EUS guided FNA from 8/2001 to 6/2003 were retrospectively reviewed. All procedures were performed by a single endosonographer (RZ). A cytopathologist was present at all EUS guided FNA procedures. Patient factors at the time of FNA including gender, age, findings on CT, findings on EUS, CA 19-9 and symptomatology were assessed. Patients were considered to have pancreatic malignancy if malignant cells were found on cytology or surgical pathology. Patients were considered not to have pancreatic malignancy only after follow-up computed tomography was performed at least 6 months later and progression of abnormalities were not identified. Statistical significance was evaluated using the chi-squared test for categorical data and an independent sample t-test for scale data. Results: Sixty patients who had undergone EUS guided FNA of the pancreas were included in this study. Of these patients the mean age was 63 and 53% were female. Ultimately, 65% were diagnosed with cancer (adenocarcinoma 37, insulinoma 2). The overall accuracy rate for EUS guided FNA was 88% (53/60). Age, gender, presence of jaundice, location and size of tumor, and level of CA 19-9 did not significantly effect accuracy rates of FNA. Accuracy rates were significantly higher when a biliary endoprosthesis was absent 95% vs 71% (p=0.029). Presence of a metallic endoprosthesis (n=5) significantly diminished accuracy rates when compared to patients without an endoprosthesis 40% vs. 95%(p=0.001), and when compared to those patients with a plastic endoprosthesis (p=0.001). Presence of a plastic biliary endoprosthesis (n=12) significantly diminished accuracy when compared to patients without an endoprosthesis 83% vs. 95% (p=0.005). Conclusions: Presence of a biliary endoprosthesis significantly decreases the accuracy rate of EUS-guided FNA of the pancreas in detecting malignancy. Presence of a metallic endoprosthesis decreases accuracy rates greater than when a plastic endoprosthesis is present. If pancreatic tissue is necessary attempts should be made to do an EUS-guided FNA prior to placement of a biliary endoprosthesis. If a biliary endoprosthesis is required prior to tissue acquisition, a plastic endoprosthesis is preferable.
VOLUME 59, NO. 5, 2004
*T1604 Endosonography (EUS) for Detection of Anomalous Union of the Pancreaticobiliary Duct (AUPBD) in Patients with Asymptomatic Gallbladder Wall Thickening Bong Min Ko, Sang Woo Cha, Young Seok Kim, Jong Ho Moon, Young Deok Cho, Yun Soo Kim, Joon Seong Lee, Moon Sung Lee, Chan Sup Shim, Boo Sung Kim BACKGROUND/AIM: Early diagnosis and treatment of AUPBD are important before malignancy arises from the biliary tract. Mucosal hyperplasia of the gallbladder (GB) may be one of the earliest changes of carcinogenesis. Thickened GB wall sign has been reported as being a clue to the diagnosis of AUPBD and a useful ultrasonongraphic finding for mucosal hyperplasia of the GB. We conducted a study to assess the usefulness of EUS, as a noninvasive diagnostic imaging modality for detection of AUPBD in the patients with asymptomatic GB wall thickening. METHOD: Thirty-five patients who had asymptomatic thicken GB wall (4 mm or more) on abdominal ultrasonography (US) were evaluated. EUS criteria for AUPBD was presence of union outside the duodenal wall. AUPBD confirmed by endoscopic retrograde cholangiopancreatography (ERCP). Histologic examination of 24 patients were made. RESULT: 1) Of 35 patients with GB wall thickening, 11 had suspicious AUPBD on EUS(31%). 2) 10 patients out of 11 patients were confirmed to AUPBD on ERCP (91%). Among 4 patients with undilated type of AUPBD on ERCP, 3 patients were detected by EUS (75%). Among 6 patients with dilated AUPBD on ERCP, all patients were detected by EUS (100%). 3) Of 24 resected GB examined histopathologically, GB cancer in 4, adenomatous hyperplasia in 5, chronic inflammation in 13, adenomyomatosis in 2 and inflammatory polyp in 1 patient. CONCLUSION: EUS is a useful noninvasive imaging modality for diagnosis of AUPBD in patients with asymptomatic GB wall thickening.
*T1605 Usefulness of Endoscopic Ultrasonography in the Differentiation Between Malignant and Benign Causes of Thickened Gallbladder Wall Don Lee, Sung Koo Lee Background: The early diagnosis of possible cancer within thickened gallbladder wall is very important. This study was aimed to confirm the usefulness of endoscopic ultrasonography (EUS) in diagnosis of gallbladder cancer within
P226
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thickened wall, and to find out the findings of EUS that favor gallbladder cancer. Methods: We reviewed 67 cases of patients who underwent cholecystectomies and who also showed thickened gallbladder wall in their preoperative EUS. According to the post-surgical pathologic diagnosis, the cases were classified into malignant and benign diseases, and then they were statistically compared with several findings of EUS of thickened gallbladder wall such as thickness, extent of wall thickening, associations of gallstones, loss or preservation of layered structure of wall, internal echo pattern within thickened wall, associations of microcyst or echogenic nodule within thickened wall, and irregularity of inner surface of thickened wall. Results: Pathologic diagnoses included 10 cancers and 57 benign gallbladder diseases. The sensitivity and specificity of EUS examination for diagnosis of the gallbladder cancer were 90% and 98% respectively, and especially in the specificity, EUS was superior to that of abdominal ultrasonography or abdominal CT scan that were also performed to enrolled patients preoperatively. Through statistical analyses, EUS findings of thickened wall such as thickness, associations of gallstones, loss or preservation of layered structure, and irregularity of inner surface of thickened wall were turned out to be the statistically significant variables in the differential diagnosis between malignant and benign causes of thickened gallbladder wall. On the multivariate analyses, loss or preservation of layered structure, and irregularity of inner surface of thickened wall were finally remained as independent variables, odds ratio (OR) 12.10: 95% CI (1.2, 137.6), OR 15.80: 95% CI (1.5, 167.0). Conclusion: EUS is useful to diagnose gallbladder cancer when gallbladder shows thickened wall and EUS findings of thicker wall, absence of gall stones, loss of normal layered structure, and irregular internal surface of thickened wall are predictive factor of gallbladder cancer.
*T1606 Predictors of Accuracy in Patients Undergoing Endoscopic Ultrasound (EUS) Guided Fine Needle Aspirate (FNA) of the Pancreas Richard Zubarik There is little data evaluating factors, which may influence the accuracy of EUS guided FNA. Aim: To determine what factors effect accuracy rates of EUS guided FNA of the pancreas in detecting malignancy. Methods: Patients undergoing EUS guided FNA from 8/2001 to 6/2003 were retrospectively reviewed. All procedures were performed by a single endosonographer (RZ). A cytopathologist was present at all EUS guided FNA procedures. Patient factors at the time of FNA including gender, age, findings on CT, findings on EUS, CA 19-9 and symptomatology were assessed. Patients were considered to have pancreatic malignancy if malignant cells were found on cytology or surgical pathology. Patients were considered not to have pancreatic malignancy only after follow-up computed tomography was performed at least 6 months later and progression of abnormalities were not identified. Statistical significance was evaluated using the chi-squared test for categorical data and an independent sample t-test for scale data. Results: Sixty patients who had undergone EUS guided FNA of the pancreas were included in this study. Of these patients the mean age was 63 and 53% were female. Ultimately, 65% were diagnosed with cancer (adenocarcinoma 37, insulinoma 2). The overall accuracy rate for EUS guided FNA was 88% (53/60). Age, gender, presence of jaundice, location and size of tumor, and level of CA 19-9 did not significantly effect accuracy rates of FNA. Accuracy rates were significantly higher when a biliary endoprosthesis was absent 95% vs 71% (p=0.029). Presence of a metallic endoprosthesis (n=5) significantly diminished accuracy rates when compared to patients without an endoprosthesis 40% vs. 95%(p=0.001), and when compared to those patients with a plastic endoprosthesis (p=0.001). Presence of a plastic biliary endoprosthesis (n=12) significantly diminished accuracy when compared to patients without an endoprosthesis 83% vs. 95% (p=0.005). Conclusions: Presence of a biliary endoprosthesis significantly decreases the accuracy rate of EUS-guided FNA of the pancreas in detecting malignancy. Presence of a metallic endoprosthesis decreases accuracy rates greater than when a plastic endoprosthesis is present. If pancreatic tissue is necessary attempts should be made to do an EUS-guided FNA prior to placement of a biliary endoprosthesis. If a biliary endoprosthesis is required prior to tissue acquisition, a plastic endoprosthesis is preferable.
VOLUME 59, NO. 5, 2004