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The Diagnostic Utility of Endoscopic Ultrasound (EUS) and ERCP in Evaluating Patients with Idiopathic Acute Recurrent Pancreatitis (IARP)
Abstracts
W1212 Utility of EUS: Elastography in the Diagnosis of Pancreatic Diseases Yoshiki Hirooka, Akihiro Itoh, Senju Hashimoto, Hiroki Kawashima, Kazuo Hara, Akira Kanamori, Hiroki Uchida, Jun Goto, Shigeto Ishikawa, Naoki Ohmiya, Yasumasa Niwa, Hidemi Goto Clinical usefulness of real-time tissue elastography (EG: Hitachi, Japan) that visualizes elastic information of tissue using transabdominal ultrasonography (US) is reported mainly in the diagnosis of a superficial organ disorders such as thyroid and breast. EG is the technology that images the difference of distortion between hard tissue and soft tissue in real time. With the cooperation of Hitachi and Pentax, clinical use of EUS-elastography (EUS-EG) became possible. We investigated utility of EUS-EG in the diagnosis of pancreatic diseases. Methods: Subjects consist of 38 patients with 45 lesions: 11 solid tumors (10 pancreatic cancer, 1 pancreatic endocrine tumor), 19 cystic lesions (10 IPMN (intraductal papillary mucinous neoplasm), 6 pseudocyst, 1 mucinous cyst adenoma, 1 solid pseudo-papillary tumor, 1 simple cyst), 13 chronic pancreatitis and 2 autoimmune pancreatitis. We observed target lesions in EUS-EG after depiction in B-mode EUS and compared both images. In this system, both B-mode and EUS-EG images are represented on dual screen at the same time, we can compare both images of same scan plane precisely. In EUS-EG, the tissue elasticity in ROI (region of interest) is expressed in difference of colors, that is, from hard to soft tissue, it is displayed continually from blue to red. We compared EUS-EG images with B-mode images of pancreatic diseases. EUB-8500 (Hitachi) as an ultrasound diagnostic machine and EG-3630UR (Pentax) as an endosonoscope were used in this study. Results: As for 11 solid tumors, in 8 cases of cancer, the sizes of tumor images on EUS-EG corresponded to those of B-mode EUS and in remaining 2 cases, EUS-EG images were revealed slightly wider in range than those of B-mode EUS. The hardness of one endocrine tumor was represented as the same degree as the pancreatic parenchyma. For cystic lesions, usually no color signals were displayed in the cysts. The parenchyma of chronic pancreatitis (including autoimmune pancreatitis) was shown as the image that various colors coexisted from hard to soft tissue. Conclusion: EUS-EG needs attention for the interpretation to show relative value of the hardness in setting ROI. EUS-elastography may be useful diagnostic modality in the diagnosis of pancreatic diseases to offer different information from that of conventional diagnostic imaging methods and be more useful technique in future if absolute evaluation of EUS-elastography become possible.
W1214 Transbronchial Needle Aspiration Followed Immediately by Endoscopic Ultrasound Guided Needle Aspiration in the Evaluation of Mediastinal Lymphadenopathy Khay L. Khoo, Khek Y. Ho, Tow K. Lim Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is a useful diagnostic tool in the evaluation of mediastinal lymphadenopathy, both as a primary modality and in cases of negative transbronchial needle aspiration (TBNA). Aim: To determine the utility of TBNA with rapid on-site cytopathologic evaluation (ROSE) combined with the option for immediate EUS-FNA in the diagnosis of mediastinal adenopathy of unknown etiology. Methods: We prospectively enrolled patients with mediastinal lymphadenopathy on CT scan who required cytologic evaluation. We first performed flexible videobronchoscopy with TBNA. If TBNA was inadequate on ROSE, EUS-FNA was performed immediately, all under topical anesthesia, conscious sedation, and in the same outpatient sitting. The same cytotechnologist was in attendance during both the consecutive procedures to make smears for instant examination. The procedures were terminated when adequate cellular specimens were achieved, or a maximum of six needle passages was done. Results: Twenty patients with mediastinal lymphadenopathy on chest CT underwent TBNA with ROSE. The TBNA specimens were adequate in 13 patients. In the remaining 7 patients, TBNA with ROSE was assessed to be inadequate; thus, EUS-FNA was also performed. Upon cytologic confirmation, TBNA with ROSE was falsely negative in one patient. The diagnostic yield of TBNA was thus 70%. EUS-FNA was positive in 6 of 7 patients, giving a diagnostic yield of 86%. Overall, this combined minimally invasive approach to mediastinal lymphadenopathy, which was well tolerated by all patients with no adverse effects, provided a diagnostic yield of 90%. The final diagnoses were non-small cell cancer (n Z 11), small cell cancer (n Z 2), metastatic adenocarcinoma (n Z 1), sarcoidosis (n Z 1), tuberculosis (n Z 1), and lymphoma (n Z 1). In the first case where this approach failed to give a diagnosis, TBNA showed lymphocytes but interval CT did not show progression of the lymphadenopathy. The second patient had non-small-cell lung cancer. Conclusions: TBNA with ROSE combined with the option for back-to-back EUS-FNA raised the diagnostic yield of TBNA alone from 70% to 90%. This combined approach is safe, convenient and potentially cost-effective for the patient, who needs not undergo another procedure on another day.
W1213 The Diagnostic Utility of Endoscopic Ultrasound (EUS) and ERCP in Evaluating Patients with Idiopathic Acute Recurrent Pancreatitis (IARP) Sammy Ho, Rahul Shimpi, John Baillie, M.S. Branch, Paul S. Jowell, Frank G. Gress Background: Initial evaluation of patients with recurrent acute pancreatitis sometimes fails to establish an etiology. Determining the cause is important as it helps to direct therapy, limits unnecessary tests, and may improve a patient’s longterm prognosis. The aim of this study was to determine the yield of EUS and ERCP in evaluating patients with IARP. Methods: All patients referred to our institution for evaluation of IARP between 2000 and 2004 were reviewed. IARP was defined as two or more episodes of pancreatitis without a definitive etiology identified after standard work-up. Only patients who underwent both EUS and ERCP were included. Results: 40 patients (14M/26F, mean age 50, range 18–82) underwent EUS and ERCP for evaluation of IARP between 2000 and 2004. 60% (24/40) had prior cholecystectomy. ERCP was successful in 88% (35/40) of patients. The combination of EUS and ERCP identified a cause of IARP in 85% (34/40) of patients: sphincter of Oddi dysfunction in 32% (11/34), chronic pancreatitis in 24% (8/34), pancreas divisum in 21% (7/34), papillary stenosis in 8% (3/34), pancreatic malignancy in 6% (2/34), microlithiasis in 6% (2/34), and IPMT in 3% (1/34). In 15% (6/40), no etiology was found. EUS alone revealed a diagnosis in 53% (21/40) of patients, while ERCP was diagnostic in 70% (28/40). The rate of post-ERCP pancreatitis was 15% (6/40), with 4 of these patients 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 58% (23/40) of patients. Two of these patients sustained another episode of pancreatitis during a median follow-up period of 30 months. Of the 6 patients whose etiology remained unknown after EUS and ERCP, none had recurrent attacks. Conclusions: 1. The etiology of IARP can be established in the majority of patients undergoing both EUS and ERCP. 2. ERCP was diagnostic in more patients than EUS, but was associated with a risk of procedure related pancreatitis. 3. Endoscopic therapy during ERCP was effective in preventing further attacks. 4. Given the lower complication rate, EUS should play an early role in the evaluation of IARP. When the etiology remains unknown, ERCP G manometry study may not only establish a diagnosis, but also direct therapy and often improve a patient’s long-term prognosis.
AB282 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
W1215 A Combined Training Program in EUS-FNA and Bronchoscopic Ultrasound-Guided FNA for Evaluation of the Mediastinum Brenda J. Hoffman, Andre K. Chong, Sandra Faias, Sarto C. Paquin, Joseph Romagnuolo, Robert H. Hawes, Peter Doelkin The utility of EUS in staging of lung cancer and evaluation of unexplained mediastinal adenopathy is well established. There are regions which are missed by EUS which may be accessed via the trachea during bronchoscopic US. (EBUS). We have shown that combined procedures can be done in a timely fashion, safely, and with significant yield. However, coordinating the presence of a pulmonologist and a gastroenterologist can be difficult. Aim: To develop a training program to include EUS and EBUS-FNA. Methods: The decision to train the EUS fellows and GI attendings was based upon the endoscopic experience, the established referral pattern, and the ability of EUS to allow screening for metastatic disease. Three attendings and 3 fellows participated in the training. Each fellow trainee was required to perform 25 bronchoscopic US FNAs using a model under the tutelage of the EBUS-FNA certified pulmonologist. The trainees in fellowship were also required to complete 25 linear array bronchoscopic FNAs using a phantom model. Every trainee was required to observe 5 bronchoscopies before performing their first live exam. Results: Each of the fellows completed the model examinations and FNAs in a manner deemed acceptable by the pulmonologist. This was done in 2 separate afternoon sessions. One attending has finished the observation period and is performing supervised EBUS. Conclusion: It is feasible to provide training in EUS/ EBUS. EUS fellows and GI endosonographers appear to have a short learning time for EBUS-FNA. Whether appropriate credentialing will be achievable remains to be seen.
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W1212 Utility of EUS: Elastography in the Diagnosis of Pancreatic Diseases Yoshiki Hirooka, Akihiro Itoh, Senju Hashimoto, Hiroki Kawashima, Kazuo Hara, Akira Kanamori, Hiroki Uchida, Jun Goto, Shigeto Ishikawa, Naoki Ohmiya, Yasumasa Niwa, Hidemi Goto Clinical usefulness of real-time tissue elastography (EG: Hitachi, Japan) that visualizes elastic information of tissue using transabdominal ultrasonography (US) is reported mainly in the diagnosis of a superficial organ disorders such as thyroid and breast. EG is the technology that images the difference of distortion between hard tissue and soft tissue in real time. With the cooperation of Hitachi and Pentax, clinical use of EUS-elastography (EUS-EG) became possible. We investigated utility of EUS-EG in the diagnosis of pancreatic diseases. Methods: Subjects consist of 38 patients with 45 lesions: 11 solid tumors (10 pancreatic cancer, 1 pancreatic endocrine tumor), 19 cystic lesions (10 IPMN (intraductal papillary mucinous neoplasm), 6 pseudocyst, 1 mucinous cyst adenoma, 1 solid pseudo-papillary tumor, 1 simple cyst), 13 chronic pancreatitis and 2 autoimmune pancreatitis. We observed target lesions in EUS-EG after depiction in B-mode EUS and compared both images. In this system, both B-mode and EUS-EG images are represented on dual screen at the same time, we can compare both images of same scan plane precisely. In EUS-EG, the tissue elasticity in ROI (region of interest) is expressed in difference of colors, that is, from hard to soft tissue, it is displayed continually from blue to red. We compared EUS-EG images with B-mode images of pancreatic diseases. EUB-8500 (Hitachi) as an ultrasound diagnostic machine and EG-3630UR (Pentax) as an endosonoscope were used in this study. Results: As for 11 solid tumors, in 8 cases of cancer, the sizes of tumor images on EUS-EG corresponded to those of B-mode EUS and in remaining 2 cases, EUS-EG images were revealed slightly wider in range than those of B-mode EUS. The hardness of one endocrine tumor was represented as the same degree as the pancreatic parenchyma. For cystic lesions, usually no color signals were displayed in the cysts. The parenchyma of chronic pancreatitis (including autoimmune pancreatitis) was shown as the image that various colors coexisted from hard to soft tissue. Conclusion: EUS-EG needs attention for the interpretation to show relative value of the hardness in setting ROI. EUS-elastography may be useful diagnostic modality in the diagnosis of pancreatic diseases to offer different information from that of conventional diagnostic imaging methods and be more useful technique in future if absolute evaluation of EUS-elastography become possible.
W1214 Transbronchial Needle Aspiration Followed Immediately by Endoscopic Ultrasound Guided Needle Aspiration in the Evaluation of Mediastinal Lymphadenopathy Khay L. Khoo, Khek Y. Ho, Tow K. Lim Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is a useful diagnostic tool in the evaluation of mediastinal lymphadenopathy, both as a primary modality and in cases of negative transbronchial needle aspiration (TBNA). Aim: To determine the utility of TBNA with rapid on-site cytopathologic evaluation (ROSE) combined with the option for immediate EUS-FNA in the diagnosis of mediastinal adenopathy of unknown etiology. Methods: We prospectively enrolled patients with mediastinal lymphadenopathy on CT scan who required cytologic evaluation. We first performed flexible videobronchoscopy with TBNA. If TBNA was inadequate on ROSE, EUS-FNA was performed immediately, all under topical anesthesia, conscious sedation, and in the same outpatient sitting. The same cytotechnologist was in attendance during both the consecutive procedures to make smears for instant examination. The procedures were terminated when adequate cellular specimens were achieved, or a maximum of six needle passages was done. Results: Twenty patients with mediastinal lymphadenopathy on chest CT underwent TBNA with ROSE. The TBNA specimens were adequate in 13 patients. In the remaining 7 patients, TBNA with ROSE was assessed to be inadequate; thus, EUS-FNA was also performed. Upon cytologic confirmation, TBNA with ROSE was falsely negative in one patient. The diagnostic yield of TBNA was thus 70%. EUS-FNA was positive in 6 of 7 patients, giving a diagnostic yield of 86%. Overall, this combined minimally invasive approach to mediastinal lymphadenopathy, which was well tolerated by all patients with no adverse effects, provided a diagnostic yield of 90%. The final diagnoses were non-small cell cancer (n Z 11), small cell cancer (n Z 2), metastatic adenocarcinoma (n Z 1), sarcoidosis (n Z 1), tuberculosis (n Z 1), and lymphoma (n Z 1). In the first case where this approach failed to give a diagnosis, TBNA showed lymphocytes but interval CT did not show progression of the lymphadenopathy. The second patient had non-small-cell lung cancer. Conclusions: TBNA with ROSE combined with the option for back-to-back EUS-FNA raised the diagnostic yield of TBNA alone from 70% to 90%. This combined approach is safe, convenient and potentially cost-effective for the patient, who needs not undergo another procedure on another day.
W1213 The Diagnostic Utility of Endoscopic Ultrasound (EUS) and ERCP in Evaluating Patients with Idiopathic Acute Recurrent Pancreatitis (IARP) Sammy Ho, Rahul Shimpi, John Baillie, M.S. Branch, Paul S. Jowell, Frank G. Gress Background: Initial evaluation of patients with recurrent acute pancreatitis sometimes fails to establish an etiology. Determining the cause is important as it helps to direct therapy, limits unnecessary tests, and may improve a patient’s longterm prognosis. The aim of this study was to determine the yield of EUS and ERCP in evaluating patients with IARP. Methods: All patients referred to our institution for evaluation of IARP between 2000 and 2004 were reviewed. IARP was defined as two or more episodes of pancreatitis without a definitive etiology identified after standard work-up. Only patients who underwent both EUS and ERCP were included. Results: 40 patients (14M/26F, mean age 50, range 18–82) underwent EUS and ERCP for evaluation of IARP between 2000 and 2004. 60% (24/40) had prior cholecystectomy. ERCP was successful in 88% (35/40) of patients. The combination of EUS and ERCP identified a cause of IARP in 85% (34/40) of patients: sphincter of Oddi dysfunction in 32% (11/34), chronic pancreatitis in 24% (8/34), pancreas divisum in 21% (7/34), papillary stenosis in 8% (3/34), pancreatic malignancy in 6% (2/34), microlithiasis in 6% (2/34), and IPMT in 3% (1/34). In 15% (6/40), no etiology was found. EUS alone revealed a diagnosis in 53% (21/40) of patients, while ERCP was diagnostic in 70% (28/40). The rate of post-ERCP pancreatitis was 15% (6/40), with 4 of these patients 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 58% (23/40) of patients. Two of these patients sustained another episode of pancreatitis during a median follow-up period of 30 months. Of the 6 patients whose etiology remained unknown after EUS and ERCP, none had recurrent attacks. Conclusions: 1. The etiology of IARP can be established in the majority of patients undergoing both EUS and ERCP. 2. ERCP was diagnostic in more patients than EUS, but was associated with a risk of procedure related pancreatitis. 3. Endoscopic therapy during ERCP was effective in preventing further attacks. 4. Given the lower complication rate, EUS should play an early role in the evaluation of IARP. When the etiology remains unknown, ERCP G manometry study may not only establish a diagnosis, but also direct therapy and often improve a patient’s long-term prognosis.
AB282 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
W1215 A Combined Training Program in EUS-FNA and Bronchoscopic Ultrasound-Guided FNA for Evaluation of the Mediastinum Brenda J. Hoffman, Andre K. Chong, Sandra Faias, Sarto C. Paquin, Joseph Romagnuolo, Robert H. Hawes, Peter Doelkin The utility of EUS in staging of lung cancer and evaluation of unexplained mediastinal adenopathy is well established. There are regions which are missed by EUS which may be accessed via the trachea during bronchoscopic US. (EBUS). We have shown that combined procedures can be done in a timely fashion, safely, and with significant yield. However, coordinating the presence of a pulmonologist and a gastroenterologist can be difficult. Aim: To develop a training program to include EUS and EBUS-FNA. Methods: The decision to train the EUS fellows and GI attendings was based upon the endoscopic experience, the established referral pattern, and the ability of EUS to allow screening for metastatic disease. Three attendings and 3 fellows participated in the training. Each fellow trainee was required to perform 25 bronchoscopic US FNAs using a model under the tutelage of the EBUS-FNA certified pulmonologist. The trainees in fellowship were also required to complete 25 linear array bronchoscopic FNAs using a phantom model. Every trainee was required to observe 5 bronchoscopies before performing their first live exam. Results: Each of the fellows completed the model examinations and FNAs in a manner deemed acceptable by the pulmonologist. This was done in 2 separate afternoon sessions. One attending has finished the observation period and is performing supervised EBUS. Conclusion: It is feasible to provide training in EUS/ EBUS. EUS fellows and GI endosonographers appear to have a short learning time for EBUS-FNA. Whether appropriate credentialing will be achievable remains to be seen.
www.mosby.com/gie