Genevieve Tessier

Intraductal optical coherence tomography during endoscopic retrograde cholangiopancreatography for investigation of biliary strictures

BACKGROUND AND STUDY AIMS Optical coherence tomography (OCT) uses infrared light reflectance to produce high-resolution cross-sectional tissue images. The aim of this study was to demonstrate the feasibility of biliary intraductal OCT during endoscopic retrograde cholangiopancreatography (ERCP) and to assess the potential of the method to detect malignant biliary strictures. PATIENTS AND METHODS Thirty-seven patients with biliary strictures were studied during therapeutic ERCP. Malignant strictures were defined as those that demonstrated malignant cells in brushing and/or biopsy specimens, and/or endoscopic ultrasound-guided fine-needle aspiration and/or surgery. Strictures that did not have malignant cells in resected specimens and were without clinical/radiological evidence of disease progression for at least a 12-month follow-up period were considered as benign. Two OCT criteria for malignancy were considered: unrecognizable layer architecture; and presence of large, nonreflective areas compatible with tumor vessels. Sensitivity and specificity for brushings/biopsies as well as OCT criteria were calculated. RESULTS Nineteen patients had malignant and 16 had benign strictures. In two patients, OCT assessment could not be performed due to tight strictures. Malignancy was confirmed by biliary brushings/biopsies in 12/19 (63 %) patients. OCT revealed that two malignancy criteria were encountered in 10/19 (53 %) and at least one criterion in 15/19 (79 %) patients with malignant strictures. No patient with benign stricture met both criteria and 5/16 met one criterion (31 %). Combining brushings/biopsy with the observation of at least one OCT criterion resulted in the diagnosis of malignancy in 16/19 (84 %) patients. CONCLUSIONS OCT may improve the sensitivity and diagnostic accuracy of biliary brushings/biopsies alone.

Unexplained Thickened Folds on CT: Does EGD Help Select Patients for EUS? A Prospective Analysis

Unexplained Thickened Folds on CT: Does EGD Help Select Patients for EUS? A Prospective Analysis Eric Lam, Rayburn Rego, Sarto C. Paquin, Tju Siang Chua, Genevieve Tessier, Ginette Raymond, Anand Sahai Background: When CT shows unexplained thickening of the gastric wall, and regular endoscopy (EGD) is inconclusive, endoscopic ultrasound (EUS) is often considered a useful next step; but this is unproven. Selective use of EUS may be more appropriate for this indication. We hypothesized that EUS adds little in patients with no alarm symptoms and in whomEGD is normal. Aim: To assess the yield of EGD and EUS in patients with unexplained thickening of the gastric wall on CT and to determine predictors of abnormal EUS. Methods: In this ongoing study, all patients referred for this indication since 5/2001were eligible. Patient and EUS data were recorded prospectively in a computerized database by a single physician who questioned, examined, and performed EGD in all patients prior to EUS. Special attention was paid to mucosal abnormalities but also to the suppleness and distensibility of the gastric wall. Results: To date, 63 consecutive patients have been enrolled: 91% aged>40, 52%male, 57% asymptomatic, 40% with normal EGD, and 62% with normal EUS. If EGD was normal, 100% (95% CI 88%-100%) of patients had normal EUS. If EGD was ABnormal, 67% of patients had abnormal EUS. When trying to predict if EUS will be normal or abnormal, the positive predictive value of EGD was 67% and the negative predictive value was 100%. The only positive predictor of abnormal EUS was age >50 (Relative risk {RR} 1.23 {95% CI 1.1-1.4}). Variables NOT predictive of abnormal EUSwere: abdominal symptoms (RR0.88 {0.48-1.6}); alarm symptoms (RR 1.44 {0.4-5.2}; or male sex (RR 1.15 {0.9-1.5}). Conclusions: The preliminary results of this ongoing study suggest that when CT shows unexplained thickening of the gastric wall: 1) EGD may be used as a tool to select patients for EUS; 2) If EGD is normal, EUS does not appear to be warranted; 3) Even in the presence of abdominal symptoms or alarm symptoms, the yield of EUS is extremely low if EGD is normal; 3) If EGD is abnormal but inconclusive, EUS appears to be justified.