Giacomo Bonanno

Magnetic resonance cholangiopancreatography and contrast-enhanced magnetic resonance cholangiopancreatography versus endoscopic ultrasonography in the diagnosis of extrahepatic biliary pathology

PurposeThis study compared the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) in evaluating the cause of extrahepatic bile duct dilatation.Materials and methodsForty-five patients (26 men, mean age 57 years) with extrahepatic biliary dilatation, as shown by transabdominal ultrasound, with or without elevated biliary and pancreatic serum indices, were prospectively studied with MRCP and EUS between September 2007 and October 2008. EUS and MRCP were performed within no more than 24 h of each other to reduce the possibility of changes due to stone migration. Image analysis was carried out in a double-blind fashion.ResultsMRCP had 88.9% diagnostic accuracy, 91.9% sensitivity and 75% specificity, with 94.4% positive predictive value and 66.7% negative predictive value. EUS had 93.3% diagnostic accuracy, 97.3% sensitivity and 75% specificity; the positive and negative predictive values were 94.7% and 85.7%, respectively.ConclusionsMRCP and EUS do not show significant statistical differences in diagnostic accuracy. MRCP is an accurate, noninvasive modality in the study of extrahepatic biliary pathology. EUS is especially reliable in patients with extrahepatic biliary obstruction caused by endoluminal sludge.RiassuntoObiettivoScopo di questo lavoro è stato confrontare l’accuratezza diagnostica della colangiopancreatografia con risonanza magnetica (CPRM) e dell’ecografia endoscopica (EUS) nel valutare la causa di dilatazione in pazienti con aumentato diametro della via biliare extra-epatica.Materiali e metodiQuarantacinque pazienti (età media 57 anni, 26 maschi) sono stati studiati da settembre 2007 a ottobre 2008 con CPRM e EUS. Sono stati inclusi nello studio pazienti con dilatazione della via biliare extra-epatica rilevata all’ecografia trans-addominale, con o senza innalzamento degli indici sierologici bilio-pancreatici. Lo studio è stato condotto in modalità prospettica ed in doppio cieco. Per ridurre al minimo possibili variazioni legate alla migrazione di calcoli, EUS e CPRM sono state eseguite con intervallo non superiore alle 24 ore.RisultatiLa CPRM ha dimostrato accuratezza diagnostica, sensibilità e specificità rispettivamente dell’88,9%, 91,9% e 75%, con valore predittivo positivo del 94,4% e valore predittivo negativo del 66,7%. La EUS ha evidenziato accuratezza diagnostica, sensibilità e specificità del 93,3%, 97,3% e 75%; valore predittivo positivo e negativo sono stati rispettivamente 94,7% e 85,7%.ConclusioniCPRM ed EUS non presentano differenze statisticamente significative nell’accuratezza diagnostica. La CPRM è metodica accurata non invasiva nella patologia biliare extraepatica; la EUS è particolarmente attendibile nei pazienti con ostruzione biliare extra-epatica da sludge.

Endoscopic features of gastro-intestinal lymphomas: From diagnosis to follow-up

Many progresses have been done in the management of gastrointestinal (GI) lymphomas during last decades, especially after the discovery of Helicobacter pylori-dependent lymphoma development. The stepwise implementation of new endoscopic techniques, by means of echoendoscopy or double-balloon enteroscopy, enabled us to more precisely describe the endoscopic features of GI lymphomas with substantial contribution in patient management and in tailoring the treatment strategy with organ preserving approaches. In this review, we describe the recent progresses in GI lymphoma management from disease diagnosis to follow-up with a specific focus on the endoscopic presentation according to the involved site and the lymphoma subtype. Additionally, new or emerging endoscopic technologies that have an impact on the management of gastrointestinal lymphomas are reported. We here discuss the two most common subtypes of GI lymphomas: the mucosa-associated lymphoid tissue and the diffuse large B cell lymphoma. A general outline on the state-of-the-art of the disease and on the role of endoscopy in both diagnosis and follow-up will be performed.

The utilization of imaging features in the management of intraductal papillary mucinous neoplasms.

Intraductal papillary mucinous neoplasms (IPMNs) represent a group of cystic pancreatic neoplasms with large range of clinical behaviours, ranging from low-grade dysplasia or borderline lesions to invasive carcinomas. They can be grouped into lesions originating from the main pancreatic duct, main duct IPMNs (MD-IPMNs), and lesions which arise from secondary branches of parenchyma, denominated branch-duct IPMNs (BD-IPMNs). Management of these cystic lesions is essentially based on clinical and radiological features. The latter have been very well described in the last fifteen years, with many studies published in literature showing the main radiological features of IPMNs. Currently, the goal of imaging modalities is to identify “high-risk stigmata” or “worrisome feature” in the evaluation of pancreatic cysts. Marked dilatation of the main duct (>1 cm), large size (3–5 cm), and intramural nodules have been associated with increased risk of degeneration. BD-IPMNs could be observed as microcystic or macrocystic in appearance, with or without communication with main duct. Their imaging features are frequently overlapped with cystic neoplasms. The risk of progression for secondary IPMNs is lower, and subsequently an imaging based follow-up is very often proposed for these lesions.

Rare gastrointestinal lymphomas: The endoscopic investigation

Gastrointestinal lymphomas represent up to 10% of gastrointestinal malignancies and about one third of non-Hodgkin lymphomas. The most prominent histologies are mucosa-associated lymphoid tissue lymphoma and diffuse large B-cell lymphoma. However, the gastrointestinal tract can be the site of rarer lymphoma subtypes as a primary or secondary localization. Due to their rarity and the multifaceted histology, an endoscopic classification has not been validated yet. This review aims to analyze the endoscopic presentation of rare gastrointestinal lymphomas from disease diagnosis to follow-up, according to the involved site and lymphoma subtype. Existing, new and emerging endoscopic technologies have been examined. In particular, we investigated the diagnostic, prognostic and follow-up endoscopic features of T-cell and natural killer lymphomas, lymphomatous polyposis and mantle cell lymphoma, follicular lymphoma, plasma cell related disease, gastrointestinal lymphomas in immunodeficiency and Hodgkins lymphoma of the gastrointestinal tract. Contrarily to more frequent gastrointestinal lymphomas, data about rare lymphomas are mostly extracted from case series and case reports. Due to the data paucity, a synergism between gastroenterologists and hematologists is required in order to better manage the disease. Indeed, clinical and prognostic features are different from nodal and extranodal or the bone marrow (in case of plasma cell disease) counterpart. Therefore, the approach should be based on the knowledge of the peculiar behavior and natural history of disease.

Role of the Endoscopic Ultrasonography in the Management of Gastric Lymphomas: Our Experience and Review of Literature

The stomach is the most common extranodal site of non-Hodgkin lymphoma (NHL) accounting for 7.1 to 10% of adult NHL (Danzon et al., 2009). The most frequent histotypes of gastric lymphomas are MALT lymphomas that arise from the stomach-associated lymphatic tissue and the Diffuse Large B-Cell Lymphoma (DLBCL) (Koch et al., 2001). Several studies have observed that in recent years both gastric-NHL incidence and survival are increasing (Danzon et al., 2009). Furthermore, the management of gastric lymphomas has changed during the last two decades with a strong reduction of surgery in flavor to conservative treatments (Yoon S.S. et al., 2004). Indeed, the progress in biologic understanding of the pathogenesis, the introduction of Helicobacter pylori (HP) eradication therapy and the introduction of conservative treatment have definitely changed the approach to the disease and gastrectomy is no longer the first choice (Fischbach, 2010). The role of HP is a consolidated finding and several studies have confirmed that a simple antibiotic therapy (AT) for HP eradication is an effective treatment for MALT lymphomas with limited extension (Fischback et al., 2004), whereas, for advanced gastric lymphomas, the golden standard of treatment is the antineoplastic chemotherapy with alkylating agents in monochemotherapy such as Clorambucil for MALT lymphomas and polichemotherapy together with immunotherapy such as R-CHOP for DLBCL (Zucca & Dreyling, 2010). The loco-regional staging of gastric lymphomas with limited disease is important in order to better understand how to treat patients and endoscopic ultrasound (EUS) technique plays in this context a pivotal role by giving information for the prevision of response to HP eradication therapy since this therapy has shown to induce a high percentage of histological remission (up to 88%) when the disease is confined to mucosa and submucosa (Caletti et al., 2002). However, the importance of EUS in assessing the response to treatment and the follow-up is controversial. During the last decade, some reports indicated the importance of EUS in evaluating the response to treatment and also in long-term follow-up of gastric lymphomas with limited disease (Yeh et al., 2003), whereas other recent reports indicated the importance of EUS also in the follow-up of local-advanced MALT lymphoma (Pavlovic et al., 2005). That notwithstanding, the latest ESMO clinical guidelines for diagnosis, treatment and follow-up

Hémorragie extraluminale suite à une échoendoscopie gastrique conventionnelle

RésuméUn homme de 75 ans a été examiné par échoendoscopie gastrique suite à une douleur abdominale et à un ictère. À la fin de l’examen endoscopique, le patient présentait une intense douleur épigastrique. Le CTscanner amis en évidence une plage de 7 cm, contenant un liquide dense, en arrière de la paroi postérieure de l’estomac et un aspect d’ischémie de la rate. Le drainage de la collection hématique, la cholécystectomie et la splénectomie ont été réalisés sept jours après l’examen diagnostique. L’hypothèse est qu’un passage difficile de l’échoendoscope à travers le pylore, secondaire à un phlegmon périvésiculaire, pourrait avoir causé la lésion d’un vaisseau splénique et donc un saignement extraluminal. Cette complication durant l’endoscopie conventionnelle n’a jamais été décrite auparavant.AbstractA 75-year-old man underwent endoscopic ultrasound examination for abdominal pain and jaundice. At the end of the examination, the patient presented severe epigastric pain; CT scan showed a 7-cm area of dense liquid behind the posterior gastric wall and ischemia of the spleen. Splenectomy and cholecystectomy were carried out 7 days after the symptoms. It was hypothesized that a little difficulty of the passage of the echoendoscope through the pylorus could have caused a small injury of the splenic vessel determining the extraluminal bleeding. Extraluminal hemorrhage following a conventional endoscopic ultrasound examination has not been described previously.