Kayoko Kunihiro

Diagnostic ability of high-frequency ultrasound probe sonography in staging early gastric cancer, especially for submucosal invasion

BackgroundAdvances in gastrointestinal endoscopy have resulted in endoscopic mucosal resection becoming the main therapy for many early gastric cancers confined to the mucosa and, in some cases, of minimal submucosal invasion. Thus, preoperative determination of the depth of the cancer is important. We compared the results of high-frequency ultrasound probe sonography with those of histologic study to clarify the usefulness of identifying of submucosal invasion and determining the depth of early gastric cancer. MethodsSubjects were 295 patients diagnosed with early gastric cancer who had undergone endoscopic mucosal or surgical resection. High-frequency ultrasound probe sonographic findings were compared with histologic findings. ResultsThe muscularis mucosae was visualized in 63% of cases of early gastric cancer. By construction on receiver operator characteristics curve, we determined that submucosal invasive cancer could be diagnosed by high-frequency ultrasound probe sonography to a depth of about 600 μm. There was no case in which invasion deeper than 1000 μm was diagnosed as a hypoechoic area limited to the mucosal layer or a fan-shaped hypoechoic area in the submucosal layer. The depth of early gastric cancer was accurately determined in 90% of cases. ConclusionsHigh-frequency ultrasound probe is a useful tool for accurately determining the depth of invasion of early gastric cancer when its limitations are understood.

Predicting the need for surgery in Crohn's disease with contrast harmonic ultrasound

Objective. Harmonic flash echo imaging (H-FEI), an intermittent scanning method using injection of Levovist, enables the evaluation of microperfusion of the gastrointestinal wall. The aim of this study was prospectively to investigate the relationship between bowel blood flow and the likelihood of the need for surgery in 70 patients with active Crohns disease (CD), using conventional ultrasonography (US) and H-FEI. Material and methods. For H-FEI, Levovist injection was followed by scanning of the bowel segment of interest with intermittent harmonic imaging for 2 min (interval, 4 s; transmission pulse at 2.3 MHz; reception at 4.6 MHz). We calculated the mean echo-intensity for the bowel wall showing strongest opacity in the FEI series for each patient. Maximum bowel-wall thickness, wall stratification, maximum echo-intensity obtained by H-FEI, CD activity index, and C-reactive protein concentration were compared between patients treated successfully with medication after H-FEI (group M) and those who proved to need surgery (group S). Results. No significant differences in clinical variables were evident between groups M (n=45) and S (n=25). The subsequent need for surgery was significantly indicated by multivariate analysis, showing loss of stratification in the bowel wall (odds ratio (OR)=5.98, 95% confidence interval (CI)=1.4–25.1, p=0.015) and high echo-intensity according to H-FEI (OR=1.02, CI=1.005–1.034, p =0.007). Conclusion. In active CD, patients with bowel segments showing a loss of stratification and rich perfusion by H-FEI are likely to need surgical treatment.

Sonographic detection of longitudinal ulcers in Crohn disease.

Background: The purpose of this study was to investigate the characteristic sonographic features, such as focal disappearance of the wall stratification sign (FD sign), of longitudinal ulcers in patients with Crohn disease (CD). Methods: A total of 545 sonographic examinations of patients with Crohn disease (n = 166), ulcerative colitis (n = 196), bacterial colitis (n = 78), ischemic colitis (n = 63), pseudomembranous colitis (n = 32), Behçets disease (n = 7), and collagenous colitis (n = 3) were extracted. The sonographic findings were compared with those of a barium contrast study, colonoscopy, and resected specimens. In transverse views of the bowel segment, wall stratification was investigated. The FD sign was defined as the disappearance of the layered structure observed in a single portion of the bowel circumference. Prevalence of the FD sign was investigated for each disease. Results: Eighty lesions (76 CD, 1 ulcerative colitis, 2 ischemic colitis, 1 Behçets disease) with active single longitudinal ulcers were detected by barium contrast study and endoscopy. Among them, the FD sign was detected by ultrasonography (US) in 73 lesions (91.3%). No lesions with the FD sign were found by US without radiological or endoscopic findings of longitudinal ulcers. An in vitro study (water‐immersion method) of resected specimens revealed that the FD sign reflected the focal destruction of wall stratification caused by the deep longitudinal ulceration. Conclusions: Ultrasonographic findings of FD sign are correlated with the existence of deep longitudinal ulcers, which are most frequently found in CD. US is a useful diagnostic modality for detecting longitudinal ulcers in patients with CD.

A Classification System of Echogenicity for Gastrointestinal Neoplasms

Background and Aims: To confirm the utility of a newly-devised endoscopic ultrasonography (EUS) echogenicity classification system, which is based on the normal five-layer structure of the gastrointestinal wall, for the differential diagnosis of gastrointestinal neoplasms. Methods: A total of 275 patients with gastrointestinal disease detected by endoscopy, 53 with submucosal tumor (22 esophageal, 27 gastric, and 4 duodenal), 208 with cancer (58 esophageal, 150 gastric), and 14 with gastric malignant lymphoma, were examined. In each case, we performed standard EUS with 7.5, 12, or 20 MHz to evaluate the echogenicity of the lesion. Echogenicity was classified into seven levels that is based on the echogenicity of the normal five-layer structure of the gastrointestinal wall. The levels are stratified from anechoic (level 0) to hyperechoic (level 6), muscularis propria and deep mucosa being referred to as level 2 and level 4, respectively. Level 6 was equivalent to or higher than the echogenicity of submucosa. Results: EUS findings revealed several distinct echogenicities among the diseases. In submucosal tumor, levels 0, 2, and 6 were observed only in patients with cyst, myogenic tumor, and lipoma, respectively. In malignancies, levels 0, 5, and 6 were not observed in this study. The echo level of malignant lymphoma was markedly lower than that of epithelial cancer. Conclusion: Our classification system of echogenicity can be a useful method in the differential diagnosis of gastrointestinal neoplasms.

Gastrointestinal Stromal Tumor in Jejunum: Diagnosis Using Contrast-Enhanced Ultrasonography and Double-Balloon Enteroscopy

Gastrointestinal stromal tumors (GISTs) in the small intestine are rare and are sometimes incidentally detected by sudden gastrointestinal bleeding. The patients often undergo surgery without an accurate diagnosis, because most of these lesions are inaccessible by conventional endoscopy. Ultrasonography (US) has become an effective diagnostic modality for gastrointestinal diseases. In addition, recent studies have revealed that the microcirculation of the gastrointestinal wall can be assessed by contrastenhanced imaging using the agent SHU 508A (Levovist; Schering, Berlin, Germany) (1, 2). However, there have been few reports of the sonographic features of GISTs. We report a patient with GIST in the jejunum that was diagnosed by US as a screening tool and that was confirmed preoperatively by double-balloon enteroscopy.

Sonographic detection of longitudinal ulcers in Crohn's disease

Background: The purpose of this study was to investigate the characteristic sonographic features, such as focal disappearance of the wall stratification sign (FD sign), of longitudinal ulcers in pa...