Kyung W. Noh

Accuracy of endoscopic ultrasonography and magnetic resonance cholangiopancreatography for the diagnosis of chronic pancreatitis : A prospective comparison study

Background The diagnosis of chronic pancreatitis (CP) remains challenging. Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) have been proposed as highly accurate diagnostic modalities. Although endoscopic retrograde cholangiopancreatography (ERCP) has been previously used as a gold standard, it is associated with a small but significant risk. We aim to compare the accuracy of EUS and MRCP with the composite gold standard using ERCP, surgical pathology, and/or long-term clinical follow-up. Methods Ninety-nine patients with clinical signs and/or symptoms suggestive of CP were prospectively enrolled. The diagnosis of CP by MRCP was established when one or more of these features were present: main duct dilation without obstruction, dilated side branches, intraductal stones, ductal irregularity, reduced T1-signal intensity, parenchymal atrophy, and reduced secretory response to secretin administration. The diagnosis of CP by EUS was made when 4 or more of the established criteria were present. Accuracy of all criteria used (“EUS only,” “MRCP only,” “either EUS or MRCP,” and “both EUS and MRCP”) was compared with the composite gold standard. Results Forty patients were diagnosed with CP by the composite gold standard whereas the remaining 59 patients were controls. EUS only seemed more sensitive but equally specific compared with MRCP only to diagnose CP. The combination of EUS and MRCP had a sensitivity of 98% for either EUS or MRCP and a specificity of 100% for both EUS and MRCP. Conclusions EUS and MRCP are highly accurate modalities for the diagnosis of CP and are complementary when used together. If confirmed in larger series, the diagnosis of CP by both EUS and MRCP is highly predictive and ERCP is unlikely to add any useful information.

Vascular Resection and Reconstruction for Pancreatic Malignancy: A Single Center Survival Study

IntroductionPancreatic cancer is one of the leading causes of cancer-related death in the USA. Recently, several centers have introduced portal and superior mesenteric vein resection and reconstruction during extended pancreatectomy, rendering the previously inoperable cases resectable.AimThe aim of this study is to confirm whether patients with locally advanced pancreatic cancer and mesenteric vascular invasion can be cured with extended pancreatectomy with vascular reconstruction (VR) and to compare their survival to patients treated with pancreatectomy without VR and those treated without resection (palliation).MethodsSurvival of 22 patients who underwent pancreatectomy with VR was compared with two control groups: 54 patients who underwent pancreatectomy without the need for VR and 28 patients whose pre-operative imaging suggested resectability but whose laparotomy indicated inoperability.ResultsA slight survival benefit was noted in patients who did not require VR (33.5%) compared to those who did require VR [20%, p = 0.18], although not reaching statistical significance. Despite a low 15% three-year survival in patients treated palliatively, this was not statistically different compared to survival after resection with VR (P = 0.23). The presence of nodal metastasis was associated with worse survival (p = 0.006), and the use of adjuvant therapy was associated with better survival (p = 0.001).ConclusionPancreatic cancers that require VR to completely resect the tumor have a similar survival to those not requiring VR. Long-term survival was achievable in approximately 1 out 5 patients requiring VR, although we were not able to demonstrate statistically improved survival compared to palliative care.

Risk factors for hyperechogenic pancreas on endoscopic ultrasound: A case-control study

Objective: Hyperechogenic pancreas (HP) suggestive of fatty replacement is a common finding during endoscopic ultrasound (EUS). Recent data have implicated pancreatic steatosis as a risk factor for pancreatitis and pancreatic malignancy. Hepatic steatosis has been linked to obesity, increased age, hypertriglyceridemia, hyperglycemia, and hyperinsulinemia. The objective of this study was to evaluate the effect of body mass index (BMI), hepatic steatosis, and other metabolic risk factors on HP seen on EUS. Methods: Patients with HP were identified by a review of a structured EUS database. The degree of echogenicity was judged relative to the liver (or spleen if the liver is hyperechogenic) at a similar depth. Various demographic and metabolic risk factors were assessed. Chronic pancreatitis was excluded based on normal findings on prior imaging studies. Each case was age matched and sex matched to 1 control with a normal pancreas on EUS. Results: By multivariate logistic regression analysis, BMI, hepatic steatosis, and alcohol use in excess of 14 g/wk were highly associated with the presence of HP compared with controls (all P < 0.002). Hepatic steatosis was the strongest predictor with an odds ratio of nearly 14-fold. Conclusions: Hepatic steatosis, alcohol use, and increased BMI are predictors of HP, which can be a marker for steatosis.

Hepatitis B vaccine nonresponse and celiac disease.

OBJECTIVES:There is a genetic predisposition to hepatitis B vaccine nonresponse. The link between human leukocyte antigen (HLA) genotype and ineffective development of immunity to the hepatitis B vaccine has been characterized in multiple studies. Celiac disease has a strong association with a particular HLA genotype of DQ2; interestingly, this HLA genotype is seen in association with nonresponders to the hepatitis B vaccine. We report a disproportionate number of patients with celiac disease who are nonresponders to the hepatitis B vaccine series.METHODS:We reviewed the hepatitis B vaccine records, serological tests for anti–hepatitis B surface antigen antibody (anti-HBs), and HLA genotypes of celiac disease patients identified as nonresponders to hepatitis B vaccine. Subjects were identified from a database of patients diagnosed with celiac disease at our institution or referred to our center for evaluation and management of celiac disease between November, 2000, and October, 2002.RESULTS:A total of 23 subjects were reviewed. All had a clinical and pathological diagnosis of celiac disease. All subjects reported receiving the full series of hepatitis B vaccinations. Of the subjects, 19 had testing for hepatitis B vaccine response. Of these 19 subjects, 13 did not achieve long-term immunity as seen by the negative qualitative or quantitative anti-HBs antibody titer. All tested subjects were either homozygous or heterozygous for DQ2.CONCLUSIONS:We postulate that celiac disease patients may have a significant predisposition to hepatitis B vaccine nonresponse. Both celiac disease and hepatitis B vaccine nonresponse is genetically mediated. Celiac disease patients may have a failure of induction of humoral immune response needed for development of long term immunity; the mechanism for this is unclear.

Pneumomediastinum following Enteryx injection for the treatment of gastroesophageal reflux disease.

We describe the case of a 68-year-old female who developed pneumomediastinum following the “Enteryx” procedure for the treatment of gastroesophageal reflux disease (GERD). The patient required hospitalization and parenteral antibiotics and responded favorably to a conservative approach. Similar complications have been observed with other endoscopic treatment modalities for GERD such as Stretta and suturing techniques. Our patient represents the third reported case of a serious complication after Enteryx implantation.

Changing trends in endosonography : Linear imaging and tissue are increasingly the issue

The indications and uses of endoscopic ultrasound (EUS) are expanding. The role of EUS-guided fine needle aspiration (EUS-FNA) is considered an essential aspect of EUS practice. A significant change in the indications and technology used for EUS has occurred. This study was designed to compare the use of radial, linear, and miniprobe endosonography equipment during a 10-year period in a single, large, EUS practice. A retrospective review of an EUS experience at a single high-volume center was performed. In this single-center experience, there has been an increase in the volume of EUS and EUS-FNA. For luminal cancer-staging cases, the radial echoendoscope is the predominant scope used for examination and has not changed significantly. In contrast, for pancreaticobiliary and mediastinal indications, the use of the linear array echoendoscope alone has increased and currently is the preferred scope for examination (33% vs. 76%, P < 0.001; 46% vs. 96%, P < 0.001). In these cases requiring EUS-FNA, the use of the linear array scope alone has increased from 17% to 73%. In this single-center experience, EUS has shifted from an imaging technology to an image-guided biopsy and therapeutic technology. The use of the linear array EUS alone has increased, especially in the evaluation of pancreatobiliary and mediastinal disease and when fine-needle aspiration is performed.

The role of surveillance endoscopy and endosonography after endoscopic ablation of high-grade dysplasia and carcinoma of the esophagus

Barretts esophagus (BE) with high-grade dysplasia (HGD) or early carcinoma treated with surgery or photodynamic therapy (PDT) is at risk of recurrence. The efficacy of endoscopic ultrasound (EUS) for surveillance after PDT is unknown. Our objective was to determine if EUS is superior to esophagogastroduodenoscopy (EGD) and/or CT scan for surveillance of BE neoplasia after PDT. The study was designed as a retrospective review with the setting as a tertiary referral center. Consecutive patients with BE with HGD or carcinoma in situ treated with PDT were followed with EUS, CT scan and EGD with jumbo biopsies every 1 cm at 3, 4, or 6-month intervals. Exclusion criteria was < 6 months of follow up and/or < 2 EUS procedures. Main outcome measurements were residual or recurrent disease discovered by any method. Results showed that 67/97 patients met the inclusion criteria (56 men and 11 women). Median follow-up was 16 months. Recurrent or residual adenocarcinoma (ACA) was detected in four patients during follow-up. EGD with random biopsies or targeted nodule biopsies detected three patients. EUS with endoscopic mucosal resection of the nodule confirmed T1 recurrence in one of these three. In the fourth patient, CT scan revealed perigastric lymphadenopathy and EUS-FNA (fine needle aspiration) confirmed adenocarcinoma. There were two deaths, one related to disease progression and one unrelated. The rate of recurrent/persistent ACA after PDT was 4/67 = 6%. EUS did not detect disease when EGD and CT were normal. Limitations of this study include non-blinding of results and preferential status of non-invasive imaging (CT) over EUS. Our experience suggests that EUS has little role in the surveillance of these patients, unless discrete abnormalities are found on EGD or cross-sectional imaging.

Endoscopic ultrasound and IL-8 in pancreatic juice to diagnose chronic pancreatitis.

Background/Aim: Pancreatic juice (PJ) [IL-8] has been proposed as a marker for pancreatic diseases. We compared the accuracy of PJ [IL-8] and endoscopic ultrasound (EUS) to diagnose chronic pancreatitis (CP). Methods: 79 patients with symptoms suspicious for CP were enrolled. PJ emptied into the duodenum was collected during an upper endoscopy with IV secretin and [IL-8] was measured. CP was diagnosed when PJ [IL-8] was >20 pg/ml. CP was diagnosed at EUS when ≧4 of the 9 established criteria were present. CP was diagnosed by using composite gold standard: ERCP, histology, CT or MRI, and clinical follow-up (mean 20 months). Results: 38 patients had CP, whereas 41 patients had no pancreatic disease. To diagnose CP, PJ [IL-8] was significantly less sensitive compared to EUS (47 vs. 71%), but equally accurate (71 vs. 80%) and specific (93 vs. 88%). By combining PJ [IL-8] and EUS, sensitivity and specificity significantly increased to 82% (either IL-8 or EUS positive) and 100% (both IL-8 and EUS positive). Conclusions: Both PJ [IL-8] and EUS are accurate diagnostic modalities for CP. PJ collection can be performed at the time of EUS. PJ [IL-8] and EUS are complementary with higher sensitivity and specificity when used together.

Mesenteric Venous Thrombosis Following Laparoscopic Antireflux Surgery

Peritoneal insufflation with carbon dioxide during laproscopic Nissen fundoplication is an essential part of the procedure. Elevations in intraperitoneal pressures during laparoscopy can result in decreased mesenteric venous flow and result in thrombosis in predisposed individuals. We describe the case of a patient who developed an insidious onset of postprandial abdominal pain following laparoscopic Nissen fundoplication related to mesenteric venous thrombosis.

The role of endoscopic ultrasound in the evaluation of chronic mesenteric ischaemia

INTRODUCTION Doppler transabdominal ultrasound is a validated screening test for chronic mesenteric ischaemia, but gas and obesity are limitations. Endoscopic ultrasound has been proposed as a comprehensive test to evaluate chronic upper abdominal pain and is capable of Doppler measurement. We aim to evaluate the accuracy of Doppler endoscopic ultrasound (D-EUS) as a single screening test to rule out chronic mesenteric ischaemia in patients with abdominal pain and compare it with Doppler transabdominal ultrasound (D-TUS). METHODS We enrolled all patients ≥50 years with chronic upper abdominal pain and vascular risk referred for endoscopic ultrasound. All were scheduled for D-EUS and D-TUS plus a confirmatory test if one of the previous resulted positive. We estimated the accuracy of both techniques comparing them using McNemar test. RESULTS 68 patients completed the study. Fifty-three (78%) underwent D-EUS, D-TUS, and a confirmatory test. Fifteen (38%) underwent follow-up after negative results. Three (4%) in the D-EUS group and 14 in the D-TUS (21%) were excluded due to artefacts. D-EUS presented a sensitivity of 63%, specificity of 84%, whilst D-TUS presented a sensitivity of 80% and a specificity of 78%. Specificity of D-EUS was not significantly different to D-TUS. CONCLUSIONS These results support the role of Doppler endoscopic ultrasound to exclude chronic mesenteric ischaemia as cause of chronic abdominal pain.