Manoop S Bhutani

Endoscopic ultrasonography: changes of chronic pancreatitis in asymptomatic and symptomatic alcoholic patients.

Changes suggestive of chronic pancreatic damage by endoscopic ultrasonography were studied in 31 asymptomatic and symptomatic alcohol abusers. Fifteen additional patients who did not drink alcohol served as controls. Eighty‐nine percent (17 of 19) of the alcohol abusers with chronic abdominal pain had chronic pancreatitis by endoscopic ultrasonography. Similarly, 58%, (7 of 12) asymptomatic alcoholic patients also had changes of chronic pancreatitis on endosonography. Endoscopic ultrasonography has thus detected changes suggestive of alcohol‐induced chronic pancreatic damage in up to 58% of asymptomatic alcoholic persons and in 89% of alcoholic persons with pancreatic type pain.

Usefulness of endoscopic ultrasound to diagnose the severity of chronic pancreatitis

Endoscopic ultrasonography (EUS) is considered the most sensitive imaging method for the diagnosis of chronic pancreatitis (CP). Several investigators have shown that EUS findings of CP correlate with the presence of CP on endoscopic retrograde pancreatography (ERP). In general, for diagnosing CP using EUS, the presence or absence of the following EUS criteria is determined: hyperechoic foci, hyperechoic strands, lobularity, shadowing calcifications, cysts, hyperechoic duct margins, visible side branches, main pancreatic duct dilatation, and main pancreatic duct irregularity. Using these criteria, we reviewed the number of EUS criteria required to diagnose early CP and whether each EUS criterion correlates with the severity of CP on ERP. CP is likely when more than three criteria (for “early CP”) or more than five criteria (for “moderate CP”) are present. Moreover, each EUS criterion has its own importance at each ERP classification level. However, the obtained images can be operator dependent, and interobserver variability may affect interpretation of CP by EUS. Therefore, we performed a quantitative computer analysis of parenchymal echogenicity and compared it with the EUS diagnosis of CP so that the diagnosis of CP on the basis of EUS criteria could be objectively supported by the quantitative analysis of EUS images. In conclusion, EUS can objectively distinguish between a normal pancreas and CP, and can be used to evaluate the severity of the CP. EUS is a useful modality for diagnosing CP and is relatively less invasive than other available modalities.

Endoscopic sonographically guided fine-needle aspiration yield in submucosal tumors of the gastrointestinal tract.

Objective. To study the yield of endoscopic ultrasonographically guided fine‐needle aspiration cytologic examination in the diagnosis of submucosal masses. Methods. From 1999 to 2003, 10 patients underwent ultrasonographically guided fine‐needle aspiration for the cytologic diagnosis of submucosal masses in our institution. The endoscopic ultrasonography records and the cytology database were consulted, and the reports were analyzed, as were slide material and the technical aspects related to these procedures. All procedures were performed under conscious sedation and cardiorespiratory monitoring on an outpatient basis. Ten patients (4 men and 6 women; mean age, 60.8 years) were studied. Results. Eight lesions were located in the stomach, and 2 were located in the esophagus, with a mean diameter of 3.3 cm. An experienced cytopathologist was present on‐site during all procedures for assessment of adequacy and preliminary cytologic examination. Cytologic diagnoses were obtained in 8 cases as follows: 6 gastrointestinal stromal tumors, 1 organizing submucosal hematoma, and 1 low‐grade mucosa‐associated lymphoid tissue–associated lymphoma. Two cases consisted of scant gastric epithelium only and were considered nondiagnostic. The cytologic diagnoses guided further clinical treatment. Conclusions. Ultrasonographically guided fine‐needle aspiration with cytopathologic analysis has a high accuracy rate (80%) for diagnosing submucosal lesions. These findings potentially affect clinical decision making.

Gastrointestinal endoscopic ultrasonography.

Although conventional endoscopy provides excellent visualization of gastrointestinal mucosa, it provides little information about intramural or nearby extramural lesions. The imaging of intraabdominal structures by conventional transabdominal ultrasound is degraded by ultrasound energy attenuation with distance. The provision of an ultrasound probe on a flexible gastrointestinal endoscope, to form an echoendoscope, provides excellent imaging of the gastrointestinal wall and of adjacent extramural structures. During the last two decades, endoscopic ultrasound, using an echoendoscope, has revolutionized the diagnosis and treatment of gastrointestinal diseases that affect the submucosa, deep bowel wall, and adjacent extramural structures. This article reviews the role of endoscopic ultrasound in the diagnosis and treatment of gastrointestinal disease, including standard and promising new applications, as well as standard and emerging new technology.

An animal model for studying endoscopic ultrasound changes of early chronic pancreatitis with histologic correlation: A pilot study

BACKGROUND AND STUDY AIMSnDue to the difficulty in obtaining pancreatic tissue for histology in humans, we developed an animal model for studying endoscopic ultrasound (EUS) changes of early chronic pancreatitis. This report on the animal model describes the serial changes of early chronic pancreatitis by EUS and correlates results with histology.nnnMATERIALS AND METHODSnFour 60 - 80-lb dogs were used in the study. Pancreatic EUS was performed to provide baseline images prior to any procedure. At laparotomy, a guide wire was passed into the pancreatic duct, and a 5-Fr pancreatic stent was introduced over the wire into the pancreatic duct. Animals were divided into two survival groups - 2 weeks and 4 weeks. In each group, EUS examination was performed under anesthesia to image the pancreas and then followed by euthanasia. Sequential pancreatic sections were taken from the head, body, and tail of the pancreas. EUS findings were correlated with histologic results with respect to degree of fibrosis, inflammation, and edema.nnnRESULTSnAt baseline EUS, the pancreas appeared homogeneous with only a few echogenic septations and echogenic margins of the main pancreatic duct. At 2 and 4 weeks poststenting, EUS images showed the following changes: lobularity, hyper and hypoechoic foci, increased echogenic septations, visible pancreatic duct side branches, and irregular margins of the main pancreatic duct.nnnCONCLUSIONSnThe dog model for chronic pancreatitis appears to be a promising method for studying sequential changes of chronic pancreatitis by EUS and correlating results with histology.

Therapeutic endoscopy and endoscopic ultrasound for gastrointestinal malignancies.

Gastrointestinal endoscopy and endoscopic ultrasound not only provide strategies to diagnose and stage malignancy, but also to administer palliative and definitive care. Options for anticancer therapy include endoscopic mucosal resection, photodynamic therapy, thermal therapy, self-expanding metal stents and recently, endoscopic ultrasound-guided therapy, such as intratumoral injection. This review summarizes the available endoscopic techniques with a discussion of indications and recent clinical data pertaining to gastrointestinal malignancy. This review will inform the reader of emerging treatment options and stress the importance of incorporating gastroenterologists into the multidisciplinary approach in the management of gastrointestinal cancers.

Endoscopic ultrasound with fine-needle aspiration facilitates diagnosis of metastatic iliac lymph node invasion in prostate cancer

on endoscopic ultrasonography (EUS) for staging prostate cancer [1]. EUS with flexible instruments has the additional potential for imaging the iliac region in the search for lymph node metastases with confirmation by EUS-guided fine-needle aspiration (FNA) in prostate cancer; this is an area that cannot be accessed with nonoptical transrectal rigid ultrasonography (TRUS) probes. A 65-year-old man was referred with an increased prostate-specific antigen (PSA) level of 37.9 ng/mL. An abdominopelvic CT scan was normal. Transrectal EUS was performed to image the prostate and revealed a hypoechoic, round nodule in the peripheral zone of the prostate (l Fig. 1). Multiple EUS-guided FNA passes were done using a 22-gauge needle (WilsonCook, Winston–Salem, North Carolina, USA). Cytopathological study showed undifferentiated adenocarcinoma. An enlarged iliac lymph node (13 mm) was seen by EUS by advancing the echoendoscope to the level of the iliac vessels (around 20 –25 cm from the anus). Transcolonic EUS-FNA of the left iliac lymph node was done in the same exam (l Figs. 2 – 4), and histopathology demonstrated metastatic undifferentiated prostate adenocarcinoma (l Fig. 5). Staging techniques for prostate cancer include ultrasonography, CT, and magnetic resonance imaging (MRI). Ultrasonography, by the transabdominal, transurethral, transperineal, or transrectal route, allows characterization of the prostate parenchyma. Other techniques for local and nodal staging of prostate cancer include MRI, magnetic resonance spectroscopic imaging (MRSI), dynamic-enhanced MRI, positron emission tomography (PET), endorectal power Doppler ultrasonography, lymphotropic MRI contrast agents, and diffusion MRI [2, 3]. EUS may be another useful method for highresolution imaging of prostate cancer [1]. Lymph node staging is an important issue in prostate cancer that directly impacts management and outcome. Digital rectal examination and TRUS are not accurate in predicting lymph node metastases [4]. A meta-analysis by Hovels et al. [5] showed a low accuracy of CT and MRI for lymph node staging of prostate cancer. We believe that there is potential for EUS with FNA to play an important, minimally invasive role in lymph node staging of prostate cancer.

Ultrasound-Guided Therapy

Utilizing-high frequency sound waves to define internal structures, ultrasound (US) provides an opportunity not only to diagnose disease but also to target treatment to malignant tumors. US has several advantages over other radiology-assisted techniques that highlight its important role as a component of anticancer therapy. US provides an opportunity to administer therapy with real-time guidance. In other words, the physician can deliver treatment while synchronously visualizing the US images to ensure proper targeting.

Choledocholithiasis with a dilated CBD masquerading as a cystic pancreatic mass: importance of real-time eus imaging in the evaluation of pancreatico-biliary lesions

showed moderate resolution of inflammation. Discussion :There are about 20 case reports of esophageal LP. It can go unrecognized for years, as it may precede the skin lesions. Women are affected slightly more frequently than men. There is no racial predilection and it affects the 50 and 60 year-olds .Our patient had typical symptoms. Oral lesions are universal in these patients. Endoscopic findings are characteristic. Proximal esophageal involvement is typical. Subtle and obvious strictures are common, multiple and at various levels. Esophageal biopsies are not always diagnostic. Typical features include basal keratinocyte damage and dense infiltrate of lymphocytes in the subepithelial layer. Fibrinogen deposits at dermoepidermal junction and necrotic keratinocytes with anucleated remnants called Civatte bodies are characteristic. Subepidermal IgM deposits are typically seen in LP. Biopsies are only diagnostic in 50 % of cases. Systemic steroids are the first line treatment and useful. Systemic retinoids and cyclosporine have been variably successful. Esophageal strictures can be successfully dilated. Koebner phenomenon occurs in esophageal LP too. The condition has a malignant potential, although no case reports have come forward yet.

A prospective comparison of enteroclysis and capsule endoscopy in the diagnosis of obscure gastrointestinal bleeding

Purpose: Enteroclysis is considered the gold standard for evaluation of small bowel diseases. Small bowel series is preferred because of its simplicity and lack of patient (pt) discomfort. Recently, capsule endoscopy (CE) was shown to be superior to small bowel radiography for evaluation of small bowel diseases. (Gastroenterol 2002; 123; 999–1005) This study was undertaken to prospectively study the diagnostic yield of enteroclysis compared with CE in pts with obscure gastrointestinal bleeding.