Nadan Rustemović

A pilot study of transrectal endoscopic ultrasound elastography in inflammatory bowel disease

BackgroundUsing standard diagnostic algorithms it is not always possible to establish the correct phenotype of inflammatory bowel disease which is essential for therapeutical decisions. Endoscopic ultrasound elastography is a new endoscopic procedure which can differentiate the stiffness of normal and pathological tissue by ultrasound. Therefore, we aimed to investigate the role of transrectal ultrasound elastography in distiction between Crohns disease and ulcerative colitis.MethodsA total 30 Crohns disease, 25 ulcerative colitis, and 28 non-inflammatory bowel disease controls were included. Transrectal ultrasound elastography was performed in all patients and controls. In all ulcerative coltis patients and 80% of Crohns disease patients endoscopy was performed to assess disease activity in the rectum.ResultsSignificant difference in rectal wall thickness and strain ratio was detected between patients with Crohns disease and controls (p = 0.0001). CD patients with active disease had higher strain ratio than patients in remission (p = 0.02). In ulcerative colitis group a significant difference in rectal wall thickness was found between controls and patients with active disease (p = 0.03). A significant difference in rectal wall thickness (p = 0.02) and strain ratio (p = 0.0001) was detected between Crohns disease and ulcerative colitis patient group. Crohns disease patients with active disease had a significantly higher strain ratio compared to ulcerative colitis patients with active disease (p = 0.0001).ConclusionTransrectal ultrasound elastography seems to be a promising new diagnostic tool in the field of inflammatory bowel disease. Further study on a larger cohort of patients is needed to definitely assess the role of transrectal ultrasound elastography in inflammatory bowel disease.

Endoscopic ultrasound elastography strain histograms in the evaluation of patients with pancreatic masses

AIM To investigate the accuracy of the strain histogram endoscopic ultrasound (EUS)-based method for the diagnostic differentiation of patients with pancreatic masses. METHODS In a prospective single center study, 149 patients were analyzed, 105 with pancreatic masses and 44 controls. Elastography images were recorded using commercially available ultrasound equipment in combination with EUS linear probes. Strain histograms (SHs) were calculated by machine integrated software in regions of interest and mean values of the strain histograms were expressed as Mode 1 (over the mass) and Mode 2 (over an adjacent part of pancreatic tissue, representing the reference area). The ratio between Mode 2 and Mode 1 was calculated later, representing a new variable, the strain histogram ratio. After the final diagnosis was established, two groups of patients were formed: a pancreatic cancer group with positive cytology achieved by fine needle aspiration puncture or histology after surgery (58 patients), and a mass-forming pancreatitis group with negative cytology and follow-up after 3 and 6 mo (47 patients). All statistical analyses were conducted in SPSS 14.0 (SPSS Inc., Chicago, IL, United States). RESULTS Results were obtained with software for strain histograms with reversed hue scale (0 represents the hardest tissue structure and 255 the softest). Based on the receiver operating characteristics (ROC) curve coordinates, the cut-off point for Mode 1 was set at the value of 86. Values under the cut-off point indicated the presence of pancreatic malignancy. Mode 1 reached 100% sensitivity and 45% specificity with overall accuracy of 66% (95%CI: 61%-66%) in detection of pancreatic malignant tumors among the patients with pancreatic masses. The positive and negative predictive values were 54% and 100%, respectively. The cut-off for the new calculated variable, the SH ratio, was set at the value 1.153 based on the ROC curve coordinates. Values equal or above the cut-off value were indicative of pancreatic malignancy. The SH ratio reached 98% sensitivity, 50% specificity and an overall accuracy of 69% (95%CI: 63%-70%). The positive and negative predictive values were 92% and 100%, respectively. CONCLUSION SH showed high sensitivity in pancreatic malignant tumor detection but disappointingly low specificity. Slight improvements in specificity and accuracy were achieved using the SH ratio.

Endoscopic ultrasound elastography as a method for screening the patients with suspected primary sclerosing cholangitis.

Objectives Currently, magnetic resonance cholangiography is being used for establishing the diagnosis of primary sclerosing cholangitis, whereas endoscopic retrograde cholangiography is reserved for therapeutic interventions. The aim of this study was to determine the role of endoscopic ultrasound elastography in the detection of inflammatory and fibrotic lesions of the common bile duct. Methods Linear endoscopic ultrasound elastography of the common bile duct was performed in 41 patients. The patients were divided into two groups: disease group (20 patients with both, primary sclerosing cholangitis and inflammatory bowel disease) and control group (21 patients). Main outcome measurements were diameter, wall thickness and wall qualitative Elasto Score of the common bile duct. Results The disease group consisted of nine females and 11 males, whereas the control group consisted of 13 females and eight males, with no sex differences observed (χ2 = 0.6, d.f. = 1, P = 0.443). There was no significant difference in the diameter of common bile duct between the studied groups: 4.67±1.83 mm in the disease group and 5.88±2.47 mm in controls (t = −1.77, d.f.  = 39, P = 0.085). Hard or mixed Elasto Score was found in 16 patients and four controls, being significantly different compared with the soft Elasto Score found in four patients and 17 controls (χ2 = 1.8, d.f.  = 1, P<0.001). A significant difference was observed in the common bile duct wall thickness: 0.89±0.59 mm in the disease group and 0.39±0.14 mm in controls (t = 3.75, d.f.  = 39, P<0.001). Conclusion Endoscopic ultrasound elastography might be a useful noninvasive method in diagnosing primary sclerosing cholangitis.

Percutaneous pancreatography under ultrasonographic guidance.

Purpose: The aim of the study was to evaluate percutaneous pancreatography as an alternative method for pancreatic duct visualisation in patients with pancreatic disease. Material and Methods: In 21 patients with pancreatic disease and previously unsuccessful ERCP, puncture of the pancreatic duct was carried out under ultrasonographic guidance with an 0.7-mm Chiba needle, and contrast injection was made under fluoroscopic control in the pancreatic duct. Results: The procedure was successful in 18 patients (86%). In 10 patients, chronic pancreatitis was found, and in 8 patients, pancreatic carcinoma. Conclusion: Percutaneous pancreatography is a good alternative method for visualisation of the pancreatic duct in patients with pancreatic disease and previously unsuccessful ERCP.

Differentiation of Pancreatic Masses via Endoscopic Ultrasound Strain Ratio Elastography Using Adjacent Pancreatic Tissue as the Reference.

Objectives The aims of this study were to evaluate diagnostic value of endoscopic ultrasound strain ratio elastography in patients with focal pancreatic masses and to determine the cutoff value between the pancreatic malignancies and inflammatory pancreatic masses using reference areas different than those used by other investigators. Methods In a prospective single-center study, strain ratio was measured in patients with pancreatic masses. After the diagnosis was established, statistical analysis was used to compare the group with pancreatic malignancies to the one with inflammatory masses. Results Strain ratio cutoff of 7.59 provided 100% sensitivity, 95% specificity, and 97% overall accuracy for differentiation of patients with pancreatic malignancies from those with inflammatory masses. Conclusions Our data show high sensitivity and specificity for the calculated strain ratio. Adjacent normal pancreatic tissue is adequate as a reference area based on the inclusion criteria. Diverse cutoff values and standardization of methods in the studies published so far require further investigations, before the implementation of the method in a routine clinical practice becomes possible.

Combined Use of Clips and Nylon Snare (''Tulip-Bundle'') as a Rescue Endoscopic Bleeding Control in a Mallory-Weiss Syndrome

Mallory-Weiss syndrome (MWS) accounts for 6–14% of all cases of upper gastrointestinal bleeding. Prognosis of patients with MWS is generally good, with a benign course and rare recurrence of bleeding. However, no strict recommendations exist in regard to the mode of action after a failure of primary endoscopic hemostasis. We report a case of an 83-year-old male with MWS and rebleeding after the initial endoscopic treatment with epinephrine and clips. The final endoscopic control of bleeding was achieved by a combined application of clips and a nylon snare in a “tulip-bundle” fashion. The patient had an uneventful postprocedural clinical course and was discharged from the hospital five days later. To the best of our knowledge, this is the first case report showing the “tulip-bundle” technique as a rescue endoscopic bleeding control in the esophagus.

P747 Extracolonic and colonic cancer risk in patients with ulcerative colitis and primary sclerosing cholangitis

P746 Clinical characteristic of Crohn’s disease patients in Polish population M. Lodyga*1, P. Eder2, M. Gawron-Kiszka3, M. Hartleb3, J. Kierkus4, M. Klopocka5, M. Kukulska6, K. Linke7, E. MaleckaPanas8, E. Poniewierka6, I. Smola6, T. Rawa9, J. Regula9, G. Rydzewska1,10 1Central Clinical Hospital of the Ministry of the Interior, Department of Internal Medicine and Gastroenterology with IBD Subdivision, Warsaw, Poland; 2Poznan University of Medical Sciences, Department of Gastroenterology, Human Nutrition and Internal Diseases, Poznan, Poland; 3Medical University of Silesia, Department of Gastroenterology and Hepatology, Katowice, Poland; 4Children’s Memorial Health Institute, Department of Gastroenterology, Hepatology, and Feeding Disorders, Warsaw, Poland; 5Nicolaus Copernicus University, Gastroenterology Nursing Unit, Centre for Therapeutic Endoscopy, University Hospital No 2, Collegium Medicum in Bydgoszcz, Torun, Poland; 6Wroclaw Medical University, Department of Gastroenterology and Hepatology, Wroclaw, Poland; 7Poznan University of Medical Sciences, 2Department of Gastroenterology, Human Nutrition and Internal Diseases, Pozan, Poland; 8Medical University of Lodz, Department of Gastrointestinal Tract Diseases, Lodz, Poland; 9Medical Centre for Postgraduate Education, Department of Gastroenterology and Hepatology, Warsaw, Poland; 10Jan Kochanowski University, Department of the Prevention of Alimentary Tract Diseases, Faculty of Medicine and Health Science, Kielce, Poland

Endoscopic Ultrasound Elastography in Inflammatory Bowel Disease

The diagnosis of inflammatory bowel disease (IBD) is based on clinical, endoscopic, radiologic and histologic criteria1. There are two main IBD phenotypes – Crohns disease (CD) and ulcerative colitis (UC). In some circumstances, especially when disease extension is restricted to the colon or in cases of acute severe pancolitis, recognition of specific IBD phenotype is very difficult. Recognition of the exact IBD phenotype is essential for guiding therapeutic decisions and detection of complications that warrant treatment. Endoscopic examination is the mainstay in the diagnosis of IBD. Endoscopic appearance (distribution and shape of lesions) helps to differentiate CD from UC in most cases. Pathohistologic analysis confirms the elements of chronic inflammation but it is frequently not diagnostic. Patients with UC may have atypical histological features such as microscopic inflammation of the ileum, patchiness of inflammation and rectal sparing at the time of diagnosis prompting physicians to make the diagnosis of CD in UC cases. Other endoscopic findings such as cobble stoning, segmental colitis, ileal stenosis and ulceration, perianal disease and pathologically confirmed multiple granulomas in the small bowel or colon strongly suggest a diagnosis of CD. The progress in genetics, serological markers and imaging studies will lead to more reliable determination of exact IBD phenotype in the future2. In the meantime, it is reasonable to explore other diagnostic options for better differentiation between different IBD phenotypes. We think that endoscopic ultrasound (EUS) elastography is a promising method to achieve this goal, picture 1 and 2. It is a new endoscopic procedure which can differentiate the stiffness of normal and pathological tissue by ultrasound. This finding is based on B-mode scanning during compressions3. There are some data on elastography applied on the GI tract, biliary tract, kidney, muscle, breast and the heart3-5. Primary sclerosing cholangitis (PSC) is a chronic liver disease of unknown etiology, characterized by cholestasis, inflammation, fibrosis and stricture formation of the biliary ducts. The pathophysiology of PSC is a complex multistep process included unclear immunological mechanisms, genetic susceptibility and various defects of the biliary epithelial cells. The disease is rare in the general population but is strongly associated with inflammatory bowel disease. The prevalence of IBD, predominantly ulcerative colitis, among PSC patients is approximately 70-90% while only 5% of patients with UC develop PSC. The percentage of

P081 - Pancreatic insufficiency in inflammatory bowel disease. Assessment by fecal elastase-1

Clinically significant disease of the pancreas in association with inflammatory bowel disease (IBD) is unusual but reported. IBD patients have a risk of developing pancreatitis as well as pancreatic insufficiency (PI). Pancreatic elastase-1 is a human and pancreas specific enzyme that is not degraded during intestinal transport and correlates with exocrine pancreatic function test. The aim of this study was to evaluate the relationship between inflammatory bowel disease and pancreatic insufficiency as an extraintestinal manifestation of IBD.

The efficacy of injection slerotherapy, fibrin glue and hemoclips in stopping bleeding from gastroduodenal ulcers

The efficacy of injection sclerotherapy, fibrin glue and hemoclips in stopping bleeding from gastroduodenal ulcers