Shaimaa Elkholy

Ultrasound, endoscopic ultrasound elastography, and the strain ratio in differentiating benign from malignant lymph nodes

BACKGROUND AND STUDY AIMS Endoscopic ultrasound elastography (EUS-elastography), or sono-elastography, has emerged in the past 2 decades as a qualitative method of estimating tissue stiffness. Strain elastography allows for semi-quantitative measurements of the average elasticity of a lesion, and previous studies have proposed the strain ratio (SR) for overcoming the limitations of the elasticity score. The main objective of this study is to assess the specificity, sensitivity and predictive values of the SR measured by EUS-elastography in differentiating benign from malignant lymph nodes (LNs). This study also aims to find significant ultrasonographic features other than the SR which could help in predicting LN malignancy. PATIENTS AND METHODS This prospective study included 126 Egyptian patients with lymphadenopathy. US and EUS-elastography and the SR were assessed, in addition to detailed sonographic features, including size, longest diameter, shortest diameter, ratio of shortest/longest diameter, echotexture (echogenic or echo-poor) and hilum (lost or preserved). RESULTS The SR cut-off value of 4.61 showed a sensitivity and specificity of 89.8% and 83.3%, respectively. This parameter had high positive and negative predictive values of 82.5% and 90.2%, respectively, for predicting malignant LNs. Univariate regression analysis showed that echogenicity, hilum preservation, elastography, the shortest dimension, the ratio of the shortest/longest dimension, ultrasound diagnosis and SR could be potential predictors of the final lymph node diagnosis. Sono-diagnosis depending on echogenicity, the shortest/longest diameter ratio and a preserved hilum in combination was the only predictive parameter in multivariate regression analysis. CONCLUSION EUS-elastography and the SR could be excellent prognostic indices in differentiating benign from malignant lymph nodes if combined with other US features.

Real time endoscopic ultrasound elastography and strain ratio in the diagnosis of solid pancreatic lesions

AIM To evaluate the accuracy of the elastography score combined to the strain ratio in the diagnosis of solid pancreatic lesions (SPL). METHODS A total of 172 patients with SPL identified by endoscopic ultrasound were enrolled in the study to evaluate the efficacy of elastography and strain ratio in differentiating malignant from benign lesions. The semi quantitative score of elastography was represented by the strain ratio method. Two areas were selected, area (A) representing the region of interest and area (B) representing the normal area. Area (B) was then divided by area (A). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated by comparing diagnoses made by elastography, strain ratio and final diagnoses. RESULTS SPL were shown to be benign in 49 patients and malignant in 123 patients. Elastography alone had a sensitivity of 99%, a specificity of 63%, and an accuracy of 88%, a PPV of 87% and an NPV of 96%. The best cut-off level of strain ratio to obtain the maximal area under the curve was 7.8 with a sensitivity of 92%, specificity of 77%, PPV of 91%, NPV of 80% and an accuracy of 88%. Another estimated cut off strain ratio level of 3.8 had a higher sensitivity of 99% and NPV of 96%, but with less specificity, PPV and accuracy 53%, 84% and 86%, respectively. Adding both elastography to strain ratio resulted in a sensitivity of 98%, specificity of 77%, PPV of 91%, NPV of 95% and accuracy of 92% for the diagnosis of SPL. CONCLUSION Combining elastography to strain ratio increases the accuracy of the differentiation of benign from malignant SPL.

Elastography and Strain Ratio in Diagnosing Different Body Masses, Could They Solve the Puzzle?

Background: Different real time elasticity scores were developed to distinguish between benign and malignant lesions, yet the most important drawback is that they are very subjective. Strain ratio as a semi-quantitative method developed by dividing the area of interest by the normal tissue to improve objectivity and reach a better diagnosis. Aim: To validate the accuracy of elastography and strain ratio in diagnosing stiffness of different body masses. Patients and methods: This prospective study included 568 patients with different body masses and lymph nodes. We reached diagnosis in 427 patients by FNA, tru-cut and/or excision biopsy. Real time Elastography and strain ratio were assessed in all patient by US or EUS-elastography. Results: The best cut off value of strain ratio in differentiating benign from malignant lesions was 6.5 with 86% sensitivity, 84% specificity, 85% accuracy, 91% PPV and 76% NPV. Elastography score had sensitivity, specificity, accuracy, PPV and NPV of 94, 78, 88, 88, 87% respectively. Adding both results to each other resulted in sensitivity of 94%, specificity of 78%, accuracy, PPV and NPV of 88%. Conclusion: Using both strain ratio and elastography increases the accuracy of differentiating benign from malignant body lesions.

Endoscopic mucosal resection of rectal squamous cell papilloma

A 22-year-old male patient presented with a 3-month history of persistent, colicky, lower abdominal pain. He was referred for colonoscopy. Total colonoscopy showed multiple small-to-medium sized pale pink, nonulcerated, polypoid lesions in the distal part of the rectum, occupying most of the circumference (▶Fig. 1). The patient’s medical history was not significant. After discussing his sexual history, he mentioned having a male partner for 2 years. Basic investigations were carried out, including human immunodeficiency virus serology; they were all negaE-Videos

Gastric Peroral Endoscopic Myotomy (G-POEM) as a Treatment for Refractory Gastroparesis: Long-Term Outcomes

Background and Aims Gastric peroral endoscopic myotomy (G-POEM) has been regarded as a novel and minimally invasive therapy for refractory gastroparesis. This study reports the long-term outcomes and possible predictive factors for successful outcomes after G-POEM in an Asian population. Methods This is a retrospective single-centre study of 16 patients who underwent G-POEM for refractory gastroparesis from August 2016 to October 2017. This study included 11 males and 5 females; in addition, 13 patients had postsurgical gastroparesis, and 3 patients had diabetes. The patients included had severe and refractory gastroparesis, as indicated by a Gastroparesis Cardinal Symptom Index (GCSI) score ≥20, and evidence of a delay on gastric emptying scintigraphy (GES). The primary outcome parameter was an assessment of the long-term clinical efficacy of the procedure. The secondary outcome parameter was the detection of possible predictive factors for success and the determination of cut-off values for such predictors. Results Technical success was achieved in 100% of the patients, with a mean procedure time of 45.25±12.96 min. The long-term clinical response was assessed in all patients during a median follow-up of 14.5 months. Clinical success was achieved in 13 (81.25%) patients. There was a significant reduction in the GCSI scores and GES values after the procedure compared to the baseline values, with P values of <0.0001 and 0.012, respectively. Univariate regression analysis showed that the GCSI and GES had significant associations with the future clinical outcomes of the patients, but this finding was not confirmed in multivariate analysis. A GCSI cut-off score of ≤30 had a high sensitivity and a negative predictive value (NPV) of 100% for predicting a successful procedure. GES (half emptying time ≤221.6 min and 2-hour retention ≤78.6%) had a high specificity and a positive predictive value (PPV) of 100%. Conclusions G-POEM is a safe and effective treatment option with a long-term efficacy of 81.6%. GCSI and GES could serve as good predictive measures.

Double-balloon enteroscopy (DBE) in patients presenting with obscure gastrointestinal bleeding (OGIB)

BACKGROUND AND STUDY AIMS Obscure gastrointestinal bleeding (OGIB) is defined as bleeding of unknown origin that persists or recurs after an initial negative investigation. Identifying the source of OGIB represents a diagnostic challenge that is frequently focused on visualizing the small intestine. Conventional diagnostic methods, such as push enteroscopy, small-bowel follow-through, radionuclide scanning, and angiography, each exhibit inherent limitations. Double balloon enteroscopy (DBE) was designed specifically to evaluate the entire small bowel. DBE allows for better visualization, biopsy of the identified lesions and application of therapeutic techniques. This study sought to assess the role of DBE in the diagnosis and management of patients with OGIB. PATIENTS AND METHODS This prospective study was conducted to analyse data from 31 patients presenting with OGIB referred for DBE in the Endoscopy Unit at the Internal Medicine Department of the Faculty of Medicine, Cairo University. RESULTS Five patients had lesions in locations other than the small intestine that accounted for GI bleeding. Thus, the potential source of OGIB was defined as the small intestine in 18 of 26 patients (69.2%), and negative DBE findings were noted in eight patients (30.8%). Major findings included small intestinal tumours in eight patients, vascular bleeding lesions in 8 patients and ulcerations in 2 patients. Endoscopic haemostasis was performed in eight patients with vascular lesions. The three patients with Petuz-Jegher syndrome underwent polypectomy of their major polyps. Patients with gastrointestinal tumours were referred for surgery. CONCLUSION DBE is an excellent endoscopic procedure that has a relatively high diagnostic and therapeutic yield. The procedure is feasible and exhibits a high safety profile with a low complication rate when performed by an experienced endoscopist.

Endoscopic ultrasound and endoscopic ultrasound-guided fine needle aspiration in the diagnosis of diffuse gastrointestinal lesions with inconclusive endoscopic biopsies

BACKGROUND/AIMS Many gastrointestinal tumors appearing as diffuse circumferential malignancies, for example, diffuse signet ring adenocarcinoma and lymphoma, might primarily involve the submucosal layer and hence are difficult to diagnose because they frequently yield negative endoscopic biopsies. This main aim of this study was to evaluate the accuracy of endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) in the diagnosis of diffuse gastrointestinal lesions with inconclusive endoscopic biopsies. MATERIALS AND METHODS This prospective study included 92 patients with diffuse or circumferential gastrointestinal lesions with non-conclusive biopsies that were taken during upper or lower endoscopy. EUS and EUS-FNA were performed on all patients with cytopathological examination. RESULTS This study included 58 males (63%) and 34 females (37%) with a mean age of 54.2 years. Seventy-two cases (78.3%) were shown to have malignant lesions, and 20 cases (21.7%) were shown to be benign. EUS had a sensitivity of 94.4%, a specificity of 65%, a positive predictive value (PPV) of 90.7%, and a negative predictive value (NPV) of 45.1% with a p<0.0001 in diagnosing malignant lesions. EUS-FNA had a sensitivity of 83%, specificity of 100%, PPV of 100%, and NPV of 61.9% with a p<0.0001. CONCLUSION Endoscopic ultrasound with EUS-FNA is an accurate procedure in the diagnosis of endoscopic biopsy-negative diffuse or circumferential gastrointestinal lesions.

Undiagnosed significant gastrointestinal wall thickening or hypertrophy, can endoscopic ultrasound and endoscopic ultrasound-fine needle aspiration help?

Background and Objectives: Many gastrointestinal tumors as diffuse circumferential malignancies as signet ring cell carcinoma and lymphoma may involve mainly the submucosal layer and hence are difficult to diagnose as they frequently yield negative endoscopic biopsies. This main aim of this study is to evaluate the accuracy of endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) in the diagnosis of diffuse gastrointestinal (GI) lesions with inconclusive endoscopic biopsies. Patients and Methods: This prospective study included 102 patients with diffuse or circumferential GI lesions with nonconclusive biopsies that were taken during upper or lower endoscopy. EUS and EUS-FNA were performed to all patients with cytopathological examination. Results: This study included 65 males (64%) and 37 females (36%), with the mean age of 54.6 years; 80 cases (78.4%) were proved to have malignant lesions; 22 cases (21.6%) were proved to be benign. EUS had a sensitivity of 95%, specificity of 65%, positive predictive value (PPV) of 91%, negative predictive value (NPV) of 45% with P < 0.0001 in diagnosing malignant lesions. EUS-FNA had a sensitivity of 83%, specificity of 100%, PPV of 100%, NPV of 62%, with P < 0.0001. Conclusion: EUS with EUS-FNA is an accurate procedure in the diagnosis of endoscopic biopsy negative diffuse or circumferential GI lesions.

Endoscopic ultrasound-guided fine-needle aspiration and cytology for differentiating benign from malignant lymph nodes

BACKGROUND AND STUDY AIMS Intra-abdominal and mediastinal lymphadenopathy are often difficult to diagnose, particularly in the absence of a primary lesion. Endosonography (EUS)-guided fine-needle aspiration and cytology (FNAC) has provided an easy and safe access to these lymph nodes, sparing the use of invasive and costly interventions. The main aim of this study is to assess the specificity, sensitivity, and predictive value of EUS-guided FNAC in the diagnosis of benign and malignant lymph nodes. In addition, the study aims to determine significant EUS features that could help in predicting lymph node malignancy. PATIENTS AND METHODS This prospective study included 142 patients with intra-abdominal or intrathoracic lymphadenopathy who were referred for EUS-guided FNAC because of inaccessibility by other imaging modalities. Ninety (63.3%) patients were found to have malignant lymph nodes, and 52 (36.6%) had lymphadenopathy of benign nature. RESULTS EUS-guided FNAC had a sensitivity and specificity of 92% and 100% respectively. It had positive and negative predictive values of 100% and 88% for malignancy, respectively. By logistic regression analysis, EUS features and shortest diameter were found to be potential predictors of malignancy with p-value of <0.0001. CONCLUSION EUS-guided FNAC is a powerful modality in the diagnosis of benign and malignant lymph nodes. Additional complementary EUS features could be added to this technique for definitive diagnosis.