Steffen Rickes

Evaluation of Criteria for the Activity of Crohn’s Disease by Power Doppler Sonography

Background/Aim: In recent years, power Doppler sonography has been proposed as a method to assess disease activity in patients with Crohn’s disease. The aim of this prospective study was to evaluate diagnostic criteria for power Doppler sonography by blinded comparison with ileocolonoscopy. Methods: Twenty-two patients with confirmed Crohn’s disease were prospectively investigated with B-mode and power Doppler sonography (HDI 5000, Philips Ultrasound) as well as ileocolonoscopy. Sonography was performed within 3 days before endoscopy. All procedures were performed by experienced examiners who were blinded to the clinical data and other results. Defined ultrasound parameters (bowel wall thickness, vascularization pattern) were used to determine a sonographic score of the activity. The degree of activity was scored from 1 (none) to 4 (high) by both ultrasound and ileocolonoscopy (pattern, extent of typical lesions). For each patient all segments of the colon and the terminal ileum were evaluated by both ultrasound and endoscopy. The weighted ĸ test was used (StatXact software) for statistical analysis. Results: In total, 126 bowel segments were evaluated by both ultrasound and endoscopy. The study showed a high concordance of power Doppler sonography and ileocolonoscopy (weighted ĸ by region: sigmoid colon: 0.81; transverse colon: 0.78; ascending colon: 0.75; cecum: 0.84; terminal ileum: 0.82). Highest concordance was found in the descending colon (weighted ĸ: 0.91; 95% CI: 0.83–0.98). Conclusions: Combination of B-mode and power Doppler sonography has a high accuracy in the determination of disease activity in Crohn’s disease when compared to ileocolonoscopy. The diagnostic criteria established in this study can be useful for the evaluation of inflammatory bowel diseases by ultrasound.

Differentiation of cystic pancreatic neoplasms and pseudocysts by conventional and echo-enhanced ultrasound

Background and Aims:  Echo‐enhanced sonography is a non‐invasive and increasingly used procedure for the differentiation of pancreatic tumors. However, the diagnostic accuracy of this procedure compared to conventional ultrasound for the differential diagnosis of cystic pancreatic neoplasms from pseudocysts has never been investigated in a prospective study.

Usefulness of the double-balloon enteroscope in colonoscopies performed in patients with previously failed colonoscopy

TO THE EDITOR: Incomplete colonoscopy can be caused by difficulty in passing through stenosis and/ or the looping of the endoscope within the colon, specifically in the sigmoid. Even with colonoscopes of variable stiffness (VS) or the use of sigmoid stabilizers, cecal intubation may not be possible [1,2]. The double-balloon enteroscope (DBE) is a relatively new device designed for examination of the small intestine. Properties of the DBE are its thin external diameter, length, flexibility, and stabilizing external overtube [3]. Thus, we used the DBE to examine the colon in patients with previously failed colonoscopies in a single center feasibility study. Patients who were evaluated for suspected colonic pathology at the University of Magdeburg, Germany during a one-year period (from April 2004 to March 2006) were included in the study. All patients had undergone at least two previous attempts at colonoscopy (range 2 4), including the use of a pediatric VS colonoscope by experienced endoscopists. The characteristics of the study group are presented in Table I.

Diagnostic quality of polyps resected by snare polypectomy : Does the type of electrosurgical current used matter?

BACKGROUND:Traditionally, snare polypectomy is performed using blended, coagulation, or pure cutting electrical current (EC). The aim of this study was to assess and compare the diagnostic quality of polyps obtained by snare polypectomy using two different electrosurgical currents.METHODS:Consecutive patients undergoing colonoscopy underwent polypectomy using either blended EC with a conventional electrosurgical generator (ESG) or using an ESG with a microprocessor that automatically controls cutting and coagulation (Endocut). An experienced blinded gastrointestinal (GI) pathologist evaluated the specimens for diameter, cautery damage (amount and degree), margin evaluability, architecture, and general histologic diagnostic quality.RESULTS:One hundred sixteen patients (69% men, mean age 63.8 ± 15 yr) underwent 148 polypectomies (78 using blended current and 70 using Endocut). We found that the cautery degree was less with the Endocut than with the blended current (p < 0.02). Cautery amount was also higher in polyps resected using blended current (56%) than Endocut (51%) but this difference did not reach statistical significance (p = 0.1). Polyps resected using Endocut had better margin evaluability (75.7% to 60.3%, p = 0.046). The overall tissue architecture was similar in both groups. Polyps removed with blended current had less overall quality as compared to polyps removed by Endocut (p = 0.024).CONCLUSIONS:More extensive tissue damage occurred using blended EC with the conventional ESG than when using Endocut. The quality of the polypectomy specimens was overall better using Endocut. Finally, the ability to evaluate resected polyp margins and overall tissue histology was better with the microprocessor-controlled ESG than with the conventional ESG.

Impact of the operator's experience on value of high-resolution transabdominal ultrasound in the diagnosis of choledocholithiasis : A prospective comparison using endoscopic retrograde cholangiography as the gold standard

Objective. Transabdominal ultrasound (US) is the most frequently used imaging method for the diagnosis of choledocholithiasis. The aim of this prospective study was to evaluate the diagnostic accuracy of high-resolution US in the diagnosis of common bile duct stones depending on the operators experience and in comparison with endoscopic retrograde cholangiography (ERC) as the gold standard. Material and methods. From April 2003 through November 2004, 126 patients referred because of clinically and biochemically suspected common bile duct stones were included in the study. Two patients were excluded because they refused to undergo ERC. Consequently, the study comprised 124 patients (86 F, 38 M, mean age 63.2 years, range 21–91 years). High-resolution US was performed (2–5 MHz sector scanner; Siemens Elegra, Erlangen, Germany) by operators who were unaware of the results of other imaging procedures. The definitive diagnosis was established by means of ERC. Results. Thirty-five out of 124 patients were investigated by experienced examiners. Twenty-seven of 35 patients (77%) were found to have stones at ERC. Bile duct stones were correctly found by US in 22 out of 27 patients (sensitivity 82%, 95% CI: 63–92). Of the 8 patients without stones at ERC, one false-positive diagnosis was made with US (specificity 88%, 95% CI: 53–98). Correct diagnoses were made in 29 out of 35 (accuracy 83%, 95% CI: 67–92) patients investigated by experienced examiners. Eighty-nine out of 124 patients were investigated by less-experienced examiners. Fifty-four of 89 patients (61%) were found to have stones at ERC. Choledocholithiasis was found correctly in only 25 out of 54 patients (sensitivity 46%, 95% CI: 34–59). Of the 35 patients without stones at ERC, three false-positive diagnoses were made with US (specificity 91%, 95% CI: 78–97). In conclusion, correct diagnoses were observed in 57 of 89 patients (accuracy 64%, 95% CI: 54–73) investigated by less-experienced examiners (p<0.05 in comparison with the results of experienced examiners). Conclusions. High-resolution US carried out by experienced examiners has a high diagnostic accuracy in the diagnosis of choledocholithiasis. Therefore, good training and continued experience are prerequisites for successful sonographic detection of bile duct stones using US. Under these conditions, further expensive and invasive methods such as ERC, magnetic resonance cholangiopancreatography and endoscopic ultrasonography may not be necessary in cases with a clear sonographic diagnosis.

Impact of high-resolution transabdominal ultrasound in the diagnosis of complications of Crohn's disease

Abstract Objective. Crohns disease is associated with intestinal complications such as strictures, fistulas and abscesses. As the management of the patients is influenced by the presence or absence of complication, sensitive diagnostic modalities to detect these complications are needed. The aim of this prospective study was to evaluate the diagnostic accuracy of high-resolution transabdominal ultrasound in the diagnosis of complications of Crohns disease. Material and methods . From April 2003 to July 2009, 58 patients (31 women, 27 men; mean age 36.3 years, range 13-86 years) with known Crohns disease were included in the study and investigated with high-resolution transabdominal ultrasound. The diagnosis of Crohns disease was based on clinical, endoscopic, histological, radiological and operative findings. Patients with other forms of enteritis (e.g. infectious) were excluded from the study. Twenty of the 58 patients were investigated on a second occasion with other symptoms than at the first admission. The time duration between the two ultrasound investigations was at least 3 months. Consequently, a total of 78 ultrasound investigations were done in 58 patients. With respect to their clinical symptoms, all patients were further investigated within 2 weeks after ultrasound with magnetic resonance imaging, and/or computed tomography, and/or enteroclysis, and/or endoscopy with biopsy. Together with clinical data (Crohns disease activity index) and surgical findings these investigations were used as reference procedure. Results. The sensitivity, specificity, positive predictive and negative predictive values of ultrasound were as follows: 0.86, 0.90, 0.83 and 0.92 for stenoses; 0.78, 0.95, 0.86, and 0.91 for fistulas; 0.90, 0.99, 0.90 and 0.99 for abscesses, respectively. Conclusions. High-resolution transabdominal ultrasound done by experienced examiners has an excellent diagnostic accuracy in the diagnosis of complications in patients with Crohns disease. Thus, it can be recommended as one of the primary investigative procedures for evaluation of Crohns disease.

Small bowel obstruction in pregnancy

BackgroundIntestinal obstruction in pregnancy is rare. Symptoms are often unspecific and a high level of suspicion is essential for early diagnosis. Fetal and maternal mortality rates are higher during pregnancy due to delay in diagnosis.CaseA 31-year-old primigravida with a history of abdominal surgery was admitted because of worsening abdominal pain, abdominal distension and elevated pancreatic enzymes. Ultrasound showed dilated small bowel loops. Explorative laparotomy revealed a small bowel obstruction with partial bowel necrosis caused by a single adhesion. A jejuno-jejunostomy was performed. Five days later, she developed peritonitis. A secondary laparotomy and caesarean section were done.ConclusionIn spite of timely diagnosis and prompt surgical intervention, our case was still complicated by peritonitis and early delivery. This underlines the necessity of immediate clinical suspicion. Small bowel obstruction should be considered in differential diagnosis of pregnant patients with a history of abdominal surgery.

Acute severe pancreatitis : contrast-enhanced sonography

Early assessment and differentiation of oedematous acute pancreatitis and necrotizing or severe acute pancreatitis allow distinct therapeutic algorithms. Spiral computed tomography is currently considered the gold standard for staging of acute severe pancreatitis. Conventional transabdominal ultrasound plays only a limited role in the staging of acute pancreatitis. The problem is that with this procedure a detection of pancreatic necrosis is difficult because it cannot assess organ perfusion. Through the use of contrast-enhancers, however, even ultrasound can nowadays examine the vascularization behaviour of the pancreas and liver parenchyma in sufficient detail. The aim of the present update article is to explain the usefulness of contrast-enhanced ultrasound in the detection of parenchymal necrosis in patients with acute severe pancreatitis.

A ‘Double-Balloon Enteroscopy Worth the Money’: Endoscopic Removal of a Coin Lodged in the Small Bowel

Double-balloon enteroscopy (DBE) has become the standard endoscopic method to diagnose and treat disorders of the small bowel. The most common therapeutic applications of DBE are hemostasis, polypectomy and stricture dilation. DBE has also been used to place stents in the small bowel and to retrieve foreign bodies such as retained capsule endoscopes. In this report, we describe the removal of a coin that had remained lodged in the jejunum for 8 days.

Sonographic diagnosis and endoscopic therapy of a biliopancreatic fistula complicating a pancreatic pseudocyst

This is the first report of a case of biliopancreatic fistula complicating a pancreatic pseudocyst diagnosed correctly by transabdominal ultrasound. The diagnosis was confirmed by magnetic resonance and endoscopic retrograde cholangiopancreatography. The fistula was treated successfully with biliary stenting. The clinical and imaging features of this exceptional complication are presented along with a brief review of the topic.