Vinod K. Parasher

Observation of thoracic duct morphology in portal hypertension by endoscopic ultrasound

BACKGROUND Thoracic duct dilation has been demonstrated in portal hypertension and hepatic cirrhosis by lymphangiography and laparotomy and at autopsy. It is thought to be secondary to increased hepatic lymph flow and has been described in the absence of ascites or esophageal varices. The aim of the present study was to observe thoracic duct morphology by endoscopic ultrasound in various subsets of patients with portal hypertension and hepatic cirrhosis and also to validate existing radiologic/surgical data. METHODS The thoracic duct of 33 patients with cirrhosis and portal hypertension was studied by endoscopic ultrasound. Patients were divided into four groups: 1, patients with ascites and esophageal varices; 2, esophageal varices without ascites; 3, without esophageal varices or ascites; 4, extrahepatic portal hypertension due to pancreatic malignancy. The thoracic duct diameter was also measured in 14 control subjects (group 5). RESULTS When the thoracic duct diameter for the five groups was compared with analysis of variance, significance was p < 0.0001; by pairwise comparison, group 1 differed from the other four groups (p < 0.05). Thoracic duct dilation (5.61 mm) was seen in group 1 patients, whereas no dilation was present in groups 2 through 4. Additionally, thoracic duct diameter in 33 portal hypertensive and/or cirrhotic patients was significantly different from that in the 14 control subjects (p = 0. 003). CONCLUSION The thoracic duct can be reliably identified by EUS in patients with hepatic cirrhosis and portal hypertension. Dilation of the duct is seen only in patients with hepatic cirrhosis, ascites, and esophageal varices. No thoracic duct dilation is present in extrahepatic portal hypertension. Contrary to existing radiologic/surgical data, thoracic duct dilation is not seen in all patients with hepatic cirrhosis and portal hypertension signifying advanced disease. A dilated thoracic duct by endoscopic ultrasound should be considered yet another sign of portal hypertension.

Endoscopic retrograde wire-guided cytology of malignant biliary strictures using a novel scraping brush

BACKGROUND Tissue sampling to differentiate benign from malignant pancreatobiliary strictures remains problematic despite the availability of several new sampling methods. A new device is described which attempts to correct some of the drawbacks. METHODS The device consists of a 10F dilator which has an attached pad of Velcro. The Velcro has semi-rigid, mushroom-shaped bristles. A cytologic sample is obtained by the abrasive action of the brush when it is passed through the stricture. Fifteen patients with obstructive jaundice underwent brushing of the bile duct using this device. RESULTS Cytologic samples obtained with this device were positive for malignancy in all 15 patients. Diagnostic confirmation was obtained by assessment of clinical course, radiologic findings, and during surgery. CONCLUSION Preliminary experience indicates that this new device enhances the yield of tissue sampling from malignant bile duct strictures.

Successful placement of percutaneous gastrojejunostomy using steerable glidewire--a modified controlled push technique.

Percutaneous gastrojejunostomy (PEG-J) is now increasingly utilized to maintain long-term enteral nutrition in patients with recurrent aspiration pneumonia. 1-3 Despite significant advances in accessories and the technology and various techniques used to place percutaneous jejunostomy tubes, 3-6 precise and consistent placement (defined as placement of the jejunostomy tube beyond the ligament of Treitz) is, as yet, not always possible. Recently, Teflon-coated con: ventional guidewires have been utilized to facilitate placement, but with limited success. 5 Glidewires have been utilized in biliary tract maneuvers for some time, but they have not been exploited in the placement of PEG-J tubes. Glidewire features advantageous for PEG-J placement include resistance to formation of kinks and a hydrophilic coating that, when wet, makes the wire extremely slippery. This combination makes the glidewire easily steerable, thus facilitating negotiation of the angles of the upper intestine. The purpose of our study was to evaluate a new technique for placement of a percutaneous jejunostomy tube utilizing a glidewire. MATERIALS AND METHODS Five patients who required gastrostomy for maintenance of enteral nutrition and prevention of recurrent aspiration were studied. They included two cases of severe neurologic deficit secondary to cerebrovascular accidents, two of trauma, and one of mental retardation.

Can ERCP contrast agents cause pseudomicrolithiasis? Their effect on the final outcome of bile analysis in patients with suspected microlithiasis

BACKGROUND Microlithiasis has been implicated in the etiology of idiopathic pancreatitis and biliary-type pain in patients with intact gallbladders. Contrast injection at endoscopic retrograde cholangiopancreatography (ERCP) is used to confirm access into the bile duct and bile is also aspirated to look for microlithiasis. It is not known whether contrast agents contain crystals that could mimic true microlithiasis. METHODS Four mL of 2 contrast agents (Hypaque and Omnipaque) were examined after centrifugation under polarizing microscopy. In the second part of the study, bile aspirated during ERCP with contrast injection was examined for microlithiasis and contrast pseudomicrolithiasis. RESULTS Contrast agents exhibited pseudomicrolithiasis that mimicked calcium bilirubinate granules. Pathologists participating in the study were not aware of contrast pseudomicrolithiasis. Nine of twelve (75%) patients would have been reported as having microlithiasis and would possibly have undergone an unnecessary cholecystectomy. CONCLUSION When bile collected during ERCP is to be examined for microlithiasis, it should be collected without contamination by a contrast agent. If this is not possible, pathologists should be aware that contrast can cause pseudomicrolithiasis.

Treatment of nondilatable malignant pharyngoesophageal strictures by Montgomery salivary bypass tube: a new approach

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4567 Evaluation of “equivocal” ct scan/mri of pancreas: another “emerging” indication for endoscopic ultrasound.

INTRODUCTION: CT scan or MRI of the pancreas are reported equivocal when no definite mass is seen on imaging. Fullness of the pancreas or enlargement of the pancreas are terms utilized to explain the abnormality. This may occur because of partial volume averaging effect, inability to delineate the C-loop from the head of the pancreas, an isodense tumor, or because of technical reasons. When this occurs, a repeat scan is suggested in a short period of time (e.g. three months). In as much so, quickly resolving the presence or absence of a mass in the pancreas is vital not only to the patients peace of mind, but also an early intervention could lead to a favorable outcome. The purpose of the present study was to evaluate by EUS, all CT scans or MRI of the pancreas which were judged as equivocal or inconclusive by the radiologist. METHODS: Twenty-nine patients were included in this study. These patients had either a CT scan or an MRI of the pancreas, which were equivocal. The indications for the study included abdominal pain, weight loss or jaundice. All CT scans and MRI which were unequivocally negative were excluded from the study. RESULTS: Twentyone of twenty-nine patients had pathology by EUS examination. Twelve patients had chronic pancreatitis, six patients had carcinoma of the pancreas, one patient had a fatty tumor infiltration (confirmed by FNA), one patient had a dilated common bile duct, and another patient had a prominent ventral/dorsal pancreas. There were eight normal studies. CONCLUSION: 1. EUS should be utilized immediately in evaluation of pancreas when CT/MRI findings are equivocal. 2. A positive exam may modify the course of the disease with an early intervention as opposed to expectant observation and repeating the original study. 3. Occult malignancy and chronic pancreatitis are the most common pathologies found by endoscopic ultrasound in this group of patients.

4596 The effect of valsalva maneuver on the thoracic duct diameter. an endosonographic study.

INTRODUCTION: Under the physiological conditions, thoracic duct diameter is reflection of lymphatic flow. Increase in the lymphatic flow causes dilation of thoracic duct.We have also shown the dilation of thoracic duct with endoscopic ultrasound in pathological conditions which result in increased lymphatic flow such as portal hypertension. The purpose of the present study was to evaluate by endoscopic ultrasound the physiological response of Valsalva Maneuver on thoracic duct diameter. Valsalva Maneuver (a physiological process) alters the vascular lymphatic dynamics. METHODS: Fifteen patients underwent evaluation of thoracic duct by endoscopic ultrasound at the end of a routine procedure. They were asked to perform the Valsalva Maneuver by pushing against the examiners hand by breathing out forcibly without an inspiration. The effectiveness of Valsalva Maneuver was observed by recording increase in pulse rate before and after the actual maneuver. Similarly, thoracic duct diameter was measured just before and after the Valsalva Maneuver. Patients with autonomic dysfunction, cardiac disease, hypertension and with portal hypertension were excluded from the study. The patients who were on ganglion blocking agents and anticholinergic agents were also excluded from the study because this may alter the actual response. RESULTS: 1. Valsalva Maneuver caused a significant increase in thoracic duct diameter as observed by endoscopic ultrasound. The mean diameter increased from 2.13 mm to 2.67 mm (p =.006). 2. Increase in thoracic duct diameter was associated with a significant increase in pulse rate indicating performance of an effective Valsalva Maneuver. The mean pulse rate increased from 81.87 to 92.13, an increase of 10.27 (p =