Endoscopic Ultrasound Criteria Research Articles

Interobserver Agreement on “Assessment of Debris” During Endoscopic Ultrasound-guided Drainage of Walled-off Pancreatic Necrosis

Background and AimsEstimation of the solid component in walled-off pancreatic necrosis (WOPN) during endoscopic ultrasound (EUS) is an important parameter to guide the selection of stent for drainage but is often not objectively quantified. MethodsWe aimed to study the interobserver agreement (IOA) among endosonographers assessing debris in the pancreatic fluid collection and their choice of stent. EUS videos of 15 patients having pancreatic fluid collection with concurrent magnetic resonance imaging (MRI) assessment of debris were independently reviewed by 40 endosonographers for the percentage of debris (10% increments) and their choice of stent (plastic or metal). The Fleiss kappa (κ) coefficient was used to assess IOA. Post-hoc analysis was done using wider debris intervals (20% or greater increments). ResultsPoor agreement was observed for the percentage of debris (κ = 0.188), which did not improve (κ = 0.196) even after including only expert endosonographers with more than 10 years of experience (n = 33). There was fair agreement (κ = 0.266) with reference MRI on the percentage of debris. On post-hoc analysis, the IOA (κ = 0.56, substantial agreement) and agreement with MRI (κ = 0.59, substantial agreement) improved as the debris intervals widened (<10%, 10%-50%, >50%). The agreement for stent selection (plastic vs metal) was poor (κ = 0.174) and did not improve with case volume (κ = 0.153 among respondents with >25 EUS-guided drainage/year; n = 21) or years of experience (κ = 0.195 for >10-year experience; n = 33). ConclusionIOA between endosonographers regarding estimation of debris in WOPN and subsequent stent choice for drainage is poor. The experience of endosonographers did not improve IOA. Studies to standardize the EUS criteria for debris assessment in WOPN and subsequent therapeutic approaches are warranted.

Pancreatic Fibrosis (Early Chronic Pancreatitis) as Emerging Diagnosis in Structural Causes of Dyspepsia: Evidence from Endoscopic Ultrasonography and Shear Wave Elastography.

A new concept for the diagnosis and management of non-functional dyspepsia in guidelines was lacking in the past decade. Medical advancement has proven pancreatic fibrosis (essential image evidence of early chronic pancreatitis) to be a cause of dyspepsia and related to pancreatic exocrine dysfunction. This study aimed to analyze the clinical picture, biomarker, and percentage of pancreatic fibrosis in the dyspeptic population. A total of 141 consecutive patients were retrospectively enrolled. They were diagnosed with peptic ulcer disease, 9.2% (n = 13); pancreatic fibrosis, 17% (n = 24); pure Helicobacter pylori infection, 19.9% (n = 28); functional dyspepsia, 53.2% (n = 75); and chronic pancreatitis, 0.7% (n = 1). Among those with pancreatic fibrosis, (n = 24), 11 were diagnosed on the basis of a pancreatic acoustic radiation force impulse exceeding 1.4 m/s, and the remaining 13 were diagnosed with early chronic pancreatitis with at least three of the Japanese endoscopic ultrasonography criteria. The anatomic distribution of parenchymal criteria of early chronic pancreatitis was head, 53%; body, 38%; and tail, 9%. There were 17 cases (71%, 17/24) without Helicobacter pylori and whose dyspepsia improved after pancreatic enzyme replacement with a ratio of 82.3% (14/17). Of the 141 cases, 19 received gastric emptying scintigraphy and Western blot analysis of chromogranin-A in duodenal mucosa. Delayed gastric emptying was more common in functional dyspepsia and chromogranin-A was expressed more in pancreatic fibrosis. In conclusion, pancreatic fibrosis (including early chronic pancreatitis) outnumbered peptic ulcer disease in the dyspeptic population and pancreatic enzyme therapy was effective for 82% of cases. In early chronic pancreatitis, pancreatic fibrosis is dominant in the head location, and duodenum mucosa chromogranin-A is a potential biomarker with increased expression in an age-matched manner.

Interobserver Reliability of the Endoscopic Ultrasound Criteria for the Diagnosis of Early Chronic Pancreatitis: Comparison between the 2009 and 2019 Japanese Diagnostic Criteria.

In 2009, diagnostic criteria for early chronic pancreatitis (DCECP2009) were proposed by the Japan Pancreas Society. This study aimed to evaluate the interobserver reliability (IOR) of endoscopic ultrasound (EUS) criteria for diagnosis of early chronic pancreatitis (ECP) between DCECP2009 and 2019 diagnostic criteria for ECP (DCECP2019) to assess the validity of the revision from the perspective of EUS findings. Among patients who underwent a detailed observation of the pancreas by EUS at our institution between January 2018 and March 2019, EUS images of 97 patients were extracted. Images were reviewed by 12 gastrointestinal endoscopy experts (eight pancreatologists, group A and four nonpancreatologists, group B). The overall kappa (K)-values for the IOR of the DCECP2009 EUS criteria were 0.424 and 0.563:0.231 for groups A:B, whereas the overall K-values for the DCECP2019 criteria were 0.618, and 0.733:0.442 for groups A:B. Regarding changes in the final diagnosis of ECP based on clinical features and EUS findings, 20 cases were definite ECP, 53 were probable ECP, and 24 were normal according to DCECP2009. In contrast, seven were definite ECP, 19 were probable ECP, and 71 were normal according to DECEP2019. IOR of DCECP2019 was higher than that of DCECP2009, which indicates an improvement in precision.

S3244 EUS Elastography in Prediction of Lymph Node Metastases in Suspected GI Cancer: A Pilot Study

INTRODUCTION: Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) are the most accurate techniques for local staging of malignant gastrointestinal (GI) cancers. Four features are used to predict metastatic lymph nodes (LNs) with 80% accuracy if all are present: hypoechogenicity, well-defined margins, round shape, and size >1 cm. Despite near 100% specificity, the challenges of obtaining a sample limits the use of FNA. EUS elastography is a real-time technology (EUS-RTE) with the potential to differentiate malignant and benign tissue via color histogram. Investigators have speculated that the subjectivity of color interpretation leads to variable results. Image J is a processing software that can be used to help minimize bias. Our goal is to establish a quantitative EUS criterion for assessment of LNs. METHODS: At least 3 EUS-RTE images of each LN were obtained. The endoscopist recorded his assessment of the LN based on the four criteria described above (“endoscopist’s impression”). If at least 3 of the 4 criteria were present, the LN was considered malignant. FNA was performed if feasible. All images were from a linear echoendoscope. Images without adequate transducer pressure as measured by the strain graph display or cytology were excluded. A stylus was used to outline the entire LN in B-mode, which was considered the region of interest (ROI). This outline was superimposed on the corresponding color histogram for processing. The number of red, green and blue pixels and total area of each ROI were quantified using Image J. RESULTS: Twenty-one LNs from 19 patients were included in the final analysis. Ten LNs were malignant (45%). Most procedures were performed for suspected esophageal or pancreatic cancer (14/19). A comparison of the endoscopist’s impression, blue pixels as a predictor of malignancy and red pixels as a predictor of benign LN is depicted in Figure 1. Sensitivity and specificity of the endoscopist’s impression was 90% and 67% respectively; accuracy was 80%. The endoscopist’s impression performed the best (95% CI, 0.63-0.98), but the difference was not statistically significant. CONCLUSION: Our study was limited by a small sample size and selection of the ROI may be another source of subjectivity. While Image J did not outperform current EUS criteria, firm conclusions cannot be drawn. Further study with a larger cohort is necessary to refine our interpretation of elastography and determine if post-procedure processing of elastography images is a useful adjunct.Figure 1

Evaluation of the relationship between chronic pancreatitis and endoscopic ultrasonography in pediatric patients

Data regarding the role of endoscopic ultrasonography (EUS) in pediatric chronic/ recurrent pancreatitis (CP/RP) is limited. The aim of this study is to evaluate the role of EUS in the diagnosis and clinical observation of RP in childhood. Between September 2016 and September 2017 EUS findings of 17 patients with RP and 20 patients in a control group were evaluated retrospectively, and the findings were compared. The control group consisted of patients who underwent EUS for cholecystolithiasis but had no pancreatitis. The most common EUS finding was ≥3 mm hyperechoic strands in 15 (88.2%) of the patients. According to the Conventional criteria, 11 patients (64.7%) had pathological findings ≥3. No patient in this study fulfilled the Rosemont criteria for the definitive diagnosis of CP. In the comparison of the EUS findings of the pancreatitis cases to the control group, hyperechoic strands ≥3mm in the pancreatic parenchyma (p&amp;lt;0.001), lobularity (p=0.004), duct dilatation (p= 0.009) and hyperechoic duct margin (p&amp;lt;0.001) were determined to have statistically significant differences. In this study, hyperechoic line is the most common EUS finding of pancreatitis in childhood. The threshold number of EUS criteria for the diagnosis of CP in pediatric patients is unclear. However, in our opinion, the Conventional criteria are more suitable than the Rosemont criteria for the diagnosis of CP in childhood. Further studies are needed in this field.

Endoscopic ultrasound-based multimodal evaluation of the pancreas in patients with suspected early chronic pancreatitis.

Diagnosis of early chronic pancreatitis is a clinical challenge and hindered by the lack of a gold standard. Endoscopic ultrasound (EUS) and the endoscopic pancreatic function test (ePFT) are the most sensitive morphological and functional methods in this setting. EUS-elastography allows for the quantification (strain ratio) of pancreatic fibrosis, and the dynamic evaluation of the main pancreatic duct compliance provides additional information. We developed a multimodal EUS-based approach for the evaluation of the pancreas by integrating these four methods in a single procedure. We aim to describe morphological and functional pancreatic abnormalities in patients with clinical suspicion of chronic pancreatitis and inconclusive EUS findings by using the multimodal EUS-based approach. This was a prospective, cross-sectional, observational study of patients with clinically suspected chronic pancreatitis and indeterminate EUS criteria of the disease. EUS criteria of chronic pancreatitis, quantitative pancreatic elastography, ePFT and compliance of the main pancreatic duct were evaluated in a single procedure. In total, 53 patients with 3-4 EUS criteria of chronic pancreatitis were included (mean age 39.7 years, 29 male). Strain ratio was abnormally high in all patients. Peak bicarbonate concentration was decreased in 43 patients (81.1%) and the main pancreatic duct compliance was reduced in 41 patients (77.3%). Some 34 patients (64.1%) had abnormal results at EUS, elastography, ePFT and compliance of the main pancreatic duct. A multimodal EUS-based test for the morphological and functional evaluation of the pancreas is presented, which allows detecting mild pancreatic abnormalities in patients with suspected early chronic pancreatitis. The presence of abnormal morphological and functional evaluation of the pancreas could support the clinical suspicion of early chronic pancreatitis in the appropriate clinical setting.

International consensus guidelines on the role of diagnostic endoscopic ultrasound in the management of chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club

BackgroundChronic pancreatitis (CP) is a complex inflammatory disease with variable presentations and outcomes. This statement is part of the international consensus guidelines on CP, specifically on the diagnostic role of endoscopic ultrasound (EUS). MethodsAn international working group with experts on the role of diagnostic EUS in the management of CP from the major pancreas societies (IAP, APA, JPS, and EPC) evaluated two key statements generated from evidence on two questions deemed to be the most clinically relevant. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the level of evidence available for each statement. To determine the level of agreement, the working group voted on each statement for strength of agreement, using a nine-point Likert scale in order to calculate Cronbach’s alpha reliability coefficient. ResultsStrong consensus was obtained for both of the following statements [1]. The ideal threshold number of EUS criteria necessary to diagnose CP has not been firmly established, but the presence of 5 or more and 2 or less strongly suggests or refutes the diagnosis, respectively. The Rosemont scoring system standardizes the reporting of EUS signs indicative of chronic pancreatitis, but further studies are needed to demonstrate an overall improvement of its diagnostic accuracy over conventional scoring [2]. Specificity, inter- and intra-observer variability and pre-test probability limit the reliability and utility of EUS to help diagnose CP especially early stages of the disease. ConclusionsThe presence of 5 or more and 2 or less EUS criteria strongly suggests or refutes the diagnosis of CP, respectively. Intra-observer variability still limits the role of EUS in diagnosing CP especially early stage disease.

Pancreatic Fibrosis and Chronic Pancreatitis: Mini-Review of Non-Histologic Diagnosis for Clinical Applications.

Pancreatic fibrosis is the dominant reversible pathological change and diagnostic factor in early chronic pancreatitis, defined by a mechanistic approach proposed in 2016. Main guidelines for chronic pancreatitis were published by the American Pancreas Association in 2014, the Japanese Society of Gastroenterology in 2015, and United European Gastroenterology in 2017. All three sets of guidelines mentioned that the staging of chronic pancreatitis is important but challenging. There are various image modalities for the non-histologic diagnosis of pancreatic fibrosis: (1) shear wave elastography, such as an acoustic radiation force impulse with a cut-off value of 1.4 m/s; (2) strain elastography using grades of strain; (3) endoscopic ultrasonography using the Rosemont criteria or endoscopic ultrasound criteria for early chronic pancreatitis proposed by the Japan Pancreas Society; (4) computed tomography using the Hounsfield scale or number of micro-calcifications; and (5) magnetic resonance imaging using the apparent diffusion coefficient and the T1w flash and T2w HASTE sequences. The clinical applications are to (1) evaluate pancreatic tumors and inflammatory disease; (2) monitor dyspepsia with early chronic pancreatitis; (3) monitor individuals with a high risk of pancreatic cancer; (4) analyze a fatty pancreas with fibrosis; (5) predict a fistula after pancreatic surgery; and (6) predict outcomes for chronic pancreatitis or pancreatic cancer. The selection of tools will be dependent on the clinical scenario. Conclusion: There are various modalities for the non-histologic diagnosis of pancreatic fibrosis. The selection of the optimal device will be dependent on the clinical scenario.

Endoscopic ultrasound and fine-needle aspiration for the detection of residual nodal disease after neoadjuvant chemoradiotherapy for esophageal cancer.

Endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) are potential tools for the detection of residual disease after neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer. This study investigated yield of EUS and FNA for detection of malignant lymph nodes (LNs) after nCRT. This was a post hoc analysis of the preSANO trial. EUS was performed 10 - 12 weeks after nCRT. 18F-fluorodeoxyglucose positron emission tomography - computed tomography (18F-FDG PET-CT) was used to guide targeting of suspicious LNs. Consecutive FNA sampling was performed for suspicious LNs identified on EUS and/or PET-CT. EUS nodal staging was compared with histopathological examination of the resection specimen. The primary outcome was the proportion of correctly identified patients with malignant LNs by radial EUS. 101 consecutive patients were included: 79 patients had no malignant LNs, of whom 62 were classified correctly by EUS (specificity 78 %); 22 patients had malignant LNs, of whom 11 were identified (sensitivity 50 %). Six of these patients had ≥ 1 suspicious LN not fulfilling EUS criteria (round, hypoechogenic, > 5 mm). Malignant LNs in falsely negative patients were predominantly located at distal LN stations. Specificity and sensitivity of conclusive FNA outcomes were 100 % (7/7) and 75 % (3/4), respectively. FNA outcome was uncertain in eight patients, half of whom appeared to have malignant LNs. EUS only detected 50 % of patients with malignant LNs 10 - 12 weeks after nCRT. To optimize sensitivity and minimize the risk of missing residual disease, FNA of LNs should be performed even in cases of low endosonographic suspicion.

Validity of Endoscopic Ultrasound Findings of Chronic Pancreatitis: Evaluation from the Viewpoint of Disease Risk Factors

Background: The diagnosis of chronic pancreatitis (CP) using endoscopic ultrasound (EUS) criteria, referred to as the Rosemont classification (RC), has been widely performed. However, the validity of the RC, which was based on expert opinion, is still controversial. If EUS findings are associated with CP, then they should be associated with risk factors for CP. In this study, to verify the appropriateness of the RC and each EUS finding, we performed a retrospective analysis from the viewpoint of risk factors for CP. Summary: Three hundred and forty-four patients were enrolled in this study. Clinical background characteristics that associate with CP were alcohol intake, smoking, history of acute pancreatitis (AP), and age. The correlation between EUS criteria for CP and clinical background was investigated. All EUS findings except the presence of cysts showed significant correlations with one or 2 of the 3 following factors: ethanol (EtOH) intake, smoking status, and history of AP. Results of the univariate and multivariate analyses showed that 3 factors (EtOH intake, smoking, and history of AP) other than age were positively correlated with the RC. Moreover, the risk of progression from normal to consistent CP to indeterminate and suggestive CP was found to increase with increasing EtOH intake. Key Messages: The RC and each EUS finding was validated from the viewpoint of risk factors for CP.

IRAK-M regulates the local and systemic immune responses in acute pancreatitis

Whether chronic pancreatitis (CP) may present with dyspepsia is controversial. We aimed at evaluating the frequency and risk factors of changes of CP in patients presenting with epigastric pain syndrome (EPS)-like symptoms.A prospective, observational, cross-sectional study was carried out in patients with EPS-like symptoms. Patients underwent endoscopic ultrasound (EUS) evaluation of the pancreas, and changes of CP were defined as the presence of five or more EUS criteria of the disease. In patients with 3 or 4 EUS criteria, magnetic resonance dynamic evaluation of the pancreas (MRI/sMRCP) and endoscopic pancreatic function test (ePFT) were carried out to confirm or exclude the presence of changes of CP. A multivariate logistic regression analysis was performed to evaluate factors associated with CP findings, and results are shown as odds ratio (OR) and 95% confidence interval (CI).213 patients were included. Changes of CP were confirmed by EUS (≥5 criteria) in 18 patients (8.4%). Thirty-four patients had 3-4 EUS criteria, and changes of CP were confirmed in 27 of them by MRI/sMRCP and ePFT (12.7%). Morphological and functional findings of CP were then present in 45 patients (21.1%). Male gender (OR 2.97; 95%CI 1.39–6.37) and alcohol and tobacco consumption (OR 6.56; 95%CI 1.97–21.85) were associated with the presence of changes of CP.Morphological and functional changes of CP are frequent in patients with EPS-like symptoms. Whether these pancreatic changes explain EPS-like symptoms requires further investigation.

Good Agreement Between Transabdominal and Endoscopic Ultrasound of the Pancreas in Chronic Pancreatitis.

We aimed to evaluate the agreement of single criteria and dedicated scores from transabdominal ultrasound ofthe pancreas (US) compared to standards by endoscopic ultrasound (EUS) and computed tomography (CT). In this observational cohort study performed in a tertiary care center, US and EUS were performed in 110 patients referred for suspected CP. Based on the Mayo score, 52 patients were diagnosed with CP. The sonographic findings obtained by both methods were registered. The number of criteria was counted and scored according to the Rosemont score. Agreement between the number of detected US and EUS criteria was substantial (ICC = 0.74 [0.61-0.83]. Adding Rosemont weighting improved the agreement (ICC = 0.88 [0.81-0.92]). Regarding individual criteria, the agreement was substantial for the detection of calcifications (κ = 0.86) and moderate for cysts and irregular or dilated pancreatic duct (κ = 0.42-0.58). Agreement for the other criteria was poorer (κ≤ 0.40). The diagnostic performance indices [95 % CI] of US for diagnosing CP (using Mayo score as reference standard) were for the unweighted score: Sensitivity: 0.65 [0.51-0.78], specificity: 0.97 [0.87-1.00]; and for Rosemont score: Sensitivity: 0.75 [0.61-0.86], specificity: 0.95 [0.83-0.99]. The agreement between US and EUS for the unweighted and weighted scores was substantial. For the features calcifications, cysts and main pancreatic duct (MPD) changes, agreement was moderate to substantial. For the other detected US criteria, the agreement with EUS was too poor to be clinically relevant.

Morphological and functional changes of chronic pancreatitis in patients with dyspepsia: A prospective, observational, cross-sectional study

ObjectiveWhether chronic pancreatitis (CP) may present with dyspepsia is controversial. We aimed at evaluating the frequency and risk factors of changes of CP in patients presenting with epigastric pain syndrome (EPS)-like symptoms. DesignA prospective, observational, cross-sectional study was carried out in patients with EPS-like symptoms. Patients underwent endoscopic ultrasound (EUS) evaluation of the pancreas, and changes of CP were defined as the presence of five or more EUS criteria of the disease. In patients with 3 or 4 EUS criteria, magnetic resonance dynamic evaluation of the pancreas (MRI/sMRCP) and endoscopic pancreatic function test (ePFT) were carried out to confirm or exclude the presence of changes of CP. A multivariate logistic regression analysis was performed to evaluate factors associated with CP findings, and results are shown as odds ratio (OR) and 95% confidence interval (CI). Results213 patients were included. Changes of CP were confirmed by EUS (≥5 criteria) in 18 patients (8.4%). Thirty-four patients had 3-4 EUS criteria, and changes of CP were confirmed in 27 of them by MRI/sMRCP and ePFT (12.7%). Morphological and functional findings of CP were then present in 45 patients (21.1%). Male gender (OR 2.97; 95%CI 1.39–6.37) and alcohol and tobacco consumption (OR 6.56; 95%CI 1.97–21.85) were associated with the presence of changes of CP. ConclusionMorphological and functional changes of CP are frequent in patients with EPS-like symptoms. Whether these pancreatic changes explain EPS-like symptoms requires further investigation.

Assessing the value of endoscopic ultrasound in predicting symptom severity and long-term clinical course in chronic pancreatitis

BackgroundTo date, no studies have evaluated the correlation between number of endoscopic ultrasound (EUS) criteria met for chronic pancreatitis (CP) and symptom severity over the course of the disease. This study assessed the relationship between number of EUS-based diagnostic criteria for CP and CP severity over time. MethodsA University of Louisville database was queried for patients undergoing EUS due to concern for chronic pancreatitis between 2005 and 2016. Patients were grouped based on EUS criteria met for CP and groups were compared along outcome and procedural variables. ResultsOf a total of 243 patients, 24, 129, and 90 patients met 1–3, 4–5, and ≥6 EUS diagnostic criteria, respectively. Median follow-up time was 33 months. Along all follow-up parameters, number of diagnostic criteria was positively correlated with an increased percentage of patients requiring operative intervention for chronic pancreatitis on univariate and multivariate analysis. ConclusionsIn addition to the role of EUS criteria in establishing the diagnostic severity of patients with symptomatic chronic pancreatitis, the number of EUS-based criteria may help predict patients who will eventually require operative intervention and thus prompt referral to a pancreatobiliary surgeon earlier in the course of a patient's disease.

Significance of normal appearance on endoscopic ultrasonography in the diagnosis of early chronic pancreatitis

Background and Objectives:The Rosemont classification (RC) was developed as a consensus-based standard for the diagnosis of chronic pancreatitis (CP) by endoscopic ultrasonography (EUS), however, it is more complicated than the conventional scoring system. We have noticed that in the early stages of CP, it is not unusual to observe pancreas with abnormal appearance coexisting with the areas of normal parenchyma. The aim of this study was to investigate the validity of a “normal” pancreas appearance and to evaluate the usefulness of modified diagnostic criteria in comparison to the traditional EUS criteria and the RC.Patients and Methods:One hundred and seventy-seven patients who had undergone both EUS and endoscopic retrograde pancreatography (ERP) within 2 months were enrolled in the study, and patients with pancreatic cancer were excluded from the study. ERP findings were used as the gold standard for the diagnosis of CP. The EUS images obtained were classified according to both the RC and our new modified criteria. The latter includes an additional criterion to the modified traditional criteria: fine-reticular pattern (F-RP) was defined as a normal pancreatic parenchyma. We compared the accuracy between the new modified EUS criteria and the RC.Results:(1) Normal or equivocal findings on ERP were obtained for 132 patients; 113 patients had F-RP on EUS. In contrast, F-RP was found in only 6 out of 45 CP cases on ERP (P < 0.0001). (2) We investigated the diagnostic capability of our new criteria for endoscopic retrograde cholangiopancreatography normal/equivocal pancreas compared to the traditional criteria. In cases where fewer than two points were defined as normal, the incidence of normal pancreas was significantly higher based on the new criteria than on the traditional criteria (P = 0.002). (3) No significant differences were found between the new criteria and the RC across all ERP grades.Conclusion:Our new proposed “normal-added EUS criteria” for diagnosing CP was equivalent to the RC.

Chronic Pancreatitis-Like Changes Detected by Endoscopic Ultrasound in Type 1 Diabetics Are Not Associated With Gastrointestinal Symptoms or Nutritional Deficiencies.

Previous studies have shown changes in the pancreas of type 1 diabetic (T1-DM) patients, similar to those present in patients with chronic pancreatitis. Our aim was to analyze the prevalence of endoscopic ultrasound (EUS) criteria for chronic pancreatitis in T1-DM, to determine the association with factors related to the diabetes and to define its clinical significance. Eighty-six T1-DM patients were prospectively included. All of them underwent EUS. Standard criteria were used. Patients were divided into 3 groups according to the number of EUS criteria they met: group A, 0 to 2 criteria; group B, 3 to 4; and group C, more than 4. Association between EUS findings and demographic or clinical factors was studied as well as the relationship between EUS abnormalities and the presence of gastrointestinal symptoms or nutritional deficiencies. Fifty-three patients (61.6%) showed at least 1 morphologic abnormality. Fifty-eight patients were included in group A, 21 in group B, and 7 in Group C. No significant differences were found when comparing the 3 groups. Chronic pancreatitis-like changes are frequent in the pancreas of T1-DM patients. These changes are not associated with demographic or clinical data. Therefore, the clinical relevance seems to be scarce.

High Incidence of Early Chronic Pancreatitis Changes in Patients Undergoing EUS for a Non-Pancreaticobiliary Indication

Introduction: The application of endoscopic ultrasound (EUS) criteria for chronic pancreatitis (CP) may be problematic in clinical practice since the prevalence of parenchymal/ductal changes is unknown in patients without abdominal pain or risk factors for CP. Autopsy data demonstrate a high prevalence of CP changes in patients without an overt history of pancreatic disease. The aim of this study is to define the prevalence of pancreatic parenchymal changes by the Rosemont classification in patients without symptoms/signs of chronic pancreatitis.Table 1: Criteria for Chronic Pancreatitis Based on Rosemont CriteriaMethods: A prospective study at a single tertiary-care center was performed. 100 consecutive patients undergoing EUS for a non-pancreatico-biliary indication were eligible. Prior to EUS, patients completed a questionnaire detailing smoking, alcohol/drug use, presence/severity of abdominal pain and sequelae of CP (weight loss, loose stool and diabetes). Immediately after EUS, findings based on the Rosemont classification were recorded. Diagnostic accuracy was calculated and Chi-Square test/t-test were used for intergroup comparisons. Results: 100 patients were enrolled (58 male (58%), mean age 63 +/- 12.9 years). Eighty patients (80%) had no abdominal pain, 29 (29%) use alcohol, 26 (26%) were active smokers and 36 (36%) were former smokers. EUS indications were gastric lesions/cancer staging (27), duodenal lesions (10), esophageal lesions/cancer staging (42), abdominal pain (4), lymphadenopathy (3), liver lesions (6), surveillance of malignancy (2) abnormal gastric thickening (3), family history of malignancy (2) and pyloric stenosis (1). One patient had a Major A criteria (1%), 8 had major B criteria (8%) and 42 (42%) had at least one minor criteria. Overall 42 patients (42%) had a single criteria for the EUS diagnosis of CP by the Rosemont Criteria (table 1). No patients met Rosemont criteria for consistent with CP, 5 were suggestive of CP (5%) and 14 (14%) were indeterminate for CP. There was no association between history of smoking, active smoking, alcohol use, abdominal pain, loose stool, weight loss or age (all p > 0.05) with any EUS diagnosis of CP based on Rosemont criteria. Conclusion: The high proportion of patients who present for non-pancreatico-biliary EUS who demonstrate EUS criteria for CP would indicate that these findings should be interpreted with caution in patients without symptoms or risk factors for CP. It appears as though some EUS criteria for CP may be normal age- or environmental-related changes and not specific for CP.

Spanish multicenter study to estimate the incidence of chronic pancreatitis.

To estimate the incidence of chronic pancreatitis in Spain as diagnosed with endoscopic ultrasound (EUS), and to assess the risk factors and complications detected. A descriptive, observational study of chronic pancreatitis cases diagnosed in Spanish health care centers with an EUS unit. A structured questionnaire was used to evaluate the incidence of the disease (cases identified over 18 months: from January 2011 to June 2012), risk factors, EUS criteria, Rosemont classification, and frequency of local complications. Twenty-three centers were selected serving a total reference area of 14,752,704 population. During the study period 1,031 chronic pancreatitis cases were diagnosed, with an incidence of 4.66 cases per 105 inhabitants/year (95% CI: 4.65-4.67). Tobacco and alcohol use appear as risk factors in 63.8% and 66.7% of cases, respectively. Of these, 53.3% met > 5 EUS criteria for chronic pancreatitis, and 69% had findings suggestive of or consistent with chronic pancreatitis according to the Rosemont classification. Most prevalent complications included calcifications (34.7%), pseudocysts (16%), and presence of an inflammatory pancreatic tumor (10.4%). The incidence of chronic pancreatitis in Spain is similar to that of other European countries. Given the widespread use of the technique, EUS units are key in detecting the disease, and their activity and results allow to estimate the incidence of chronic pancreatitis over wide, representative population areas.

Usefulness of percutaneous elastography by acoustic radiation force impulse for the non-invasive diagnosis of chronic pancreatitis.

To determine the accuracy of the acoustic radiation force impulse (ARFI) technique for the diagnosis of chronic pancreatitis. We present an observational, single-center study that included patients with suspected chronic pancreatitis in the period between October 2012 and September 2015 who underwent endoscopic ultrasound (EUS) and were classified according to the standard and Rosemont criteria. The same group of patients was assessed by the ARFI technology using ACUSON S2000™ equipment with Virtual Touch™ Quantification software for the assessment of pancreatic stiffness by obtaining the shear wave velocity (SWV) in the head, body and tail of the pancreas. Data were analyzed using ANOVA and nonparametric correlation methods. Diagnostic accuracy was obtained by analyzing receiver operating characteristic (ROC) curve. A total of thirty-three patients were studied (45.5% women); mean age was 58.3 ± 11.8 years. Seventeen with a diagnosis of chronic pancreatitis and sixteen classified as normal according to standard criteria. A significant difference was detected between the means of SWV in pancreatic body of patients without (SWV: 1.27 m/s) and with chronic pancreatitis (SWV 1.57 m/s), p = 0.037. The area under the ROC curve was 71.3% (95% CI 0.532-0.895) and the accuracy of ARFI for diagnosing chronic pancreatitis was 69.7% for a SWV of 1.4 m/s in the pancreatic body. The SWV means in head (r = 0.421, p < 0.05) and body (r = 0.455, p < 0.05) of the pancreas showed a significant correlation with the number of EUS criteria for chronic pancreatitis. Quantification of pancreatic stiffness with ARFI elastography technique has proven to be useful for the non-invasive diagnosis of chronic pancreatitis.

The usefulness of endoscopic ultrasonography in differentiation between benign and malignant gastric ulcer.

Gastric ulcer may be benign or malignant. In terms of therapy and patient’s prognosis early detection of malignancy is very important. The aim of this study was to assess the usefulness of endoscopic ultrasound (EUS) in differentiation between benign and malignant gastric ulcer. A prospective study included 20 consecutive adult patients with malignant gastric ulceration and 20 consecutive adult patients with benign gastric ulceration. All the patients underwent EUS. A total of 6 parameters were analyzed: ulcer width, ulcer depth, the thickness of the gastric wall along the edge of ulceration (T0), the thickness of the gastric wall 2 cm from the edge of ulceration (T2), loss of layering structure of the gastric wall, and the presence of regional lymph nodes. EUS criteria for malignancy and a point-score of malignancy were defined. The critical value of total point-score was also calculated showing the best reliability parameters. There are 4 criteria for malignancy of gastric ulceration: T0 > 10 mm, T2 > 5 mm, EUS visualization of at least one lymph node, loss of layering structure of the gastric wall. Furthermore, T2 > 5 mm was the only EUS independent predictor of ulcer malignancy. The total point score of ≥ 4 was the cut-off pointscore value which gave the best reliability parameters in the assessment of malignant ulcers: sensitivity of 70%, specificity of 95%, positive predictive value of 93.3%, negative predictive value of 76% and accuracy of 82.5%. According to the results obtained in this study, we can conclude that EUS is usefull in differentiation between benign and malignant gastric ulcer.