Endoscopic Ultrasound Findings Research Articles

Characteristics and endoscopic ultrasound findings of gastrointestinal lesions: single-center experience

Aims: We aimed to present the characteristics, indications, endoscopic ultrasonography procedure details, diagnoses and complication rate of patients who underwent endosonpgraphy in a single center. Methods: Forty six patients admitted to Trakya Unversity Faculty of Medicine and underwent EUS (±FNA) procedure between January 2021 and May 2022 were included in the study. Patients files were analysed retrospectively. Demographic characteristics, presence and types of comorbidity, presence and types of malignancy in the family, use of antithrombotic drugs, laboratory data, details of eus procedure, pathology results, adverse events were recorded. The data obtained in the study were analyzed using Statistical Package for Social Science for Windows 26 package program. Results: A total of 46 patients were included in the study. 46% (n=21) were women. The median age was 64 (28-87). Antithrombotic use was present in 25% of the patients. Comorbidities were present in 84% of patients. The indications for EUS were predominantly pancreatic lesions (n=31). Aspirations were performed in addition to ultrasonographic examination in 78% (n=36) of the patients. 19 G (Gauge) needles were used in 30 and 25 G needles were used in 6 patients. Biopsy stations were stomach (n=31), duodenum (n=4), esophagus (n=1). Median long axis of the lesions was 34 (7-173) mm and the short axis was 26 (1-76) mm. 42% of the biopsied pancreatic lesions were cystic and 58% were solid. The CA19-9 level in solid lesions was statistically significantly higher than cystic (1512 /28 U/ml; p= 0.008). CA19-9 level was found mean 2061±3295 U/ml in patients with adenocarcinoma (n=8), 71±106 U/ml in cystic neoplasm and 152±338 in benign disorders (p=0.026). Cut-off value predicting adenocarsinoma with %87,5 spesifity and %87,5 sensitivity in our cohort was 174 U/ml (( AUC 0.85 ( 0.63-1)). Spesifity and sensitivity of the level 40 ( nearest level to universaly detected upper limit: 37 U/mL) was %62,5 and %87,5 respectively. Comparing malignant and benign lesions of pancreas overall, no statistical significance was found of CA19-9 level in predicting the diagnosis of tumor (p=0.15). Of the patients who underwent biopsy, 61% were malignant and 39% were benign. Malignant diagnoses were: adenocarsinoma, cystic neoplasm, gastrointestinal stromal tumor, neuroendocrine tumor, mesenchymal tumor, lumphoma, metastasis. Benign diagnoses were: otoimmune pancreatitis, normal cyst, chronic pancreatitis, pseudocyst, walled-off necrosis, polyp, no lesion. Post-procedure complications were not observed in any of the patients. Conclusion: The availability of endoscopic ultrasonography is expanding nowadays. Endoscopy ultrasonography is a precise, advantageous, and risk-free technique when performed by trained personnel.

The Association between the Growth Pattern and Malignancy in the Formation of Ulceration in Gastric Gastrointestinal Stromal Tumor.

Objective In general, surface ulceration in gastric gastrointestinal stromal tumor (GIST) is considered a malignant feature; however, the mechanism underlying its formation has not been evaluated in detail. In this study, we analyzed the factors involved in ulceration using resected specimens of gastric GIST. Methods A total of 48 samples were retrospectively analyzed. We examined the association of surface ulceration of gastric GIST with the MIB-1 labeling index, mitotic number, tumor size, endoscopic ultrasound (EUS) findings and growth pattern on computed tomography (CT). Results The proportion of men was significantly higher in the ulceration group than in the non-ulceration group (p=0.04146), whereas age was not significantly different between the groups. Tumor was significantly larger in the ulceration group than in the non-ulceration group (p=0.0048). There was no correlation between tumor size and ulcer number. The MIB-1 index was not related to ulceration, nor were EUS findings. The number of mitotic cells tended to be higher in the ulceration group than in the non-ulceration group (p=0.05988). Intraluminal growth pattern was strongly associated with ulceration (p=0.00019). After a multivariate analysis, the growth pattern was the only factor associated with ulceration of gastric GIST. Conclusion Although formation of surface ulceration in gastric GIST was partially associated with the degree of malignancy, the growth pattern was the most important factor associated with ulceration in gastric GIST.

THE IMPACT OF THE COVID-19 PANDEMIC ON ENDOSCOPIC ULTRASOUND PROCEDURES IN A HIGH-VOLUME ENDOSCOPY UNIT IN BRAZIL.

•In pancreatic neoplasms the EUS plays a key role in the management. •During the pandemic period, lockdown measures prevented patients with comorbidities from performing EUS. •The D-EUS decreased during COVID-19, while I-EUS increased and EUS-TA was the most commonly I-EUS procedure performed, with no increase in adverse events. •Despite the moderate impact of the pandemic period in endoscopic services around the world, EUS-TA of solid and cystic tumors of the pancreas was the main indication. Background - Reports of the impact of the 2020 COVID-19 pandemic period/2020 on endoscopic ultrasound (EUS) are scarce. Objective - We analyzed the impact of the pandemic period/2020 on the demographics, indications, and number of diagnostic EUS (D-EUS) and interventional EUS (I-EUS) procedures performed in a high-volume endoscopy unit compared with the previous non-pandemic period/2019. Methods - We retrospectively reviewed the medical records of all patients undergoing D-EUS or I-EUS from March 1, 2019, to February 29, 2020 (non-pandemic period/2019) and from March 1, 2020, to February 28, 2021 (pandemic period/2020). Data compared between the study periods included sex, age, comorbidities, EUS findings and diagnosis, need for interventional procedures during EUS, and adverse events (AEs). Results were significant at P<0.05. Results - EUS procedures decreased from 475 in the non-pandemic period/2019 to 289 in the pandemic period/2020, accounting for a 39% reduction. In non-pandemic period/2019, 388 (81.7%) D-EUS and 88 (18.5%) I-EUS were performed, against 206 (71.3%) D-EUS and 83 (28.7%) I-EUS in pandemic period/2020 (P=0.001). Only 5/289 (1.7%) patients had COVID-19. Fewer patients with comorbidities underwent EUS during pandemic period/2020 due to lockdown measures (P<0.001). D-EUS decreased, whereas I-EUS increased (P<0.001). EUS-guided tissue acquisition (EUS-TA) was the most common I-EUS, performed in 83/289 (28.7%) patients in pandemic period/2020, against 88/475 (18.5%) in non-pandemic period/2019 (P=0.001). AEs did not differ significantly between the study periods. Conclusion - Pandemic Period/2020 had a moderate impact on reducing EUS procedures due to the risks involved. Although I-EUS increased, EUS-related AEs did not. Solid and cystic pancreatic tumors remained a major indication for EUS-TA even during the pandemic period/2020.

Proposal and Validation of New Diagnostic Criteria for Diagnostic Weights of Endoultrasonographic Findings for Early Chronic Pancreatitis.

[Background and study aim] A commonly applied method for diagnosing chronic pancreatitis (CP) uses endoscopic ultrasonography (EUS), assigning weights to each EUS diagnostic finding. It is the Rosemont classification (RC). In 2019, to improve EUS diagnostic specificity, Japanese diagnostic criteria for early chronic pancreatitis (ECP) were revised. Nevertheless, the criteria use no weighting of EUS diagnostic findings, as the RC does. This study was undertaken to propose diagnostic criteria that would weight each EUS finding of ECP and that would be more specific than the RC. [Methods] By EUS of the pancreas, 773 patients underwent detailed observation from January 2018 to March 2019 at our institution. An expert finalized all cases when patients were diagnosed. Using data from the medical records, 97 consecutive patients with EUS diagnostic findings of ECP based on the Japanese diagnostic criteria of ECP2009 (JDCECP2009) were selected. The definition under the RC of "Indeterminate for CP" was equivalent to ECP. Each case was diagnosed using (1) JDCECP2009 and (2) the Japanese diagnostic criteria of ECP2019 (JDCECP2019). Moreover, the four diagnostic EUS findings in JDCECP2019 were applied to the RC, weighted (modified-JDCECP2019), and subsequently compared with the earlier diagnostic criteria. As Modified-JDCECP2019, we suggested (3) RC-A-the current four items scored related to the RC, and (4) RC-B-the five items scored by dividing lobularity with and without honeycombing. [Results] Diagnoses produced based on each criterion were normal: ECP = (1) 20:77, (2) 46:51, (3) 52:42, and (4) 60:35. [Conclusions] Modified-JDCECP2019 may provide EUS diagnoses for ECP with higher specificity.

Benefits of pancreatic parenchymal endoscopic ultrasonography in predicting microscopic precancerous lesions of pancreatic cancer

Pancreatic cancer primarily arises from microscopic precancerous lesions, such as pancreatic intraepithelial neoplasia (PanIN) and acinar-to-ductal metaplasia (ADM). However, no established method exists for predicting pancreatic precancerous conditions. Endoscopic ultrasonography (EUS) can detect changes in pancreatic parenchymal histology, including fibrosis. This study aimed to elucidate the relationship between pancreatic parenchymal EUS findings and microscopic precancerous lesions. We retrospectively analyzed 114 patients with pancreatobiliary tumors resected between 2010 and 2020 and evaluated the association between pancreatic parenchymal EUS findings and the number of PanIN, ADM, and pancreatic duct gland (PDG). Of the 114 patients, 33 (29.0%), 55 (48.2%), and 26 (22.8%) had normal EUS findings, hyperechoic foci/stranding without lobularity, and hyperechoic foci/stranding with lobularity, respectively. Multivariate analyses revealed that abnormal EUS findings were significantly associated with the frequency of PanIN (hyperechoic foci/stranding without lobularity: OR [95% CI] = 2.7 [1.0–7.3], with lobularity: 6.5 [1.9–22.5], Ptrend = 0.01) and ADM (hyperechoic foci/stranding without lobularity: 3.1 [1.1–8.2], with lobularity: 9.7 [2.6–36.3], Ptrend = 0.003) but not with PDG (hyperechoic foci/stranding without lobularity: 2.2 [0.8–5.8], with lobularity: 3.2 [1.0–10.2], Ptrend = 0.12). We observed a trend toward a significantly higher number of precancerous lesions in the following order: normal findings, hyperechoic foci/stranding without lobularity, and hyperechoic foci/stranding with lobularity. Pancreatic parenchymal EUS findings were associated with the increased frequency of PanIN and ADM. Lobularity may help predict the increased number of precancerous lesions.

Esophageal cancer T-staging on MRI: A preliminary study using cine and static MR sequences

ObjectivesTo evaluate the added value of cine MR in addition to static MRI for T-Staging assessment of esophageal cancer (EC). Materials and methodsThis prospective monocentric study included 54 patients (mean age 66.3 ± 9.4 years, 46 men) with histologically proven EC. They underwent MRI on a 3 T-scanner in addition to the standard workup. Acquisitions included static and cine sequences (steady-state-free-precession and real-time True-FISP during water ingestion). Three radiologists independently assessed T-staging and diagnosis confidence by reviewing (1) static sequences (S-MRI) and (2) adding cine sequences (SC-MRI). Inter-reader agreement was performed. MRI T-staging was correlated to reference standard T-staging (histopathology or consensus on endoscopic ultrasonography and imaging findings) and to clinical outcome by log-rank test. ResultsBoth S-MRI and SC-MRI T-staging showed a significant correlation with reference T-staging (rs = 0.667, P < 0.001). SC-MRI showed a slightly better performance in distinguishing T1-T3 from T4 with a sensitivity, specificity and AUC of 76.5% (95% CI: 50.1–93.2), 83.8% (68–93.8) and 0.801 (0.681–0.921) vs 70.6% (44–89.7), 83% (68–93.8) and 0.772 (0.645–0.899) for S-MRI. Compared to S-MRI, SC-MRI increased inter-reader agreement for T4a and T4b (κ = 0.403 and 0.498) and T-staging confidence. ConclusionMRI is accurate for T-staging of EC. The addition of cine sequences allows better differentiation between T1-T3 and T4 tumors with increased diagnostic confidence and inter-reader agreement.

Clinical Characteristics and Endoscopic Management of Duodenal Lipomas: 10-Year Experience from a Tertiary Center in China.

Duodenal lipomas are rarely found in the gastrointestinal tract. Most published literature referring to the tumors is limited to case series. There remained issues about the understanding and management of duodenal lipomas to be clarified. We aimed to investigate the clinical and endoscopic features of duodenal lipomas. Additionally, outcomes of endoscopic resection for duodenal lipomas were evaluated. A total of 29 duodenal lipomas resected endoscopically from December 2011 to October 2021 were included. Clinical characteristics, endoscopic features, and endoscopic ultrasound findings were analyzed retrospectively. The endoscopic resection was performed in 3 ways: hot snare polypectomy, endoscopic mucosa resection, and endoscopic submucosal dissection. Of the 29 duodenal lipomas, 21 were located at the second portion with a mean size of 25.8 mm (range, 7-60 mm). Yamada type IV was the most common macroscopic type in 14 lesions, exhibiting a tendency of forming large peduncles. Seven patients had digestive symptoms. The occurrence of symptoms is associated with the tumor size. Endoscopic ultrasound was performed on 23 duodenal lipomas, of which 20 demonstrated homogenous echogenicity and 3 presented heterogeneous with tubular anechoic region. The endoscopic resection operation was successfully conducted on 29 patients without severe adverse events. The rate of en bloc and endoscopic complete resection was 93.1% and 86.2%, respectively. Recurrence was noted in 1 patient. Clinical characteristics with typical endoscopic ultrasound features are helpful in duodenal lipomas diagnosis. The endoscopic resection is a safe and effective treatment for duodenal lipomas with considerable long-term outcomes.

Endoscopic ultrasonographic features of submucosal lesions of upper digestive tract suspected gastrointestinal stromal tumors and their correlation with progression and pathological risk grade of the lesions

Objective: To investigate the endoscopic ultrasonographic (EUS) characteristics of submucosal lesions of upper digestive tract suspected gastrointestinal stromal tumors (GIST) and their correlation with biological behaviors and pathological risk grade of the tumors. Methods: Retrospective cohort study. The EUS findings, follow-up review, surgical treatment and pathological data of patients with suspected GIST at the Gastrointestinal Endoscopy Center of Peking University People's Hospital from January 2013 to April 2021 were collected. All samples were divided into follow-up group and treatment group based on the pathological condition and the patient's treatment intention. According to whether or not the tumor was enlarged in EUS, the follow-up group was divided into non-enlarged group and enlarged group. Paired T-test was used to compare the lesion size before and after follow-up, and logistic regression was used to analyze the risk factors of tumor enlargement. According to the treatment methods, the treatment group was further divided into endoscopic treatment group and surgical treatment group. According to the pathological results and risk grade, the treatment group was further divided into the low-risk group and the medium-risk group. The risk factors of pathological malignant risk were analyzed by logistic regression, and the tumor diameter of patients with moderate or above pathological risk was predicted by receiver operation characteristic (ROC) curve. The relationship between the findings of EUS and the progression and pathological risk of GIST were also explored. Results: Seventy-three cases including 23 males and 50 females, with an age of 58 (30-88) years, were included in the follow-up group, with a mean lesion diameter of (1.21±0.49) cm before follow-up, median follow-up interval of 33.8 months, and a lesion diameter of (1.18±0.49) cm after follow-up. There was no significant difference (all P>0.05) in lesion diameter between before and after follow-up. There was no significant difference (all P>0.05) between tumor enlargement group (18 cases, 24.7%) and non-enlargement group (55 cases, 75.3%). One hundred and thirty-eight cases, including 52 males and 86 females, with an age of 60 (19-84) years, were enrolled in the treatment group, with a mean EUS estimated diameter of (2.55±1.35) cm and pathological diameters of (3.43±2.42) cm. Ninety-five (68.8%) of these cases were pathologically confirmed as GIST while 43 cases were diagnosed as other tumor types, including 37 benign tumors and 6 malignant tumors. In multifactorial logistic regression analysis, only the increase of tumor diameter [OR (95%CI): 1.800 (1.172-2.766), P=0.007] was a risk factor for pathological intermediate or higher risk. The optimal tumor diameter for predicting pathological intermediate or higher risk using ROC curve analysis was 2.75 cm, with a sensitivity 71.4%, specificity 79.0%, Youden index 0.5 and area under ROC curve 0.807 (95%CI: 0.703-0.909). Conclusions: EUS is essential for assessing the risk of progression and malignancy of submucosal lesions of upper digestive tract suspected GIST. For lesions of small diameter, the interval of follow-up shall be relatively extended while the indication of treatment could be partially waived.

A vanished gastric gastrointestinal stromal tumor

BackgroundLocal resection is the standard treatment for gastrointestinal stromal tumors (GISTs). Laparoscopic and endoscopic cooperative surgery (LECS) is a minimally invasive surgery used to resect GISTs. Herein, we report an extremely rare case of a gastric GIST that grossly vanished during LECS.Case presentationA 50-year-old Japanese female was referred to our hospital after an abnormality was detected during an esophagogastroduodenoscopy (EGD) at her annual health checkup. Based on EGD, endoscopic ultrasound (EUS), and computer tomography (CT) findings, the patient was diagnosed with a 50-mm submucosal tumor (SMT) with intraluminal growth on the anterior wall of the lesser curvature of the upper body of the stomach. We routinely use LECS to treat the intraluminal growth type of GISTs. During the intraoperative endoscopy, the intraluminal submucosal tumor, which was detected preoperatively, had vanished. A red-white scar was observed in the regressed tumor region. LECS was performed by resecting at a distance away from the scar tissue and closing the gastric wall with intracavitary sutures. In the evaluation from the tumor section view of the original resected specimen, a 22 × 14 × 8 mm lobular neoplasm was observed that was predominantly located in the gastric submucosa to the muscularis propia. Pathological findings confirmed the diagnosis of GIST with intermediate risk indicated by the Fletcher classification. The patient continued postoperative adjuvant chemotherapy with imatinib and no recurrence was detected over 12 months after surgery.ConclusionLECS was performed on the vanished gastric GIST, providing the best surgical treatment and leading to an accurate diagnosis and optimal postoperative care.

Diagnostic Accuracy of Endoscopic Ultrasonography in Selecting Patients for Endoscopic Submucosal Dissection for Early Gastrointestinal Neoplasms.

Tumor invasion depth and lymph node metastasis determine the prognosis of gastrointestinal (GI) neoplasms. GI neoplasms limited to mucosa (m1 or m2) and superficial submucosa (sm1) can be treated effectively with minimally invasive endoscopic therapy, while the deep invasion of the submucosa (sm2 or sm3) is associated with lymph node metastasis, and surgical resection is required. Correct staging is therefore crucial for preoperative evaluation and planning. Endoscopic ultrasonography (EUS) can be used to detect the depth of invasion due to its close proximity to the lesion. The diagnostic accuracy of EUS, when compared to conventional endoscopic staging, is debated as it can under- or overstage the lesion. We aim in this study to determine if EUS can accurately differentiate mucosal from submucosal GI neoplasms to select patients with early GI lesions for endoscopic submucosal dissection (ESD) or surgery. From March 2014 to February 2022, 293 patients with early superficial GI neoplasms were admitted to our endoscopic unit for EUS staging. To evaluate the accuracy of EUS, we compared the preoperative EUS findings with the definitive histopathologic findings on the resected specimen. Overall, 242 of 293 lesions were correctly staged by EUS (82.59%). In the evaluation of submucosal invasion or deeper, EUS understaged 38 of 293 (12.96%) and overstaged 13 of 293 (4.43%) lesions. EUS has excellent accuracy in staging superficial GI neoplasms; its use is highly recommended before ESD since it can also detect lymph node metastases around the lesions, thus changing the indication from ESD to surgery.

Spontaneous retroperitoneal hematoma with duodenal obstruction with diagnostic use of endoscopic ultrasound: A case series and literature review

Spontaneous retroperitoneal hematoma is rare and can cause duodenal obstruction. We report four cases of spontaneous retroperitoneal hematoma with duodenal obstruction, wherein endoscopic ultrasound was useful for diagnosis. The patients complained of vomiting with stable vital signs. Computed tomography, esophagogastroduodenoscopy, and endoscopic ultrasound findings were similar in all cases. Contrast-enhanced computed tomography revealed a low-density mass around the 2nd to 3rd part of the duodenum. Esophagogastroduodenoscopy showed an edematous, reddish, but non-neoplastic duodenal mucosa with stenosis of the lumen. Endoscopic ultrasound revealed a low-echoic mass around the duodenum and high-echoic floating matter suggesting debris and anechoic areas that indicated a liquid component. These findings suggested hematomas or abscesses. Although pseudoaneurysm of the pancreaticoduodenal artery was suspected in Case 3, we chose conservative treatment because the aneurysm was small. In Case 4, median arcuate ligament syndrome was suspected on angiography. No aneurysms or arteriovenous malformations were found; thus, endovascular embolization was not performed. The patients were treated conservatively and discharged within 3–5 weeks. English literature queries on spontaneous retroperitoneal hematoma with duodenal obstruction in MEDLINE revealed 21 cases in 18 studies. The clinical features of these patients and the present four cases have been discussed.

The effectiveness of endoscopic ultrasonography findings to distinguish benign and malignant intraductal papillary mucinous neoplasm

Background and aimsAccurate evaluation of intraductal papillary mucinous neoplasm (IPMN) is necessary to inform clinical decision-making. But it is still difficult to distinguish benign and malignant IPMN preoperatively. This study aims to evaluate the utility of EUS to predict the pathology of IPMN.MethodsPatients with IPMN who underwent endoscopic ultrasound within 3 months before surgery were collected from six centers. Logistic regression model and random forest model were used to determine risk factors associated with malignant IPMN. In both models, 70% and 30% of patients were randomly assigned to the exploratory group and validation group, respectively. Sensitivity, specificity, and ROC were used in model assessment.ResultsOf the 115 patients, 56 (48.7%) had low-grade dysplasia (LGD), 25 (21.7%) had high-grade dysplasia (HGD), and 34 (29.6%) had invasive cancer (IC). Smoking history (OR = 6.95, 95%CI: 1.98–24.44, p = 0.002), lymphadenopathy (OR = 7.91, 95%CI: 1.60–39.07, p = 0.011), MPD > 7 mm (OR = 4.75, 95%CI: 1.56–14.47, p = 0.006) and mural nodules > 5 mm (OR = 8.79, 95%CI: 2.40–32.24, p = 0.001) were independent risk factors predicting malignant IPMN according to the logistic regression model. The sensitivity, specificity, and AUC were 0.895, 0.571, and 0.795 in the validation group. In the random forest model, the sensitivity, specificity, and AUC were 0.722, 0.823, and 0.773, respectively. In patients with mural nodules, random forest model could reach a sensitivity of 0.905 and a specificity of 0.900.ConclusionsUsing random forest model based on EUS data is effective to differentiate benign and malignant IPMN in this cohort, especially in patients with mural nodules.

Imaging of paraduodenal pancreatitis: A systematic review.

Paraduodenal pancreatitis (PP) represents a diagnostic challenge, especially in non-referral centers, given its potential imaging overlap with pancreatic cancer. There are two main histological variants of PP, the cystic and the solid, with slightly different imaging appearances. Moreover, imaging findings in PP may change over time because of disease progression and/or as an effect of its risk factors exposition, namely alcohol intake and smoking. To describe multimodality imaging findings in patients affected by PP to help clinicians in the differential diagnosis with pancreatic cancer. The systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-analyses 2009 guidelines. A Literature search was performed on PubMed, Embase and Cochrane Library using (groove pancreatitis [Title/Abstract]) OR (PP [Title/Abstract]) as key words. A total of 593 articles were considered for inclusion. After eliminating duplicates, and title and abstract screening, 53 full-text articles were assessed for eligibility. Eligibility criteria were: Original studies including 8 or more patients, fully written in English, describing imaging findings in PP, with pathological confirmation or clinical-radiological follow-up as the gold standard. Finally, 14 studies were included in our systematic review. Computed tomography (CT) findings were described in 292 patients, magnetic resonance imaging (MRI) findings in 231 and endoscopic ultrasound (EUS) findings in 115. Duodenal wall thickening was observed in 88.8% of the cases: Detection rate was 96.5% at EUS, 91.0% at MRI and 84.1% at CT. Second duodenal portion increased enhancement was recognizable in 76.3% of the cases: Detection rate was 84.4% at MRI and 72.1% at CT. Cysts within the duodenal wall were detected in 82.6% of the cases: Detection rate was 94.4% at EUS, 81.9% at MRI and 75.7% at CT. A solid mass in the groove region was described in 40.9% of the cases; in 78.3% of the cases, it showed patchy enhancement in the portal venous phase, and in 100% appeared iso/hyperintense during delayed phase imaging. Only 3.6% of the lesions showed restricted diffusion. The prevalence of radiological signs of chronic obstructive pancreatitis, namely main pancreatic duct dilatation, pancreatic calcifications, and pancreatic cysts, was extremely variable in the different articles. PP has peculiar imaging findings. MRI is the best radiological imaging modality for diagnosing PP, but EUS is more accurate than MRI in depicting duodenal wall alterations.

Endoscopic Ultrasound Appearance of Jejunal Ectopic Pancreas Mimicking Metastatic Nodule in a Cancer Patient

The ectopic pancreas is a benign subepithelial tumor (SET) mostly found incidentally in the stomach and duodenum. Here, we present computed tomography (CT) scans and endoscopic ultrasound (EUS) images from a 71-year-old Taiwanese man newly diagnosed with colonic adenocarcinoma. CT examination revealed a mural nodule in the proximal jejunum, with good enhancement after IV contrast medium administration. Push enteroscopy was performed to localize the lesion and evaluate its nature, and a 1 cm subepithelial lesion was found. The lesion appeared hyperechoic within the submucosal layer of the bowel wall on endoscopic ultrasound examination. A tattoo was performed, and the lesion was removed during the resection of colon cancer. The histopathology confirmed the presence of pancreatic tissue inside. As far as we know, this is the first description in the literature of an endoscopic ultrasound finding of a jejunal ectopic pancreas.

Mini-probe endoscopic ultrasound for the diagnosis of congenital esophageal or duodenal stenosis.

The usefulness of endoscopic ultrasound (EUS) in pediatric populations has been recently appreciated; however, published studies on mini-probe EUS in the diagnosis of congenital esophageal stenosis (CES) or congenital duodenal stenosis (CDS) in pre-school patients remain scarce. This study aimed to report the utility of mini-probe EUS for the diagnosis of CES or CDS in pre-school patients based on the etiology. We retrospectively reviewed the medical records of pediatric patients with CES or CDS who underwent mini-probe EUS through the stenotic segments at our hospital between December 2006 and December 2021. Five patients with CES and one with CDS were enrolled. The median age and body weight when EUS was performed were 12.5months and 8.5kg, respectively. Hypoechoic lesions were observed on EUS in three patients, which were assessed as cartilage; one patient had no hypoechoic lesion but had a focal thickness of the muscular layer. They were diagnosed with tracheobronchial remnants based on EUS. The full circumferential wall thickness of the esophagus was visualized in one patient with fibromuscular hypertrophy. The histopathological findings confirmed the diagnoses. In the patient with CDS, EUS findings revealed pancreatic parenchyma encircling the stenotic part of the duodenum. The preoperative diagnosis was annular pancreas. The patient underwent duodenoduodenostomy, and intraoperative findings confirmed the diagnosis. Mini-probe EUS can be recommended as a feasible and safe technique for infants and toddlers. It can effectively diagnose CES or CDS based on etiology and can inform treatment strategies for pre-school patients.

Gastric hamartomatous inverted polyp: Report of three cases with a review of the endoscopic and clinicopathological features.

A gastric hamartomatous inverted polyp (GHIP) is a rare submucosal tumor characterized histopathologically by a submucosal inverted proliferation of cystically dilated hyperplastic gastric glands. Only 42 GHIPs have been reported in English literature. Few GHIPs have been reported to accompany adenocarcinomas. We reported on three patients with a GHIP and reviewed the clinicopathological and endoscopic features of GHIPs. This study included two men and one woman with a GHIP. The endoscopic, histopathological, and immunohistochemical features of the endoscopically resected specimens were analyzed. A gene mutation analysis was also performed. All the tumors were located in the body of the stomach, with a median size of 20mm. Two tumors were sessile, and the remaining tumor had a pedunculated appearance. The overlying mucosa mainly appeared normal but was reddish in one tumor. The histopathological examination of the tumors revealed a well-circumscribed and lobular submucosal proliferation of cystically dilated hyperplastic glands. The immunohistochemical analysis revealed that the MUC5AC-positive foveolar epithelium was located in the center, and MUC6-positive pseudo-pyloric or pepsinogen-I and H+/K+ ATPase-positive fundic-type glands were located at the periphery of two tumors. No carcinomatous components were noted in any of the tumors. Moreover, no significant mutations in oncogenes or tumor suppressor genes were noted. Our review revealed that approximately three fourths of GHIP cases showed an submucosal tumor-like feature, whereas endoscopic features, including the endoscopic ultrasonography findings, were not characteristic. Because an endoscopic diagnosis of a GHIP may be difficult, complete endoscopic resection may be required for a pathological diagnosis.

Does the Absence of Contrast Passage Into the Duodenum During Intraoperative Cholangiogram Truly Predict Choledocholithiasis?

Background and AimsThe absence of contrast passage to the duodenum is frequently encountered during an intraoperative cholangiogram (IOC), and patients with this finding are suspected of having choledocholithiasis. This study was conducted to determine the positive predictive value (PPV) of the absence of contrast passage during IOC and identify predictors, if any, that increase the pretest probability of choledocholithiasis in these patients. MethodsAll laparoscopic cholecystectomies with IOCs between September 1, 2019, and September 1, 2021, at a tertiary medical center were reviewed to identify those with abnormal cholangiograms due to only the lack of contrast passage to the duodenum. Patient demographic information, pre- and postoperative laboratory results, and radiographic studies were recorded. Postprocedural clinical outcomes including endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) findings were tabulated to determine the presence of choledocholithiasis. Patient factors and outcomes were compared between a cohort that was found to have choledocholithiasis vs those who were not. Finally, multiple logistic regression was performed to identify predictors of choledocholithiasis. ResultsOf 320 IOCs, 31(9.7% of all abnormal IOCs) showed the lack of contrast passage in the duodenum as the only abnormality. The PPV of an IOC with the lack of contrast in the duodenum was 29%. Preoperative bilirubin levels, postoperative aspartate aminotransferase levels, and postoperative alanine transaminase levels were significant predictors of choledocholithiasis in this group of patients. ConclusionsThe lack of contrast passage to the duodenum as the sole finding of an abnormal IOC has poor PPV for choledocholithiasis. Thus, it is reasonable to consider using less invasive modalities such as EUS and/or magnetic resonance cholangiopancreatography before ERCP in these patients.

Esophageal schwannoma with unusual endoscopic ultrasound imaging findings

Esophageal schwannoma with unusual endoscopic ultrasound imaging findings

Natural Course of Asymptomatic Upper Gastrointestinal Subepithelial Lesion of 2 cm or Less in Size.

There is limited evidence of a natural course of an upper gastrointestinal (UGI)-subepithelial lesion (SEL) of 2 cm or less in size. This study aims to determine the natural course of UGI-SELs and find the risk factors of the endoscopic and endoscopic ultrasonography (EUS) findings associated with an increase in size. The medical records of 2539 patients with UGI-SELs between 2004 and 2016 were reviewed retrospectively. A total of 672 SELs of 2 cm or less in size were analyzed through EUS and followed up for at least 36 months. The mean follow-up duration was 68 months (range: 36-190 months), and 97 SELs (14.4%) showed an increase in size with a mean increase rate of 1.2 mm/year. Initial size (aOR 1.03, 95% confidence interval (CI) 1.01-1.06), an endoscopic finding of a hemorrhagic spot (aOR 3.13, 95% CI 1.14-8.60), and an EUS finding of a lesion in the fourth layer (aOR 1.87, 95% CI (1.21-2.88) were related to an increase in size. An endoscopic finding of translucidity (aOR 0.28, 95% CI (0.10-0.76) and an EUS finding of calcification (aOR 0.30, 95% CI 0.09-0.95) were inversely related to an increase in size. There was no death related to UGI-SELs during the follow-up. While most UGI-SELs of 2 cm or less in size showed no significant size change and favorable prognosis, an individualized follow-up strategy needs to be considered in case of the presence of hemorrhagic spots and lesions in the fourth layer.

Role of endoscopic ultrasound in the evaluation of unexplained extrahepatic bile duct dilatation.

This study was performed to assess the diagnostic performance of endoscopic ultrasonography (EUS) in patients with extrahepatic bile duct (EBD) dilatation and develop a novel model incorporating EUS-based signature with clinical parameters for distinguishing the malignant dilation of EBD. The EUS data and clinical parameters of the patients were collected and analyzed retrospectively. First, we evaluated the diagnostic performance of EUS in detecting the cause of EBD dilatation. Then, we performed univariate and multivariate binary logistic regression analyses based on clinical and EUS features. Finally, a nomogram was established to aid in distinguishing between malignant dilation and noncalculous benign dilatation of EBD in patients. A total of 184 patients were enrolled. For the diagnosis of malignant dilation, EUS achieved an accuracy of 90.76%, sensitivity of 85.96%, and specificity of 92.91%. For the diagnosis of calculous dilation, EUS achieved an accuracy of 100%, sensitivity of 100%, and specificity of 100%. For the diagnosis of noncalculous benign dilatation, EUS achieved an accuracy of 90.76%, sensitivity of 90.90%, and specificity of 90.58%. Multivariable logistic regression analyses indicated that abnormal liver function test, elevated tumor markers, and EUS findings were the well-diagnostic factors of malignant EBD dilation. The nomogram established by these factors showed good calibration and discrimination. EUS is a useful examinational modality in the work-up of EBD dilatation. In combination with abnormal liver function test and elevated tumor markers, EUS may provide additional information for the detection of malignant dilation of EBD and should be further investigated.