Endosonography In Diagnosis Research Articles

Endosonographic Diagnosis of Rectal Mucocele: The "Onion Skin" Sign.

Endosonographic Diagnosis of Rectal Mucocele: The "Onion Skin" Sign.

Endosonographic diagnosis of advanced neoplasia in intraductal papillary mucinous neoplasms.

Pancreatic cancer has a high mortality rate with minimal proven interventions. Intraductal Papillary Mucinous Neoplasms (IPMNs) are known precursor lesions for pancreatic cancer. Identification of pancreatic cysts has improved from advances in abdominal imaging. Despite multiple revisions of the international consensus recommendations and various guidelines by other major societies, successful risk stratification of the malignant potential of mucinous pancreatic cysts remains challenging. Specifically, detection and accurate classification of advanced neoplasia (high-grade dysplasia and/or adenocarcinoma) in IPMNs is suboptimal with current diagnostic strategies. Development of interventional techniques utilizing endoscopic ultrasound include - through-the-needle microforceps biopsy, next-generation or whole genome molecular analysis of cyst fluid, and needle-based confocal laser endomicroscopy. These techniques suffer from a series of limitations in technical success, diagnostic yield, and clinical feasibility, but a combination approach may offer a solution that optimizes their cyst evaluation and risk stratification. Assessment and comparison of these techniques is restricted by lack of adequate surgical specimens for testing of diagnostic accuracy, resulting in a possible sample bias. Additional large-scale multicenter studies are needed to accumulate evidence for the utility and feasibility of their translation into clinical practice. Great strides have been made in pancreatic cyst evaluation, but further research is required to improve diagnostic accuracy and clinical management of IPMNs.

Relevance of endosonography in diagnosis of tumor and pretumor pathology of the larynx, oropharynx and laryngopharynx

Aim. The study objective is studying the possibility of endosonography in the diagnosis of tumor and pretumor pathology of the larynx, oropharynx and laryngopharynx. Materials and methods. Endosonographic study was conducted in 20 patients with tumors and suspected tumors of the larynx, laryngopharynx and oropharynx. Results. The use of endoscopic ultrasound (EUS) method was useful and important in determining the thickness and structure of the tumor, with hyperplasia of the lingual and palatine tonsils. Endosonographic picture of fibrous changes after surgery and post-radiation changes, lack of blood flow in the fibrous tissue and blurred contours gave additional information in the differential diagnosis of tumor and non-tumor changes. The results of the ultrasound examination performed in the standard B-mode for the presence of tumors, cysts and formations, suspicious of the tumor of the submucosal layer of the oropharynx and larynx, which were not determined by endoscopic examination, were confirmed. Conclusion. Obtaining a sonographic image simultaneously with endoscopic examination of the formations in the submucosal layer of the oropharynx and larynx will shorten the diagnostic algorithm of the study in patients with pathological changes in this area. The use of endosonography made it possible to confirm the data obtained by ultrasound examination in B-mode and which were not confirmed by endoscopic examination.

Ectopic pancreas in the upper gastrointestinal tract: Is endosonographic diagnosis reliable? Data from the German Endoscopic Ultrasound Registry and review of the literature.

Background:Ectopic pancreas (EP) belongs to the most frequent subepithelial lesions (SELs) of the upper gastrointestinal (GI) tract. In the majority of cases, it is detected incidentally. Differential diagnosis from mesenchymal subepithelial tumors may be difficult.Methods:Among 24,308 endosonographic examinations and interventions, which were prospectively enrolled in the database of the German Endoscopic Ultrasound (EUS) Registry from January 2009 to August 2013, 575 were performed for suspected SELs of the upper GI tract. Sixty three cases of EP of the upper GI tract (stomach, n = 53; duodenum, n = 10; esophagus, n = 0) were extracted and retrospectively reviewed.Results:In 65.1% of cases, radial echoendoscopes or radial miniprobes were used for examination. Nearly 84% of EP was found in the stomach, 16% in the duodenum, none in the esophagus. In 88.9% of cases, the EUS examination discerned the layer of origin. In 59% of cases EP was described as a heterogeneous, in 28.6% as a homogeneous-hypoechoic and in 7.9% as a homogeneous-echogenic subepithelial mass lesion. Mean diameter was 13.0 mm × 8.1 mm, the mean ratio between long and short axis diameter was 1.75. EUS-guided fine needle aspiration (EUS-FNA) was used to accomplish cytological or histological diagnosis in only 6.3% of cases.Conclusions:EP accounts for 11% of all EUS examinations performed for subepithelial lesions of the upper GI tract and prospectively enrolled in the German EUS registry. Rather than being an eyecatcher, EP is a chameleon with numerous differential diagnoses. In selected cases, EUS-FNA may help clarifying the diagnosis.

Helpfulness of rectoanal endosonography in diagnosis of sexual abuse in a child

BackgroundClinical importance of sexual abuse in children has rapidly expanded in recent years, but despite of it, the lack of medical signs in the vast majority of sexual abuse cases, makes it difficult to assess. Given that, owing to our prior experience in endosonography (EUS) of the anal canal in child with anorectal malformations, we wanted to test EUS as a diagnostic method of sexual abuse in a child. PurposeThe purpose of our study is to present our experience in the use of anorectal EUS among children with suspected sexual abuse. Materials/methodsWe present 40 consecutive patients (34 boys and 6 girls, age: 10months–13years) recruited from April 2010 to December 2012, with suspected sexual abuse those made a transrectal EUS. ResultsThe procedure was well-tolerated in all patients without complications. Rectoanal EUS findings were normal in 27 patients and showed a partial interruption in the external anal sphincter in 8, scars in 2, double rail image in 2, and rectal wall hematoma in 1. ConclusionsThe interpretation of findings in children depends of historical, physical, and laboratory findings. We believe that anal EUS is another aid in the constellation of clinical factors that could help in diagnostic of sexual abuse.

The efficacy of endoscopic endosonography in diagnosis of benign and malignant stenoses of common bile duct

To define criteria and to estimate diagnostic significance of endosonography in differential diagnosis of benign and malignant stenoses of common bile duct. We presented the results of survey and treatment of 57 patients with benign and malignant stenoses of common bile duct. The technique of endosonography is described. We have formulated major criteria of differential diagnostics of tumoral and non-tumoral lesion of extrahepatic bile ducts. Comparative analysis of endosonography, ultrasound, computed tomography and magnetic resonance cholangiopancreatography was performed. Sensitivity, specificity and accuracy of endosonography in diagnosis of stenosis cause is 97.7%, 100% and 98.2% respectively. So it exceeds the efficacy of other diagnostic X-ray methods. In modern surgical clinic endosonography should be mandatory performed. It is necessary for final diagnostics of cause of common bile duct stenosis especially in case of its low location.

Contrast enhanced endosonography in diagnosis of pancreatic cancer

Contrast enhanced endosonography in diagnosis of pancreatic cancer

Evaluation of Rosemont Classification for Non-calcific Chronic Pancreatitis (NCCP) Based on Histopathology: A Retrospective Study

Introduction: Rosemont classification represents a consensus-based scoring system to standardize endosonographic diagnosis of chronic pancreatitis. To this date, its diagnostic accuracy has not been validated based on the gold standard, namely histopathology. The aim of this study was to assess the accuracy of Rosemont classification in NCCP patients undergoing total pancreatectomy and islet autotransplantation (TPIAT). Methods: Adult patients undergoing TPIAT for NCCP between July 2009 and January 2013 were included if they underwent endoscopic ultrasound (EUS) at our center within 1 year before surgery. The presence or absence of major and minor Rosemont criteria was determined by expert endosonographers using linear EUS. Patients were categorized into normal, indeterminate, suggestive, and consistent with CP based on the major and minor criteria as per the Rosemont classification. Histology was obtained at time of TPIAT from the resected pancreas by wedge biopsy of head, body, and tail. All histopathology was reviewed by a GI pathologist blinded to EUS features and clinical outcomes. Available pancreatic tissue was graded for severity of intralobular and perilobular pancreatic fibrosis by the Ammann classification system. A fibrosis score (FS) ≥2 was considered abnormal. Results: Fifty patients (42 females; mean age 37.9±10.8 years) underwent TPIAT with preoperative EUS during the study period. As expected, none of the patients had any major A feature as our study population consisted of only NCCP. None of our patients could be categorized into the “consistent” with CP category. Sensitivity, specificity, PPV, and NPV for “normal,” “indeterminate,” and “suggestive” of CP are shown in Table 1. A box plot is also shown.Table 1: Diagnostic Performance of Rosemont Classification Based on HistopathologyConclusion: In our study, Rosemont classification for NCCP correlated poorly with histopathology. Although Rosemont scoring adds more complexity, it may not improve the diagnostic accuracy of EUS for NCCP. Further attempts should be made to refine the EUS diagnostic criteria for CP to enhance its reliability in diagnosing NCCP.Figure 1

Endosonographic Diagnosis of Chronic Pancreatitis

Chronic pancreatitis (CP) is characterized by irreversible damage that engenders fibrosis and necrosis of pancreatic tissue, with the consequent loss of endocrine and exocrine function of the pancreas. The clinical course of CP engenders a high rate of morbidity and mortality over a 20-25-year period. In view of this fact, current efforts emphasize the establishment of early diagnosis to commence intervention that can positively affect the natural course of the disease. Endoscopic ultrasonography (EUS) is a well-established and less-invasive modality for CP diagnosis. The higher imaging resolution provided by EUS enables detection of subtle pancreatic abnormalities, not only parenchymal but also ductal changes, that are undetectable using other modalities. This review presents an overview of the endosonographic diagnosis of chronic pancreatitis.

Endosonographic diagnosis of aberrant right subclavian artery that leads to disphagia lusoria

Endosonographic diagnosis of aberrant right subclavian artery that leads to disphagia lusoria

Su1401 Endosonographic Diagnosis of Intraductal Papillary Mucinous Pancreatic Neoplasm (IPMN) of Pancreas by EUS and IDUS-Single Center Prospective Study

Su1401 Endosonographic Diagnosis of Intraductal Papillary Mucinous Pancreatic Neoplasm (IPMN) of Pancreas by EUS and IDUS-Single Center Prospective Study

Update on the Role of Endoscopic Ultrasound in Chronic Pancreatitis

Chronic pancreatitis (CP) remains an important healthcare problem that adversely affects quality of life. Endoscopic ultrasound (EUS) is a preferred test for the diagnosis of early CP. The Rosemont classification strictly defines and assigns weighting to the previously described ductal and parenchymal criteria. Recent histological correlation studies have improved our understanding of the accuracy of EUS criteria. Digital imaging analysis and complementary functional testing may complement endosonographic diagnosis. EUS-directed celiac plexus blockade and ductal access techniques have expanded the therapeutic armamentarium for pain management in CP.

Schwierige endosonografische Differenzialdiagnosen am Pankreas - zystische Läsionen

Zystische Läsionen des Pankreas sind häufig und werden zunehmend als Zufallsbefunde bildgebender Diagnostik entdeckt. Im Gegensatz zu anderen parenchymatösen Organen sind dysontogenetische Pankreaszysten sehr selten. Unter den Zufallsbefunden dominieren zystische Neoplasien unterschiedlichen Malignitätsrisikos, bei symptomatischen zystischen Pankreasläsionen handelt es sich dagegen überwiegend um akute oder chronische Pseudozysten. Die Endosonografie spielt neben anamnestisch-klinischen Kriterien in der differenzialdiagnostischen und prognostischen Charakterisierung eine herausragende Rolle. In einer Sitzung sind morphologische Beurteilung, Darstellung der Vaskularisation und Feinnadelaspiration von Zysteninhalt, Zystenwandung und soliden Anteilen möglich. Dennoch können Differenzialdiagnose und Entscheidungsfindung über das weitere Vorgehen im Einzelfall erhebliche Probleme aufwerfen, die in dieser Übersicht diskutiert werden. Es wird ein evidenzbasierter diagnostischer Algorithmus für zystische Pankreasläsionen vorgestellt.

Long-Term Clinical Outcome of Patients with Gastric Gastrointestinal Stromal Tumors

About 10-30% of gastrointestinal stromal tumors prove to be malignant. Nevertheless, the natural history of gastric gastrointestinal stromal tumors has not been fully elucidated. To determine the long-term clinical outcome of nonresected gastric gastrointestinal stromal tumors. Clinical follow-up of patients with endosonographic characteristics compatible with gastric gastrointestinal stromal tumors was conducted based on Israeli population registry. Lesions with features suggesting malignancy were usually referred to surgery. Follow-up endoscopic ultrasound examinations of nonoperated patients were reviewed. Seventy-one patients with presumable gastric gastrointestinal stromal tumors were followed. Seventeen patients underwent operation; median tumor size was 43 mm (range 29-70 mm). Within a median of 43 months (range 2-131 months) ten patients died of causes unrelated to gastrointestinal stromal tumor. Forty-four patients with endosonographic diagnosis of gastric gastrointestinal stromal tumors were followed expectantly for a median of 12 years (range 5-15 years). All these patients are alive and without complications associated with gastrointestinal stromal tumor. Follow-up endoscopic ultrasound examinations demonstrated no change in tumor size in six, decrease (by 1-5 mm) in six, and increase (by 2-21 mm) in eight. Therapeutic decisions guiding surgical interventions may be based on clinical presentation, comorbidity, and endosonographic characteristics. Nonoperated patients may be safely followed conservatively.

Anal endosonographic findings in women after vaginal delivery

Objective To estimate a frequency of obstetric anal sphincters defects in women after vaginal delivery. Methods The study included 102 women, aged from 16 to 40 years (mean age 28.6 years). 28 women had perineal lacerations of 3rd and 4th degree. 22 women had instrumental delivery. Anal endosonography was performed on all participants using BK Medical scanner Pro focus with a 3D endoprobe during the first week after delivery. Starck's classification was used to score sphincters defects. Results The endosonographic images were abnormal in 8 out of 102 women (7.8%). Follow-up examinations after 6 weeks confirmed defects in 6 out of 102 women (5.8%). Five women had external anal sphincter torn, and 1 woman had both sphincters, internal and external, defected. Discordance between endosonographic diagnosis of defect and clinical assessment of sphincters continuity was demonstrated in 6 (5.9%) out of 8 initially found, including 2 (1.9%) false endosonographic results and 4 (3.9%) false clinical diagnosis (occult sphincter defects). The endosonography sensitivity and accuracy in sphincter defect diagnostic amounted to 100% and 98%, respectively. Conclusions (1) Anal sphincters’ tears in symptomatic women are not as frequent as it was believed. (2) The defect diagnosis in the first week after delivery should be verified by a follow-up endosonography in 6 weeks, after regression of the edema and hematoma.

Pseudocyst of the pancreas

Currently, the preoperative diagnosis of a pancreatic cyst is based on clinical and imaging findings, frequently in conjunction with chemical analysis of cyst fluid and cytologic evaluation. The purpose of these diagnostic tests is to distinguish benign from malignant cysts of the pancreas. Accordingly, it is imperative to distinguish pancreatic pseudocysts from their mimics. In this study, the authors explored the cytomorphologic features of pseudocyst of the pancreas and evaluated the role of Alcian blue and mucicarmine stains in the cytologic evaluation of pancreatic cysts. Forty-two patients were identified who had an eventual diagnosis of pancreatic pseudocyst and had an endoscopic ultrasound-guided fine-needle aspirate available. Clinical and imaging findings and chemical analyses of cyst fluid were recorded. The cytologic preparations were evaluated for gastrointestinal contamination, inflammatory cells, mucin, and pigmented material. The cytomorphologic features of 110 neoplastic mucinous cysts (intraductal papillary-mucinous neoplasms/mucinous cystic neoplasms of the pancreas) were evaluated and compared with the pseudocysts. The majority of patients (95%) had a prior episode of pancreatitis. On imaging, the pseudocysts were unilocular (92%). In 69% of cases, the endosonographic diagnosis was that of a pseudocyst. The mean carcinoembryonic antigen level was 41 ng/mL. In contrast, the cytopathologist rendered a definitive diagnosis of pseudocyst in only 10% of cases. The majority of smears (75%) revealed neutrophils and/or histiocytes. Atypical epithelial clusters were identified in 3 cases, 1 of which was diagnosed as suspicious for carcinoma. Yellow pigmented material, which was identified in 13 pseudocysts (31%), was not observed in neoplastic mucinous cysts. Alcian blue- and mucicarmine-positive material was identified in 64% and 40% of pseudocysts, respectively, and in 57% and 38% of neoplastic mucinous cysts, respectively. The diagnosis of a pseudocyst depended primarily on clinical and imaging findings and on chemical analysis of cyst fluid. The cytologic features frequently were nonspecific. The presence of yellow pigmented material served as a surrogate marker of a pseudocyst. Special stains for mucin did not distinguish pseudocysts from neoplastic mucinous cysts.

Recurrent Obscure Gastrointestinal Bleeding from a Stromal Tumor of the Proximal Jejunum Diagnosed Using Endosonography

Purpose: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the alimentary tract and account for 1% of all gastrointestinal malignancies. Such tumors are often found incidentally but may present with intestinal obstruction or bleeding. We present a patient with GIST of the proximal jejunum (PJ) complicated by recurrent obscure bleeding. Eventual diagnosis was made using endoscopic ultrasound (EUS). Methods: 60 year old male presented with multiple episodes of melena. Two weeks prior he had coronary angioplasty and was taking aspirin and plavix. The esophagogastroduodenoscopy and colonoscopy showed no source of bleeding. The bleeding persisted when small bowel enteroscopy (SBE) was performed. Actively bleeding area was noted around a small ulcer in PJ, presumed to be aspirin-induced. The endoscopic therapy was successful and no mass lesion was seen. The small bowel capsule endoscopy (SBCE) showed no bleeding source and abdominal CT Scan was normal as well. After aspirin therapy was restarted the patient developed recurrent melena. Repeat endoscopy showed no source of bleeding and another SBCE showed only fresh blood in PJ. The red cell scintigraphy scan localized the bleeding to the PJ. A mesenteric angiogram showed a vascular mass in the PJ which was embolized. Repeat SBE combined with EUS showed a 3.8 cm × 2.5 cm, submucosal, highly vascular, heterogenous mass in PJ originating from the muscle layer. The complete laparoscopic resection of the tumor was performed. Grossly the tumor measured 4 cm with fleshy, yellow cut surface. Histology confirmed GIST with positive staining for CD117, SMA and vimentin with low malignant potential. The patient has had no bleeding since and is tolerating antiplatelet therapy well. Results: GISTs occur in the stomach (60%–70%) and small intestine (25%–35%) and rarely in the colon, rectum, esophagus, and appendix. Common to such tumors is expression of Kit (CD117 antigen), a major diagnostic criterion. About 30% of GISTs are malignant, with larger tumors more invasive. Surgery is usually curative in smaller lesions while in large metastatic lesions adjuvant chemotherapy using Gleevac shows great promise. The endosonographic diagnosis of GIST in the small bowel is difficult as deep intubation of this part of the bowel is limited with this technology. Our patient developed recurrent bleeding from GIST in the PJ and with forward-view enteroscopy only the localization of the bleeding was achieved. EUS provided a definite diagnosis which in part was facilitated by its side-viewing technology. Conclusion: We conclude that EUS appears safe in PJ and can prove highly effective in diagnosis of pathology in this location when other standard diagnostic modalities have been inconclusive.

Digital Image Analysis (DIA) Is a Useful Adjunct to Endosonographic Diagnosis of Submucosal Lesions (SML) of the Gastro-Intestinal Tract

Establishing definitive diagnosis of gastrointestinal SML remains a challenge. Information from EUS further delineates the lesions, but histologic data remain the gold standard. To enhance the diagnostic capability of EUS, with the hope to circumvent the need for tissue acquisition, EUS images were digitally analyzed using the technique described pervious by us to discern any parameters that can differentiate clinically significant lesions such as, gastrointestinal stromal cell tumors (GIST) and carcinoids from more benign lesions such as such as, lipoma. Objective: To evaluate the role of DIA of EUS images of SML. Methods: Patients with histopathologically confirmed SML who had undergone EUS evaluation were identified from our database. Representative regions of interest (ROIs) were digitally selected from their EUS images [Gastrointest Endosc 2006;63(5): AB 256, Gastrointest Endosc 2007;65(5):AB 103, & Das, Gastrointest Endosc 2008 (in press)]. Texture analyses were performed using histogram, run-length and co-occurrence matrix (measuring runs of pixels and distribution of pairs of pixels), gradient analysis (spatial distribution of pixels), auto-regressive analysis (measurement of local interaction amongst pixels of different grey level values) and also wavelet analysis (which measures parameters of spatial frequency). Results: A total of 106, 111 and 124 ROIs were selected from EUS images of 8, 10 and 28 patients with lipoma, carcinoids and GIST, respectively. Principal component analysis (PCA) was used for data reduction and later a neural network (ANN) based predictive model was built, trained and validated using the extracted texture features for classification. The performance characteristics of the ANN model in classifying lipoma, carcinoids and GIST is shown in Table. Three types of features of pixel distribution had high discriminatory power: Kurtosis (measure of the steepness of the pixel distribution), angular second momentum and horizontal and vertical grey level non-uniformity (parameters estimating the second order joint conditional probability density functions of spatial distribution of two neighboring pixels). Conclusion: DIA of texture features of EUS images is a useful non-invasive adjunct to endosonographic diagnosis of submucosal lesions. Tabled 1 SML Sensitivity Specificity PPV NPV AUC ∗ AUC of ROC curve. Lipoma 0.90 0.77 0.64 0.95 0.92 Carcinoid 0.79 0.81 0.67 0.89 0.86 GIST 0.81 0.79 0.74 0.86 0.89 ∗ AUC of ROC curve. Open table in a new tab

Endosonographic Diagnosis of Solid Pancreatic Tumors: A Retrospective Analysis from a Tertiary Referral Center

The sensitivity of endosonography for pancreatic tumors is good, but differentiation between malignant and benign lesions remains a challenge. We, therefore, analyzed the correlation between endosonographic findings and pancreatic carcinoma in a population with a high prevalence of chronic pancreatitis. 171 endosonographic examinations were retrospectively evaluated using 22 dichotomous criteria. Final diagnosis was defined by the results of pancreas resection or by clinical follow-up (median: 41 months). A sum score was established after multivariate analysis. Final diagnosis was carcinoma, chronic pancreatitis, neuroendocrine tumor and normal pancreas in 67, 65, 9, and 38 subjects (prevalence 39 %, 38 %, 5 %, 22 % respectively) After multivariate analysis, carcinoma was significantly correlated with six endosonographic criteria and age, which resulted in the following score (yes = 1, no = 0): (dilated pancreatic duct) + (vascular infiltration) + (suspicious lymph nodes) + (tumor edge with pseudopodia-like extensions) + (age > 50 years) - (increased pancreas parenchyma echogenicity) - (tumor diameter < 10 mm) + 3. After receiver operating characteristic analysis, the area under the curve was 0.85. For score values of 5 (4) or more, sensitivity was 0.63 (0.93), specificity 0.91 (0.55), positive predictive value 0.82 (0.57), negative predictive value 0.79 (0.92), positive likelihood ratio 7.24 (2.05), and negative likelihood ratio 0.41 (0.14). A simple and potentially useful score for the prediction of pancreatic cancer based on six endosonographic criteria and patient age was established. Distribution of final diagnoses in the patient population argues for the score's applicability in clinical practice of a tertiary referral center and warrants prospective validation.

Endosonographic diagnosis and follow‐up of phlegmonous gastritis

We report a case of phlegmonous gastritis in a 36-year-old man presenting with anorexia, epigastralgia, and high fever. Endoscopy showed an edematous lesion suggesting a submucosal lesion. Endosonography revealed thickening of the gastric wall, mainly involving the submucosa, with a few anechoic areas. The separation between the submucosa and the muscularis propria was unclear. The patient was treated with antibiotics and endoscopic mucosal resection. Culture of the aspirated pus from the lesion revealed Streptococcus pyogenes. Follow-up endosonography performed 1 week later showed significant improvement.