Intraductal Ultrasonography Research Articles

自己免疫性膵炎における膵内胆管狭窄の検討

自己免疫性膵炎における膵内胆管狭窄の検討

WEO NEWSLETTER AND CONTENTS

WEO NEWSLETTER AND CONTENTS

Preoperative evaluation of the longitudinal extent of borderline resectable hilar cholangiocarcinoma by intraductal ultrasonography

In patients with hilar cholangiocarcinoma (HC), longitudinal tumor extent is important for curative resection. The purpose of this study was to evaluate the longitudinal extents of HC using transpapillary intraductal ultrasonography (IDUS) for optimal surgical planning. From July 2006 to April 2010, a total of 42 patients with borderline resectable HC were enrolled at Samsung Medical Center, a tertiary referral hospital in Seoul, Korea. All patients were evaluated using multi-detector computed tomography (MDCT), endoscopic retrograde cholangiopancreatography (ERCP) and IDUS. The new modified Bismuth Type (MBT) classification, in which the traditional Bismuth type IV stage is divided into stages IVa and IVb, was used to determine whether the tumor invaded the left lateral section. Among the subtypes of HC, the periductal infiltrative type (PDI) and intraductal papillary neoplasm of the bile duct (IPN-B) were compared. The accuracies of CT, ERCP, and IDUS were assessed through comparison with the postoperative histology findings. A total of 42 patients were prospectively enrolled, and the tumor extent could be assessed histologically in 30 patients. The accuracies of CT, ERCP, and IDUS were 66.6%, 60%, and 90%, respectively. The accuracy of IDUS was 85.7% in 21 patients with PDI and 100% in nine patients with IPN-B. Hilar cholangiocarcinoma staging based on IDUS findings was highly accurate. We therefore highly recommend using IDUS for optimal surgical planning in patients with borderline resectable HC.

A case of intraductal papillary mucinous neoplasms after recurrent acute pancreatitis.

We report a case of main pancreatic duct (MPD)-type intraductal papillary mucinous neoplasms of the pancreas (IPMNs), in whom diagnostic imaging modalities showed abnormal findings after 4 episodes of acute pancreatitis. The patient was 51years old at his first admission for acute pancreatitis. He experienced two more episodes of acute pancreatitis, though repeated computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) showed no abnormality to explain the cause of the pancreatitis. After 3½ years from his first episode of pancreatitis, CT and endoscopic ultrasonography revealed pancreatic duct dilation of the pancreas head. Seven years after the first admission, a second ERCP and intraductal ultrasonography revealed a partially dilated MPD with papillary tumors. He underwent pancreaticoduodenectomy, and the pathological diagnosis was intraductal papillary mucinous adenoma with moderate atypia. This case suggests that acute pancreatitis can precede visualized IPMNs. Therefore, acute recurrent pancreatitis with unknown etiology should be followed up for the possibility of IPMNs, in order to detect neoplastic changes in the early stage to provide a better prognosis for the patient.

The role of endoscopy in the management of choledocholithiasis

The role of endoscopy in the management of choledocholithiasis

Endoscopic Pancreatic Duct Stents Reduce the Incidence of Post–Endoscopic Retrograde Cholangiopancreatography Pancreatitis in High-Risk Patients

Pancreatitis is the most common and potentially serious complication of post-endoscopic retrograde cholangiopancreatography (ERCP). Post-ERCP pancreatitis (PEP) is caused mostly by postprocedural papillary edema and retention of pancreatic juice. We conducted a randomized controlled trial to determine whether placement of a temporary-type, pancreatic duct stent prevents PEP and to identify risk factors for PEP. We analyzed data from 426 consecutive patients who underwent ERCP-related procedures at 37 endoscopic units. The patients were assigned randomly to groups that received stents (S group, n = 213) or did not (nS group, n = 213). The stent used was temporary, 5F in diameter, 3 cm long, and straight with an unflanged inner end. The overall frequency of PEP was 11.3%. The frequencies of PEP in the S and nS groups were 7.9% and 15.2%, respectively; the lower incidence of PEP in the S group was statistically significant based on the full analysis set (P = .021), although there was no statistically significant differences in an intention-to-treat analysis (P = .076). There were significant differences in PEP incidence between groups in multivariate analysis for the following risk factors: pancreatography first, nonplacement of a pancreatic duct stent after ERCP, procedure time of 30 minutes or more, sampling of pancreatic tissue by any method, intraductal ultrasonography, and difficulty of cannulation (≥15 min). Patients with more than 3 risk factors had a significantly greater incidence of pancreatitis. Placement of a pancreatic duct stent reduces the incidence of PEP. Several risk factors are associated with PEP.

Su1376 Preoperative Evaluation of Longitudinal Tumor Extent by Intraductal Ultrasonography in Borderline Resectable Hilar Cholangiocarcinoma

Su1376 Preoperative Evaluation of Longitudinal Tumor Extent by Intraductal Ultrasonography in Borderline Resectable Hilar Cholangiocarcinoma Da Min Kim, E Ryoung Choi, Jong Kyun Lee, Kyu Taek Lee, Kwang Hyuck Lee, Dong-Wook Choi, Sung Ho Choi, Jin-Seok Heo, Kee Taek Jang, Sang-Mo Park, Jae Hoon Lim Samsung medical center, Seoul, Republic of Korea Objective: In hilar cholangiocarcinoma (HC), longitudinal tumor extent is important issue for curative resection. The purpose of this study was to evaluate longitudinal tumor extent of HC with intraductal ultrasonography (IDUS) for optimal surgical plan. Materials and Methods: Patients with borderline resectable HC were prospectively enrolled. All patients were evaluated by multi-detector computed tomography (MDCT), endoscopic retrograde cholangiopancreatography (ERCP), IDUS, and/or magnetic resonance imaging (MRI). We used new modified Bismuth type (MBT) which divided traditional Bismuth type IV into IVa and IVb whether tumor invaded left lateral section. Accuracies of CT, ERCP, and IDUS for the longitudinal tumor extent were compared with postoperative histologic tumor extent. We also sub-analyzed the tumor extent as periductal infiltrative type (PDI) and intraductal papillary neoplasm of the bile duct (IPN-B). Results: A total of 42 patients were prospectively enrolled. Among 42 patients, 31 patients underwent surgery for curative intension. Tumor extent could be assessed histologically in 30 patients. When comparing preoperative and postoperative MBT, the accuracies of CT, ERCP and IDUS were 66.6%, 60%, and 90%, respectively. Overestimation was in one patient and underestimation was in two patients by IDUS. Accuracy of IDUS was 85.7% in 21 patients with PDI and 100% in 9 patients with IPN-B. Conclusion: The IDUS for assessing longitudinal tumor extent was highly accurate than other conventional images. IDUS can give advantage for optimal surgical plan in HC.

Mo1501 Clinical Utility of Intraductal Ultrasonography (IDUS) in the Reduction of the Recurrence Rate of the Common Bile Duct Stones After Endoscopic Papillotomy

Intraductal ultrasonography (IDUS) is highly accurate diagnostic tool in detection of common bile duct stones (CBDs). The aim of this study was to clarify whether IDUS right after endoscopic papillotomy(EPT) contributes to decrease the recurrence rate of CBDs for a 5-year period.

Mo1356 Intraductal Ultrasound (IDUS) Substantiates the Diagnosis of Bile Duct Strictures of Unknown Etiology: Results of a Histopathologically Controlled Retrospective Study Including 402 Patients

All procedures were performed under general anesthesia with endotracheal intubations. Trans-gastric NOTES approach was achieved by puncturing the gastric wall using a needle knife followed by a 8mm-balloon (CRETMESO/ PYL5839, Boston Scientific, USA) dilation for small sized endoscope and a 18mm-balloon (CRETMESO/PYL5841, Boston Scientific, USA) dilation for big sized endoscope. Carbon dioxide was used for laparoscopy and NOTES pneumoperitoneum. Following the peritoneoscopy, the endoscope was withdrawn into the stomach and gastric wall incision was closed with EndoClips. The animals were survived for 2 weeks and then sacrificed for post-mortem examination. Blood was drawn at 1h preoperatively and 1h, 12h, 2d, 7d postoperatively. WBC was tested and Inflammatory markers (TNF-a, IL-6) were analyzed by ELISA. Results: The peritoneoscopy was successfully finished by both NOTES route and laparoscopic route. There were no intra-operative and post-operative complications. No significant differences were found between SG, BG and LG in terms of TNF-a levels at 1h pre-operatively (P 0.414) and at 1h (P 0.9173), 12h(P 0.3352), 2d(p 0.6208), 7d(p 0.4109) post-operatively. There was no significant difference in IL-6 levels at the same time points as above among the 3 groups (p 0.05). There was no significant difference of WBC counts among the 3 groups at 2d (p 0.2879) and 7d (p 0.0690) post-operatively. Conclusions: Transgastric NOTES peritoneoscopy is not less invasive than laparoscopy and a small sized endoscope is not superior to a big sized one for NOTES procedure in terms of inflammatory response.

Post-ERCP pancreatitis in 2364 ERCP procedures: is intraductal ultrasonography another risk factor?

Acute pancreatitis is considered a relevant major complication following endoscopic retrograde cholangiopancreatography (ERCP); according to literature data, the incidence varies between 1.5 % and 17 %. In the present study, we aimed to identify potentially new, hitherto unknown risk factors for post-ERCP pancreatitis. A total of 2364 ERCP procedures performed in 1275 patients during the years 2004 - 2008 were included in the study. Post-ERCP pancreatitis was defined as acute abdominal pain within 48 hours following ERCP with at least 3-fold elevated levels of serum lipase and a requirement for analgesic drugs for at least 24 hours. The severity of the pancreatitis was determined using the Imrie score. In our cohort study a total of 54 different patients (2.3 %) developed post-ERCP pancreatitis. In 50 of these patients (92.6 %) the pancreatitis was mild; in 54 (7.4 %) it was severe. Patients with post-ERCP pancreatitis had highly significantly lower bilirubin levels than patients who did not have post-ERCP pancreatitis ( P < 0.001). Length of hospital stay, duration of analgesics, and need for analgesic drugs were significantly higher in patients suffering from severe pancreatitis ( P ≤ 0.01). In multivariate analysis, among other, already well-described risk factors we identified intraductal ultrasonography as another risk factor for post-ERCP pancreatitis, with a hazard ratio of 2.41 ( P = 0.004). According to our retrospective data, intraductal ultrasonography seems to be another independent risk factor for developing post-ERCP pancreatitis, which needs to be further elucidated in prospective studies.

The role of intraductal US in the management of idiopathic recurrent pancreatitis without a definite cause on ERCP

The cause of pancreatitis is unknown in as many as 30% of cases of recurrent acute pancreatitis, even after ERCP. To investigate the role of intraductal US (IDUS) for managing idiopathic recurrent pancreatitis (IRP). Prospective study. Tertiary referral hospital. Thirty-one patients with suspicious IRP with negative findings on ERCP. IDUS during ERCP. IDUS findings showing any possible cause of pancreatitis. IDUS revealed small bile duct stones (≤3 mm) in 5 patients (16.1%) and sludge in 3 patients (9.7%). The detection rate for a bile duct stone and sludge was significantly higher in patients with a dilated CBD than a nondilated CBD on ERCP (71.4 vs 12.5%; P < .05). Recurrent pancreatitis did not develop in 7 of 8 patients with biliary stones or sludge after an endoscopic sphincterotomy (EST). Two patients (6.5%) demonstrated a small polypoid lesion on the distal end of the pancreatic duct. One patient underwent surgery for intra-ampullary cancer, and another one underwent EST without another attack of pancreatitis. Three patients (9.7%) showed evidence of chronic pancreatitis with small pancreatic stones and/or calcifications on IDUS. Small number of patients. IDUS results were not compared with those of conventional EUS. There was no reference standard for chronic pancreatitis as diagnosed by IDUS. IDUS identified a possible cause of idiopathic recurrent pancreatitis in 42% of patients with negative findings on ERCP. The IDUS-guided approach combined with ERCP and EST may be useful for decreasing recurring attacks of pancreatitis.

ENDOSCOPIC DIAGNOSIS AND TREATMENT OF AMPULLARY NEOPLASM (WITH VIDEO)

For ampullary cancer, pancreaticoduodenectomy is considered to be the standard treatment. Endoscopic papillectomy (EP) has been utilized in cases of ampullary adenoma since the early 1980s. We aimed to provide a review concerning EP. We conducted a review of studies regarding EP for ampullary neoplasms. Since neither lymphatic permeation, vascular invasion, nor lymph node metastasis is observed in patients with ampullary cancer limited to the mucosa, EP of such tumors without ductal infiltration into the pancreatic/bile duct can be justified as radical treatment. For its application in patients with ampullary neoplasms, accurate pretreatment staging is indispensable. EUS, which can be carried out on an outpatient basis with a low risk of complications, is useful for differential diagnosis as well as detection of periampullary tumors. Although intraductal US of the bile duct tends to result in overestimation of tumor staging in cases of ampullary neoplasm, it can provide useful information for making therapeutic decisions, especially in cases appropriate for EP. While the technical success rate of EP is high, the complication rate and recurrence rate are not as low as a satisfactory level. Pancreatic duct stenting after EP is expected to contribute to prevention of post-EP pancreatitis. There is no consensus regarding the mode of resection current nor the need for addition of biliary/pancreatic sphincterotomy and biliary stenting. EP has been reported to be useful in selected patients with ampullary neoplasms. Data on further long-term follow up after EP are awaited.

Endoscopic diagnosis of extrahepatic bile duct carcinoma: Advances and current limitations

The accurate diagnosis of extrahepatic bile duct carcinoma is difficult, even now. When ultrasonography (US) shows dilatation of the bile duct, magnetic resonance cholangiopancreatography followed by endoscopic US (EUS) is the next step. When US or EUS shows localized bile duct wall thickening, endoscopic retrograde cholangiopancreatography should be conducted with intraductal US (IDUS) and forceps biopsy. Fluorescence in situ hybridization increases the sensitivity of brush cytology with similar specificity. In patients with papillary type bile duct carcinoma, three biopsies are sufficient. In patients with nodular or infiltrating-type bile duct carcinoma, multiple biopsies are warranted, and IDUS can compensate for the limitations of biopsies. In preoperative staging, the combination of dynamic multi-detector low computed tomography (MDCT) and IDUS is useful for evaluating vascular invasion and cancer depth infiltration. However, assessment of lymph nodes metastases is difficult. In resectable cases, assessment of longitudinal cancer spread is important. The combination of IDUS and MDCT is useful for revealing submucosal cancer extension, which is common in hilar cholangiocarcinoma. To estimate the mucosal extension, which is common in extrahepatic bile duct carcinoma, the combination of IDUS and cholangioscopy is required. The utility of current peroral cholangioscopy is limited by the maneuverability of the "baby scope". A new baby scope (10 Fr), called "SpyGlass" has potential, if the image quality can be improved. Since extrahepatic bile duct carcinoma is common in the Far East, many researchers in Japan and Korea contributed these studies, especially, in the evaluation of longitudinal cancer extension.

Endoscopic diagnosis of pancreaticobiliary maljunction

Pancreaticobiliary maljunction (PBM) is a congenital anomaly defined as a junction of the pancreatic and bile ducts located outside the duodenal wall, usually forming a markedly long common channel. As the action of the sphincter of Oddi does not functionally affect the junction in PBM patients, continuous pancreatobiliary reflux occurs, resulting in a high incidence of biliary cancer. PBM can be divided into PBM with biliary dilatation (congenital choledochal cyst) and PBM without biliary dilatation (maximal diameter of the bile duct ≤ 10 mm). The treatment of choice for PBM is prophylactic surgery before malignant changes can take place. Endoscopic retrograde cholangiopancreatography (ERCP) is the most effective examination method for close observation of the pattern of the junction site. When the communication between the pancreatic and bile ducts is maintained, despite contraction of the sphincter on ERCP, PBM is diagnosed. In these patients, levels of pancreatic enzymes in the bile are generally elevated, due to continuous pancreatobiliary reflux via a long common channel. Magnetic resonance cholangiopancreatography and 3D-computed tomography can diagnose PBM, based on findings of an anomalous union between the common bile duct and the pancreatic duct, in addition to a long common channel. Endoscopic ultrasonography and intraductal ultrasonography can demonstrate the junction outside the duodenal wall, and are useful for the diagnosis of associated biliary cancer. Gallbladder wall thickness on ultrasonography can be a screening test for PBM.

A Case of Sclerosing Cholangitis without Pancreatic Involvement Thought to be Associated with Autoimmunity

Sclerosing cholangitis (SC) is one of the lesions frequently seen in IgG4-related systemic diseases, causing biliary stricture and mimicking bile duct carcinoma and primary sclerosing cholangitis (PSC). Although it often accompanies autoimmune pancreatitis (AIP), autoimmune-related SC without a pancreatic lesion is very rare. A 79-year-old woman was referred to our institution with suspected diagnosis of bile duct carcinoma in the previous hospital. The patient was not icteric and fever free, but with an elevated level of serum biliary enzyme, which lead us to detect this disease. Clinical images including computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP) and intraductal ultrasonography (IDUS) demonstrated multiple strictures at the intrahepatic bile duct and enhanced wall thickness at the upper common bile duct, however her pancreas was normal. Repeated endoscopic procedures with multiple biopsies from the biliary strictures demonstrated fibrous ductal tissues with lymph-plasma cell infiltration (>10 IgG4(+) cells/HPF). By positron emission tomography using (18)F-fluorodeoxyglucose (FDG-PET), the uptake of FDG was not remarkable in areas other than the biliary lesions. Additional laboratory tests showed elevated levels of serum IgG (2,571 mg/dL), and γ-globulin (29%), and positive autoantibodies, but normal IgG4 (53.2 mg/dL). Together with clinical images, laboratory and histological findings, we diagnosed this patient as sclerosing cholangitis which was thought to be associated with autoimmunity. After one year of follow-up without steroid therapy, idiopathic thrombocytopenic purpura (ITP) developed with an increased level of serological markers. We encountered a rare case of sclerosing cholangitis expected to be associated with autoimmunity, which showed biliary strictures mimicking bile duct carcinoma and needed careful diagnosis. Unlike the typical AIP, the current case demonstrated distinct serological findings and no other organ involvement. Further study is needed to clarify the characteristics of sclerosing cholangitis associated with autoimmunity with a large number of cases.

LATERAL SPREAD ALONG THE MAIN PANCREATIC DUCT IN BRANCH‐DUCT INTRADUCTAL PAPILLARY‐MUCINOUS NEOPLASMS OF THE PANCREAS: USEFULNESS OF INTRADUCTAL ULTRASONOGRAPHY FOR ITS EVALUATION

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas tend to spread intraepithelially along the pancreatic duct wall. We evaluated histopathological intraductal lateral spread (LS) along the main pancreatic duct (MPD) from branch-duct IPMN and investigated the usefulness of intraductal ultrasonography (IDUS) for its preoperative diagnosis. Twenty-four patients with branch-duct IPMN who had undergone preoperative IDUS and surgery were reviewed clinicopathologically. The prevalence and histological length of LS along the MPD from branch-duct IPMN, characteristics of the patients with LS, and efficacy of LS assessment by IDUS were examined. LS along the MPD was observed in 54% of the subjects. In the group of patients with LS, its mean length was 25.2±16.8mm (5-50mm) and the diameter of the MPD was 6mm or greater. Of the patients with LS, those in whom the length of LS along the MPD was longer than the diameter of the cystically dilated branch accounted for 30%. The diameter of the MPD in the group with LS was significantly greater than that in the group without LS (P=0.03). The sensitivity, specificity, and overall accuracy of IDUS in the detection of LS were 92%, 91%, and 92%, respectively. LS along the MPD was detected in about half of the resected cases of branch-duct IPMN. Preoperative transpapillary IDUS may be beneficial for the determination of the resection line, especially in those branch-duct IPMN patients in whom the MPD is 6 mm or greater in diameter.

INTRADUCTAL ULTRASONOGRAPHY IN THE DIAGNOSIS OF BILE DUCT STONES: WHEN AND WHOM?

Biliary intraductal ultrasonography (IDUS) is highly sensitive in visualizing bile duct stones (BDS). Indications for IDUS, however, in cases of suspected BDS have not yet been established. The aim of the present study was to elucidate adequate indications for IDUS in cases that undergo endoscopic retrograde cholangiopancreatography (ERCP) due to suspected BDS. A total of 213 patients who were suspected of having BDS were included in this retrospective study. The patients were divided into two groups: Group A in which BDS was visualized by ERCP; and Group B in which BDS was demonstrated only by IDUS. Comparison between the groups was carried out. ERCP successfully visualized BDS in 166 patients. Forty-seven patients underwent IDUS, which revealed BDS and biliary sludge in 12 and eight patients, respectively. The diameter of the largest stone was 13 ± 6 mm in Group A and 5 ± 1 mm in Group B (P < 0.001). The sensitivity, specificity, and accuracy of ERCP in the diagnosis of BDS were 93%, 100%, and 94%, respectively. The sensitivity was influenced by the size of BDS: 100% in cases of stones ≥ 8 mm in size, but 74% in those with stones < 8 mm. In cases with stones < 8 mm, the sensitivity was significantly affected by the bile duct diameter (≥ 12 mm vs < 12 mm, P < 0.05). When ERCP fails to visualize stones in patients with suspected BDS, IDUS is recommended, especially in those with a bile duct ≥ 12 mm in diameter.

Obstructive jaundice caused by a portal cavernoma

A 69-year-old Japanese man was admitted to our hospital because of acute cholangitis with biliary obstruction. The cause of obstruction was either compression by a portal cavernoma or cavernous transformation. Multidetector row computed tomography (MDCT) and abdominal ultrasonography (US) revealed a portal cavernoma around the common bile duct. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiography (ERC) demonstrated characteristic short, smooth narrowing of the bile duct. Endoscopic US and intraductal US demonstrated collateral vessels around the bile duct and were helpful for ruling out a neoplastic lesion. Thus, a combination of imaging modalities was useful for diagnosing this hepatobiliary complication, portal biliopathy.

DISCRIMINATION BETWEEN SCLEROSING CHOLANGITIS‐ASSOCIATED AUTOIMMUNE PANCREATITIS AND PRIMARY SCLEROSING CHOLANGITIS, CANCER USING INTRADUCTAL ULTRASONOGRAPHY

Differentiation of sclerosing cholangitis-associated autoimmune pancreatitis (SC-AIP), primary sclerosing cholangitis (PSC) and cancer of the hilar part of the bile duct (CHB) has been challenging. The aim of the present study was to evaluate characteristic intraductal ultrasonography (IDUS) features that could be used to discriminate SC-AIP from PSC and CHB. Six patients with SC-AIP, 10 patients with PSC and 12 patients with CHB were identified. We reviewed the following bile duct features observed using IDUS to determine their usefulness for differentiating SC-AIP from PSC and CHB: presence of symmetrical wall thickness, wall thickness, presence of homogeneous internal foci and presence of lateral mucosal lesions continuous to the hilar. IDUS results (SC-AIP, PSC, CHB) were as follows: wall thickness (mm), 3.7±0.9, 2.6 ±0.9, 2.8±0.0.6; presence of symmetrical wall thickness, 100% (6/6), 20% (2/10), 8.3% (1/12); presence of homogeneous internal foci, 100% (6/6), 10% (1/10), 8.3% (1/12); and presence of lateral mucosal lesions continuous to the hilar, 83.3% (5/6), 40%(4/10), 25% (3/12). Symmetrical wall thickness of the bile duct, homogeneous internal foci and lateral mucosal lesions continuous to the hilar were detected significantly more often among the patients with SC-PSC than among the patients with PSC or CHB (P<0.05). IDUS findings, such as symmetrical wall thickness, presence of homogeneous internal foci and presence of lateral mucosal lesions continuous to the hilar can facilitate the differential diagnosis of SC-AIP from PSC and CHB.

Diagnosis value of intraductal ultrasonography for pancreatic diseases

Objective To evaluate the value of intraductal ultrasonography(IDUS)in diagnosis of pancreatic diseases.Methods We retrospectively reviewed the imaging data of 63 patients with pancreatic diseases who underwent IDUS from February 2005 to February 2010.A 20 MHz over-the-guidewire intraductal US catheter probe was used during endoscopic retrograde cholangio-pancreatography(ERCP)for further examination of the pancreas.We also compared the results of CT,magnetic resonance imaging(MRI),endoscopic ultrasonography(EUS)and abdominal ultrasonography in diagnosis of pancreatic diseases,so as to further evaluate the value of IDUS in the clinical diagnosis of pancreatic diseases.Results The accuracies of IDUS in diagnosis of chronic pancreatitis(23 cases),pancreatic cancer(10 cases),intraductal papillary mucinous tumors(IPMT,25 cases),and pancreatic adenoma(4 cases)were 93.7%(59/63),100.0%(63/63),90.5%(57/63),and 96.8%(61/63),and the Kappa values were 0.854,1.00,0.898,and 0.848,respectively.The diagnostic accuracies and Kappa test values of IDUS were better than those of the other four methods.IDUS correctly diagnosed the pancreatic cystadenocarcinoma in one patient before operation.Conclusion IDUS has a high diagnostic value for pancreatic diseases.