7/27/2019 W1346 The Role of Intraductal Ultrasound for Patients with Strictures in Intrapancreatic Portion of Distal Common

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W1346

The Role of Intraductal Ultrasound for Patients with Strictures

in Intrapancreatic Portion of Distal Common Bile Duct At ERCPHyun Jeong Kim, Young Deok Cho, Soo Hoon Eun, Young Dae Kim,

Jae Young Jang, Young Koog Choeon, Young Seok Kim, Jong Ho Moon,Yeon Soo Kim, Joon Seong Lee, Moon Sung Lee, Chan Sup Shim,Boo Sung KimBackground: In the strictures of distal common bile duct (CBD), ERCP is the mainprocedure. However, its diagnostic accuracy is insufficient, even with the additionof brushing and biopsy. Aims: This study was performed to evaluate the role of

intraductal ultrasound (IDUS) for the patients with strictures in intrapancreaticportion of distal CBD at ERCP. Patients & Methods: Between June 2003 and May2004, thirty patients (M:F Z 16:14, median age 66 years (range 23 - 81)) withstrictures of distal CBD at ERCP were studied. To all patients, MR and IDUS witha high-frequency (20 MHz) were performed as well as laboratory test of totalbilirubin and CA19-9, and ERCP. The final diagnosis was confirmed by pathology orclinical follow-up. Results: Fourteen patients had malignant strictures and sixteenhad benign. There were statistical differences in total bilirubin (9.94 vs. 1.91 mg/dL)and CA19-9 (199.76 vs. 84.99 U/mL) level between malignant and benign strictures.MR, ERCP and IDUS resulted in sensitivity 85.71% (12/14) vs. 85.71% (12/14), vs.100% (14/14), specificity 75% (12/16) vs. 68.75% (11/16) vs. 81.25% (13/16) andaccuracy 80% (24/30) vs. 76.67% (23/30) vs. 90% (27/30). MR, ERCP and IDUSproduced 76.67% (23/30) accordance rate but two among these were confirmedunexpectedly as benign strictures after operation. Other benign strictures weremanaged by endoscopic therapy. Malignant strictures were operated in 12 andpalliated in 2. IDUS showed 0% of false negative finding and increased the accuracyof ERCP from 76.67% to 90%. Conclusions: In malignant strictures of distal CBD,IDUS would rarely show as negative and improve the diagnostic accuracy of ERCP.Additionally, the laboratory test of total bilirubin, CA19-9 is helpful in differentialdiagnosis of benign and malignant strictures. Key words: Stricture, distal CBD,ERCP, IDUS

W1347

A Prospective Evaluation of Tandem EUS and ERCP As a Single

Procedure in Patients with Suspected CholedocholithiasisAbdulrahman M. Aljebreen, Nahla AzzamBackground: Endoscopic retrograde cholangiography (ERC) has been consideredthe gold standard for diagnosis of choledocholithiasis; however it has a significantmorbidity and mortality. Endoscopic ultrasound (EUS) is a potential alternative toERC, one that it is less invasive with a risk of complications similar to upperendoscopy. The aim of this study was to compare the diagnostic performance ofEUS and ERC as a single tandem procedure (TP) for patients with suspectedcholedocholithiasis. Methods: A prospective series of 48 patients (67% women,mean age of 43 year, range 13-95 years) suspected to have choledocholithiasisbased on clinical, biochemical and cross sectional imaging (US or CT) dataunderwent radial EUS followed by ERC as a single TP by the same endoscopiest.The endoscopiest was blinded to the clinical, biochemical and imaging data and theEUS result was recorded as positive or negative for choledocholithiasis just aftercompleting the EUS exam. Results: EUS diagnosed choledocholithiasis in 20patients (42%). EUS diagnosis was confirmed by ERC and sphincterotomy asfollows: 20 true-positive, 25 true-negative, 2 false-negative, 1 false positive. EUS has91% sensitivity, 96% specificity, 95% positive predictive value and 93% negative

predictive value with an overall diagnostic accuracy of 94 %. The average pethidineand diazepam dose (mg) which were given were: 98 (SD 32) and 17 (SD 6)respectively. Mild pancreatitis occurred in 1 patient (2%), minor sphincterotomybleeding which was controlled during the procedure occurred in 2 patients (4%)but no cardiopulmonary complications occurred. Conclusion: The results of thisstudy show that EUS is highly reliable for the diagnosis of choledocholithiasis.Tandem EUS and ERCP is relatively safe with no additional complicationsspecifically attributable to performance of EUS.

Diagnostic performance of EUS in patients with suspected choledolithiasis

EUS

Sensitivity (95% CI) 91% (79-100%)Specificity (95% CI) 96% (89-100%)Positive predictive value (95% CI) 95% (86-100%)Negative predictive value (95% CI) 93% (83-100%)Accuracy (95% CI) 94% (87-98%)

W1348

Contrast-Enhanced EUS (CE-EUS) Using a New Microbubble

Contrast Agent (MRX-815) - A Feasibility Study in a Porcine ModelRobert F. Wong, Orhan Tarcin, Nischita Reddy, Ijaz Ahmed,Douglas Brining, Terry O. Matsunaga, Manoop S. BhutaniIntroduction: Limitations of EUS with regards to pancreatic malignancy includeclearly defining vascular involvement and differentiating benign from malignantmasses. The purpose of this feasibility study was to evaluate a new microobubblecontrast agent, MRX-815 (ImaRx Therapeutics, Tuscon, AZ) to define and/orenhance the echogenicity of the peri-pancreatic vasculature and the pancreatic and

hepatic parenchyma during EUS. Methods: In an IACUC-approved study, EUS wasperformed in 3 adult swine using a radial echoendoscope (Pentax EG-3630UR) toimage the liver, pancreas and peri-pancreatic vasculature - including the celiac axis(CA), inferior vena cava (IVC), superior mesenteric artery (SMA), splenic vein (SV)and portal vein confluence (PVC). EUS was performed at baseline and after IVadministration of MRX-815 - perfluoropropane filled bubbles (mean diameter:1.1-3.3 microns). Methods of administration included bolus injection (2 ml ofcontrast diluted in saline) and constant infusion (2 ml contrast diluted in 50 mlsaline, infused at 4 ml/min). Image densitometry was assessed with Image J software(http://rsb.info.nih.gov/nih-image/). Analysis included enhancement on bothgrayscale imaging and Color Doppler of the vasculature, pancreas and liver. Results:Infusion of MRX-815 readily enhanced grayscale and Color Doppler imaging of thevasculature, including systemic and mesenteric veins and arteries. Mean time toenhancement after bolus was 8s (C2) for the CA and 17s (C2) for the PVC. Withcontinuous infusion, mean time was 30s (C12) for the CA and 38s (C11) for thePVC. Length of enhancement was greater for continuous infusion (405 C 151s)compared to bolus infusion (170 C 27s) (p Z 0.005). After bolus, the pancreaticparenchyma became more hypoechoic with accentuation of the pancreatic borders.At baseline, blood flow in the hepatic parenchyma, as assessed by Color Doppler,

was imperceptible, but after contrast injection was easily detectable. Dopplerenhancement was not noticed in the pancreas. On quantitative image analysis,densitometry of the pancreatic parenchyma was significantly less after bolusinjection (p ! 0.01), but not with continuous infusion. Color Doppler imagedensities of the liver and portal vein also showed significant quantitative increase(p ! 0.05 and p ! 0.01). Conclusions: CE-EUS with MRX-815 enhances the peri-pancreatic vasculature including color Doppler signals and pancreatic borders andattenuates grayscale imaging of the pancreatic parenchyma. This may be a usefulmethod to improve pancreatic cancer staging and to differentiate benign frommalignant masses. Research Support: ImaRx, Pentax Corp. and University of TexasMedical Branch.

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Patients with Obstructive Jaundice and Abnormal Imaging:Role of EUS/EUS-FNA in ManagementSaradhi V. Saripalli, Naveen B. Krishna, Rizwan Safdar, Banke AgarwalBackground: The role of EUS/EUS-FNA in management of patients with suspectedpancreatic cancer who have obstructive jaundice at initial presentation is debated.Because of the high probability of malignancy in this patient group, some arguethat all of these patients be taken for surgery unless there is unresectable tumoridentified by CT/MRI. We investigated the value of EUS/EUS-FNA in patients withobstructive jaundice and abnormal imaging suspicious for malignant etiology.Patients and Methods: Patients were considered for inclusion if they underwentEUS/EUS-FNA at St. Louis University Hospital between March 2002 and May 2005for obstructive jaundice and had 1) biliary stricture on ERCP or 2) abnormal CT/MRIwith mass lesion or biliary dilation. Patients with ampullary and duodenal tumorswere excluded. Final diagnosis was based on definitive cytology, surgical pathologyor clinical follow up of at least 6 month. Cytology suspicious for malignancy (n Z 6)was considered negative for malignancy for analysis. Results: 146 patients met theinclusion criteria for the study. Final diagnosis was available in 135 patients and onlythese patients were included for further analysis. Sixty-six patients had ERCP priorto EUS and had a biliary stricture while other 69 patients did not have an ERCPprior to EUS. A mass lesion was seen on CTscan in 49 patients. Ninety-eight patientshad malignant stricture, of which 91 were diagnosed with EUS-FNA and includedpancreatic adenocarcinoma (n Z 78), cholangiocarcinoma (nZ 11), gallbladdercancer (nZ 1), HCC (nZ 1), metastatic tumor in hilar nodes (n Z 3), metastatictumor to pancreas (nZ 3) and malignant lymphoma (nZ 1). Thirty-seven patientshad benign etiology of stricture including chronic pancreatitis (n Z 11), PSC(n Z 2), CBD stones (n Z 12), ampullary stenosis (n Z 9) and abscesses/fluidcollection pressing on CBD in patients with history of OLT. The accuracy ofEUS/EUS-FNA was 94.8% with 92.8% sensitivity, 100% specificity, 84.1% NPV and100% PPV. Conclusions: The accuracy of EUS-FNA in patients with pancreatic cancer,particularly those with obstructive jaundice are improving with increasingexperience amongst the endosonographers and the cytologists. The negativepredictive value of 84.1% in our cohort suggests that withholding surgery might berealistic option if the there is no definitive evidence of malignancy by EUS-FNA,particularly in patients who are poor surgical risk or are reluctant to undergosurgery.

Abstracts

AB274 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006 www.giejournal.org