Ultrasound analysis for pancreatic panniculitis: A case report / 中南大学学报(医学版)

Pancreatic panniculitis (PP) is a necrotizing inflammation of subcutaneous fat that is a rare complication of pancreatic disease appearing in 2% to 3% of all patients. It is more common in the elderly and often affects the extremities. It presents as skin inflammation with pain and erythema nodules. We report a case of acute pancreatitis associated with PP in an old female. She was admitted for vomiting and abdominal pain for 3 days and presented with a 2-week history of erythematous subcutaneous nodules on her legs. Laboratory and ultrasonic findings revealed acute pancreatitis. High frequency ultrasound showed hypoechoic foci in subcutaneous soft tissue layer and adipose layer. Histopathological examination confirmed the diagnosis of PP. Nodules disappeared with the resolution of acute pancreatic inflammation. PP may be the first manifestation of pancreatic disease. Imaging features of this pathology are seldom described and ultrasonic diagnosis experience is worth to be accumulated.

Eficacia y seguridad del drenaje ecoendoscópico de colecciones líquidas peripancreáticas en un hospital de referencia / Efficacy and safety of echoendoscopy drainage of liquid peripancreatic collections in a reference hospital

RESUMEN Introducción: El drenaje guiado por ecoendoscopía es considerado como la mejor opción para el drenaje de las colecciones liquidas peripancreáticas. No hay reportes en nuestro medio de la experiencia en esta terapia endoscópica. Objetivos: detallar las características, eficacia y seguridad de los drenajes ecoendoscópicos de las colecciones liquidas peripancreáticas en el Hospital Nacional Edgardo Rebagliati Martins. Material y métodos: se realizó un estudio transversal retrospectivo de todos los pacientes con colecciones liquidas peripancreáticas sintomáticas sometidos a drenaje ecoguiado. Se analizaron variables demográficas, características ecoendoscópicas asociadas al procedimiento terapéutico y dispositivos empleados. La eficacia se evaluó con la tasa de éxito técnico y de éxito clínico. La seguridad se evaluó en base a las principales complicaciones inmediatas y posteriores. Se empleó estadística descriptiva básica. Resultados: Se realizaron 17 drenajes ecoguiadas de colecciones peripancreáticas (10 pseudoquistes y 7 necrosis pancreáticas encapsuladas o WON) en 17 pacientes: 9 mujeres (52,9%) y 8 hombres (47,1%). El rango de edad de los pacientes fue de 26-72 años, con una mediana de 59 años. El tamaño promedio de las colecciones liquidas fue 14,8 cm con un rango de 8-24 cm. El acceso transgástrico se empleó en 16 casos (94,1%) y el acceso transduodenal en 1 caso (5,9%). Se empleó prótesis plástica (6 casos), prótesis metálica autoexpandibles (SEMS) biliar (4 casos) y prótesis de aposición luminal (LAMS) en 7 casos. El éxito técnico fue del 100% (17 pacientes), mientras que el éxito clínico fue de 70,6% (12 pacientes). Las complicaciones ocurrieron en 41,2%: infección de colección (2 casos), perforación, sangrado en zona de drenaje, obstrucción de prótesis plástica, migración de prótesis al interior de colección y al lumen gástrico (1 caso cada uno). El manejo quirúrgico de éstas complicaciones fue necesaria en 3 casos, mientras que en los otros 4 casos solo requirió manejo médico - endoscópico. Conclusiones: los drenajes guiados por ecoendoscopía de las colecciones liquidas peripancreáticas tienen alta tasa de éxito técnico y clínico con reducido porcentaje de complicaciones.

ABSTRACT Introduction: Endoscopic ultrasound (EUS) guided drainage is considered the best option for peripancreatic fluid collections drainage. There are no previous reports in our country of this type of endoscopic therapy. Objectives: To detail the characteristics, efficacy and safety of EUS-guided drainage of peripancreatic fluid collections at Edgardo Rebagliati Martins National Hospital. Materials and methods: We carried out a retrospective cross-sectional study of all patients who underwent EUS-guided drainage of symptomatic peripancreatic fluid collections. Demographics, procedure-related endosonographic features and devices used were analyzed. We assessed the effectiveness with technical and clinical success rate. Clinical safety was assessed based on major immediate and delayed adverse events. Basic descriptive statistics was used. Results: A total of 17 patients (9 women, 52.9% and 8 men, 47.1%) with peripancreatic fluid collections (10 pseudocysts and 7 walled-off necrosis) underwent EUS-guided drainage. The median age of the patients was 59 years (range 26 - 72 years). The mean diameter of the fluid collections was 14.8 cm (range 8-24 cm). Transgastric route was used in 16 cases (94.1%) and transduodenal route in 1 case (5.9%). Plastic stent (6 cases), biliary self expanding metal stent (4 cases) and lumen apposing stent (7 cases) were used. The technical success rate was 100% (17 patients), while clinical success rate was 70.6% (12 patients). Adverse events occurred in 41.2%: infection (2 cases), perforation, bleeding, plastic stent occlusion, stent migration into the collection cavity and out of the collection cavity (1 case each one). Surgical management of adverse events was necessary in 3 cases, while the 4 other cases only required medical - endoscopic management. Conclusions: EUS-guided drainage of peripancreatic fluid collections have a high technical and clinical success rate with a low percentage of adverse events.

Utilidad del contraste endovenoso en ecoendoscopía pancreática. Reporte de casos / Usefulness of intravenous contrast in pancreatic echoendoscopy. A case series

RESUMEN El empleo del contraste endovenoso permite aumentar la capacidad diagnostica de la ecoendoscopía en muchas condiciones patológicas de forma no invasiva, mediante la evaluación de patrones de realce en tiempo real (hipo, iso e hipercaptación), permitiendo a su vez definir diagnósticos diferenciales o predecir diagnósticos histológicos con alta precisión por medio de la caracterización de la vascularidad o microvasculatura de un órgano o lesión. Sin embargo, su empleo en nuestro medio está limitado por no contar con estos medios de contraste. Reportamos tres casos de ecoendoscopía contrastada realizada en patología pancreática realizada en nuestro hospital, en el que se describe la utilidad en el diagnóstico y manejo de lesiones sólidas y quísticas del páncreas.

ABSTRACT The intravenous contrast (IV) allows for improving the diagnostic accuracy of echoendoscopy for many pathologic conditions. IV contrast provides a non-invasive method that through the use of real-time enhancement patterns (hypo, iso, and hypercaptation), a highly accurate histological diagnosis can be made by characterizing the microvasculature of an organ or a lesion. However, the lack of availability of IV contrast limited its use in our setting. We reported three cases of endoscopic ultrasound with IV contrast performed in the pancreatic department of National Hospital Eduardo Rebagliati Martins in Lima, Peru. We described the effectiveness of IV contrast in the diagnosis and the management of solid and cystic lesions in the pancreas.

Prediabetes and type 2 diabetes are independent risk factors for computed tomography-estimated nonalcoholic fatty pancreas disease

OBJECTIVES: Nonalcoholic fatty pancreas disease (NAFPD) is characterized by excessive fat deposition in the pancreas in the absence of alcohol consumption. In this study, we aimed to detect a possible relationship between adipose tissue accumulation, prediabetes and diabetes. METHODS: This cross-sectional and retrospective study included 110 patients. Three groups were classified as controls, patients with prediabetes and patients with type 2 diabetes. The abdominal computed tomography (CT) attenuation measurement results of the pancreas were evaluated independently by two experienced radiologists. CT measurements and biochemical parameters were compared between study groups. The relationship between continuous variables was assessed by using one-way ANOVA. To determine the changes in the dependent variable for the effects on study groups, the independent variable was adjusted using ANCOVA. A p-value less than 0.05 was considered statistically significant. RESULTS: The presence of prediabetes and type 2 diabetes was correlated with a decrease in the mean Hounsfield Unit (HU) value of the pancreas (p=0.002). Age was determined to be an independent risk factor and was correlated with NAFPD (p=0.0001). When compared to the controls (p=0.041), 71% of patients with prediabetes and 67% of patients with type 2 diabetes were observed to have an increased incidence of NAFPD. Decreased serum amylase was found to be correlated with the mean HU value of the pancreas (p=0.043). CONCLUSION: NAFPD was independently correlated with both prediabetes and type 2 diabetes adjusted for age (p=0.0001) in this study. Additionally, age was determined to be an independent risk factor and was correlated with NAFPD.

Pancreatic endosonographic findings and clinical correlation in Crohn's disease

OBJECTIVES: We aimed to evaluate the incidence of pancreatic alterations in Crohn's disease using endoscopic ultrasound (EUS) and to correlate the number of alterations with current clinical data. METHODS: Patients diagnosed with Crohn's disease (n=51) were examined using EUS, and 11 variables were analyzed. A control group consisted of patients with no history of pancreatic disease or Crohn's disease. Patients presenting with three or more alterations underwent magnetic resonance imaging (MRI). Pancreatic function was determined using a fecal elastase assay. RESULTS: Two of the 51 patients (3.9%) presented with four EUS alterations, 3 (5.9%) presented with three, 11 (21.5%) presented with two, and 13 (25.5%) presented with one; in the control group, only 16% presented with one EUS alteration (p<0.001). Parenchymal abnormalities accounted for 39 of the EUS findings, and ductal abnormalities accounted for 11. Pancreatic lesions were not detected by MRI. Low fecal elastase levels were observed in 4 patients, none of whom presented with significant pancreatic alterations after undergoing EUS. Ileal involvement was predictive of the number of EUS alterations. CONCLUSION: A higher incidence of pancreatic abnormalities was found in patients with Crohn's disease than in individuals in the control group. The majority of these abnormalities are related to parenchymal alterations. In this group of patients, future studies should be conducted to determine whether such morphological abnormalities could evolve to induce exocrine or endocrine pancreatic insufficiency and, if so, identify the risk factors and determine which patients should undergo EUS.

Evaluación rápida "in situ" de punción con aguja fina guiada por endosonografía mejora rendimiento diagnóstico de lesiones pancreáticas sólidas / Rapid on-site evaluation with endoscopic ultra sound-guided fine needle improves diagnostic yield of solid pancreatic masses

BACKGROUND: The use of endoscopic ultrasound with fine needle aspiration (EUS-FNA) has improved the characterization and staging of pancreatic solid masses. The primary strategy for improving the ability to diagnose malignant masses is the use of rapid on site evaluation (ROSE) by a cytopathologist. OBJECTIVE: To evaluate the diagnostic yield of EUS-FNA after the implementation of ROSE in an academic center. MATERIAL AND METHODS: Prospective enrollment and follow-up of EUS-FNA with ROSE during 2015 and 2016, was compared to EUS-FNA without ROSE in previous years (2011-2014) in Hospital Clínico UCChristus. Clinical and endosonographic features, cytopathological and histological diagnosis and number of passes per procedure were evaluated. All EUS-FNA included cytology and cellular block for definitive diagnosis. RESULTS: 59 pancreatic solid masses were included in the analysis. 44 EUS-FNA were performed with ROSE, compared with 15 EUS-FNA without ROSE. The mean age of patients included was 62.8 years, 54.2% male gender, and most masses studied were in the head of pancreas (77.6%). In EUS 86.5% were hypoechoic and 56.9% had poor defined margins. No differences in baseline characteristics were observed between groups. EUS-FNA led to diagnosis in 86.2% of the overall sample. The diagnostic rate was superior in the group of EUS-FNA with ROSE, compared to EUS-FNA without ROSE (97.7% vs 50%, p < 0.0001). The mean number of passes was inferior in EUS-FNA ROSE (+) (2.71 vs 5.78, p < 0.0001). No differences in rate of complications were observed between groups. CONCLUSION: The use of ROSE associated to EUS-FNA improves the diagnostic yield in the evaluation of pancreatic solid masses. Our findings are consistent with those described in the literature, recommending the use of ROSE in EUS-FNA in centers where the diagnostic yield is less than 90% without the use of ROSE

INTRODUCCIÓN: La adquisición de tejido mediante el uso de endosonografía, con punción con aguja fina, (EUS-FNA) ha mejorado el diagnóstico de lesiones pancreáticas sólidas. La principal medida para aumentar el rendimiento diagnóstico de la EUS-FNA es la evaluación por citopatólogo próximo al lugar de punción (in situ) (técnica conocida en inglés como ROSE "rapid on-site evaluation"). OBJETIVO: Evaluar el rendimiento diagnóstico de EUS-FNA en lesiones pancreáticas sólidas posterior a la implementación de ROSE en un centro universitario. MATERIAL Y MÉTODOS: Registro prospectivo de EUS-FNA realizadas con ROSE durante el período 2015-2016, comparado con EUS-FNA con evaluación histopatológica diferida realizada entre los años 2011-2014, en Hospital Clínico UC-Christus. Se evaluaron características clínicas, endosonográficas, diagnóstico histopatológico y número de pases por procedimiento. Todas las EUS-FNA incluyeron citología y block celular para diagnóstico definitivo. RESULTADOS: Se incluyeron en el análisis 59 lesiones pancreáticas sólidas evaluadas con EUS-FNA. Seguimiento prospectivo de 44 EUS-FNA con ROSE, que fueron comparadas con 15 EUS-FNA sin evaluación in situ (retrospectivo). La muestra total incluyó individuos con un promedio de 62,8 años de edad, 54,2% hombres, donde 77,6% de las lesiones se ubicaba en la cabeza pancreática. Endosonográficamente 86,5% de las lesiones eran hipoecoicas y 56,9% tenían márgenes poco definidos. La EUS-FNA fue diagnóstica en 86,2% del total de la muestra. Las EUS-FNA realizadas con ROSE presentaron un mayor rendimiento diagnóstico respecto a las efectuadas sin evaluación in situ (97,7% vs 50%, p < 0,0001). El número de pases por procedimiento fue menor (2,7% vs 5,8%, p < 0,0001) en el grupo con ROSE. No hubo diferencias en complicaciones en ambos grupos. CONCLUSIÓN: La evaluación por citopatólogo in situ de la muestra obtenida por EUS-FNA mejora el rendimiento diagnóstico de las lesiones pancreáticas sólidas. Nuestros hallazgos apoyan el uso de ROSE asociado a EUS-FNA, siendo concordantes con las recomendaciones actuales de utilizar evaluación histopatológica in situ en EUS-FNA, especialmente en centros donde el rendimiento diagnóstico sin uso de ROSE es menor a 90%.

Ultrasonido endoscópico en patologías del páncreas / Endoscopic ultrasound in pancreatic diseases

El ultrasonido endoscópico (EUS) ha revolucionado el diagnóstico y el manejo de muchas patologías de la vía digestiva, particularmente la patología pancreática, convirtiéndose en un examen prácticamente imprescindible en el abordaje diagnóstico y terapéutico de un paciente con un problema de páncreas. Es necesario dejar en claro que el método no es único y que para lograr una sensibilidad alta y cumplir el objetivo de realizar lo más adecuado, debe sumarse a otros métodos de acuerdo a cada caso, como la ecografía, la tomografía axial computarizada (TAC), la resonancia magnética (MRI) en sus diferentes modalidades, y las pruebas del laboratorio clínico microbiológico y patología. En este artículo se revisarán algunos casos de enfermedades evaluadas con este método, que muestran por qué el EUS, es una herramienta clave para el médico de urgencias y de consulta externa, el internista, el cirujano, el médico del servicio hospitalario y el personal de salud en general, al momento de definir, clasificar y orientar el manejo de determinadas patologías en el tubo digestivo. El EUS es una importante ayuda y no debe ser extraña al personal médico, debe tenerla presente junto a las demás pruebas diagnósticas en patología pancreática. Se señalarán los aspectos más relevantes en cada caso y las indicaciones del EUS.

Endoscopic ultrasound (EUS) has revolutionized the diagnosis and management of many diseases of the digestive tract, particularly the pancreatic ones, becoming a practically essential test in the diagnosis and therapeutic management of a patient with a pancreatic problem. It's necessary to establish the final diagnosis are necesary many tests to achive high sensitivity. It should join with other methods according to each case, such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) in its various forms, and chemical, microbiological and pathology tests. In this article we reviewed some cases of pathologies evaluated by this diagnosis test, which demonstrate why the EUS, is a key for the emergency and outpatient physician, internist, surgeon, doctor of the hospital service and staff health in general, when defining, classifying and guide the management of certain diseases in the digestive tract. The EUS is an important tool and should not be foreign to the medical staff, who must consider it, with other diagnostic tests for pancreatic disease. This article point out the most important aspects in each case and indications of EUS.

MRI Findings of Intrinsic and Extrinsic Duodenal Abnormalities and Variations

This pictorial review aims to illustrate the magnetic resonance imaging (MRI) findings and presentation patterns of anatomical variations and various benign and malignant pathologies of the duodenum, including sphincter contraction, major papilla variation, prominent papilla, diverticulum, annular pancreas, duplication cysts, choledochocele, duodenal wall thickening secondary to acute pancreatitis, postbulbar stenosis, celiac disease, fistula, choledochoduodenostomy, external compression, polyps, Peutz-Jeghers syndrome, ampullary carcinoma and adenocarcinoma. MRI is a useful imaging tool for demonstrating duodenal pathology and its anatomic relationships with adjacent organs, which is critical for establishing correct diagnosis and planning appropriate treatment, especially for surgery.

Von Hippel-Lindau Syndrome: Demonstration of Entire Disease Spectrum with 68Ga-DOTANOC PET-CT

Von Hippel-Lindau (VHL) syndrome is a rare neoplastic disorder characterized by central nervous system (CNS) and visceral tumors. We here present 68Ga-labelled [1, 4, 7, 10-tetraazacyclododecane-1, 4, 7, 10-tetraacetic acid]-1-Nal3-Octreotide positron emission tomography computed tomography findings in a 52 year old female with VHL syndrome, demonstrating both CNS and visceral tumors.

Modified Retroperitoneal Access for Percutaneous Intervention after Pancreaticoduodenectomy

Percutaneous access to the surgical bed after pancreaticoduodenectomy can be a challenge, due to the post-operative anatomy alteration. However, immediate complications, such as surgical bed abscess or suspected tumor recurrence, are often best accessed percutaneously, as open surgical or endoscopic approaches are often difficult, if not impossible. We, hereby, describe a safe approach that is highly replicable, in accessing the surgical bed for percutaneous intervention, following pancreaticoduodenectomy.

EUS Elastography: Advances in Diagnostic EUS of the Pancreas

Elastography is an imaging modality for the evaluation of tissue stiffness, which has been used for the analysis of superficial organs, such as those of the breast and prostate. The measurement of tissue elasticity has been reported to be useful for the diagnosis and differentiation of tumors, which are stiffer than normal tissues. Endoscopic ultrasonography elastography (EUS-EG) is a promising imaging technique with a high degree of accuracy for the differential diagnosis of solid pancreatic tumors. Recent introduction of second generation EUS-EG allows for the quantitative analysis of tissue stiffness. Here, we review our knowledge and preliminary experience with the use of EUS-elastography for the diagnosis of pancreatic disease.

Multidetector-row CT of Malignant Biliary Obstruction / 대한소화기학회지

Multidetector-row computed tomography (MDCT) is useful for the evaluation of malignant biliary obstruction because it allows faster scanning, which decreases motion and breathing artifacts, as well as thinner collimation. In addition, MDCT leads to improved 3-dimensional assessment of vascular structures and biliary tree. The purpose of this pictorial essay is to introduce scanning techniques and image acquisition methods for the evaluation of malignant biliary obstruction and to highlight the unique display of diagnostic information by multiplanar reformations of the biliary tract with MDCT.

role of computerized axial tomography [CT], ultrasonography [US], transhepatic cholangiography [PTC] and endoscopic retrograde cholangiopancreatography [ERCP] in differentiating inflammatory from malignant pancreatic focal mass lesion

Fifteen patients with focal inflammatory masses of the pancreas were thoroughly studied over 3-year period from 25 patients who have had suspected pancreatic disease. Ultrasound [US] and computerized axial tomography [CT] were performed as a screening. Subjective pancreatic enlargement and/or distortion [nodular or irregular contour] were detected in 15 cases. Transhepatic cholangiography [THC] was performed allowed a diagnosis of inflammatory disease in three patients demonstrating long smooth stricture of the common bile duct [CBD] and the 4th patient had a short, smooth stricture producing incomplete obstruction suggesting malignancy and in three the distal CBD was completely obstructed with rat- tail tapering highly suggestive of malignancy. Endoscopic retrograde cholangiopancreatography [ERCP] was successful in eight patients since they permitted pancreatitis in three, two patients malignancy could not be determined and three patients had findings usually associated with malignancy, two of them had complete obstruction of the pancreatic duct, while one had "double duct sign". The mass identified by CT usually of the same pancreatic attenuation, although five contained small areas of low attenuation suggesting inflammation. Ten patients with pancreatic head mass demonstrated obstructive jaundice. On US the inflammatory masses appeared hypoechoic. The pancreatic duct was identified sonographically in four of five patients seen by CT

Diagnostic value of endoscopic retrograde cholangiopancreatography in the evaluation of biliary and pancreatic disorders

Recent advances in fibreoptic instrumentation facilitate the direct observation of the duodenum and ampulla of Vater. Cannulation of ampulla of Vater with injection of dye provide cholangiopancreatogram in essentially all cases. An analysis of this procedure in 100 consecutive patients with biliary and pancreatic symptoms and signs reveal that it is safe and effective technique that may add significant new information in the evaluation of these patients

[Echotomography in the diagnosis of pancreatic diseases]

The diagnostic value of pancreatic echotomography was evaluated through a series of595 pancreatic echo-tomography. The study was performed by means of a normal scanning instrument yielding delayed type images, without grey color scale. Results were classified as technical failures, [generally due to intestinal gas-interposition], accurate diagnosis, dubious, wrong diagnosis, and false positive or false negative results. 7,6% false positive results were registered among 368 patients devoid of pancreatic diseases. Among 227 patients with documented diseases the diagnosis was accurate in 62,5% of cases. This percentage rose to 71,7V% when technical failure were excluded [142 cases from 198], the best score was obtained with pancreatic pseudocysts. A comparison could be drawn between the diagnostic value of both ECT and arteriography in sixty five cases. There was no significant difference between the two methods. On the other hand retrograde wirsungography and ECT appeared to be complementary technics. When associated, these methods allowed the diagnostic accuracy to be 87% of cases. This rate was significantly higher than hese obtained by either ECT or retrograde wirsungography when utilised alone