Tissue Harmonic Imaging Compared with Conventional BMode Ultrasound, Biphasic CECT and Tissue Diagnosis in Evaluation of Pancreatic Masses

Background: Tissue harmonic imaging (THI) is a newer method that can diagnose and differentiate various types of pancreatic masses. The aim of this study was to evaluate the efficacy of tissue harmonic imaging for detection and differentiation of pancreatic masses and its comparison with conventional B-mode ultrasound, biphasic CECT abdomen and tissue diagnosis. Methods: 31 patients who presented with a suspicion of pancreatic mass clinically or radiologically were enrolled in this study. All patients underwent both conventional B-mode ultrasound abdomen and THI. Biphasic CECT abdomen was done for diagnostic reference. Pancreatic lesions were documented regarding site, size, internal architecture, and status of peri-pancreatic vessels. The USG diagnosis was compared with biphasic CECT and tissue diagnosis. Results: There was statistically significant difference between THI and conventional B-mode USG in visualization of image quality (p<0.001) and solid-cystic differentiation (SCD) (p=0.001). Taking tissue diagnosis as the standard, out of the 25 (80.6%) cases which were diagnosed as malignant on USG and biphasic CECT, 18(72%) cases were confirmed to be malignant on tissue diagnosis. There was no statistically significant difference between biphasic CECT and USG (conventional B-mode and THI) in the diagnosis of benign and malignant masses in pancreas (p=1). Conclusions: THI is superior to conventional B-mode USG in the Sonography of pancreatic masses because THI has better overall image quality, lesion conspicuity, visualization of lesion margin and fluid–solid differentiation. It should be routinely utilized as part of the diagnostic workup of patients with pancreatic masses.

Superiority of non-capsulated 14C-urea breath test over capsule based method for detection of Helicobacter pylori infection – a preliminary report.

Background: 14C-urea breath test (14C-UBT) is employed as a ‘gold standard’ technique for the detection of active gastric Helicobacter pylori infection and is recommended as the best option for “test-and-treat” strategy in primary health care centers. Aim: To compare the performance of capsulated and non-capsulated 14C-UBT protocols for the detection of H. pylori infection in patients. Methods: Fifty eight H. pylori infected patients underwent routine upper GI endoscopy and biopsies were processed for rapid urease test (RUT) and histopathology examination. Capsulated 14C-UBT was done in a novel way by using 74 kBq of 14C-urea along with 6.0 MBq of 99mTc-diethylene triamine penta-acetic acid (99mTc-DTPA) to simultaneously monitor the movement and the fate of ingested capsule after delineating the stomach contour by using 20.0 MBq of 99mTechnetium pertechnetate (99mTcO4-) under dual head gamma camera. Noncapsulated 14C-UBT was performed within 2 days of the previous test and the results of these protocols were compared. Results: In 3 out of 58 H. pylori positive cases (5.17%), 14C-UBT results were found to be negative by using the capsulated method. Interestingly, on monitoring the real time images of the capsule in these cases it was found that misdiagnosis of H. pylori infection occurred mainly due to either rapid transit of the 14C-urea containing capsule from the upper gastric tract or its incomplete resolution in the stomach during the phase of breath collection. Conclusion: Use of non-capsulated 14C-UBT protocol appears to be a superior option than the conventional capsule based technique for the detection of H. pylori infection.

Endoscopic ultrasound-guided treatment of bleeding duodenal varix.

A 35-year-old man presented with recurrence of upper gastrointestinal bleed after eradication of esophageal varices. Upper gastrointestinal endoscopy revealed submucosal lesion in the duodenum and endoscopic ultrasound (EUS) demonstrated it to be a duodenal varix. Cyanoacrylate glue was injected into the duodenal varix and successful obliteration of the duodenal varix was demonstrated on a follow up EUS.

Successful resolution of bronchobiliary and biliocutaneous fistula by prolonged endoscopic transpapillary biliary drainage.

Bronchobiliary fistula is a rare condition that has been usually treated surgically. We report successful resolution of a rare case of combined bronchobiliary and biliocutaneous fistula by prolonged endoscopic transpapillary biliary drainage. The patient developed these fistulae following right hepatectomy for blunt trauma to the abdomen. Although endoscopic biliary drainage has been reported to be effective in healing of post-traumatic and post-surgical bile leaks, there are limited reports describing the efficacy of endoscopic drainage in complex biliary fistulas. This case report describes the successful closure of complex biliary fistula by prolonged endoscopic drainage.

Endoscopic examination of the upper esophagus by withdrawal of endoscope over guide wire.

Upper gastrointestinal (UGI) endoscopy is an important diagnostic modality in evaluation of patients with upper gastrointestinal (GI) disorders. However, lesions located in the cricopharyngeal area and upper esophagus can be missed, as this area may not be well visualized during endoscopy. This study was conducted to study the utility of a new technique of endoscopic examination of the upper esophagus by withdrawal of endoscope over guide wire in diagnosing esophageal disorders. Patients with suspected upper esophageal disorders on history and radiological investigations were assessed using guide wire assisted endoscopic examination during withdrawal of the endoscope. In this technique, endoscope is inserted into the esophagus under vision and thereafter the whole of esophagus, stomach and proximal duodenum is examined. The endoscope is then withdrawn into the mid-esophagus, a guide wire is fed into the biopsy channel, and thereafter inserted into the esophagus. Once guide wire has been advanced into the esophagus, the endoscope is withdrawn gently over the guide wire into esophagus carefully examining for lesions in upper esophagus and cricopharyngeal area. Twenty cases of various abnormalities localized to the upper esophagus were studied. The final diagnosis in these patients was cervical esophageal web (10), post transhiatal esophagectomy leak (4), heterotopic gastric mucosa (3), posttraumatic esophageal perforation (2), and Zenker's diverticulum (1). Intact web was detected in 2 patients and in 8 patients fractured web was seen. Guide wire assisted examination of upper esophagus improved the ability to visualize and characterize these lesions and no complications were encountered as a result of this procedure. Endoscopic examination of the upper esophagus by withdrawal of endoscope over guide wire is safe and effective in diagnosing anatomical abnormalities of the upper esophagus that may be missed or poorly characterized during standard endoscopy.

Comparison of multidetector computed tomographic colonography and conventional colonoscopy for detection of colorectal polyps and cancer.

BACKGROUND: Computed tomographic colonography (CTC) is a new technique for detecting colonic neoplasms. Data on the utility of this method in the Indian population are limited. METHODS: Forty-two patients with symptoms of colonic disease underwent CTC and conventional colonoscopy (CC) within one week of each other and the findings at these two investigations were compared. RESULTS: The entire colon could be evaluated in 38 patients on CTC and in 23 patients on CC. Of the 19 patients who had incomplete CC, 14 had occlusive colonic lesions. Of the 86 lesions detected on CC, 76 (88.4%) were correctly identified on CTC with regard to location and size. CTC was false negative for 10 lesions and false positive for 5 lesions in 3 patients. The sensitivity and specificity of CTC were 65% and 77%, respectively, for lesions 1-5 mm; 97% and 83% for 6-9 mm-sized lesions; and 100% and 100% for lesions 10 mm or larger. Extracolonic findings were seen in 24 of 42 patients (57%). CONCLUSIONS : CTC is reliable for detecting lesions 6 mm or larger in size. It permits evaluation of the region proximal to an occlusive growth, which is often not possible with CC.