The use of radial endosonography findings in the prediction of cholangiocarcinoma in cases with distal bile duct obstructions.

BACKGROUND/AIMS: We retrospectively collected the data of radial endosonographic (EUS) imaging findings of the patients with the distal bile duct obstructions due to different benign and malignant conditions. We aimed to assess and analyze the EUS findings in the distal bile duct obstruction which can predict or detect the existence of cholangiocarcinoma originating from the distal bile duct wall. METHODOLOGY: We gathered the data of 192 cases with distal biliary stricture due to various causes which all were diagnosed. RESULTS: With EUS, The sensitivity and specificity for diagnosis of cholangiocarcinoma in lesions were respectively as following: Firstly, small hypoechoic mass which interrupts to see lumen and choledoch wall with total occlusion at distal choledoch: 75.8%, 88.1%. Secondly, hypoechoic and irregular thickening than surrounding regions at distal choledoch wall: 68.1%, 87.3%. Thirdly, appearance of lumen prompt termination at distal choledoch: 57.1%, 87.6%. Lastly, appearance where lumen narrows short segment: 13.6 %, 59.3 %. CONCLUSIONS: EUS findings including hypoechoic mass appearance completely occluding the lumen or heterogeneously increased irregular wall-thickness in the distal bile duct were found to be highly predictive and sensitive for detecting malignancy originating from the distal bile duct.

Intrahepatic localization of pancreatic pseudocyst: a case report.

The location of a pseudocyst in the liver is an exceptional event. We report here a case developing right and left intrahepatic pseudocyst following acute biliary pancreatitis. Ultrasound and computed tomography scan revealed a 13-cm right and two 4-cm left intrahepatic collections. Percutaneous puncture permitted us to detect a high level of amylase in the collection, confirming the diagnosis of intrahepatic pseudocyst. Percutaneous drainage resulted in 3000 mL of fluid discharge. The mechanism involved in this patient was rupture of the pancreatic pseudocyst in the retroperitoneal cavity and erosion reaching the right hepatic parenchyma retroperitoneally posterior to the hepatoduodenal ligament and the left hepatic parenchyma via the hepatogastric ligament. Besides, endoscopic sphincterotomy was performed with endoscopic retrograde cholangiopancreatography for cholangitis. After performing endoscopic sphincterotomy, the cysts in the left lobe resolved dramatically. Intrahepatic pseudocyst should be kept in mind when an intrahepatic collection is found in a patients with chronic or recent episode of acute pancreatitis. Computed tomography and high level of amylase in the collection plays an important role for diagnosing this complication. In case of abdominal pain and large intrahepatic pseudocyst, percutaneous drainage can be performed.

The efficacy of endoscopic ultrasonography in local staging of rectal tumors.

BACKGROUND/AIMS: The purpose of this study was to research the efficacy and reliability of endoscopic rectal ultrasonography in local staging (T and N stages) of rectal tumors. MATERIALS AND METHODS: This retrospective study was carried out by the Department of Gastroenterology, Izmir Atatürk Training and Research Hospital, which is tertiary level. Thirty-one patients with adenocarcinoma were included in the study. The patients found operable according to computed tomography underwent preoperative local staging by endoscopic ultrasonography. Radial endoscopic ultrasonography and T and N stages were evaluated. RESULTS: It was observed that endoscopic rectal ultrasonography had 80.6% accuracy, 93.4% sensitivity, and 96.5% specificity in T stage; 70% accuracy, 70% sensitivity, and 86% specificity in the detection of presence of lymph node; and 76% accuracy, 100% sensitivity, and 22% specificity in the detection of the nature of lymph node. CONCLUSIONS: In this study, it was observed that endoscopic rectal ultrasonography is an efficient and reliable method in the detection of local lymph node and the depth of invasion of rectal tumors (T staging), although it is not reliable enough to determine the characteristics of lymph nodes.

Combined use of endosonography and endoscopic retrograde cholangiopancreatography in the same session.

BACKGROUND/AIMS: The diagnostic value of endoscopic ultrasound in common bile duct stones is high. In this investigation, we evaluated the feasibility of endoscopic ultrasound preceding endoscopic retrograde cholangiography in the same session and the potential benefits in increasing the therapeutic endoscopic retrograde cholangiography ratio in the treatment of choledocholithiasis. METHODS: One hundred and sixty-five consecutive patients who presented with elevated ALP and bilirubin levels and were referred for endoscopic retrograde cholangiography of biliary stones diagnosed with magnetic resonance cholangiopancreatography were evaluated. During the evaluation period (mean: 2 weeks), 50 patients with reductions in ALP and bilirubin by at least half relative to baseline values were enrolled into the study. Endoscopic ultrasound was performed prior to endoscopic retrograde cholangiography. Time spent to perform endoscopic ultrasound was noted. For the presence of common bile duct stone, we used retrograde cholangiography findings as the standard of reference. RESULTS: Median endoscopic ultrasound time was 10.66 minutes (SD±1.52). Bile duct stones were revealed with retrograde cholangiography in 34 patients (68%). Sensitivity, specificity (with 95% confidence intervals [CIs]), positive predictive value and negative predictive value of endoscopic ultrasound were calculated. In identifying common bile duct stones on endoscopic ultrasound, sensitivity, specificity, positive predictive value, and negative predictive value were statistically determined as 91.2% (95% CI), 88.3% (95% CI), 91%, and 81.3%, respectively. CONCLUSIONS: Our results indicate that in the presence of local experience and availability of endoscopic ultrasound, it is feasible to perform endoscopic ultrasound prior to endoscopic retrograde cholangiography. The sensitivity, specificity, positive predictive value, and negative predictive value for detecting choledocholithiasis in suspected cases are high. Endoscopic ultrasound preceding endoscopic retrograde cholangiography in the same session has the potential to decrease diagnostic endoscopic retrograde cholangiography and increase therapeutic endoscopic retrograde cholangiography. Need to perform magnetic resonance cholangiopancreatography in the presence of easily accessible endoscopic ultrasound should be questioned.

Role of radial endosonography in the diagnosis of acute cholangitis.

BACKGROUND AND STUDY AIM: We aimed to assess radial endoscopic ultrasound (EUS) features of the bile duct wall as well as biliary luminal liquid characteristics in cases with acute cholangitis. PATIENTS AND METHODS: This prospective study was performed during the period from January 2009 to February 2010 in a tertiary referral center. Twenty-eight patients with acute cholangitis and 60 patients without acute cholangitis but with cholestasis due to gallstone disease were enrolled in the study. During radial EUS examination, sonographic features of the common bile duct wall, the intraductal luminal content, and nearby periductal structures were investigated. Mild hyperechogenic-heterogenic appearances with waving-type movements without acoustic shadowing enclosing one-third of the common bile duct were noted as purulent materials. RESULTS: EUS indicated an increased focal and/or diffuse concentric bile duct wall thickness (>1.5 mm) in 68 and 27% of the cases with and without acute cholangitis, respectively. The mean bile duct wall thickness was 1.9 mm (0.9-2.9 mm) and 1.1 mm (0.6-2.1 mm) in the study and control groups, respectively (P < 0.05). On EUS, a pericholedochal hypoechoic strand more than 1.5 cm in length was present in 13 of 28 patients with acute cholangitis (46%). It was less than 1 cm long in 11 cases without acute cholangitis (18%). Bile duct content with heterogenous dense echogenicity without acoustic shadowing was present in 18 patients (64%) with acute cholangitis and in two patients (3%) without cholangitis. Those 20 patients were successfully drained with a same-day endoscopic retrograde cholangiography (ERCP) procedure which confirmed purulent biliary content after sphincterotomy. Same-day ERCP revealed no purulent material drainage from the bile duct in the other eight patients without cholangitis. The accuracy and positive and negative predictivity of diffuse concentric wall thickening and a peribiliary hypoechoic strand of greater than 1.5 cm in length for a diagnosis of acute cholangitis were 91, 86.3, and 67.1%, and 76, 72, and 54%, respectively. For purulent material, the accuracy and positive and negative predictive values of EUS for acute cholangitis were noted to be 87, 93.3, and 82%, respectively. CONCLUSION: Through this study, it was concluded that EUS findings such as diffuse and/or concentric wall thickening of more than 1.5 mm and intraductal heterogenous echogenicity without acoustic shadowing are highly accurate and predictive for diagnosing acute cholangitis.

Does presence of common bile duct stones in patients with acute biliary pancreatitis affect the severity of illness or laboratory findings?

BACKGROUND/AIMS: To determine the effect of stone within the common bile duct, on the severity of acute biliary pancreatitis. MATERIAL AND METHODS: This is a prospective and cross sectional study which was conducted at a tertiary care hospital including 103 patients. Serum biochemical values and white blood cell counts at the first 12th and 72nd hours of presentation were evaluated. The patients were grouped according to the presence or absence of common bile duct stones which were diagnosed by endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography. Besides, the patients were classified as mild and severe acute pancreatitis according to the data provided by computed tomography (Balthazar scoring) and clinical assessment and blood samples. RESULTS: Among the 103 patients with acute biliary patients, radial endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography revealed stones and/or sludge within the common bile duct or ampulla in 41 (39.8%) patients. There was not any persistent common bile duct stone in 62 (60.2%) patients. Severe pancreatitis developed in 9 (22%) of 41 patients who were determined to have stones by endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography, and in 13 (21%) of 62 patients who were not. There was no difference in the incidence of progressing to severe acute biliary patients between patients with and without common bile duct stones (p=0.45). CONCLUSION: Presence of common bile duct stones do not correlate with the severity of acute biliary pancreatitis.

Current Diagnosis and Management of Gastrojejunocolic Fistula.

We herein report the case of a 51-year-old man with gastrojejunocolic fistula. It is one of the late severe complications of gastrectomy and gastrojejunostomy and is considered to be induced by a stomal ulcer due to inadequate resection of the stomach and incompleteness of vagotomy. The main clinical presentation of this condition is chronic abdominal pain, weight loss, diarrhea, gastrointestinal bleeding and fecal vomiting. The diagnostic workup should include barium enema, gastroscopy and sometimes colonoscopy and abdominal tomography for excluding and ruling out the possibility of malignant extraluminal disease. The historical approach of the treatment of this rare entity was 2-3-phased operations which included colostomy. However today, medical management has recently been recommended as the first-line therapy, with parenteral and enteral support treatments. The preferred surgical approach is single-stage gastrocolic resection and anastomosis and this has been favored to minimize mortality.

Asymptomatic occult cysto-biliary communication without bile into cavity of the liver hydatid cyst: a pitfall in conservative surgery.

BACKGROUND: An occult cysto-biliary communication in liver hydatid disease is still a major problem in surgical practice. Radiologic and intraoperative findings may not be helpful to detect cysto-biliary communications in some asymptomatic patients with liver hydatid disease. Biliary leakage is a troubling complication that arises after conservative surgery in patients who have occult "insidious" cysto-biliary communications. We aimed to identify the factors which are associated with the risk of occult insidious cysto-biliary communications in patients preoperatively who developed biliary leakage after surgery. PATIENTS AND METHODS: We investigated the records of 183 asymptomatic patients treated for liver hydatid cyst and analyzed potential predictors of occult insidious cysto-biliary communication, retrospectively. RESULTS: There were 115 female and 68 male patients; the mean age was 42.3 years. Occult insidious cysto-biliary communications which presented as postoperative biliary leakage found in 24 (13.1%). Independent clinical predictors were alkaline phosphatase >133 U/L, total bilirubin levels >1.2 mg/dL, white blood cell count >10,000/mm(3) and cyst diameter >10 cm on multivariate analysis. Seventeen of 24 were low output biliary fistula which resolved spontaneously within 9.2 days. The remaining 7 were high output biliary fistula for which endoscopic sphincterotomy was performed in all patients, fistulas resolved within 22.6 days. Average interval between endoscopic sphincterotomy and fistula closure was 10.3 days. Mean hospital stay was longer in patients with biliary leakage than in those without (9.8 vs. 4.2 day p<0.001). There was no hospital mortality. CONCLUSION: The predictors demonstrated in this study should allow the likelihood of occult insidious cysto-biliary communication to be determined and, thus, indicate the need for additional procedures during operations to prevent the complications of biliary leakage.