Ultrasonography in the diagnosis of acute cholecystitis

Role of endoscopic ultrasound in idiopathic pancreatitis

Recurrent acute pancreatitis (RAP) is defined based on the occurrence of two or more episodes of acute pancreatitis. The initial evaluation fails to detect the cause of RAP in 10%-30% of patients, whose condition is classified as idiopathic RAP (IRAP). Idiopathic acute pancreatitis (IAP) is a diagnostic challenge for gastroenterologists. In view of associated morbidity and mortality, it is important to determine the aetiology of pancreatitis to provide early treatment and prevent recurrence. Endoscopic ultrasound (EUS) is an investigation of choice for imaging of pancreas and biliary tract. In view of high diagnostic accuracy and safety of EUS, a EUS based management strategy appears to be a reasonable approach for evaluation of patients with a single/recurrent idiopathic pancreatitis. The most common diagnoses by EUS in IAP is biliary tract disease. The present review aims to discuss the role of EUS in the clinical management and diagnosis of patients with IAP. It elaborates the diagnostic approach to IAP in relation to EUS and other different modalities. Controversial issues in IAP like when to perform EUS, whether to perform after first episode or recurrent episodes, comparison among different investigations and the latest evidence significance are detailed.

Long-term Outcomes of Symptomatic Gallbladder Sludge

GOALS AND BACKGROUND

Long-term outcomes of symptomatic gallbladder (GB) sludge are not fully established. This study aimed to determine whether patients with symptomatic GB sludge could experience subsequent biliary events.

STUDY

This study investigated consecutive patients who presented with typical biliary pain and underwent abdominal ultrasonography from March 2003 to December 2012. A prospectively maintained database of these patients, excluding those with gallstones, was reviewed retrospectively. We compared the development of biliary events such as acute cholecystitis, acute cholangitis, and acute pancreatitis between both GB sludge and non-GB sludge cohorts.

RESULTS

In all, 58 and 70 patients were diagnosed with and without GB sludge, respectively. The 5-year cumulative biliary event rate was significantly higher in the GB sludge (33.9% vs. 15.8%, P=0.021) and the hazard ratio of subsequent biliary events was 2.573 (95% confidence interval, 1.124-5.889; P=0.025) in patients with GB sludge. The 5-year cumulative rate of each biliary event was higher in the GB sludge cohort (15.6% vs. 5.3% in acute cholecystitis, 15.5% vs. 5.3% in acute cholangitis, 18.4% vs. 11.1% in acute pancreatitis, respectively), although it was not statistically significant. Among the GB sludge cohort, subsequent biliary events were less frequent in patients who underwent cholecystectomy compared with those who did not (2/16, 12.5% vs. 17/42, 40.4%; P=0.067).

CONCLUSIONS

GB sludge accompanying typical biliary pain can cause subsequent biliary events and cholecystectomy may prevent subsequent biliary events. Therefore, GB sludge would be considered as a culprit of biliary events.

Endoscopic ultrasonography in patients with elevated carbohydrate antigen 19-9 of obscure origin

AIM: To evaluate the efficacy of endoscopic ultrasonography (EUS) in patients with elevated carbohydrate antigen (CA) 19-9 levels of obscure origin.

METHODS: Patients who had visited Pusan National University Hospital because of elevated serum CA 19-9 levels, between January 2007 and December 2009, were retrospectively enrolled. EUS had been performed on all subjects, in addition to routine blood tests, endoscopy, abdominal computed tomography (CT) and other clinical exams, which had not revealed any abnormal findings suggestive of the origin of the elevated CA 19-9 levels.

RESULTS: Of the 17 patients, gallbladder sludge was detected in 16 patients (94.1%) and common bile duct sludge was observed in 3 patients (17.6%). After the administration of ursodeoxycholic acid to 12 of the patients with gallbladder sludge, CA 19-9 levels normalized in 6 of the patients after a median of 4.5 mo.

CONCLUSION: EUS is a useful diagnostic method for patients with elevated CA 19-9 levels of obscure origin, even if the reason for abnormal levels of this serum marker cannot be determined through prior examinations, including abdominal CT.

[I Brazilian consensus of endoscopic ultrasonography]

BACKGROUND

In the last 20 years, several papers have focused on demonstrating the impact of endoscopic ultrasonography findings on the management of different clinical scenarios in digestive disease. This fact is an indirect evidence of the difficulty of popularization of the method. On other hand, the limited availability of endoscopic ultrasonography in Brazil is a direct evidence of this limitation. This was the rationale for the organization of a consensus meeting on endoscopic ultrasonography. It was aimed to identify the best evidence that support the use of endoscopic ultrasonography in gastroenterology.

METHODS

A panel of experts on endoscopic ultrasonography was selected based on the files of the Gastroenterology and Endoscopy Societies and on the registries of endoscope manufacturers. Two members of the meeting selected the relevant topics that were transformed into questions. The topics and the questions were debated among the experts five months before the consensus meeting. The experts were asked to perform systematic reviews in order to answer the questions so it could be possible to grade the answers based on the strength of the evidence. During the two days of the meeting the answers were presented, debated and voted. Consensus was reached when a minimum of 70% of the voters were in agreement. The final consensus report was submitted to the experts' evaluation and approval.

RESULTS

Seventy nine questions were debated by the experts at the pre-Consensus meeting. As the result of this debate 85 questions came out and were assigned to the members of the panel. During the Consensus meeting 22 experts debated and voted 85 answers. Consensus was reached for several clinical scenarios for which the impact of endoscopic ultrasonography findings were supported by level 1 evidences: differential diagnosis of subepithelial lesions and thickening of gastric folds, staging and diagnosis of unresectable esophageal cancer, indirect signs of peritoneal involvement of gastric cancer, MALT gastric lymphoma and rectal cancer staging, diagnosis of common bile duct and gallbladder stones, diagnosis of chronic pancreatitis and differential diagnosis of a solid mass in chronic pancreatitis, differential diagnosis of the pancreatic cyst, prediction of the results of the endoscopic treatment of esophageal varices and diagnosis and staging of non-small cell lung cancer.

CONCLUSIONS

There are the highest levels of evidences that support the indication of endoscopic ultrasonography for several digestive diseases and even for non-small cell lung cancer.

Review of idiopathic pancreatitis

Recent advances in understanding of pancreatitis and advances in technology have uncovered the veils of idiopathic pancreatitis to a point where a thorough history and judicious use of diagnostic techniques elucidate the cause in over 80% of cases. This review examines the multitude of etiologies of what were once labeled idiopathic pancreatitis and provides the current evidence on each. This review begins with a background review of the current epidemiology of idiopathic pancreatitis prior to discussion of various etiologies. Etiologies of medications, infections, toxins, autoimmune disorders, vascular causes, and anatomic and functional causes are explored in detail. We conclude with management of true idiopathic pancreatitis and a summary of the various etiologic agents. Throughout this review, areas of controversies are highlighted.

Complications vésiculaires après chirurgie bariatrique

With the increased incidence of obesity in the developed countries, and the failure of medical treatments, bariatric surgery has increased rapidly. Although laparoscopic gastroplasty is the most popular bariatric intervention in France, the gold standard tends to be the laparoscopic gastric bypass. The severe weight loss caused by this type of procedure induces specific middle or long term complications such as biliary lithiasis. In this literature we describe different physiopathological mechanisms of lithiasis after gastric bypass by coeliosurgery or gastroplasty, their diagnosis, and preventive treatment to avoid these complications.

Endoscopic ultrasonography in detection of cholelithiasis in patients with biliary pain and negative transabdominal ultrasonography

BACKGROUND

The aim of the study was to evaluate endoscopic ultrasonography (EUS) as a single method for diagnosing cholecystolithiasis in patients with a clinical suspicion of cholecystolithiasis, but with a normal transabdominal ultrasonography (TUS).

METHODS

A prospective study was performed on patients with biliary type of colic and normal US of the gallbladder. All patients had at least one normal TUS examination (mean 2.1, range 1-5) performed by an experienced radiologist. All patients were subsequently examined with EUS. EUS examination was performed with either a mechanical radial scanning echo-endoscope (Olympus GF-UM20) or a linear echo-endoscope (Pentax FG32-UA or FG34-UA). Patients in whom EUS demonstrated cholecystolithiasis were offered laparoscopic cholecystectomy within 2 weeks.

RESULTS

A total of 35 patients (31 F and 4 M) were included. In 18 out of 35 (52.4%) patients cholecystolithiasis was diagnosed by EUS. In 15 out of 17 patients the EUS diagnosis was verified by surgery. At follow-up after 12 months, 13 of the 15 patients (87%) with verified gallbladder stones had no abdominal discomfort, whereas 2 patients (13%) complained of persistent and unchanged abdominal pain.

CONCLUSION

EUS seems to be a promising imaging method in the detection of microlithiasis in the gallbladder in patients with clear biliary colic and normal transabdominal US.

Idiopathic acute pancreatitis

After routine investigations, including a thorough history, routine laboratory study, and noninvasive imaging with transcutaneous ultrasonogram, 10% to 25% of cases of acute pancreatitis have no readily identifiable cause and are termed idiopathic. But modern medicine has made notable advances in uncovering various causes of acute pancreatitis, and several new diagnostic tools that allow clinicians to less invasively approach the patient without sacrificing the diagnostic yield have been introduced. By being knowledgeable of these new changes and by their proper use in a proper circumstances, clinicians will be able to find the cause more accurately and earlier. This better management will not only improve the well-being of the patients but also reduce the number of "true" idiopathic acute pancreatitis to a minimum.

Detection of choledocholithiasis by EUS in acute pancreatitis: a prospective evaluation in 100 consecutive patients

BACKGROUND

ERCP is the standard for detection of choledocholithiasis in patients with acute biliary pancreatitis, and, if performed early, ERCP decreases morbidity. However, there are procedure-related complications. The aim of the present prospective study was to evaluate the ability of EUS to detect choledocholithiasis in patients presenting with acute pancreatitis.

METHODS

The study group comprised 100 consecutive patients who presented with acute pancreatitis. EUS, and immediately thereafter, ERCP were performed by separate blinded examiners within 24 hours of admission. The diagnostic accuracy of EUS in identifying gallbladder stones was compared with that of transcutaneous US. The diagnostic accuracy of EUS in detecting choledocholithiasis was then compared with that of US and ERCP based on the results of endoscopic instrumentation of the bile duct after sphincterotomy.

RESULTS

EUS was more sensitive than US in detecting gallbladder stones (100% vs. 84%, p < 0.005). The sensitivities of ERCP and EUS for choledocholithiasis were both 97%, and the overall accuracies were 96% and 98%, respectively, with no significant difference. EUS detected the absence of choledocholithiasis in 65 of 66 patients (specificity = 98%). Endosonographic examination was successful in all patients, whereas ERCP was unsuccessful in 5 patients (p > 0.05). Post-endoscopic sphincterotomy bleeding developed in 4 patients; there was no EUS-related morbidity (p > 0.05).

CONCLUSION

EUS is more sensitive than US in detecting biliary stones in patients with acute pancreatitis. It is as accurate as ERCP in detecting choledocholithiasis. EUS can be used to select patients with acute pancreatitis who require therapeutic ERCP, thus avoiding diagnostic ERCP and its associated potential for complications in the majority of patients.

EUS for detection of occult cholelithiasis in patients with idiopathic pancreatitis

BACKGROUND

The aim of this study was to evaluate the use of endoscopic ultrasonography (EUS) in detecting occult cholelithiasis and determining a probable etiology in patients classified as having idiopathic pancreatitis by conventional radiologic methods.

METHODS

A prospective study was performed in 89 consecutive patients with acute pancreatitis. Transcutaneous ultrasonography (US), CT, or both was performed on all patients within 24 hours of admission. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in all patients with confirmed or suspected biliary pancreatitis. EUS was performed in patients classified as having idiopathic pancreatitis.

RESULTS

Cholelithiasis was identified in 64 patients (72%) by conventional radiologic methods. Eighteen patients (20%) were classified as having idiopathic pancreatitis after evaluation by US (all 18 patients), repeated US (9 patients), CT (6 patients) and ERCP (13 patients). EUS performed in these 18 patients revealed small gallbladder stones (1 to 9 mm) in 14 patients; 3 were found to have concomitant choledocholithiasis. All stones were confirmed by subsequent ERCP and cholecystectomy. The remaining 4 patients in whom no etiology was identified had no clinical or radiologic evidence of cholelithiasis at a median follow-up of 22 months.

CONCLUSION

Cholelithiasis is detected by EUS in a large number of patients classified as having idiopathic pancreatitis by conventional radiologic examinations. With identification of a biliary cause of acute pancreatitis, treatment can be initiated early, thereby reducing the risk of recurrent pancreatitis with its associated morbidity and mortality. EUS is a valuable diagnostic modality in the management of patients with acute pancreatitis.

Acute cholecystitis in the emergency department

Acute cholecystitis is a frequent consideration in patients presenting to the emergency department with the challenging complaint of upper abdominal pain. It is estimated that 20% of American adults have gallstones, and of these a large percentage (about one-third) will at some point develop acute cholecystitis. The epidemiology and associated risk factors of acute cholecystitis are briefly reviewed along with the pathogenesis and clinical presentation of the disease. Finally, an approach to the diagnosis in the emergency department and suggested management is discussed including a comparison of the strengths and weaknesses of ultrasonography and hepatobilary scintigraphy.