7
Endosonography in the management of biliopancreatic disorders

https://doi.org/10.1016/j.bpg.2009.06.008Get rights and content

Over the past two decades, endoscopic endosonography (EUS) has evolved into an indispensible diagnostic and therapeutic utility in the diagnosis and treatment of patients with pancreatobiliary disease. In this article, we summarise its current potential and provide an update of the latest literature.

Section snippets

Detection, diagnosis and staging of mass lesions

Patients who present with symptoms of a suspicious hepatopancreatobiliary malignancy need extensive evaluation to examine the nature of a potential lesion and to determine its resectability. For this, endosonography (EUS) has proved to be a valuable technique for detection, diagnosis and staging of pancreatic, ampullary and bile duct cancer.

Detecting bile duct stones

Nowadays, ERCP is considered to be a therapeutic investigation because of its risk for complications [35]. Consequently, patients with an intermediate or low pre-test probability of having common bile duct stones (CBDSs) would benefit from a diagnostic test that does not expose them to risk, but reliably sets an indication to proceed to ERCP. Barkun et al proposed a model to calculate the pre-test probability of CBDS involving age, bilirubin level and data from trans-abdominal US [36]. When the

Pancreatic cysts

EUS can be very helpful in the differential diagnosis of pancreatic cysts. Pancreatic cysts are divided in non-neoplastic and neoplastic cysts. The former cysts may arise in the course of acute or chronic pancreatitis and have no malignant potential. Neoplastic cysts, however, depending on their origin, do have a malignant potential and are important to diagnose to direct further management, including pancreatic resection. Neoplastic cysts include, for example, mucinous cystadenoma (MCN) and

Chronic pancreatitis

EUS is sensitive to subtle changes that may be associated with ‘early’ chronic pancreatitis (CP). The diagnosis of CP by EUS depends on the presence or absence of multiple EUS criteria of CP. The first diagnostic EUS criteria of CP were suggested by Lees et al in 1979 [53]. In 1993, these criteria were refined by Wiersema et al and these comprised parenchymal EUS features (including (1) echogenic foci, (2) focal regions of reduced echogenicity (strands) and (3) increased parenchymal lobularity)

Interventional EUS for pancreatobiliary disease

With the introduction of curvilinear-array echoendoscopes, EUS has turned from a solely observational diagnostic tool into an advanced interventional technique offering the possibility to not only acquire tissue samples for diagnostic purpose by means of FNA, but also to introduce, for example, drugs by fine-needle injection (FNI). Furthermore, various accessories such as guide wires can be advanced through a needle into a target structures to carry out EUS-guided cyst, biliary and pancreatic

Conclusion

EUS has proved to be a valuable tool in the diagnosis and treatment of biliopancreatic diseases. With the ongoing developments in cross-sectional imaging, including MD-CT and magnetic resonance imaging, diagnostic indications for EUS may decline, although its ability to acquire instant tissue samples remains appealing and of great clinical use. Undoubtedly, applications of interventional EUS will further evolve and develop to aid in the management of patients with complex biliary and pancreatic

Conflict of interest

None.

References (70)

  • F. Maluf-Filho et al.

    Radial endoscopic ultrasound and spiral computed tomography in the diagnosis and staging of periampullary tumors

    Pancreatology

    (2004)
  • M.E. Cannon et al.

    EUS compared with CT, magnetic resonance imaging, and angiography and the influence of biliary stenting on staging accuracy of ampullary neoplasms

    Gastrointest Endosc

    (1999)
  • K. Ito et al.

    Preoperative evaluation of ampullary neoplasm with EUS and transpapillary intraductal US: a prospective and histopathologically controlled study

    Gastrointest Endosc

    (2007)
  • V. Pugliese et al.

    Endoscopic retrograde forceps biopsy and brush cytology of biliary strictures: a prospective study

    Gastrointest Endosc

    (1995)
  • M. de Bellis et al.

    Influence of stricture dilation and repeat brushing on the cancer detection rate of brush cytology in the evaluation of malignant biliary obstruction

    Gastrointest Endosc

    (2003)
  • J. DeWitt et al.

    EUS-guided FNA of proximal biliary strictures after negative ERCP brush cytology results

    Gastrointest Endosc

    (2006)
  • E. Vazquez-Sequeiros et al.

    Evaluation of indeterminate bile duct strictures by intraductal US

    Gastrointest Endosc

    (2002)
  • S. Loperfido et al.

    Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study

    Gastrointest Endosc

    (1998)
  • E. Buscarini et al.

    EUS for suspected choledocholithiasis: do benefits outweigh costs? A prospective, controlled study

    Gastrointest Endosc

    (2003)
  • T. Karakan et al.

    EUS versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a prospective randomized trial

    Gastrointest Endosc

    (2009)
  • P.E. Rautou et al.

    Morphologic changes in branch duct intraductal papillary mucinous neoplasms of the pancreas: a midterm follow-up study

    Clin Gastroenterol Hepatol

    (2008)
  • F. Gress et al.

    Endoscopic ultrasound characteristics of mucinous cystic neoplasms of the pancreas

    Am J Gastroenterol

    (2000)
  • N.A. Ahmad et al.

    Can EUS alone differentiate between malignant and benign cystic lesions of the pancreas?

    Am J Gastroenterol

    (2001)
  • W.R. Brugge et al.

    Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study

    Gastroenterology

    (2004)
  • M. Tanaka et al.

    International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas

    Pancreatology

    (2006)
  • E. Rajan et al.

    Age-related changes in the pancreas identified by EUS: a prospective evaluation

    Gastrointest Endosc

    (2005)
  • M.F. Catalano et al.

    EUS-based criteria for the diagnosis of chronic pancreatitis: the rosemont classification

    Gastrointest Endosc

    (2009)
  • A.V. Sahai et al.

    Prospective assessment of the ability of endoscopic ultrasound to diagnose, exclude, or establish the severity of chronic pancreatitis found by endoscopic retrograde cholangiopancreatography

    Gastrointest Endosc

    (1998)
  • L.C. Hookey et al.

    Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes

    Gastrointest Endosc

    (2006)
  • S. Varadarajulu et al.

    Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts (with videos)

    Gastrointest Endosc

    (2008)
  • E. Burmester et al.

    EUS-cholangio-drainage of the bile duct: report of 4 cases

    Gastrointest Endosc

    (2003)
  • S.S. Lee et al.

    EUS-guided transmural cholecystostomy as rescue management for acute cholecystitis in elderly or high-risk patients: a prospective feasibility study

    Gastrointest Endosc

    (2007)
  • G. Tessier et al.

    EUS-guided pancreatogastrostomy and pancreatobulbostomy for the treatment of pain in patients with pancreatic ductal dilatation inaccessible for transpapillary endoscopic therapy

    Gastrointest Endosc

    (2007)
  • A. Nakaizumi et al.

    Endoscopic ultrasonography in diagnosis and staging of pancreatic cancer

    Dig Dis Sci

    (1995)
  • L. Palazzo et al.

    Endoscopic ultrasonography in the diagnosis and staging of pancreatic adenocarcinoma. Results of a prospective study with comparison to ultrasonography and CT scan

    Endoscopy

    (1993)
  • Cited by (0)

    View full text