Efficacy of endoscopic ultrasonography in evaluation of undetermined etiology of common bile duct dilatation on abdominal ultrasonography

Background: The cause of common bile duct [CBD] dilatation cannot be determined by imaging modalities in many patients. The aim of this study was to assess the value of endoscopic Ultrasonography [EUS] in detecting the cause of CBD dilatation in patients in whom Ultrasonography could not demonstrate the cause of dilation

Methods: Prospectively, 152 consecutive patients who were referred for evaluation of dilated CBD [diameter >7 mm] of undetermined origin by Ultrasonography were included in this study. All the patients underwent EUS. Final diagnoses were determined by using endoscopic retrograde cholangiopancreatography [ERCP], EUS-guided fine needle aspiration [FNA], surgical exploration, or follow-up for at least 10 months. Patients with choledocholithiasis were referred for ERCP and sphincterotomy, and patients with operable tumors were referred for surgery. Patients with inoperable tumors underwent biliary stenting with or without chemoradiotherapy

Results: 152 patients [54% female] with dilated CBD were included. Mean [+/-SD] age of the patients was 60.4 [+/-17.3] years. The mean CBD diameter for all study group in transabdominal Ultrasonography and EUS were 11.7 millimeter and 10.1 millimeter, respectively. Most of the patients with dilated CBD and abnormal liver function test [[LFT] had an important finding in EUS and follow-up diagnosis including peri-ampullary tumors. Mean diameter of CBD in patients with and without abnormal LFT were 10.5 IU/L and 12.1 IU/L, respectively. Final diagnoses included choledocholithiasis in 32 [21.1%], passed CBD stone in 35 [23%], opium-induced CBD dilation in 14 [9.2%], post-cholecystectomy states in 20 [13.1%], ampullary adenoma/carcinoma in 15 [15.8%], cholangiocarcinoma in 14 [9.2%], and pancreatic head cancer in 9 [5.9%] patients

Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EUS for patients with abnormal EUS were 89.5%, 100.0%, 100.0%, 91.2%, and 90.9%, respectively

Conclusion: After diagnosis of CBD dilation by transabdominal Ultrasonography, EUS may be a reasonable choice for determining the etiology of dilated CBD and tumor staging

Clinical and pathological features of non-functional neuroendocrine tumors of pancreas: a report from Iran

Pancreatic neuroendocrine tumors [PNETs] are rare tumors with variable malignant potential, prognosis, and survival. We aimed to assess the characteristics of patients with non- functional PNET in our hospital. From Nov 2010 to Nov 2013, all patients who came to endosonography unit of Shariati hospital, Tehran, Iran, and had pancreatic lesions were assessed. Tumor samples were obtained through fine needle aspiration. Various characteristics of the non- functional PNET were recorded and patients were followed up to three years. Twenty eight non func-PNET cases, aged 37-72 years were identified, 15 [53.6%] of whom were men. Fifteen [53.6%] tumors were located in the head and 5[17.8%] in the body of the pancreas. The mean tumor size was 3.9 Cm and 10.7%, 28.6%, 32.1%, and 28.6% of the patients were at stages I, II, III and IV, respectively. Of the patients, 12 [43%] underwent surgery, 3 [10.7%] received chemotherapy, and 13 [46.4%] received no treatment. During the mean follow-up of 16 months, the disease had progressed in 3 [10.7%] patients and 10 [35.7%] had died. In univariate analysis, tumor size>3Cm and Ki-67>20% were correlated with survival rate but not in multivariate analysis. Iranian patients with non- functional PNET present similar characteristics to world patients. There is a need to establish efficacy of tumor samples which are obtaining through fine needle aspiration for assessing tumor grading

Assessment and treatment of choledocholithiasis when endoscopic sphincterotomy is not successful

Background: Choledocholithiasis exists in approximately 15% of patients with gallstones and is present in 3%-10% of those undergoing cholecystectomy

Methods: In this study, we retrospectively analyzed the outcome patients with choledocholithiasis that were managed by open common bile duct [CBD] exploration according to our center's protocol. Endoscopic retrograde cholangiopancreatography [ERCP] was performed for CBD stone clearance. If ERCP and sphincterotomy were not successful, open surgical exploration of CBD was performed with T-tube inser-tion without routine intraoperative cholangiography [IOC]

Results: We studied 1462 patients with choledocholithiasis. ERCP was successful in in 1276 [87.2%] patients. A total of 186 [12.8%] underwent surgery. Of these, 82 [45.2%] had CBD exploration and T-tube insertion without IOC. Choledochoduodenostomy was performed in 82 [44.1%] patients and choledochojejunostomy was performed in 20 [10.8%]. Retained stones were found only in 4 cases which were treated by ERCP

Conclusion: ERCP is successful in most cases with choledocholithiasis. If ERCP fails, open exploration of CBD and T-tube insertion, or biliary-enteric anastomosis are acceptable ways for CBD drainage. The rate of retained stone is not more than expected, thus elective IOC is more acceptable than routine IOC. Routine IOC is time-consuming and particularly difficult in elderly patients and emergency conditions

[Indications and prevalence of disorders in a referral clinic for endoscopic ultrasonography]

Endoscopic ultrasonography [EUS] has a pivotal role in staging and diagnosis of different gastrointestinal [GI] disorders. Although this equipment is not readily available and not all gastroenterologists are trained in this technique, the importance and efficacy of this imaging modality is obvious for all gastroenterologists. We report the indications and prevalence of lesions visualized by EUS, in a EUS center. We evaluated the demographic characteristics, indications, and recorded EUS diagnosis of patients during a 5 year [2007-2011] period. During the study period, 3198 patients [51.2% males] underwent EUS. Upper GI endosonography, within which, pancreatobiliary disorders followed by gastric cancer were the most common indications for patient referral. The rate of patient referral for EUS increased yearly. EUS is an accurate method for the diagnosis of different GI abnormalities. The most common cause for patient referrals are benign pancreatobiliary disorders

Sampling error in histopathology findings of nonalcoholic fatty liver disease: a post mortem liver histology study

Many clinical trials and natural history studies on nonalcoholic fatty liver disease [NAFLD] and nonalcoholic steatohepatitis [NASH] rely heavily on liver histology to define their endpoints. There are many indications that the liver is not uniformly involved in NAFLD thus sampling error is a major concern. This study aims to evaluate the uniformity of various histologic features in livers affected with NAFLD. Samples from a forensic autopsy series were studied and subjects with NAFLD identified. We took specimens from three different parts of each liver and recorded the degrees of steatosis, hepatocyte ballooning, lobular inflammation, portal inflammation, and fibrosis. A NASH activity index [NAI] which is the sum of scores of histologic features was also calculated. The agreement between the 3 samples from each liver was studied. There were 945 autopsies performed; 896 were suitable for histologic evaluation and 283 had NAFLD. Of these, 146 livers were available to our study from which 438 samples were taken. Fibrosis [intra-class correlation [ICC] = 0.87], lobular inflammation [kappa = 0.83], and portal inflammation [kappa = 0.83] were fairly uniformly distributed in the damaged liver. Steatosis was less uniform [kappa = 0.64], and hepatocyte ballooning was least uniformly distributed [kappa = 0.57]. The ICC for NAI was 0.86, which indicated good agreement. The individual histologic features of NAFLD and NASH are not uniformly distributed in the liver. Hepatocyte ballooning is especially non-uniform. Such non-uniformity should be taken into account when interpreting results of studies that rely on paired biopsies. A summary score such as NAI is less affected by sampling error