A novel approach to facilitate dilation of complex non-traversable esophageal strictures by efficient wire exchange using a stent pusher.

BACKGROUND: Dilation of non-traversable complex strictures is frequently difficult. For a tight stricture, over-the-wire dilation is difficult using a flexible biliary guidewire as opposed to a more rigid guidewire with a spring tip made for use with polyvinyl over-the-wire dilators (Savary). However, passage of the more rigid, spring-tipped wire is not always possible. A new method is discussed here whereby a biliary guidewire is exchanged consistently with a rigid, spring-tipped wire to facilitate dilation of complex strictures. METHODS: The wire exchange was carried out using a 10F stent pusher. The latter is readily available and semi-rigid, and its large lumen easily accommodates a Savary guidewire. Furthermore, because it can be passed through an endoscope, it can be passed without difficulty through an extremely tight stricture because the device does not buckle in the proximal esophagus or mouth. RESULTS: Dilation was successful in 6 patients using this technique with no complications. Four patients required placement of the stent pusher through a therapeutic endoscope. CONCLUSION: A method is described that facilitates dilation of complex, tight esophageal strictures by exchange of a flexible biliary guidewire with a more rigid Savary wire using a stent pusher.

Can ERCP contrast agents cause pseudomicrolithiasis? Their effect on the final outcome of bile analysis in patients with suspected microlithiasis.

BACKGROUND: Microlithiasis has been implicated in the etiology of idiopathic pancreatitis and biliary-type pain in patients with intact gallbladders. Contrast injection at endoscopic retrograde cholangiopancreatography (ERCP) is used to confirm access into the bile duct and bile is also aspirated to look for microlithiasis. It is not known whether contrast agents contain crystals that could mimic true microlithiasis. METHODS: Four mL of 2 contrast agents (Hypaque and Omnipaque) were examined after centrifugation under polarizing microscopy. In the second part of the study, bile aspirated during ERCP with contrast injection was examined for microlithiasis and contrast pseudomicrolithiasis. RESULTS: Contrast agents exhibited pseudomicrolithiasis that mimicked calcium bilirubinate granules. Pathologists participating in the study were not aware of contrast pseudomicrolithiasis. Nine of twelve (75%) patients would have been reported as having microlithiasis and would possibly have undergone an unnecessary cholecystectomy. CONCLUSION: When bile collected during ERCP is to be examined for microlithiasis, it should be collected without contamination by a contrast agent. If this is not possible, pathologists should be aware that contrast can cause pseudomicrolithiasis.

Observation of thoracic duct morphology in portal hypertension by endoscopic ultrasound.

BACKGROUND: Thoracic duct dilation has been demonstrated in portal hypertension and hepatic cirrhosis by lymphangiography and laparotomy and at autopsy. It is thought to be secondary to increased hepatic lymph flow and has been described in the absence of ascites or esophageal varices. The aim of the present study was to observe thoracic duct morphology by endoscopic ultrasound in various subsets of patients with portal hypertension and hepatic cirrhosis and also to validate existing radiologic/surgical data. METHODS: The thoracic duct of 33 patients with cirrhosis and portal hypertension was studied by endoscopic ultrasound. Patients were divided into four groups: 1, patients with ascites and esophageal varices; 2, esophageal varices without ascites; 3, without esophageal varices or ascites; 4, extrahepatic portal hypertension due to pancreatic malignancy. The thoracic duct diameter was also measured in 14 control subjects (group 5). RESULTS: When the thoracic duct diameter for the five groups was compared with analysis of variance, significance was p < 0.0001; by pairwise comparison, group 1 differed from the other four groups (p < 0.05). Thoracic duct dilation (5.61 mm) was seen in group 1 patients, whereas no dilation was present in groups 2 through 4. Additionally, thoracic duct diameter in 33 portal hypertensive and/or cirrhotic patients was significantly different from that in the 14 control subjects (p = 0. 003). CONCLUSION: The thoracic duct can be reliably identified by EUS in patients with hepatic cirrhosis and portal hypertension. Dilation of the duct is seen only in patients with hepatic cirrhosis, ascites, and esophageal varices. No thoracic duct dilation is present in extrahepatic portal hypertension. Contrary to existing radiologic/surgical data, thoracic duct dilation is not seen in all patients with hepatic cirrhosis and portal hypertension signifying advanced disease. A dilated thoracic duct by endoscopic ultrasound should be considered yet another sign of portal hypertension.

Endoscopic retrograde wire-guided cytology of malignant biliary strictures using a novel scraping brush.

BACKGROUND: Tissue sampling to differentiate benign from malignant pancreatobiliary strictures remains problematic despite the availability of several new sampling methods. A new device is described which attempts to correct some of the drawbacks. METHODS: The device consists of a 10F dilator which has an attached pad of Velcro. The Velcro has semi-rigid, mushroom-shaped bristles. A cytologic sample is obtained by the abrasive action of the brush when it is passed through the stricture. Fifteen patients with obstructive jaundice underwent brushing of the bile duct using this device. RESULTS: Cytologic samples obtained with this device were positive for malignancy in all 15 patients. Diagnostic confirmation was obtained by assessment of clinical course, radiologic findings, and during surgery. CONCLUSION: Preliminary experience indicates that this new device enhances the yield of tissue sampling from malignant bile duct strictures.