Specialized clinical cytology may improve the results of EUS (endoscopic ultrasound)-guided fine-needle aspiration (FNA) from pancreatic tumors.

BACKGROUND AND STUDY AIMS: A variety of factors (needle type, needle passes, tumor location, cytological assessment, etc.) may influence the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNAC) from pancreatic tumors. Whereas most published studies report a diagnostic accuracy of > 80 % for EUS-FNAC, the results in routine settings are often considerably lower. This retrospective study aimed to define the effect of switching microscopic assessment from a standard pathology department to a highly specialized institute of cytology. PATIENTS AND METHODS: A total of 63 patients underwent EUS-FNAC of solid or semisolid pancreatic masses. Specimens of the first consecutive 20 cases (Phase 1) were assessed by the local department of pathology. Then in Phase 2, involving another 43 subsequent cases, a specialized cytology laboratory examined all aspirates. All EUS-FNACs were performed in the same manner, using a 22-gauge needle. After cytological evaluation, all patients either underwent surgery or were followed up for at least 6 months. RESULTS: Of the tumors, 56 were solid and 7 semisolid; the mean size was 30 mm. Sensitivity (sens.), specificity (spec.), positive predictive value (PPV), and negative predictive value (NPV) of EUS-FNAC were 38.5 % (95 %CI [confidence interval] 13.9 - 68.4 %), 100 % (59.0 - 100 %), 100 % (47.8 - 100 %), and 46.7 % (21.3 - 73.4 %) during Phase 1 versus 91.4 % (95 %CI 76.9 - 98.2 %), 100 % (63.1 - 100 %), 100 % (89.1 - 100 %), and 72.7 % (39.0 - 94.0 %) during Phase 2. CONCLUSION: These results emphasize the considerable impact of a dedicated cytological evaluation on the results of EUS-FNAC.

Do it yourself: building an ERCP training system within 30 minutes (with videos).

BACKGROUND: Ex vivo training of ERCP by using simulators is desirable before trainees perform endoscopy in patients. OBJECTIVE: We aimed to construct a simple and inexpensive but realistic simulator for ERCP training. DESIGN: Construction and establishment of an ERCP simulator. SETTING: Endoscopy suite. INTERVENTION: An ERCP simulator was assembled by using a polyvinylchloride hose, insulated wire end sleeves, a plastic board, and hose clamps. MAIN OUTCOME MEASUREMENTS: Application of the simulator for endoscopic training, with focus on endoscope maneuverability as well as on alignment and intubation of the papilla and assessment of simulator performance by a short questionnaire. RESULTS: Because of the sufficient diameter of the hose and varying orientations of the wire end sleeves, the system allows for realistic endoscope maneuvering and wire intubation of the "papillary orifices." Trainees feel better prepared and more confident in the technique before performing ERCP in patients for the first time. LIMITATIONS: Extensive validation and statistical evaluation is lacking. CONCLUSION: The construction offers the opportunity to provide a readily available simulator for initial access to basic ERCP techniques.

Splanchnic arterial blood flow is significantly influenced by breathing-assessment by duplex-Doppler ultrasound.

Duplex ultrasound is established for the assessment of mesenteric ischemia but potential influences of breathing on mesenteric arterial blood velocity have not been investigated so far. In 100 patients without abdominal diseases (39 men; age 59.4 ± 18.0 years), peak systolic (PSV), end diastolic velocity (EDV) and resistance index (RI) were assessed in the celiac trunk (CT) and the superior mesenteric artery (SMA) by Doppler ultrasound during expiration and deep inspiration. Expiratory PSVs in the CT and the SMA (153.4 ± 42.5 and 145.3 ± 39.5 cm/s) were significantly higher than inspiratory velocities (135.4 ± 36.8 and 131.9 ± 42.2 cm/s, p < 0.0001 and p = 0.0002), with expiratory PSVs exceeding inspiratory PSVs in more than 75% of patients. The mean percentage of PSV-variation was 21.5% ± 15.3% and 24.6% ± 19.1%, respectively. The study demonstrates that breathing may exert considerable periodic effects on splanchnic arterial hemodynamics. We, therefore, recommend that to prevent an underestimation of arterial stenosis, mesenteric Doppler ultrasound should be performed during expiration.

Contrast-enhanced ultrasound in the diagnosis of malignant mesenchymal liver tumors.

PURPOSE: Contrast-enhanced ultrasound can differentiate malignant from benign hepatic tumors, but has not been studied in malignant mesenchymal liver tumors. METHODS: We describe the findings of contrast-enhanced ultrasound in a cohort of five patients with histological-proven malignant hepatic mesenchymal tumors. RESULTS: The presence of imaging features such as peripheral (nodular) enhancement, chaotic central vascularization, and absence of contrast enhancement in the late phase allowed differentiation from hemangiomas. CONCLUSIONS: If these findings are demonstrated in large hepatic tumors, then the diagnosis of hemangioma is unlikely and further workup is necessary.

Application of the glucose hydrogen breath test for the detection of bacterial overgrowth in patients with cystic fibrosis--a reliable method?

Patients with cystic fibrosis (CF) have recently been deemed highly susceptible for bacterial intestinal overgrowth (BIO). We aimed to define the prevalence of BIO in children with CF by applying the H(2)-glucose breath test. Forty children with CF and ten healthy children received 1 g/kg D-glucose orally. Breath samples for H(2) content (ppm) were collected for 3 h. BIO was suspected if the breath hydrogen content increased by more than 20 ppm or if baseline concentrations topped 20 ppm. In 27 of 40 CF children (68%), breath hydrogen content exceeded 20 ppm. Whereas the breath hydrogen exhalation persisted above 20 ppm in almost all these children throughout the sampling period, none of the remaining children increased above this threshold. The high rate of CF children with elevated fasting hydrogen breath concentrations indicates that this phenomenon is less a sign of BIO rather than a consequence of global malabsorption and intestinal dysmotility.

Does secretin-stimulated MRCP predict exocrine pancreatic insufficiency?: A comparison with noninvasive exocrine pancreatic function tests.

BACKGROUND: Data on magnetic resonance cholangiopancreatography with secretin stimulation (S-MRCP) for the assessment of exocrine pancreatic insufficiency (EPI) are limited. We compared pancreatic function tests with the findings of S-MRCP in patients with chronic pancreatitis (CP) and disease controls. METHODS: S-MRCP was performed in 23 patients (18 CP, 5 disease controls). MRCP images were analyzed for secretin-induced duodenal liquid filling (0=no filling; 1=duodenal bulb; 2=up to lower flexure; 3=beyond lower flexure). EPI was evaluated by fecal elastase, fecal fat concentration, and a 13C mixed chain triglyceride breath test. Clinically relevant EPI was stated if 2 of 3 tests were pathologic. RESULTS: EPI was diagnosed in 10 of 18 patients with CP. Patients without EPI showed either grade 2 (n=4) or grade 3 (n=9) duodenal filling, whereas only 1/10 patients with EPI showed grade 3 duodenal filling. Sensitivity and specificity of S-MRCP for the diagnosis of EPI were 69% and 90%, respectively. CONCLUSIONS: Assessment of duodenal filling should be performed in patients who undergo S-MRCP for the evaluation of pancreatic morphology. However, minor degrees of duodenal filling are equivocal and require further diagnostic evaluation.

Patient age is a strong independent predictor of 13C-aminopyrine breath test results: a comparative study with histology, duplex-Doppler and a laboratory index in patients with chronic hepatitis C virus infection.

1. Noninvasive tests for the staging of chronic hepatitis C virus (HCV) infection would be an attractive alternative to liver biopsy. The 13C-aminopyrine breath test (ABT) has been proposed for the noninvasive assessment of hepatic function and partly correlates with fibrosis. We aimed to investigate causes for the lack of discriminatory power for different degrees of hepatic fibrosis. 2. Eighty-three patients (median age 49 years (28-78 years)) with chronic HCV infection underwent the ABT after an oral load of 75 mg N,N-dimethyl-13C-aminopyrine. Portal vein flow was assessed by duplex-Doppler and a laboratory index (aspartate aminotransferase to platelet ratio index or APRI) was calculated. Parameters were compared with liver histology. 3. The cumulative 13C-recovery differed significantly between patients without relevant fibrosis (fibrosis score 0-2) and cirrhosis (5-6), beginning after 30 min of sampling (P < 0.05). The ABT did not discriminate patients with fibrosis scores 3-4 from the remaining two patient groups. Sensitivity and specificity for the prediction of cirrhosis was 73.4-82.8% and 63.2-68.4%, depending on the sampling time. Compared with the fibrosis score (P = 0.04), patient age was a highly significant independent predictor for the 13C-recovery (P < 0.0001). Aspartate aminotransferase to platelet ratio index and duplex-Doppler predicted cirrhosis with 76.6%vs. 87.5% sensitivity and 63.2%vs. 68.4% specificity. 4. Our data suggest an age-dependent decrease of cytochrome P450 activity which probably accounts for the large overlap of ABT results that preclude clear differentiation. This is also consistent with former pharmacodynamic trials. Age-adapted reference ranges could improve ABT results.

Improved preoperative tumor staging by 5-aminolevulinic acid induced fluorescence laparoscopy.

BACKGROUND: We report our data in 35 patients who underwent preoperative conventional and fluorescence-based staging laparoscopy. We use the data to address the questions of whether fluorescence examination increases the yield of metastatic lesions and alters treatment intervention. METHODS: Fluorescence laparoscopy was successfully performed in 30 patients with GI malignancies. After sensitization with 5-aminolevulinic acid, conventional white-light mode and fluorescence-light laparoscopies were sequentially performed. A suspected malignancy was biopsied. OBSERVATIONS: In 5 patients, examinations were incomplete because of adhesions. In 9 of 10 patients, hepatic or peritoneal metastases were detected by white-light examination. In 4 of these 9, blue-light examination yielded more metastatic lesions. In one patient with no lesions by white- or blue-light examination, surgery revealed hepatic metastasis in a location not accessible to laparoscopic examination. In 18 patients, surgery confirmed the absence of metastatic lesions. CONCLUSIONS: A fluorescence, blue-light examination yielded more lesions than the conventional white-light examination but did not alter treatment intervention and did not enhance yield when metastatic lesion is in an inaccessible location. Continued research should focus on whether treatment intervention will be altered by the fluorescence examination.

Total body metabolism of 13C-octanoic acid is preserved in patients with non-alcoholic steatohepatitis, but differs between women and men.

OBJECTIVES: Among numerous factors which account for the pathogenesis of non-alcoholic steatohepatitis (NASH), hepatic mitochondrial beta-oxidation is considered to play a pivotal role. We performed a (13)C-based breath test with a medium-chain fatty acid to non-invasively assess total body beta-oxidation in patients with NASH and in healthy controls. METHODS: We performed a simplified (13)CO(2)-based breath test in 16 patients with histologically proven NASH and 24 healthy controls. One hundred milligrams of sodium (13)C-octanoate dissolved in 200 ml of water were orally administered and breath samples were collected before and during 3 h following administration. The samples were analysed for the cumulative (13)CO(2) recovery (%-cum-dose) by non-dispersive infrared spectrometry. Additionally, data of 69 patients who had undergone a C-octanoate breath test for the assessment of gastric emptying were retrospectively evaluated for the %-cum-dose. RESULTS: The cumulative (13)CO(2) recovery 3 h after the administration of the substrate did not differ among patients with NASH and controls (34.6 +/- 7.0% vs. 34.6 +/- 6.5%, P = 0.90). Compared with men, women yielded a significantly higher cumulative (13)CO(2) excretion in both controls (30.1 +/- 5.7% vs. 38.5 +/- 4.4%, P = 0.0008) and NASH patients (30.2 +/- 5.4% vs. 39.0 +/- 6.5%, P = 0.031). Forty-two of 69 patients (61%) of the gastric emptying group showed a normal gastric emptying rate. Among these patients, women also demonstrated a tendency for a higher (13)CO(2) recovery compared with men (P = 0.055). This was not the case in 27 patients with delayed gastric emptying (P = 0.47). CONCLUSIONS: Though hepatic mitochondrial function might be impaired in patients with NASH, total beta-oxidation of octanoic acid remains normal. Gender-specific metabolic modifications seem to account for significant differences of the cumulative (13)CO(2) recovery in women and men. This may have further consequences for the appraisal of (13)C breath tests which involve octanoic acid. Further trials focusing on the assessment of body composition and energy expenditure could contribute essential further information.