Double splenic artery pseudoaneurysm associating splenic infarction in chronic pancreatitis.

Pseudoaneurysm represents a rare complication in chronic pancreatitis, caused by enzymatic digestion of peripancreatic arteries or the erosion of a visceral artery by pseudocysts. The presence of multiple pseudoaneurysms is rarely seen and their association with splenic infarction has been rarely reported. This case presentation reports the concomitant presence of two pseudoaneurysms with different mechanisms of formation, one of them diagnosed by EUS features and histology of pseudotumoral chronic pancreatitis; the second was diagnosed by contrast-enhanced transabdominal US and CT scan. Their association with splenic infarction was explained by ischemic pathogenesis.

Added value of intravenous contrast-enhanced ultrasound for characterization of cystic pancreatic masses: a prospective study on 37 patients.

UNLABELLED: The aim of this study was to evaluate the added value of contrast-enhanced ultrasound (CEUS) in the pancreatic cystic mass (PCM) diagnosis by using a qualitative and quantitative analysis in order to make a relevant characterization. PATIENTS AND METHOD: Between December 2008 and November 2011, 37 patients with PCM discovered at ultrasound examination were prospectively followed. A qualitative and quantitative CEUS analysis was performed in order to differentiate etiologies of the PCM. In the quantitative analysis several parameters were followed: Peak Intensity (PI), Time to Peak (TTP), maximum ascending gradient (GRAD), Time to maximum gradient (TTG) and Area Under the Curve (AUC). Normalized ratios were also calculated. In all patients a definite cytological or histological diagnosis was obtained. RESULTS: Thirty-seven patients were studied: 12 with pancreatitis-associated pseudocyst and 25 with cystic tumors (10 serous cystic adenoma, 5 mucinous cystic adenoma, 6 cystadenocarcinomas, 2 solid pseudopapillary tumors and 2 intraductal papillary mucinous neoplasms). There was a significant difference of the nAUC and nTTP between pseudocyst and cystic tumors, p=0.03 and p=0.01, respectively. A normalized TTP value above 7 sec was suggestive for the diagnosis of pseudocysts with 79.16 % accuracy. There was a significant difference of nTTP and nTTG between the benign and malignant lesions. nTTP < 9 sec and nTTG < 8.5 sec rules out malignant cysts in almost 90% of cases. CONCLUSION: The CEUS is useful in the diagnosis of PCM. The quantitative analysis of the enhancement of the cystic wall may discriminate the different types of the PCM.

The safety of endoscopic ultrasonography-guided drainage of pancreatic fluid collections without fluoroscopic control: a single tertiary center experience.

BACKGROUND: Endoscopic ultrasonography (EUS) is preferred for guiding drainage of pancreatic fluid collections, with a success rate exceeding 90% when fluoroscopy is used. When fluoroscopy cannot be used, drainage can still be performed, but no data regarding the safety of such a procedure have yet been published. AIM: To establish the safety of EUS-guided drainage without fluoroscopic control and to identify criteria for the selection of suitable patients. METHODS: The pancreatic fluid collections considered suitable for EUS-guided drainage were >5 cm in diameter, symptomatic, without ductal communication. We attempted EUS-guided drainage of PC prospectively in 24 patients: 9 with abscesses and 15 with pseudocysts. RESULTS: Drainage was successful in 20 cases (83.3%), with complete resolution after a median 18 months' follow-up. EUS-guided drainage failed in four patients (16.7%): one in the abscess group due to symptomatic pneumoperitoneum and three in the pseudocyst group due to thick wall. Drainage failure was associated with a diameter <6 cm and wall thickness >2 mm and was considered to be due to the sliding of the cystotome on the pseudocyst wall. During follow-up there was one procedure unrelated death (4.1%) and no pancreatic fluid collections relapses. CONCLUSIONS: Fluoroscopic control represents a helpful tool, but it is not always necessary for EUS-guided drainage of pancreatic fluid collections. EUS-guided drainage is possible, efficient and safe without fluoroscopy in selected pancreatic fluid collections with a diameter larger than 6 cm and a thin wall. Collections with a thick wall should be drained under fluoroscopy or referred directly for surgery.

The added value of real-time harmonics contrast-enhanced endoscopic ultrasonography for the characterisation of pancreatic diseases in routine practice.

Endoscopic ultrasonography is an imaging method used in the diagnosis of pancreatic diseases. The differentiation between inflammatory tumor-like masses and pancreatic adenocarcinoma still remains difficult. Contrast enhanced harmonic endoscopic ultrasonography (CEH-EUS) is a new technique, recently available in commercial use and less evaluated. It is used to characterize the microcirculation in pancreatic disorders--hypervascularized masses such as neuroendocrine tumors or hypovascularized masses such as adenocarcinomas--and to better visualize the necrotic areas in acute pancreatitis and the vascularisation of mural nodules and septa in pancreatic cystic lesions.

Contrast-enhanced ultrasound of the pancreas--a method beyond its potential or a new diagnostic standard?

Contrast-enhanced ultrasound is a relatively new technique, currently used for liver tumors diagnosis. Newer contrast agents are composed of stabilized micro-bubbles capable of traversing the capillary circulation. Lately, the method has also been used in the assessment of pancreatic disorders. Pulse inversion harmonic imaging allows the assessment of the hypervascularised masses as neuroendocrine tumors, of the hypoperfused masses as adenocarcinomas and of the necrotic areas in acute pancreatitis. Also, this imaging method allows a better assessment of the pancreatic tumor resectability and the identification of septa inside the cystic lesion. Contrast-enhanced ultrasound might represent a valuable additional imaging method to contrast CT for selected cases.