Background and Study Aims: During pancreatobiliary imaging by endoscopic ultrasound (EUS) at the authors' institution, it is customary to attempt to obtain the "stack sign", where the bile duct and the pancreatic duct can be seen to run in parallel through the pancreatic head, We suspected that such a view may not be attainable in patients with pancreas divisum because of the short ventral pancreatic duct, The aim of the study was to investigate whether the presence of pancreas divisum could be suspected on the basis of EUS findings,Patients and Methods: The stack sign is obtained by positioning the echo endoscope in the long scope position with the transducer in the duodenal bulb. The balloon is then inflated and advanced snugly into the apex of the bulb, From this position, the bile duct (closest to the transducer) and the pancreatic duct can be seen to run in parallel through the pancreatic head. We attempted to obtain a stack sign during EUS examinations of six patients with pancreas divisum, EUS; was done in these patients to look for evidence of chronic pancreatitis and the pancreas divisum was confirmed by endoscopic retrograde pancreatography, An attempt to obtain the stack sign was also made in 30 patients who had EUS for pancreatobiliary indications but did not have pancreas divisum,Results: In only two out of six patients with pancreas divisum (33 %) were we able to obtain a stack sign, This was significantly different from the rate of observation of a stack sign in 83.3 % (25/30) of patients who did not have pancreas divisum (P=0.04), Of the two patients with pancreas divisum in whom a stack sign was seen, the ventral duct was markedly dilated (6.6 mm) in one, and the other patient had an unusually large ventral pancreas,Conclusions: The absence of a stack sign during pancreatobiliary imaging by EUS may suggest the diagnosis of pancreas divisum,

Background: Patients with advanced (T4 and/or M1) esophageal cancer are offered palliative therapy. Computed tomography (CT) is sensitive for distant metastases but is less sensitive than endosonography for T4 disease and celiac lymphadenopathy. The aim of this study was to determine whether initial CT or endosonography costs less to diagnose advanced esophageal cancer.Methods: A decision model compared the costs of the 2 strategies. Sensitivity analysis and threshold analysis were used to identify the most important determinants of the overall cost of identifying advanced disease.Results: Initial CT is the least costly strategy if the probability of finding advanced disease by initial CT is greater than 20%, if the probability of finding advanced disease by initial endoscopic ultrasound (EUS) is less than 30%, or if the cost of EUS is greater than 3.5 times the cost of CT. However, in our referral center population, endosonography found advanced disease more frequently than CT (44% vs. 13%; p < 0.0001) and the least costly strategy was initial endosonography (expected cost $804 vs. $844).Conclusion: CT remains as the initial staging test of choice in most clinical settings. However, in referral centers, initial EUS may be reasonable, but individualized model inputs must be obtained before reliable conclusions can be drawn.

BACKGROUND:Mild chronic pancreatitis is difficult to diagnose and the diagnosis is therefore not sought routinely in patients with dyspepsia. The aim of our study was to compare the prevalence of endosonographic pancreatic abnormalities in patients with dyspepsia and control subjects.METHODS:The number of endosonographic abnormalities was compared prospectively in patients with dyspepsia and control patients. Patients in whom there was any suspicion of pancreatic disease were analyzed separately.RESULTS:Between November 1998 and January 1999, 156 patients with dyspepsia were compared with 27 control patients. The groups were similar except that control patients were significantly older and more likely to be men. The mean number of endosonographic abnormalities was higher in dyspeptic patients than in control patients (mean number of abnormalities 3.3: 95% CI [2.9, 3.6] vs. 1.9: 95% CI [0.3, 1.7]). The strongest independent predictors of severe endosonographic abnormalities (defined as 5 or more abnormalities) were the presence of suspected pancreatic disease (odds ratio 7.29: 95% CI [2.03, 26. 14]) and dyspepsia (odds ratio 7.21: 95% CI [1.99, 26.26]). In the dyspepsia group, no clinical variables were significant predictors of severe abnormalities. However, most patients had nonspecific-type dyspepsia or persistent symptoms after therapeutic trials of acid suppression.CONCLUSIONS:Dyspepsia may be an atypical presentation of pancreatic disease in patients with persistent or nonspecific symptoms. Endosonography may be useful to screen for pancreatic disease in patients with persistent dyspepsia.

BACKGROUND: Endoscopic ultrasound (EUS) is sensitive for gastric varices, peri-gastric vessels, and ascites in patients with suspected or proven liver disease (e.g. with stigmata of cirrhosis and/or portal hypertension), but the prevalence of these findings in normals(i.e. no clinical suspicion for liver disease) is unclear. AIM: To determine the prevalence of EUS signs of portal hypertension in normals. METHODS: The presence of “varices” (measurable rounded anechoic submucosal structures), peri-gastric vessels, and ascites was compared in consecutive EUS patients with no history, clinical evidence, or risk factors for cirrhosis (other than possible alcohol [EtOH] consumption). Drinkers were also compared to nondrinkers. RESULTS: 181 pts were studied: 42 drinkers and 139 nondrinkers. Overall, 12% had measurable submucosal vessels, 7% had perigastric vessels, and 5% had at least one small triangle of ascites. Drinkers and non-drinkers did not differ significantly for age (51 vs 61yrs) and race (83% and 83% white) but were significantly more often males (52% vs 35%; P=0.05). Drinkers had peri-gastric vessels and ascites significantly more frequently and showed a non-significant trend towards more frequent varices. CONCLUSIONS: 1) Measurable gastric submucosal vessels, perigastric vessels, and small triangles of ascites may be seen by EUS in normals. 2) The increased frequency of these findings in drinkers as compared to non-drinkers who all have no other clinical evidence of cirrhosis and/or portal hypertension suggests that EUS may be useful to detect gastric changes due to EtOH and/or subclinical portal hypertension. BACKGROUND: Endoscopic ultrasound (EUS) is sensitive for gastric varices, peri-gastric vessels, and ascites in patients with suspected or proven liver disease (e.g. with stigmata of cirrhosis and/or portal hypertension), but the prevalence of these findings in normals(i.e. no clinical suspicion for liver disease) is unclear. AIM: To determine the prevalence of EUS signs of portal hypertension in normals. METHODS: The presence of “varices” (measurable rounded anechoic submucosal structures), peri-gastric vessels, and ascites was compared in consecutive EUS patients with no history, clinical evidence, or risk factors for cirrhosis (other than possible alcohol [EtOH] consumption). Drinkers were also compared to nondrinkers. RESULTS: 181 pts were studied: 42 drinkers and 139 nondrinkers. Overall, 12% had measurable submucosal vessels, 7% had perigastric vessels, and 5% had at least one small triangle of ascites. Drinkers and non-drinkers did not differ significantly for age (51 vs 61yrs) and race (83% and 83% white) but were significantly more often males (52% vs 35%; P=0.05). Drinkers had peri-gastric vessels and ascites significantly more frequently and showed a non-significant trend towards more frequent varices. CONCLUSIONS: 1) Measurable gastric submucosal vessels, perigastric vessels, and small triangles of ascites may be seen by EUS in normals. 2) The increased frequency of these findings in drinkers as compared to non-drinkers who all have no other clinical evidence of cirrhosis and/or portal hypertension suggests that EUS may be useful to detect gastric changes due to EtOH and/or subclinical portal hypertension.

Background and Study Aims: To evaluate the utility of a suspension of galactose microparticles available as SHU508A (Levovist) as a contrast agent during endoscopic ultrasonography (EUS).Materials and Methods: Three sets of experiments were performed on three 20-25 kg swine (Sus scrofa) under general anesthesia, Upper EUS was performed with an echo endoscope with color Doppler capability (Pentax FG-32 UA), The celiac artery, superior mesenteric artery, aorta, portal vein, pancreas, and gastrointestinal wall were imaged by EUS, Multiple intravenous bolus injections of 400 mg/ml of SHU508A were made, and their effect on color Doppler and gray-scale imaging during EUS was studied.Results: After contrast injection there was a significant, visually noticeable enhancement of the color Doppler signals from the celiac artery, superior mesenteric artery, and portal vein, Vessels with weak to no color Doppler signals before injection of SHU508 A for example, the celiac artery and superior mesenteric artery were observed to have strong color signals after injection, The effect of SHU508 A on color Doppler imaging was easily appreciated subjectively without the need for complex quantitative measurements, No visually noticeable color Doppler enhancement was seen in vessels such as the aorta that had a very pronounced color Doppler signal even prior to the injection of contrast, Movement of particulate matter was seen in the portal vein on the gray scale.Conclusion: Intravenous SHU508 A as a contrast agent significantly enhances color Doppler signals during EUS, Vascular contrast of this sort could potentially have a significant role in improving the accuracy of EUS in diagnosing malignant vascular invasion, the detection of occult pancreatic neoplasms, and the diagnosis of vascular thrombosis.

PURPOSE:To evaluate the accuracy, safety, and clinical utility of endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) of pancreatic masses.METHODS:Forty-seven patients were referred for EUS with a pancreatic mass and suspicion of pancreatic cancer based upon painless obstructive jaundice, epigastric abdominal pain plus weight loss/anorexia, or idiopathic pancreatitis. All patients underwent EUS with both radial (Olympus UM20) and linear array (Pentax FG32-UA) systems. After TNM staging by EUS, ultrasound directed FNA of the pancreatic mass was performed using a 23 gauge, 4 cm long needle.RESULTS:EUS-guided FNA was performed in all 47 patients. Results: successful targeting = 100%, adequate cellularity = 100%,FINDINGS:adeno Ca = 25, squamous cell Ca = 1, lymphoma = 1, poorly differentiated Ca= 1, atypical cytology or suspicious for carcinoma = 9, no malignant cells = 10. The sensitivity, specificity, positive predictive value and negative predictive value of EUS-guided pancreatic FNA for the diagnosis of malignancy was 64%, 100%, 100% and 16% respectively.CONCLUSIONS:EUS with FNA is useful for detection of malignancy in a pancreatic mass. The procedure appears to have a complication rate of 2%. Impact of this technique on clinical management of patients needs further evaluation.