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Background: Because of its inherent risks, ERCP should only be performed for purposes of treatment. EUS and MRCP have emerged as diagnostic alternatives before therapeutic ERCP. Objective: Our purpose was to test the accuracy of EUS in predicting the need for therapeutic ERCP in low-risk patients. Design: Prospective, unblinded, single-center study. Setting: Academic center of the University of Witten/Herdecke. Patients: Fifty patients with clinical, laboratory, or transabdominal US findings suggestive of biliary obstruction were included. Interventions: After clinical assessment and US, all patients underwent EUS. If EUS was conclusive, either ERCP with sphincterotomy (EST) was performed or the patients were followed up for 1 year. If EUS was inconclusive, MRCP was performed, followed by ERCP or a 1-year follow-up. After each diagnostic step, the examiner decided whether any biliary conditon was present and whether therapeutic ERCP was necessary. The decicions were compared with the results of ERCP with EST or the outcome after the 1-year follow-up. Main Outcome Measurements: Accuracy of EUS in predicting the need for therapeutic ERCP. Results: Nine patients had ERCP with EST. The final assessment classified 2 of these interventions as having been unnecessary. EUS was conclusive in 49 cases. After EUS, the accuracy of the decision on the presence of a biliary condition increased from 82% to 96% and on the need for therapeutic ERCP from 86% to 96%. Limitation: Single-center experience. Conclusion: EUS accurately predicts the need for therapeutic ERCP in patients at low risk for biliary obstruction. [Copyright &y& Elsevier]

Background: Initial clinical applications have shown that US elastography might be able to distinguish tissues because of their specific consistency. Objective: (1) To investigate the feasibility of EUS elastography of the pancreas and (2) to describe elastographic patterns of the normal pancreas and the pancreas affected by inflammatory or focal disease. Design: Prospective single-center study. Setting: Academic center of the University of Witten/Herdecke. Patients: Twenty patients with normal pancreas, 20 patients with chronic pancreatitis, and 33 patients with focal pancreatic lesion, histologically later proven in 32 of these 33 cases. Interventions: Commercially available US equipment was used. The elasticity of tissue was reconstructed in real time within a sample area and was translated into a color scale imaging relative tissue elasticity within this area. Representative loops of at least 20 seconds were recorded regarding each region of interest. Results: Adequate elastographic recordings could be obtained in all 73 patients. Patients with hypoechoic and intermediately echogenic normal pancreas revealed a relatively homogeneous elastographic pattern. Thirty-one focal lesions, including 30 neoplasms and most of the chronically inflamed pancreata had a honeycomb pattern dominated by hard strands. This pattern showed analogies to the histologic structure of 10 resected tumors. Other patients with chronic pancreatitis and those with hyperechoic healthy pancreas had miscellaneous elastographic appearances. Conclusions: EUS elastography of the pancreas is feasible and produces plausible results. The examination of homogeneous tissue is impaired by the relative scale used. Chronic pancreatitis and hard tumors cannot be distinguished by elastography, probably because of their similar fibrous structure. [Copyright &y& Elsevier]