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An accurate diagnosis of pancreatic fibrosis is clinically important and may have potential for staging chronic pancreatitis. The aim of this study was to diagnose the grade of pancreatic fibrosis through a quantitative analysis of endoscopic ultrasound elastography (EUS-EG). From September 2004 to October 2010, 58 consecutive patients examined by EUS-EG for both pancreatic tumors and their upstream pancreas before pancreatectomy were enrolled. Preoperative EUS-EG images in the upstream pancreas were statistically quantified, and the results were retrospectively compared with postoperative histological fibrosis in the same area. For the quantification of EUS-EG images, 4 parameters (mean, standard deviation, skewness, and kurtosis) were calculated using novel software. Histological fibrosis was graded into 4 categories (normal, mild fibrosis, marked fibrosis, and severe fibrosis) according to a previously reported scoring system. The fibrosis grade in the upstream pancreas was normal in 24 patients, mild fibrosis in 19, marked fibrosis in 6, and severe fibrosis in 9. Fibrosis grade was significantly correlated with all 4 quantification parameters (mean r = −0.75, standard deviation r = −0.54, skewness r = 0.69, kurtosis r = 0.67). According to the receiver operating characteristic analysis, the mean was the most useful parameter for diagnosing pancreatic fibrosis. Using the mean, the area under the ROC curves for the diagnosis of mild or higher-grade fibrosis, marked or higher-grade fibrosis and severe fibrosis were 0.90, 0.90, and 0.90, respectively. An accurate diagnosis of pancreatic fibrosis may be possible by analyzing EUS-EG images.

Clinical guidelines of the European Society of Gastrointestinal Endoscopy recommend the insertion of self-expandable metallic stents (SEMS) as opposed to plastic stents (PS) in patients with unresectable malignant perihilar stricture (MHS). However, PS are cheaper and easier to insert into the biliary duct compared to SEMS. Furthermore, PS are removable and easy to move into subsequent drainage procedures. We conducted the present retrospective single-center study to elucidate the predictive factors associated with stent patency period duration in patients with unresectable MHS who would benefit from a long patency period after PS placement. This study included 56 consecutive patients with unresectable MHS who were drained using PS. PS failure occurred in 26 (46.4%) patients. The median patency period was 72 days (95% confidence interval: 29.8-114). The only significant predictive factor associated with the length of the stent patency period was history of previous endoscopic sphincterotomy (EST). Median patency periods with and without previous EST were 28 and 109 days, respectively (P = 0.016). In conclusion, we suggest that conventional biliary drainage with PS is still a suitable option for the treatment of unresectable MHS in patients without previous EST.

Background and Aim Although peripancreatic vascular lesions are occasionally encountered in autoimmune pancreatitis (AIP), there are few reports focusing on these involvements. We aimed to investigate the peripancreatic vascular involvements associated with AIP. Methods We retrospectively analyzed 54 AIP patients who met the International Consensus Diagnostic Criteria for AIP between July 2003 and October 2010. All of the 54 patients were subjected to multiphasic multidetector computed tomography, and the prevalence, location and prognosis of peripancreatic vascular involvements were investigated. Results Of the 54 AIP patients, 24 (44.4%) exhibited involvements in the form of peripancreatic vascular lesions (stenoses of the splenic vein in 22 and of the superior mesenteric-portal vein in 13, development of perigastric collateral circulation in 18, gastric varices with a red color sign in one and thrombosis inside the portal vein in one). Diffuse-type AIP was associated with a significantly higher prevalence of vascular involvements compared with focal-type AIP (P = 0.033). A total of 14 out of 16 patients who underwent corticosteroid treatment showed improvement in vascular lesions. One case followed up without corticosteroid treatment and presenting an obstruction of the splenic vein exhibited involvements in the form of an infarction and hemorrhagic cysts of the spleen and ultimately underwent distal pancreatectomy and splenectomy. Conclusions Autoimmune pancreatitis patients show a high prevalence of peripancreatic vascular involvements. Thus, patients with vascular involvements are suitable candidates for steroid therapy with evaluation of its potential merits and demerits, even if they are asymptomatic.

Contrast-enhanced endoscopic ultrasonography (CE-EUS) was introduced in the early 1990s. The concept of the injection of carbon dioxide microbubbles into the hepatic artery as a contrast material (enhanced ultrasonography) led to "endoscopic ultrasonographic angiography". After the arrival of the first-generation contrast agent, high-frequency (12 MHz) EUS brought about the enhancement of EUS images in the diagnosis of pancreatico-biliary diseases, upper gastrointestinal (GI) cancer, and submucosal tumors. The electronic scanning endosonoscope with both radial and linear probes enabled the use of high-end ultrasound machines and depicted the enhancement of both color/power Doppler flow-based imaging and harmonic-based imaging using second-generation contrast agents. Many reports have described the usefulness of the differential diagnosis of pancreatic diseases and other abdominal lesions. Quantitative evaluation of CE-EUS images was an objective method of diagnosis using the time-intensity curve (TIC), but it was limited to the region of interest. Recently developed Inflow Time Mapping™ can be generated from stored clips and used to display the pattern of signal enhancement with time after injection, offering temporal difference of contrast agents and improved tumor characterization. On the other hand, three-dimensional CE-EUS images added new information to the literature, but lacked positional information. Three-dimensional CE-EUS with accurate positional information is awaited. To date, most reports have been related to pancreatic lesions or lymph nodes. Hemodynamic analysis might be of use for diseases in other organs: upper GI cancer diagnosis, submucosal tumors, and biliary disorders, and it might also provide functional information. Studies of CE-EUS in diseases in many other organs will increase in the near future.

Background Small-bowel tumors (SBTs) represent a diagnostic challenge. Objective To evaluate the usefulness of contrast-enhanced CT (CECT), fluoroscopic enteroclysis (FE), videocapsule endoscopy (VCE), and double-balloon endoscopy (DBE) and the outcome after treatment. Design Single-center, retrospective study. Setting Tertiary-care referral hospital. Patients Between June 2003 and May 2011, 159 consecutive patients with SBTs (93 malignant and 66 benign) were enrolled. Main Outcome Measurements Comparison of diagnostic yields among CECT, FE, VCE, and DBE and the prognosis. Results CECT and FE had significantly lower diagnostic yields of SBTs ≤10 mm, but VCE and DBE had high yields of SBTs regardless of size. CECT had a significantly lower diagnostic yield of epithelial tumors compared with subepithelial tumors. When stratified by the site, the diagnostic yield of VCE for SBTs located only in the distal duodenum/the proximal jejunum (73%) was significantly lower than that for SBTs located in other areas (90%). Comparisons among the 4 methods revealed that VCE and DBE had significantly higher diagnostic yields than CECT, and DBE had significantly higher diagnostic yields than VCE, but a combination of CECT and VCE had a diagnostic yield similar to that of DBE. The histologic diagnostic yield of SBTs by DBE was 92%, and 25% of SBTs were enteroscopically treated. Metastatic tumors had the poorest overall survival, followed by adenocarcinomas and malignant lymphomas. Limitations Retrospective comparative study. Conclusion For the detection of SBTs, a combination screening method by using VCE and CECT is recommended. DBE is useful for histologic diagnosis and endoscopic treatment.

Background: The sensitivity of transpapillary biliary forceps biopsy for malignancy has been reported as varying from 43–81%. Therefore, there are false negatives in more than 20% of patients, which makes it difficult to diagnose benign biliary stricture as benignancy in a clinical setting. Methods: To clarify the number of tissue samples that should be obtained during transpapillary forceps biopsy to distinguish benign biliary stricture from malignancy, patients undergoing transpapillary biliary forceps biopsy at our institute were examined retrospectively in this study. Results: Seventy-two biliary forceps biopsy procedures were performed on 61 patients. The final diagnoses were malignant biliary stricture in 34 patients and benign stricture in 27 patients. The overall sensitivity and specificity for malignancy in this study were 76.5% and 100%, respectively. There were zero out of 10 (0%) false-negative patients when three or more tissue samples were obtained. In contrast, when four or more tissue samples were obtained, eight out of eight (100%) patients had negative diagnoses for malignancy and were finally diagnosed with benignancy. Conclusion: We suggest that three or more tissue samples are recommended for the diagnosis of biliary malignant stricture.

A 90-year-old woman was admitted to our hospital because of a high-grade fever and appetite loss. On computed tomography scan, a huge cystic lesion about 10 cm in diameter was observed in the pelvic cavity, attached to the vagina and the neck of uterus. Pyometra was strongly suspected; however, a probe could not be inserted into the opening of the uterus because of atrophic changes. Therefore, we decided to perform endoscopic ultrasound (EUS)-guided drainage of the pyometra using the transrectal route. Foul-smelling yellow-brown pus was aspirated. A guide-wire was inserted and a 7 Fr catheter was inserted into the pyometra through an external fistula. We thus completed the treatment of pyometra without surgical resection.

The objectives of this study were to retrospectively evaluate the lesion detection rate of gastric cancer using only virtual gastroscopy generated from MDCT images and the accuracy of invasion depth diagnosis (T staging) using virtual gastroscopy together with contrast-enhanced MDCT with multiplanar reconstruction (MPR) images (virtual gastroscopy with MPR), and to compare the diagnostic performance between virtual gastroscopy with MPR images and endoscopic ultrasound.The subjects consisted of 175 patients with a total of 186 endoscopically proven gastric cancer lesions. All patients underwent dynamic MDCT (arterial and venous phase) for preoperative staging and underwent surgery or endoscopic treatment. In 129 patients (135 lesions) who were also examined using endoscopic ultrasound, the T staging accuracy was also compared between the two modalities. Two endoscopists independently evaluated the lesion detection rate on virtual gastroscopy images alone and determined the T stage on virtual gastroscopy with MPR images. The T staging included the ability to differentiate T1a from T1b lesions.The overall lesion detection rate was 67.7% (126/186). The detection rates of T1a, T1b, and T2 or deeper were 37.8% (28/74), 75.0% (39/52), and 98.3% (59/60), respectively, showing statistically significant differences (p0.001). The T staging accuracies were 82.2% (111/135) using virtual gastroscopy with MPR images and 83.7% (113/135) using endoscopic ultrasound, showing no statistically significant difference (p = 0.850). The main causes of over- and understaging were an ulcer or ulcer scar and poorly differentiated adenocarcinomas, non-solid type, respectively.Virtual gastroscopy with MPR imaging is a useful modality in the T staging of gastric cancer.

Background Management of small-bowel polyps in Peutz-Jeghers syndrome (PJS) by using fluoroscopic enteroclysis (FE), double-balloon enteroscopy (DBE), and videocapsule enteroscopy (VCE) remains incompletely determined. Objective To evaluate the usefulness of FE, VCE, and DBE and compute the polyp growth rate. Design Single-center retrospective study. Setting Tertiary referral hospital. Patients Between June 2003 and January 2010, 18 consecutive patients with PJS were enrolled. Main Outcome Measurements Polyp detection rates among FE, VCE, and DBE, histology of resected polyps, and the polyp growth rate. Results Total enteroscopy rate was higher at VCE (89%) than at DBE (52%; 27% in patients with ≥2 previous laparotomies and 90% in patients with ≤1 [ P = .001]). FE demonstrated fewer polyps than DBE, whereas VCE had detection rates similar to those of DBE. Of 387 DBE-resected and 22 surgically resected polyps, histologic analysis of 110 retrieved polyps showed adenoma or adenocarcinoma in 30.0% of polyps >20 mm and in only 1.3% of polyps ≤20 mm ( P 10 mm (X1; P = .0366) and colorectal polyps >5 mm (X2; P = .002) were independent predictors of the growth rate of small-bowel polyps (Y), and a forward stepwise selection model was constructed: Y=0.136 × X1 + 0.289 × X2 − 0.589 ( R 2 = 0.665). Limitations Small sample size. Conclusions DBE and VCE were useful for the management of small-bowel polyps in PJS. VCE may replace barium examinations for surveillance after polyp resection at intervals depending on the polyp growth rate.

We investigated the feasibility of using real-time tissue elastography (EG) with transcutaneous ultrasonography (EG-US) for pancreatic diseases.A preliminary study (phase I) and a prospective (phase II) study were conducted. Phase I: subjects were 10 volunteers, 5 with cancer, 2 with endocrine tumor, 5 with chronic pancreatitis, 14 with intraductal papillary-mucinous neoplasm. To determine the characteristic EG images (diagnostic criteria for phase II), B-mode images were compared with EG images and histopathologic findings. Phase II: 53 consecutive patients were enrolled. The visualization rate by EG-US in lesions visualized by B mode was assessed, and the correct diagnosis rate by B mode alone (B diagnosis) or in combination with EG-US was evaluated.Phase I: normal parenchyma was a homogeneous color. In cancer, EG-US showed a markedly hard area with soft spots inside. Endocrine tumor was uniform and soft comparable to parenchyma. Chronic pancreatitis showed a mixture of various colors. Phase II: we identified 77.4% (41/53) of the lesions and observed 60.0% (15/25) of the cancers, 100% (3/3) of the endocrine tumor, 92.0% (23/25) of the cases of chronic pancreatitis cases on EG-US. The B-diagnosis rates ranged from about 70% to 80%. The diagnosis rates of the combination were more than 90% of lesions of each type.The EG-US is feasible in the diagnosis of pancreatic diseases.

Narrow band imaging (NBI), based on modifying spectral features by narrowing the bandwidth of spectral transmittance, makes it possible to clearly observe the microvascular architecture or fine superficial structure of the gastrointestinal tract. Using a thinner video endoscope recently developed and not equipped with magnifying mode, the authors have evaluated the clinical usage of NBI for the pancreatobiliary region. Between June and July 2006, peroral pancreatoscopy or cholangioscopy was performed for 10 patients with pancreatobiliary diseases. The scope with an outer diameter of 2.9 mm was used. Non-magnifying NBI observation was compared with standard observation. NBI observation visualized the small vessels and superficial architecture, which were difficult to depict on standard observation. Furthermore, NBI clearly delineated the margin of the small-protruding lesion. Consequently, NBI pancreatoscopy was more useful for diagnosing tumor spread in the main pancreatic duct of the intraductal mucinous neoplasm.

膵疾患診断における超音波内視鏡（EUS）の有用性はすでに確立されており，必須の検査法であると考えられている．基本となるBモード画像で同等以上の画質が得られることが証明されたことで，EUSがメカニカルラジアル走査方式から電子走査方式（電子ラジアル型，電子コンベックス型）に変化することは必然的なものとなった．電子走査方式になることで，ティッシュハーモニックイメージング法，カラードプラ断層法・パワードプラ断層法，造影ハーモニックイメージング法，三次元画像，real time tissue elastography®などがEUSで行えるようになった．このように多方面からのtissue characterizationが可能になったことは膵疾患診断に関する有用性がさらに向上したことを意味する．今後はさらに症例を蓄積し明確な臨床的有用性を証明してゆく必要がある．本稿では，電子走査型EUSで可能になった種々の画像診断法に関して概説する．

Background and study aims Advances in endoscopy have led to imaging of the details of the gastric mucosa, but the histological diagnosis usually has to be confirmed by endoscopic biopsy. A method of confocal endomicroscopy that has recently been developed allows the observation of living cells in vivo. Several investigators have reported that the technique is of value, but there have as yet been no studies describing its application in gastric cancer. Patients and methods Twenty-seven patients with early gastric cancer underwent confocal endomicroscopy (Pentax EG-3870CIK; Pentax, Tokyo, Japan). After intravenous administration of fluorescein sodium, confocal images obtained from the normal mucosa and from cancerous lesions were interpreted by two pathologists independently and compared with the histological findings, including CD34 immunostaining of biopsy specimens or resected specimens from the same sites. Results Fluorescein yielded high-quality confocal images of the gastric mucosa; if cancer could be targeted (59%) images were mostly graded good. The images corresponded to the hematoxylin-eosin staining of transverse sections of specimens from the same sites. In the results for the interpretation by the two pathologists, the accuracy for the diagnosis of gastric cancer was 94.2% (pathologist A), and 96.2% (pathologist B), respectively. The accuracy decreased substantially when poor images and inaccessible lesions were included. Conclusions Confocal endomicroscopy is useful in the diagnosis of gastric cancer but good quality images cannot always be obtained. In the future, it may allow virtual biopsy and help reduce unnecessary biopsies.

In recent years, ultrasound technology has made remarkable strides, and the application of these latest advances to endoscopic ultrasonography (EUS) and intraductal ultrasonography (IDUS) is crucially important. EUS equipped with electronic scanners (both radial and convex types) has been developed, and now EUS with the function of tissue harmonic imaging (THI) and color/power Doppler is applicable clinically. THI facilitates the acquisition of ultrasound images clearer than those of fundamental imaging, and color/power Doppler sonography demonstrates the precise hemodynamics with the use of a contrast agent. In addition, the progress of image processing technology has realized three-dimensional (3D) images in EUS and IDUS. Reconstruction of 3D images enables us to diagnose more objectively. Here we describe the roles of these new ultrasound technologies in the diagnosis of biliary malignancies.

Objective: The purpose of our investigation was to determine the usefulness of digital radiography (DR) for diagnosing the depth of invasion of esophageal carcinoma. Methods: We evaluated 59 patients with esophageal carcinomas who underwent DR. During continuous DR in tangential views, the most distended image of the esophagus was chosen. Percent esophageal stenosis (PES) was based on the diameter across the lesion of maximal narrowing and the average of the normal oral and anal side diameters. The maximal thickness of the tumor was measured on sequentially prepared specimens. We evaluated whether the percent of esophageal stenosis correlated with the maximal thickness of the tumor on histologic findings. Receiver-operating characteristic (ROC) curves were constructed to establish the cut-off level for PES in diagnosing the depth of tumor invasion. Accuracies for the depth of the invasion were calculated based on PES using DR. For the accuracy rate, DR was compared with endoscopy and endoscopic ultrasonography (EUS). Results: There was a close correlation between PES and pathological thickness of the tumor. PES values (mean ± S.D.) were 2.45 ± 0.75% in Tis and T1a tumors, 13.3 ± 10.9% in T1b tumors, 35.2 ± 11.1% in T2 tumors, 55.2 ± 18.1% in T3 tumors, and 86.1 ± 7.5% in T4 tumors. Using the ROC analysis, 12.5, 37.5, and 44.4% were the highest cut-off values of PES for differentiating ≤T1a, ≤T1b, and ≤T2 tumors. Regarding T staging, 45 (76%) of 59 lesions were staged correctly with EUS, whereas 47 (80%) were staged correctly with DR. Conclusion: DR is useful for diagnosing the depth of the invasion because esophageal stenosis calculated using DR is an objective index of tumor infiltration. The accuracy rate of the depth of invasion with DR was as good as that of EUS.

The differentiation of benign from malignant intraductal papillary mucinous tumors (IPMT) is often difficult even by various examination methods. We evaluated the qualitative and quantitative diagnostic ability of contrast-enhanced transabdominal ultrasonography (CE-US), mainly in differentiating benign from malignant tumors in patients with IPMT.There were 21 patients with IPMT who underwent CE-US and endoscopic ultrasonography (EUS). Surgery was performed in all 21 patients. Pathological findings were 4 with carcinoma and 17 with adenoma. CE-US was performed using a contrast agent (Levovist; Tanabe, Osaka, Japan) consisting of galactose microbubbles and a small (0.1%) admixture of palmitic acid, and the following items were evaluated by the following procedure. (1) Two reviewers with experienced sonographic and endosonographic ability evaluated CE-US images before and after contrast enhancement and classified the enhancement effects into three grades. In addition, the presence or absence of enhancement effects by CE-US was compared with that of mural nodules visualized by EUS. (2) In all 21 patients, changes in intensity after contrast enhancement were quantitatively measured using an HDI Lab. HDI Lab was provided by ATL (Philips; Bothell, WA) and these software tools rapidly quantify image characteristics within multiple ROI (regions of interest) and make comparisons between several areas or images. In both the early and late phases, the post-enhancement intensity, difference between pre- and post-enhancement intensity, and the percentage change ((post-enhancement value-pre-enhancement value)/pre-enhancement value) were compared between malignant and benign lesions, and the ability of CE-US to differentiate between benign and malignant lesions was evaluated in comparison with the ability of EUS to diagnose the degree of malignancy.(1) In both the early and the late phases, both reviewers observed enhancement effects in all 21 patients. And both reviewers observed mural nodules by EUS in all 21 patients. (2) In all 21 patients who underwent resection of IPMT, the intensity increased in both the early and late phases. When the patients with carcinoma were compared with those with adenoma, the post-enhancement intensity was significantly higher, and the difference between pre- and post-enhancement intensity and the percentage change in the early phase and the late phase was significantly more marked in the carcinoma group (p= 0.019, p= 0.002, p= 0.015, p= 0.012, and p= 0.039, respectively).CE-US was useful for qualitatively diagnosing tumor lesions in patients with IPMT. Moreover, quantitative changes in intensity can be a parameter for the differential diagnosis of benign and malignant tumors.

In diagnostic imaging, techniques represented by computed tomography (CT) and magnetic resonance imaging (MRI), diagnosis by evaluation of plain images in combination with contrast-enhanced images is considered important. Recently, the ultrasound contrast media that can be administered from peripheral veins have been developed, and their utility is reported not only for the circulatory organ area but also the digestive organ area, mainly for liver diseases. As for the pancreato-biliary diseases, there often are the cases that visualization of the diseases itself is not easy by transabdominal ultrasonography, so, the evaluation of contrast-enhanced ultrasonography remains difficult. In contrast, endoscopic ultrasonography (EUS) is thought to be one of the most valuable modality for those diseases. The mainstream of an operation method of EUS was mechanical radial type, but in late years, endoscopic ultrasonography of an electronic linear method and an electronic radial method have been developed. Because an electronic scan method was adopted, we get possible to apply technology of color Doppler flow imaging and power Doppler flow imaging and harmonic imaging methods to EUS. We would like to outline the usefulness of contrast-enhanced color/power Doppler EUS and contrast-enhanced harmonic EUS, moreover, tissue harmonic imaging and three dimensional imaging, on the basis of our experiences.

Purpose: In this study, we evaluated the diagnostic usefulness of contrast-enhanced transabdominal ultrasonography (CE-US) in pancreatic mass lesions that could be detected by US. Material and Methods: CE-US was performed in 37 patients with various pancreatic mass lesions to evaluate the characteristic vascular findings. Results: Pancreatic tubular adenocarcinoma showed negative enhancement pattern in 16 cases and a slight spotty enhancement pattern in 5 cases. Poorly differentiated adenocarcinoma showed slight homogeneous enhancement pattern in 1 case and acinar cell carcinoma was expressed as a heterogeneous enhancement pattern in 3 cases on CE-US. Endocrine cell tumor had a strong homogeneous enhancement pattern in 3 cases, a strong central enhancement in 1 case and a strong peripheral enhancement in 2 cases. Pseudotumorous pancreatitis showed an iso-enhancement pattern in 6 cases. Conclusion: CE-US is useful in evaluating the vascularity of the lesions in various pancreatic mass lesions in real-time images, and may be useful for the differential diagnosis of pancreatic mass lesions.

膵疾患画像診断における最近の進歩について概説した．超音波検査はLevovist®やSonazoid®などの超音波造影剤が使用可能になることで，B-mode画像に血行動態を加味した診断が出来ることになった．このことは電子走査化によってEUSにおいても重要な意義を有することになった．細胞質や細胞外液中に存在する水分子の水素原子核（プロトン）の拡散を検出し拡散強調画像（DWI）として画像化する技術やperfusion CTの現状を知ることは膵の画像診断を考える上で極めて重要である．

This study was designed to compare intraductal ultrasonography of the gallbladder wall with histopathologic findings and to assess the clinical usefulness of this imaging method in gallbladder disease. Thirty-one gallbladder specimens were examined by intraductal ultrasonography retrospectively. The gallbladder is composed of three layers: an innermost hyperechoic layer, a middle hypoechoic layer, and an outermost hyperechoic layer. The second layer on ultrasonograms corresponds to the muscle layer plus the fibrous tissue of the superficial perimuscular connective tissue layer. In cases in which the thickness of the second layer was 500 microns or less, little fibrous tissue was seen and the second layer was approximately identical to the muscle layer on sonograms. Clinical study was performed on 22 gallbladders. The use of a guidewire through the papilla facilitated intraductal ultrasonographic examination. The intraductal sonographic probe could be inserted into the gallbladder fundus in 13 of 22 cases. In nine unsuccessful cases, technical difficulties were as follows: sharply angulated gallbladder (four cases), stenosis of the gallbladder (two cases), difficulty in transmitting power in the correct direction (three cases). With regard to the area visualized in 13 successful cases, in three cases the area visualized was 100%, in seven cases it was 75%, and three cases it was 50%. Intraductal ultrasonographic images could be obtained in 83.3% (10 of 12) of elevated lesions of the gallbladder. The indications for intraductal ultrasonography will be cases in which an abnormality was detected by transabdominal ultrasonography or other modalities in which the physician does not know whether or not to operate. In conclusion, we defined the intraductal sonographic images of gallbladder wall and clarified the clinical indications for use of this imaging method.

To assess the diagnostic ability and safety of endoscopic retrograde cholangiopancreatography (ERCP) in in-depth preoperative examination of children patients with pancreaticobiliary maljunction (PBM).In 63 patients with a definite diagnosis of PBM, the ability to visualize the bile and main pancreatic ducts was compared between ERCP, which was performed in 63 patients with a definite diagnosis of PBM, and magnetic resonance cholangiopancreatography (MRCP), which was performed before ERCP in 29 patients. For ERCP, its complications were also evaluated.The intrahepatic bile ducts could be visualized using ERCP in 44 patients (69.8%) and using MRCP in 18 (62.1%). The extrahepatic bile ducts could be visualized using ERCP in 59 patients (93.7%) and using MRCP in 29 (100%). The rates of the visualization of the main pancreatic duct and pancreaticobiliary ductal union were significantly higher in using ERCP than in using MRCP (96.8 vs. 41.4% and 90.5 vs. 37.9%, respectively; P0.0001). As complications, hyperamylasemia developed in 12 patients (19%), but no other severe complications such as pancreatitis were observed.ERCP as part of an in-depth preoperative examination of children with PBM is useful and safe.

The aims of this study were to compare the detection rates of gastrointestinal follicular lymphoma lesions by video capsule endoscopy (VCE) and double-balloon endoscopy (DBE), and to determine the pathologic diagnostic yields of DBE-directed biopsies. A total of 27 consecutive patients were enrolled. No significant difference in detection rates was observed in 12 patients who underwent total enteroscopy at both VCE and DBE. Pathologic diagnostic yields stratified by location were 91 % in the proximal duodenum at esophagogastroduodenoscopy, 88 % in the jejunum at antegrade DBE, 52 % in the ileum at retrograde DBE, and 57 % in the terminal ileum at colonoscopy. VCE and DBE were helpful in determining treatment in 44 % of patients.

To assess the clinical benefits of preoperative endoscopic nasobiliary drainage (ENBD) in patients with perihilar cholangiocarcinoma.The advantages of ENBD have been previously reported. However, no studies to date have examined a large number of patients, including those with Bismuth-Corlette (B-C) type III to IV tumors. In addition, sufficient data on the risk factors associated with ENBD complications are not available.This study involved 164 consecutive patients with suspected perihilar cholangiocarcinoma (128 patients with B-C type III-IV tumors) who had undergone unilateral ENBD between January 2007 and December 2010. The success and efficacy of this procedure and the risk factors for post-ENBD cholangitis and pancreatitis were retrospectively evaluated.The ENBD procedure was successful in 153 (93.3%) of the 164 patients. Of these 164 patients, 65 had serum total bilirubin (TB) levels of 2.0 mg/dL or more before the drainage. The first unilateral ENBD was successfully performed in 60 of the 65 patients, and the TB level decreased to less than 2.0 mg/dL after ENBD in 50 of these 60 patients (83.3%). The significant predictive factors for ENBD efficacy included the pre-ENBD TB level (P = 0.032; 95% confidence interval [CI], 1.01-1.23) and post-ENBD cholangitis (P = 0.012; 95% CI, 1.61-43.2). Post-ENBD cholangitis occurred in 47 (28.8%) of the 163 patients, and a previous endoscopic sphincterotomy (EST) was found to be a significant risk factor for post-ENBD cholangitis (P = 0.008; 95% CI, 1.30-5.46). Post-ENBD pancreatitis occurred in 33 (20.1%) of the 164 patients (26 grade 1 patients, 4 grade 2 patients, and 3 grade 3 patients). The significant risk factors included undergoing pancreatography (P0.001; 95% CI, 2.44-31.1) and the absence of previous EBS or ENBD (P0.001; 95% CI, 3.03-29.2).Unilateral ENBD of the future remnant lobe(s) exhibited a high success rate, suggesting that it is an effective and suitable preoperative drainage method for perihilar cholangiocarcinoma even in patients with B-C type III to IV tumors. To reduce the postprocedural complications, ENBD should be performed without EST or pancreatography.

Symptoms of choledochal cysts sometimes persist or become exacerbated. As preoperative management for patients with these cysts, we prospectively employed endoscopic drainage, based on the theory that protein plugs cause symptoms by obstructing the pancreatobiliary ducts.Children with choledochal cysts underwent endoscopic retrograde cholangiopancreatography (ERCP). When ERCP showed compaction with filling defects in patients with persistent or worsening symptoms (study patients), the placement of a short biliary stent tube was attempted for drainage. The clinical and ERCP findings of the study patients were compared with those of patients who were asymptomatic at ERCP (asymptomatic patients).There were 13 study patients (median age 2.9 years) and 41 asymptomatic patients (4.7 years) enrolled in the study between August 2005 and February 2011. Study patients more frequently had jaundice and elevated transaminase levels. ERCP showed that all study patients had obstruction or compacted filling defects in the common channel or the narrow segment distal to the cyst. Insertion of a stent tube was successful in 11 patients. Symptoms were relieved soon after biliary drainage. Surgery revealed that the obstructing materials were protein plugs, except in one case, which involved fatty acid calcium stones.These results support the protein plug theory. Endoscopic short-tube stenting is adequate and effective as preoperative management.

We used contrast-enhanced endoscopic ultrasonography (CE-EUS) to diagnose a case of solid-pseudopapillary neoplasm (SPN) in an adult man. A 58-year-old man was referred to our hospital because of a pancreatic mass found by positron emission tomography (PET) using (18)F-fluorodeoxyglucose (FDG) during a medical checkup in 2009. Trans-abdominal ultrasonography revealed a 24-mm hypoechoic mass at the pancreatic tail with calcification inside. Multiphasic computed tomography (CT) showed a solid mass with delayed enhancement. EUS revealed a hypoechoic mass without lateral shadowing, and neither a septum nor cystic component was detected. CE-EUS using Sonazoid(®) showed a hypovascular mass compared with the surrounding pancreatic parenchyma, and the inside of the mass was enhanced like an alveolus nest, suggesting pseudopapillary change. Diagnosis of a solid-pseudopapillary neoplasm and a concomitant small neuroendocrine tumor was made by distal pancreatectomy.

In the early 2000s, the main stream of endoscopic ultrasonography (EUS) changed from a mechanical scanning method to electronic radial or linear scanning methods. Subsequently, useful applications in trans-abdominal ultrasonography came within reach of EUS. In particular, contrast-enhanced EUS (CE-EUS) and EUS-elastography became cutting-edge diagnostic modalities for pancreatic disorders. Each type of pancreatic disorder has characteristic hemodynamics. CE-EUS uses color Doppler flow imaging and harmonic imaging to classify pancreatic lesions. EUS-elastography can assess tissue hardness by measuring its elasticity. This parameter appears to correlate with the malignant potential of the lesions. Tissue elasticity studies can provide information on both its pattern and distribution. The former is the conventional method of morphological diagnosis, but it is restricted to observations made in a region of interest (ROI). The latter is an unbiased analysis that can be performed by image analysis software and is theoretically constant, regardless of the ROI. Though EUS-fine needle aspiration (FNA) is also a very useful diagnostic tool, there are several limitations. Diagnostic EUS-FNA of pancreatic cystic lesions has marginal utility mainly due to low sensitivity. Therefore, in particular, endoscopists should keep this limitation in mind.

Background Pancreatic endocrine tumors (PETs) develop in relatively few patients, but they are often difficult to diagnose because of their small size and various clinical symptoms. Objective The aim of this study was to investigate the usefulness of EUS combined with contrast enhancement (CE-EUS) in the preoperative localization of PETs and the differentiation between malignant and benign PETs. Design and Setting Single-center retrospective study. Patients Sixty-two pathologically certified PETs of 41 patients who underwent EUS, multiphasic multidetector computed tomography (MDCT), and transabdominal US at our institute since 2001. Interventions Intravenous injection of US contrast media. Main Outcome Measurements Comparison of EUS, MDCT, and US in the preoperative identification of PETs, and the characteristic findings of EUS with malignancy. Results EUS showed high sensitivity (95.1%) in identifying PETs compared with MDCT (80.6%) and US (45.2%). Multivariable logistic regression analysis showed that heterogeneous ultrasonographic texture was the most significant factor for malignancy (OR = 53.33; 95% CI, 10.79-263.58). Most heterogeneous hypoechoic areas and anechoic areas corresponded to hemorrhage or necrosis on pathologic examination. They were identified as filling defects in CE-EUS and were more clearly recognized than in conventional EUS. Limitations Retrospective study. Conclusion EUS has higher sensitivity in preoperative localization of PETs compared with MDCT and US. The characteristics of EUS and CE-EUS findings in malignant PETs were clarified, and they will improve the diagnostic accuracy of PETs.

Double-balloon endoscopy (DBE) utilizes both oral and anal routes. The proper selection of the initial route is important for more rapid management of obscure gastrointestinal bleeding (OGIB). The aim of this retrospective study was to clarify the accuracy of the transit time of video capsule endoscopy (VCE) to the lesion as a predictive indicator for the decision on the initial DBE route.Of 172 patients who underwent both DBE and VCE, 65 who were diagnosed with small-intestinal hemorrhagic lesions by both means were enrolled. The relation between VCE transit time to the lesion and the DBE route by which the lesion was discovered was analyzed, distinguishing between 46 complete and 19 incomplete VCEs.Among the 46 patients with a complete VCE, the transit time and position of the lesion were strongly correlated. The best cutoff values for route selection by the VCE transit time from capsule intake and from the duodenal bulb to the lesion, determined using a receiver operating characteristic (ROC) curve, were 60% and 50%, respectively, of the transit time to the cecum. At that point, the accuracy of route selection was 90% and 94%, respectively. Positions shown by VCE for ileal lesions tended to be more proximal than those shown by surgery. In the 19 patients with incomplete VCEs, the best cutoff for transit time was 180 min from the duodenal bulb.The VCE transit time was useful for determining the route for DBE in OGIB. This parameter was most accurate when the cutoff value for the selection was half of the small-bowel transit time in the complete VCE examination.

Contrast-enhanced endoscopic ultrasonography (CE-EUS) and EUS-elastography are cutting-edge diagnostic modalities for pancreatic disorders. Each pancreatic disorder has characteristic hemodynamics. CE-EUS uses color Doppler flow imaging to classify pancreatic lesions into a spectrum of solid and cystic patterns. Although there is overlap in the patterns generated by specific types of tumors, some types of tumors tend to produce distinct flow images. EUS-elastography can assess tissue hardness by measuring its elasticity. This parameter appears to correlate with the malignant potential of the lesions. Tissue elasticity studies can provide information on both its pattern and distribution. The former is the conventional method of morphologic diagnosis, but it is restricted to observations made in a region of interest. The latter is an unbiased analysis that can be performed by image analysis software and is theoretically constant, regardless of regions of interest. The evolving modalities of CE-EUS and EUS-elastography might provide clinical utility in the diagnosis of pancreatic disorders.

Intraductal papillary mucinous neoplasms (IPMNs)have a wide pathologic spectrum and it is difficult to differentiate malignant from benign tumors. The aim of this study was to identify predictors of malignancy using contrast-enhanced endoscopic ultrasound (CE-EUS).In our institute, main duct type and mixed type IPMNs, branch duct type IPMNs with mural nodules, and IPMNs with coexistent invasive ductal cancer were indications for surgery. Eighty-seven IPMNs (14 main duct, 25 mixed, and 48 branch duct type) were resected and CE-EUS findings were compared with pathologic findings. Twelve clinicopathological variables and CE-EUS morphologic findings were assessed.Mural nodules defined as blood flow supplied protrusions were classified into 4 types: type I: low papillary nodule, type II: polypoid nodule, type III:papillary nodule, and type IV: invasive nodule.Forty-two, 26, 16, and 3 were pathologically diagnosed as adenoma,noninvasive carcinoma, invasive IPMNs, and coexistent invasive ductal cancer, respectively. Multivariable logistic regression analysis showed that types III/IV mural nodule (odds ratio = 10.8; 95% confidential intervals = 2.75-56.1) and symptomatic IPMNs (odds ratio = 4.31; 95% confidential intervals = 1.37-14.7) were significant for malignancy. For mural nodule diameter, invasive IPMNs were significantly larger, but types III and IV mural nodules were more frequently associated with malignancy, particularly invasive cancer, at 88.9% and 91.7%, respectively. The diagnosis of IPMNs with types III or IV mural nodule as malignant resulted in a sensitivity of 60%, specificity of 92.9%, and accuracy of 75.9%.In conclusion, new morphologic criteria were useful to identify the malignant potentials of IPMNs.

The analysis of morphology obtained by endoscopic ultrasonography (EUS) has been the main aim of EUS diagnosis. On the other hand, various disorders have their own characteristic vascularities in the digestive organs. The combination of diagnosis with morphology and vascularities is thought to be important and useful. Needless to say, the core function of EUS is ultrasonography, and EUS should follow state-of-the-art technology of ultrasonography. In this chapter, we discuss EUS angiography, contrast-enhanced EUS (CE-EUS) using the first contrast agent (Albunex), the next agent (Levovist), and the latest agent (Sonazoid).

Small-bowel obstruction (SBO) sometimes remains undiagnosed and untreatable without surgery.To evaluate the diagnostic yields of SBO between double-balloon endoscopy (DBE) and fluoroscopic enteroclysis (FE), and the outcome of enteroscopic treatment.Single-center, retrospective, and prospective study.Tertiary-referral hospital.Between June 2003 and July 2007, 66 consecutive patients with SBO were enrolled, investigated, and treated.A comparison of diagnostic yields between DBE and FE, and the prognosis after enteroscopic balloon dilation.The diagnostic yield of DBE for SBO (95%) was higher than that of FE (71%) in 59 patients who underwent both examinations (P= .004). The first treatment included 27 surgical, 25 enteroscopic, and 14 conservative therapies. Of 47 enteroscopic balloon dilation procedures in 22 patients, 45 (96%) were successful. Of 16 patients with Crohn's disease, 11 (69%) remained asymptomatic over the postdilation follow-up period but 5 relapsed: 2 recovered by repeated dilations, but 3 required surgery. Of 6 patients who had diseases other than Crohn's disease, 4 (67%) remained asymptomatic but 2 relapsed: one with remission of metastasis recovered by repeated dilations, and one with ischemic enteritis required surgery. Anastomotic stricture was an independent marker of the symptom-free outcome (hazard ratio 0.037-0.084, P= .037). Two acute pancreatitis, one perforation, and one exacerbation of SBO complications occurred.Small sample size and participation bias.DBE was useful for the diagnosis of SBO. Balloon dilation is considered an alternative to surgery in patients with fibrotic strictures both related and unrelated to Crohn's disease.

The usefulness of 18F-fluoro-2-deoxyglucose positron emission tomography (18FDG-PET), whose high rate of FDG accumulation indicates high metabolism and malignant potential, has already been reported. The aims of this study were to evaluate the malignancy of primary gastrointestinal stromal tumour (GIST) in the stomach by 18FDG-PET and to correlate the FDG uptake values with known risk factors as determined by histology after EUS-guided fine needle aspiration (EUS-FNA) or endoscopic biopsy.Of 29 patients with histologically proven GI-mesenchymal tumours, 21 with gastric GISTs underwent 18FDG-PET. Tumour size, mitotic index, Ki-67 labelling index (LI) and cellularity of the tumour tissue were compared with the standardized uptake value (SUV) of FDG.Strong correlations were found between the SUV of FDG and EUS size, and mitotic index of EUS-FNA specimens (tumour size versus SUV, p=0.004, r=0.542; number of mitotic cells versus SUV, p=0.0078; n=21). Moreover, we examined the association between SUV and risk categories based on EUS-FNA findings using ROC curves. The cut-off values of FDG SUV were 2.2, 4.2 and 6.5 for the very low-, low-, intermediate- and high-risk groups, respectively.18FDG-PET may be used to assess malignancy of GISTs. This image modality helps us determine the management strategy for these patients and complements the information on the biological behaviour and cellular proliferation of the tumours.

Endoscopic ultrasonography (EUS) is considered the most useful diagnostic modality for regional staging; however, it is still difficult to diagnose lymph node metastasis by EUS images only. In this study, we report the usefulness of contrast-enhanced EUS (CE-EUS) in the evaluation of benign lymph nodes (BLN) or malignant lymph nodes (MLN) based on blood flow patterns.In the retrospective study, CE-EUS was performed in 46 patients in whom EUS revealed lymph node in the mediastinum or abdominal cavity. The subjects consisted of 22 patients with BLN and 24 patients with MLN. The lesions were examined by EUS, and the maximal and minimal diameters of lymph nodes were measured. Thereafter, the shape and internal echoes were investigated, and the findings were morphologically classified based on Catalano's report. Enhancement effects and the diagnostic capability of CE-EUS were evaluated. In the prospective study, BLNs were differentiated from MLN using the enhancement patterns on CE-EUS based on the results of the retrospective study, and the diagnostic capability was evaluated.In the retrospective study, there were no significant differences in the maximal diameter and maximal/minimal diameter ratio between MLN and BLN. The morphology was classified into four types. Based on the morphological classification, the sensitivity, specificity, and accuracy rate were 88.2%, 77.3%, and 82.1%, respectively. On CE-EUS, the enhancement pattern was classified into three types. The BLN lesions showed uniform enhancement (19/22). In all patients with MLN, a defect of enhancement was observed (24/24). The sensitivity, specificity, and accuracy rate of CE-EUS were 100%, 86.4%, and 92.3%, respectively. In the prospective study, the sensitivity, specificity, and accuracy rate of CE-EUS were 100%, 81.8%, and 92.0%, respectively.CE-EUS is useful for differentiating BLN from MLN.

The patient was a 58-year-old woman. Gallbladder stones and occult blood in feces were detected during a physical check-up, then the patient was referred to Nagoya University Hospital. In this case the fistula was difficult to diagnosed by ultrasound and endoscopic ultrasound (EUS) of the upper intestinal tract because the gallbladder was filled with stones. Barium enema and endoscopic retrograde cholangiopancreatography did not reveal fistula. Curved-linear array EUS of the colon showed fistula.

To estimate the detectability of anomalous connection in pancreatobiliary disease (ACPBD) cases, measuring gallbladder wall blood flow (GWBF).In the retrospective study, we enrolled 42 subjects with gallbladder wall thickening. GWBF velocity was determined as an average value of the peak velocity of color signals on the gallbladder wall, three times in each case. Based on the findings on endoscopic ultrasonography (EUS) or endoscopic retrograde cholangiopancreatography (ERCP), the 42 subjects were divided into 11 cases with ACPBD and 31 cases without ACPBD. In the prospective study, the subjects were 92 cases with gallbladder wall thickening. Using the cut-off level of the flow velocity obtained in the retrospective study, the usefulness of measuring GWBF velocity in diagnosing ACPBD was evaluated.In the retrospective study, imaging of GWBF was obtained in 40 of the 42 subjects. The mean GWBF velocity of the ACPBD cases was 29.4+/-3.9 cm/s (mean+/-SD), which was significantly different (P0.0001; 95% CI 5.48-13.2) from that of the without ACPBD cases (20.1+/-5.9 cm/s). Based on this result, we prepared a receiver operating characteristic curve, and the cut-off level appropriate for diagnosing ACPBD was estimated to be 25 cm/s. In the prospective study, GWBF was detected in 86 of the 92 subjects. Based on the EUS or ERCP findings, the 92 subjects were divided into 15 cases with ACPBD and 77 cases without ACPBD. When a cut-off level of 25 cm/s was employed, ACPBD could be diagnosed with a sensitivity of 87.0% (13/15) and a specificity of 87.3% (62/71).Measurement of GWBF velocity, which is less invasive and provides objective values, is very useful for diagnosing ACPBD prior to the development of malignant tumors in cases with gallbladder wall thickening.

Background and study aim Ensdoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been reported as a useful technique for histological diagnosis of submucosal or extrinsic gastrointestinal and pancreatic lesions. The aim of this study was to evaluate the use of EUS-FNA for the diagnosis of lesions either within or adjacent to the wall of the colon and rectum. Patients and methods A total of 22 patients with a lesion within the wall of, or adjacent to, the colon or rectum underwent EUS-FNA. They were divided into two groups: patients who had previously had a malignancy (the "previous +ve" group, n = 11), and patients who had not previously had a malignancy (the "previous -ve" group, n = 11). In the four patients who had lesions located proximal to the sigmoid colon, EUS-FNA was performed using a guide wire and overtube. The success rates for adequate tissue sampling and for detecting malignant and benign masses by EUS-FNA were evaluated and the success rate for detection was compared with the success rate of EUS and computed tomography. Results Sufficient tissue for evaluation was obtained from 21 of the 22 patients (95.5 %). The overall rate of detection of malignant and benign masses was 95.5 % (21/22) for EUS-FNA and 81.8 % (18/22) for pre-EUS-FNA imaging investigations. Of the 11 patients in the previous +ve group, ten were diagnosed with recurrences of primary malignancies; of the 11 patients in the previous -ve group, four were diagnosed with primary malignancies and seven were diagnosed with benign lesions. There were no complications related to the EUS-FNA procedure. Conclusions EUS-FNA is a safe technique which is useful in the planning of treatment for patients who have a mass within the wall or adjacent to the wall of the entire length of the colon or rectum.

Background and Aim: It is common knowledge that endoscopic ultrasonography (EUS) can accurately diagnose pancreatic diseases. Echoendoscopes for EUS are roughly classified into two categories, the mechanical radial scanning echoendoscope (MR-ES) and the electronic linear array echoendoscope, both of which have their merits and demerits. In 2000, a newly designed echoendoscope, the electronic radial scanning echoendoscope (ER-ES), appeared. The aim of the present study was to compare B-mode image quality between the ER-ES and the MR-ES in pancreatic diseases. Methods: Patients with pancreatic diseases (30 cystic diseases and 22 solid diseases) underwent EUS with both ER-ES and MR-ES. The B-mode images obtained using both echoendoscopes were graded using a scoring system and statistically analyzed. The assessed point for cystic lesions was the existence of mechanical-noise-like ring-like artifacts derived using multiple reflections (‘ring-down’), grating robe and so on, and that for solid lesions was the scale of penetration. The authors compared maneuverability, endurance and endoscopic images between the two types of echoendoscopes. Results: The ER-ES had a significantly higher score than the MR-ES (P

Background: The availability of an electronic radial scanning echoendoscope has facilitated the clinical use of tissue harmonic imaging. This study compares the quality of US images acquired by tissue harmonic imaging during electronic radial scanning EUS to those acquired by fundamental imaging. Methods: Electronic radial scanning EUS was performed in 108 patients with pancreatic lesions (58 cystic, 50 solid). US images acquired by fundamental imaging at a frequency of 7.5 MHz were compared with those acquired by tissue harmonic imaging by using transmitting and receiving frequencies of, respectively, 4.0 and 8.0 MHz at the same scanning plane. Cystic lesions were evaluated for boundary/septum and nodules, and solid lesions, for boundary and internal structure. US images acquired by tissue harmonic imaging and fundamental imaging during electronic radial scanning EUS were compared, by using a Likert scale for the respective evaluation criteria, by two independent endoscopists. Observations: For cystic lesions, tissue harmonic images were significantly clearer than fundamental images for visualizing boundary and septum ( p p = 0.0003, Reviewer 1; p = 0.0007, Reviewer 2). For solid lesions, tissue harmonic images were significantly clearer than fundamental images for visualizing boundary ( p = 0.0003, Reviewer 1; p p = 0.0003, Reviewer 1; p = 0.0009, Reviewer 2). Conclusions: US images acquired by tissue harmonic imaging appear to be clearer compared with those acquired by fundamental imaging.

We describe the standard endoscopic ultrasonography (EUS) procedure of the pancreas used in our institute. Both radial scanning and convex (or linear) scanning methods have valid uses, so these two methods will coexist in the future. Physicians learning EUS need to master both types. It is important to standardize both types of EUS procedure. Generally, physicians persist in the method mastered first and don’t make use of the other method. In order to plan the standardization of EUS procedures, it may be reasonable to standardize the procedures of both type EUS simultaneously, comparing radial scan mode and linear (convex) scan mode. Here we demonstrate our standard procedures for both EUS modes, mainly emphasizing the visualization maneuver of the pancreas.