High-grade pancreatic intraepithelial neoplasia diagnosed based on changes in magnetic resonance cholangiopancreatography findings:A case report

BACKGROUND High-grade pancreatic intraepithelial neoplasia(PanIN)exhibits no mass and is not detected by any examination modalities.However,it can be diagnosed by pancreatic juice cytology from indirect findings.Most previous cases were diagnosed based on findings of a focal stricture of the main pancreatic duct(MPD)and caudal MPD dilatation and subsequent pancreatic juice cytology using endoscopic retrograde cholangiopancreatography(ERCP).We experienced a case of high-grade PanIN with an unclear MPD over a 20-mm range,but without caudal MPD dilatation on magnetic resonance cholangiopancreatography(MRCP).CASE SUMMARY A 60-year-old female patient underwent computed tomography for a follow-up of uterine cancer post-excision,which revealed pancreatic cysts.MRCP revealed an unclear MPD of the pancreatic body at a 20-mm length without caudal MPD dilatation.Thus,course observation was performed.After 24 mo,MRCP revealed an increased caudal MPD caliber and a larger pancreatic cyst.We performed ERCP and detected atypical cells suspected of adenocarcinoma by serial pancreatic juice aspiration cytology examination.We performed a distal pancreatectomy and obtained a histopathological diagnosis of high-grade PanIN.Pancreatic parenchyma invasion was not observed,and curative resection was achieved.CONCLUSION High-grade Pan-IN may cause MPD narrowing in a long range without caudal MPD dilatation.

Magnetic resonance cholangiopancreatography study of pancreaticobiliary maljunction and pancreaticobiliary diseases

AIM: To discuss the imaging anatomy about pancreaticobiliary ductal union, occurrence rate of pancreaticobiliary maljunction (PBM) and associated diseases in a Chinese population by using magnetic resonance cholangiopancreatography (MRCP).

Magnetic resonance cholangiopancreatography for the detection of pancreatic duct stones in patients with chronic pancreatitis

AIM:To assess the role of magnetic resonance cholangiopancreatography(MRCP) in detection of pancreatic duct stones(PDS) in patients with chronic pancreatitis(CP).METHODS:Clinical data of 78 CP patients who were treated at the First Affi liated Hospital of Xi'an Jiaotong University(China) between January 2004 and July 2008 were retrospectively analyzed.A predictive model of pancreatic duct stones was established through logistic regression and its effectiveness was verifi ed.Among these patients, MRCP was performed in 60 patients who served as a control group, while 44 patients with a higher predictive value than the entry threshold of the predictive model served as an experimental group.RESULTS:The positive rate of PDS in the 78 patients with CP was 19.2%(15/78).The predictive entry threshold of the predictive model was 5%(P < 0.05).The possibility of existence of PDS could be predicted according to the following 4 indexes:gastrointestinal symptoms, intermittent abdominal pain, diabetes mellitus(DM)/impaired glucose tolerance(IGT) and positive B-mode ultrasound results.The incidence of PDS in the experimental group was higher than that in the control group(P < 0.05).CONCLUSION:MRCP is strongly suggested for the detection of PDS in patients with gastrointestinal symptoms, intermittent abdominal pain, DM/IGT and positive B-mode ultrasound results.

Clinical significance of magnetic resonance cholangiopancreatography utilizing half-Fourier acquisition single-shot fast spin-echo in diagnosing bile duct diseases

Objective: To investigate the clinical significance of magnetic resonance cholangiopancreatography (MRCP) utilizing half-Fourier acquisition single-shot fast spin-echo (HASTE) in the diagnosis of bile duct diseases. Methods: Forty-three patients with obstructive jaundice and 4 without were enrolled in this study. The underlying diseases included bile duct calculi ( 13 cases) , chronic cholangitis ( 14 cases) malignant tumors (18 cases) and congenital biliary cysts (2 cases). All patients underwent examinations with magnetic resonance imaging (MRI) and MRCP, and 39 were also examined with B-type ultrasonography, 33 with CT and 25 with ERCP and PTC. Three-dimensional image reconstruction was performed using volume-rendered technique ( VRE) on the basis of the data obtained by MRCP. Results: The biliary calculi were displayed as circular filling defects in MRCP images, with the proximal end of dilated bile duct taking the form of the mouth of a cup. The bile duct of patients with chronic cholangitis showed distal end dilation and thinner proximal end without discontinuity. Interception of the bile ducts was most frequent (72. 2% ) in cases of malignant bile duct obstruction, in which the ducts may also be mastoid or resembling rat tails. 72. 2% of the cases had severe dilation of the bile ducts, which occur in only 16. 0% of the benign cases, with significant difference between them (P <0. 01) . In images of intrahepatic biliary cyst, intrahepatic duct dilated in the shape of a bursa in connection with the duct. By MRCP, 20 malignant obstructions of the bile ducts were identified with 2 misdiagnoses, and in 25 cases of benign obstructions identified by MRCP, only 1 misdiagnoses occurred. Thus MRCP had the sensitivity, specificity and accuracy of 90.0% , 96.3% and 93.6% respectively in discriminating benign and malignant diseases of the bile ducts, showing a total diagnostic accuracy of 94. 0% that was similar to that of ERCP (92.0% ) but significantly higher than those of both CT (75. 0% ) and B-type ultrasonic examination (74. 0% ). Conclusion: In diagnosing obstructive jaundice, HASTE MRCP is similar to ERCP but better than CT and B-type ultrasonography , with the merits of fast imaging and high resolution as an ideal sequence for MRCP imaging.

Oral Gd-DTPA as a negative gastrointestinal contrast agent in magnetic resonance cholangiopancreatography

Objective: To evaluate the value of oral Gd-DTPA as a negative contrast agent during magnetic resonance cholangiopancreatography (MRCP) to eliminate the high signals of the gastrointestinal tract. Methods: To select the optimal concentration of oral Gd-DTPA for MRCP, a phantom study was performed followed by clinical trial in 15 cases undergoing MRCP before and after oral Gd-DTPA (in a total volume of 250 ml 1∶5 diluted Gd-DTPA, 1.488 g/L). MRCP images were acquired using two-dimensional single slice fast spin-echo (SSTSE) sequence and half-Fourier acquisition single slice fast spin-echo (HASTE) sequence. Results: The phantom study showed that the 1∶5 diluted oral Gd-DTPA was best in decreasing the signal intensity both in T2-weighted imaging (59.5%) and in HASTE sequence (82.45%). The high signal intensity of the stomach and intestinal fluid was completely suppressed in all the cases. The depictions of the common bile duct and pancreatic duct were markedly improved by using the oral contrast agent (P<0.05). Conclusion: Oral Gd-DTPA is effective and safe for eliminating the high signal of the gastrointestinal tract to improve the depiction of the biliary system by MRCP.

Evolution of incidental branch-duct intraductal papillary mucinous neoplasms of the pancreas: A study with magnetic resonance imaging cholangiopancreatography

AIM To investigate the type and timing of evolution of incidentally found branch-duct intraductal papillary mucinous neoplasms(bd-IPMN) of the pancreas addressed to magnetic resonance imaging cholangiopancreatography(MRCP) follow-up.METHODS We retrospectively evaluated 72 patients who underwent, over the period 2006-2016, a total of 318 MRCPs(mean 4.4) to follow-up incidental, presumed bdIPMN without signs of malignancy, found or confirmedat a baseline MRCP examination. Median follow-up time was 48.5 mo(range 13-95 mo). MRCPs were acquired on 1.5T and/or 3.0T systems using 2D and/or 3D technique. Image analysis assessed the rates of occurrence over the follow-up of the following outcomes:(1) imaging evolution, defined as any change in cysts number and/or size and/or appearance; and(2) alert findings, defined as worrisome features and/or high risk stigmata(e.g., thick septa, parietal thickening, mural nodules and involvement of the main pancreatic duct). Time to outcomes was described with the Kaplan-Meir approach. Cox regression model was used to investigate clinical or initial MRCP findings predicting cysts changes.RESULTS We found a total of 343 cysts(per-patient mean 5.1) with average size of 8.5 mm(range 5-25 mm). Imaging evolution was observed in 32/72 patients(44.4%; 95%CI: 32-9-56.6), involving 47/343 cysts(13.7%). There was a main trend towards small(< 10 mm) increase and/or decrease of cysts size at a median time of 22.5 mo. Alert findings developed in 6/72 patients(8.3%; 95%CI: 3.4-17.9) over a wide interval of time(13-63 mo). No malignancy was found on endoscopic ultrasound with fine-needle aspiration(5/6 cases) or surgery(1/6 cases). No clinical or initial MRCP features were significantly associated with changes in bd-IPMN appearance(P > 0.01).CONCLUSION Changes in MRCP appearance of incidental bd-IPNM were frequent over the follow-up(44.4%), with relatively rare(8.3%) occurrence of non-malignant alert findings that prompted further diagnostic steps. Changes occurred at a wide interval of time and were unpredictable, suggesting that imaging followup should be not discontinued, though MRCPs might be considerably delayed without a significant risk of missing malignancy.

Role of diffusion-weighted magnetic resonance imaging in the diagnosis of extrahepatic cholangiocarcinoma

AIM: To determine the clinical value of diffusion-weight- ed imaging (DWI) for the diagnosis of extrahepatic cholangiocarcinoma (EHCC) by comparing the diagnostic sensitivity of DWI and magnetic resonance cholan-giopancreatography (MRCP). METHODS: Magnetic resonance imaging examination was performed in 56 patients with suspected EHCC. T1- weighted imaging, T2-weighted imaging, MRCP and DWI sequence, DWI using single-shot spin-echo echoplanar imaging sequence with different b values (100, 300, 500, 800 and 1000 s/mm2), were performed. All cases were further confirmed by surgery or histopathological diagnosis. Two radiologists jointly performed the analysis of the DWI and MRCP images. Apparent diffusion coefficient (ADC) value and signal-noise ratio were calculated for EHCC. Sensitivity, specificity, accuracy, positive predictive value and negative predictive value were tested using DWI with a b value of 500 s/mm2 and MRCP images, respectively. RESULTS: Histopathological diagnosis confirmed that among the 56 cases, 35 were EHCC (20 hilar and 15 distal extrahepatic), 16 were cholangitis, and 5 were cal-culus of bile duct. Thirty-three out of the 35 EHCC cases were detected by DWI. EHCC exhibited differential levels of high signal intensity in DWI and low signal intensity in the ADC map. The mean value for ADC was (1.31 ± 0.29) × 10-3 mm2/s. The detection rate of EHCC was significantly higher by DWI (94.3%) than by MRCP (74.3%) (P < 0.05). There was a significant difference in sensitivity (94.3% vs 74.3%), specificity (100% vs 71.4%), accu- racy (96.4% vs 73.2%), positive predictive value (100% vs 81.3%), and negative predictive value (91.3% vs 62.5%) between DWI and MRCP in diagnosing EHCC. CONCLUSION: DWI has a high sensitivity for the detection of EHCC as it shows the EHCC lesion more unambiguously than MRCP does. DWI can also provide additional clinically important information in EHCC patients when added to routine bile duct MR imaging protocols.

Exocrine pancreatic function assessed by secretin cholangio-Wirsung magnetic resonance imaging

BACKGROUND:Magnetic resonance cholangiopancreato-graphy (MRCP) is useful to assess exocrine pancreatic function by combining rapid imaging acquisition with the administration of secretin, a gastrointestinal hormone that stimulates the secretion of bile and pancreatic juice. However, extensive data on this method are lacking. This study aimed to determine whether MRCP with secretin administration is able to simultaneously detect alterations of both the pancreatic ducts and exocrine pancreatic function. METHODS:All subjects older than 18 years who underwent magnetic resonance imaging (MRI) and cholangio-Wirsung magnetic resonance imaging (CWMRI) for suspicion of benign or malignant pancreatic diseases from January 2006 to December 2006 were enrolled in the study. MRI and CWMRI were carried out using a dedicated apparatus. RESULTS:Eighty-seven patients (46 males, 41 females, mean age 59.7±14.6, range 27-87 years) were enrolled. Of the 87 patients, 39 had a normal pancreas on imaging, 20 had an intrapapillary mucinous tumor (IPMT), and the rest had chronic pancreatitis (7), serous cystadenoma (6), a previous attack of acute biliary pancreatitis (5), congenital ductal abnormalities (5), mucinous cystadenoma (3), previous pancreatic head resection for autoimmune pancreatitis (1), or cholangiocarcinoma (1). Morphologically, we found two pseudocysts (one of the 7 patients with chronic pancreatitis, and one of the 5 patients after an attack of acute pancreatitis;the latter pseudocyst communicated with the main pancreatic duct). Calcifications were found in 3 of the 7 patients with chronic pancreatitis. All patients with IPMT and mucinous cystadenoma and 3 patients with serous cystadenoma were histologically confirmed. The remaining patients were followed up adequately to confirm the diagnosis by imaging. According to the Matos criteria, 73 patients (83.9%) were of grade 3, 8 grade 2, 4 grade 1, and 2 grade 0. The only pancreatic diseases which impaired the exocrine pancreatic secretion stimulated by secretin were chronic pancreatitis (57.1% of the patients, grade 0-1) and the IPMT mixed type in 2 of the 4 patients was grade 1. CONCLUSION:Secretin MRCP is a useful technique to simultaneously detect the presence of alterations of the pancreatic ducts and exocrine pancreatic function.

Endoscopic ultrasound diagnostic gain over computed tomography and magnetic resonance cholang-iopancreatography in defining etiology of idiopathic acute pancreatitis

BACKGROUND About 10%-30%of acute pancreatitis remain idiopathic(IAP)even after clinical and imaging tests,including abdominal ultrasound(US),contrast-enhanced computed tomography(CECT)and magnetic resonance cholangiopancreatography(MRCP).This is a relevant issue,as up to 20%of patients with IAP have recurrent episodes and 26%of them develop chronic pancreatitis.Few data are available on the role of EUS in clarifying the etiology of IAP after failure of one or more cross-sectional techniques.AIM To evaluate the diagnostic gain after failure of one or more previous crosssectional exams.METHODS We retrospectively collected data about consecutive patients with AP and at least one negative test between US,CECT and MRCP,who underwent linear EUS between January 2017 and December 2020.We investigated the EUS diagnostic yield and the EUS diagnostic gain over different combinations of these crosssectional imaging techniques for the etiologic diagnosis of AP.Types and frequency of EUS diagnosis were also analyzed,and EUS diagnosis was compared with the clinical parameters.After EUS,patients were followed-up for a median of 31.5 mo to detect cases of pancreatitis recurrence.RESULTS We enrolled 81 patients(63%males,mean age 61±18,23%with previous cholecystectomy,17%with recurrent pancreatitis).Overall EUS diagnostic yield for AP etiological diagnosis was 79%(20%lithiasis,31%acute on chronic pancreatitis,14%pancreatic solid or cystic lesions,5%pancreas divisum,5%autoimmune pancreatitis,5%ductal abnormalities),while 21%remained idiopathic.US,CECT and MRCP,taken alone or in combination,led to AP etiological diagnosis in 16(20%)patients;among the remaining 65 patients,49(75%)obtained a diagnosis at EUS,with an overall EUS diagnostic gain of 61%.Sixty-eight patients had negative US;among them,EUS allowed etiological diagnosis in 59(87%).Sixty-three patients had a negative CECT;among them,47(74%)obtained diagnosis with EUS.Twenty-four had a negative MRCP;among them,20(83%)had EUS diagnosis.Twenty-one had negative CT+MRCP,of which 17(81%)had EUS diagnosis,with a EUS diagnostic gain of 63%.Patients with biliary etiology and without previous cholecystectomy had higher median values of alanine aminotransferase(154 vs 25,P=0.010),aspartate aminotransferase(95 vs 29,P=0.018),direct bilirubin(1.2 vs 0.6,P=0.015),gammaglutamyl transpeptidase(180 vs 48,P=0.006)and alkaline phosphatase(150 vs 72,P=0.015)Chronic pancreatitis diagnosis was more frequent in patients with recurrent pancreatitis at baseline(82%vs 21%,P<0.001).During the follow-up,AP recurred in 3 patients,one of which remained idiopathic.CONCLUSION EUS is a good test to define AP etiology.It showed a 63%diagnostic gain over CECT+MRCP.In suitable patients,EUS should always be performed in cases of IAP.Further prospective studies are needed.

Endoscopic retrograde cholangiopancreatography in the treatment of pancreaticopleural fistula in children

BACKGROUND Pancreaticopleural fistula(PPF)is a rare disease,especially in children.Conservative treatment and surgery are traditional therapies,but surgery is invasive.The emergence of endoscopic retrograde cholangiopancreatography(ERCP)has provided a new noninvasive treatment for PPF and may become the first choice for children with PPF.AIM To explore the treatment response to ERCP for PPF in children.METHODS Seven children with PPF were hospitalized in the Gastroenterology Department of Beijing Children’s Hospital from December 2007 to May 2019.Data on these seven patients’clinical characteristics,diagnosis,treatments,and outcomes were analyzed,and their treatment responses following surgery and ERCP were compared.The correlation between the length of hospital stay and conservative treatment was analyzed.Peer-reviewed articles written in English and Chinese published from January 2009 to December 2019 were obtained from various open data sources and reviewed.RESULTS The seven patients comprised three boys and four girls with a mean age of 6.57±3.26 years.The main symptoms were chest tightness and pain(n=4),intermittent fever(n=3),dyspnea(n=3),and abdominal pain(n=1),and all patients had bloody pleural effusion.All seven patients were diagnosed with PPF by magnetic resonance cholangiopancreatography,and all were initially treated conservatively for a mean of 34.67±22.03 d with a poor response.Among five patients who underwent ERCP,one required surgery because of intubation failure;thus,the success rate of ERCP was 80%.Two patients were successfully treated with surgery(100%).The postoperative hospital stay of the two patients treated by surgery was 20 and 30 d,respectively(mean of 25 d),and that of the four patients treated by ERCP ranged from 12 to 30 d(mean of 19.25±8.85 d).The recovery time after ERCP was short[time to oral feeding,4-6 d(mean,5.33±1.15 d);duration of closed thoracic drainage,2-22 d(mean,13.3 d)].Analysis of previous cases of PPF published worldwide during the past decade showed that the treatment success rate of ERCP is not lower than that of surgery.There was no significant difference in the postoperative hospital stay between surgery(16±10.95 d)and ERCP(18.7±6.88 d,P>0.05).A positive linear correlation was found between the overall hospital stay and ERCP intervention time(R2=0.9992).CONCLUSION ERCP is recommended as the first-choice treatment for PPF in children.ERCP should be performed as early as possible if conditions permit.

Response letter to “Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the outcomes?” with imaging aspects

Radiological imaging findings may contribute to the differentiation of malignant biliary obstruction from choledocholithiasis in the etiology of acute cholangitis.

Early detection of pancreatic cancer

The diagnosis of pancreatic cancer associates an appalling significance.Detection of preinvasive stage of pancreatic cancer will ameliorate the survival of this deadly disease.Premalignant lesions such as Intraductal Papillary Mucinous Neoplasms or Mucinous Cystic Neoplasms of the pancreas are detectable on imaging exams and this permits their management prior their invasive development.Pancreatic intraepithelial neoplasms(PanIN)are the most frequent precursors of pancreatic adenocarcinoma(PDAC),and its particular type PanIN high-grade represents the malignant non-invasive form of PDAC.Unfortunately,PanINs are not detectable on radiologic exams.Nevertheless,they can associate indirect imaging signs which would rise the diagnostic suspicion.When this suspicion is established,the patient will be enrolled in a follow-up strategy that includes performing of blood test and serial imaging test such as computed tomography or magnetic resonance imaging,which will cost in the best-case scenario a burden of healthcare systems,and potential mortality in the worst-case scenario when the patient underwent resection surgery,worthless when there is no moderate or high grade dysplasia in the final histopathology.This issue will be avoid having at its disposal a diagnostic technique capable of detecting high-grade PanIN lesions,such is the cytology of pancreatic juice obtained by nasopancreatic intubation.Herein,we review the possibility of detection of early malignant lesions before they become invasive PADC.

Classification of anatomical morphology of cystic duct and its association with gallstone

BACKGROUND Gallstones are common lesions that often require surgical intervention.Laparo-scopic cholecystectomy is the treatment of choice for symptomatic gallstones.Preoperatively,the anatomical morphology of the cystic duct(CD),needs to be accurately recognized,especially when anatomical variations occur in the CD,which is otherwise prone to bile duct injury.However,at present,there is no optimal classification system for CD morphology applicable in clinical practice,and the relationship between anatomical variations in CDs and gallstones remains to be explored.AIM To create a more comprehensive clinically applicable classification of the morphology of CD and to explore the correlations between anatomic variants of CD and gallstones.METHODS A total of 300 patients were retrospectively enrolled from October 2021 to January 2022.The patients were divided into two groups:The gallstone group and the nongallstone group.Relevant clinical data and anatomical data of the CD based on magnetic resonance cholangiopancreatography(MRCP)were collected and analyzed to propose a morphological classification system of the CD and to explore its relationship with gallstones.Multivariate analysis was performed using logistic regression analyses to identify the independent risk factors using variables that were significant in the univariate analysis.RESULTS Of the 300 patients enrolled in this study,200(66.7%)had gallstones.The mean age was 48.10±13.30 years,142(47.3%)were male,and 158(52.7%)were female.A total of 55.7%of the patients had a body mass index(BMI)≥24 kg/m2.Based on the MRCP,the CD anatomical typology is divided into four types:Type I:Linear,type II:n-shaped,type III:S-shaped,and type IV:W-shaped.Univariate analysis revealed differences between the gallstone and nongallstone groups in relation to sex,BMI,cholesterol,triglycerides,morphology of CD,site of CD insertion into the extrahepatic bile duct,length of CD,and angle between the common hepatic duct and CD.According to the multivariate analysis,female,BMI(≥24 kg/m2),and CD morphology[n-shaped:Odds ratio(OR)=10.97,95%confidence interval(95%CI):5.22-23.07,P<0.001;S-shaped:OR=4.43,95%CI:1.64-11.95,P=0.003;W-shaped:OR=7.74,95%CI:1.88-31.78,P=0.005]were significantly associated with gallstones.CONCLUSION The present study details the morphological variation in the CD and confirms that CD tortuosity is an independent risk factor for gallstones.

Imaging tests for accurate diagnosis of acute biliary pancreatitis

Gallstones represent the most frequent aetiology of acute pancreatitis in many statistics all over the world, estimated between 40%-60%. Accurate diagnosis of acute biliary pancreatitis(ABP) is of outmost importance because clearance of lithiasis [gallbladder and common bile duct(CBD)] rules out recurrences. Confirmation of biliary lithiasis is done by imaging. The sensitivity of the ultrasonography(US) in the detection of gallstones is over 95% in uncomplicated cases, but in ABP, sensitivity for gallstone detection is lower, being less than 80% due to the ileus and bowel distension. Sensitivity of transabdominal ultrasonography(TUS) for choledocolithiasis varies between 50%-80%, but the specificity is high, reaching 95%. Diameter of the bile duct may be orientative for diagnosis. Endoscopic ultrasonography(EUS) seems to be a more effectivetool to diagnose ABP rather than endoscopic retrograde cholangiopancreatography(ERCP),which should be performed only for therapeutic purposes.As the sensitivity and specificity of computerized tomography are lower as compared to state-of-the-art magnetic resonance cholangiopancreatography(MRCP)or EUS,especially for small stones and small diameter of CBD,the later techniques are nowadays preferred for the evaluation of ABP patients.ERCP has the highest accuracy for the diagnosis of choledocholithiasis and is used as a reference standard in many studies,especially after sphincterotomy and balloon extraction of CBD stones.Laparoscopic ultrasonography is a useful tool for the intraoperative diagnosis of choledocholithiasis.Routine exploration of the CBD in cases of patients scheduled for cholecystectomy after an attack of ABP was not proven useful.A significant rate of the so-called idiopathic pancreatitis is actually caused by microlithiasis and/or biliary sludge.In conclusion,the general algorithm for CBD stone detection starts with anamnesis,serum biochemistry and then TUS,followed by EUS or MRCP.In the end,bile duct microscopic analysis may be performed by bile harvested during ERCP in case of recurrent attacks of ABP and these should be followed by laparoscopic cholecystectomy.

Diagnostic approach to patients with acute idiopathic and recurrent pancreatitis,what should be done?

Acute recurrent pancreatitis (ARP) is a common clinical condition that may be difficult to diagnose. Endoscopic ultrasound (EUS) is proposed to be a safe first line test of choice in the majority of patients. When interventions are needed to remove biliary stones, evaluate sphincter of Oddi or pancreas divisum, endoscopic retrograde cholangiopancreatography (ERCP) is recommended. Magnetic resonance cholangiopancreatography (MRCP) can be a suitable alternative from a diagnostic standpoint although may not be widely available. Finally, genetic testing is increasingly used to detect certain mutations that are associated with this diagnosis.

Multiple imaging techniques in the diagnosis of ampullary carcinoma

BACKGROUND: Ampullary carcinoma is a neoplasia with a good prognosis compared to pancreatic cancer. But it is difficult to early diagnose because it lacks clear clinical symptoms. This study aimed to evaluate the efficacy of abdominal ultrasonography (US), enhanced computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) in detecting ampullary carcinoma. METHODS: Forty-one patients with ampullary carcinoma who had been confirmed pathologically among the inpatients at the First Affiliated Hospital of Zhejiang University School of Medicine from February 2003 to March 2007 were analyzed retrospectively. The accuracy of US, CT, MRCP and ERCP were compared in the diagnosis of ampullary carcinoma. RESULTS: The accurate rate for detection of ampullary carcinoma with US was 26.83%. The accuracy of CT and ERCP in detection of ampullary tumors was 84.62% and 100%, respectively, which were significantly higher than that of US (P<0.05). The accuracy of MRCP in detection of ampullary tumors was similar to that of US in spite of visualization of obstruction and dilatation of the pancreaticobiliary duct with MRCP. CONCLUSIONS: Because of the obscure and late onset of symptoms, ampullary carcinoma is difficult to diagnose early. Multiple imaging techniques should be carried out appropriately in order to early diagnose the disease and improve the prognosis.

Strategy to differentiate autoimmune pancreatitis from pancreas cancer

Autoimmune pancreatitis (AIP) is a newly described entity of pancreatitis in which the pathogenesis appears to involve autoimmune mechanisms. Based on histological and immunohistochemical examinations of various organs of AIP patients, AIP appears to be a pancreatic lesion reflecting a systemic "IgG4-related sclerosing disease". Clinically, AIP patients and patients with pancreatic cancer share many features, such as preponderance of elderly males, frequent initial symptom of painless jaundice, development of new-onset diabetes mellitus, and elevated levels of serum tumor markers. It is of uppermost importance not to misdiagnose AIP as pancreatic cancer. Since there is currently no diagnostic serological marker for AIP, and approach to the pancreas for histological examination is generally difficult, AIP is diagnosed using a combination of clinical, serological, morphological, and histopathological features. Findings suggesting AIP rather than pancreatic cancer include:fluctuating obstructive jaundice; elevated serum IgG4 levels; diffuse enlargement of the pancreas; delayed en- hancement of the enlarged pancreas and presence of a capsule-like rim on dynamic computed tomography; low apparent diffusion coefficient values on diffusion-weighted magnetic resonance image; irregular narrowing of the main pancreatic duct on endoscopic retrograde cholangiopancreatography; less upstream dilatation of the main pancreatic duct on magnetic resonance cholangiopancreatography, presence of other organ involvement such as bilateral salivary gland swelling, retroperitoneal fibrosis and hilar or intrahepatic sclerosing cholangitis; negative work-up for malignancy including endoscopic ultrasound-guided fine needle aspiration; and steroid responsiveness. Since AIP responds dramatically to steroid therapy, accurate diagnosis of AIP can avoid unnecessary laparotomy or pancreatic resection.

Pancreatic ductal system obstruction and acute recurrent pancreatitis

Acute recurrent pancreatitis is a clinical entity largely associated with pancreatic ductal obstruction. This latter includes congenital variants, of which pancreas divisum is the most frequent but also controversial, chronic pancreatitis, tumors of the pancreaticobiliary junction and sphincter of Oddi dysfunction. This review summarizes current knowledge about diagnostic work-up and therapy of these conditions.

MRCP and MRI findings in 9 patients with autoimmune pancreatitis

AIM： To evaluate magnetic resonance cholangiopancreatography （HRCP） findings in conjunction with magnetic resonance （MR） images in autoimmune pancreatitis （AIP） patients. METHODS： Nine patients with AIP underwent HRI, HRCP, endoscopic retrograde cholangiopancreatography （ERCP）, computed tomography, and ultrasonography. The HRCP and MR images taken before and after steroid therapy were reviewed and compared with other imaging modalities. The HRCP findings of the AIP cases were compared to those of 10 cases with carcinoma of the head of the pancreas.RESULTS： On MRCP, the narrowed portion of the main pancreatic duct noted on ERCP was not visualized, while the non-involved segments of the main pancreatic duct were visualized. The degree of upstream dilatation of the proximal main pancreatic duct was milder than that seen in cases of pancreatic carcinoma. Stenosis or obstruction of the lower bile duct was detected in 8 patients. MR images showed enlargement of the pancreas with decreased signal intensity on T1- weighted MR images, increased signal intensity on T2- weighted MR images, and, in 3 patients, a hypointense capsule-like rim. After steroid therapy, the previously not visualized portion of the main pancreatic duct was seen, along with improvement of the bile duct stenosis. Pancreatic enlargement decreased, and the abnormal signal intensity on both T1- and T2-weighted MR images became isointense.CONCLUSION： MRCP cannot differentiate irregular narrowing of the main pancreatic duct seen with AIP from stenosis of the main pancreatic duct seen with pancreatic carcinoma. However, MRCP findings in conjunction with MR imaging of pancreatic enlargement that shows abnormal signal intensity on T1- and T2- weighted MR images are useful in supporting a diagnosis of AIP.

Hepatobiliary complications of alveolar echinococcosis: A long-term follow-up study

AIM:To determine the long-term hepatobiliary complications of alveolar echinococcosis(AE) and treatment options using interventional methods.METHODS:Included in the study were 35 patients with AE enrolled in the Echinococcus Multilocularis Data Bank of the University Hospital of Ulm.Patients underwent endoscopic intervention for treatment of hepatobiliary complications between 1979 and 2012.Patients' epidemiologic data, clinical symptoms, and indications for the intervention, the type of intervention and any additional procedures, hepatic laboratory parameters(pre- and post-intervention), medication and surgical treatment(pre- and post-intervention), as well as complications associated with the intervention and patients‘ subsequent clinical courses were analyzed.In order to compare patients with AE with and without history of intervention, data from an additional 322 patients with AE who had not experienced hepatobiliary complications and had not undergone endoscopic intervention were retrieved and analyzed.RESULTS:Included in the study were 22 male and 13 female patients whose average age at first diagnosis was 48.1 years and 52.7 years at the time of intervention.The average time elapsed between first diagnosis and onset of hepatobiliary complications was 3.7 years.The most common symptoms were jaundice, abdominal pains, and weight loss.Thenumber of interventions per patient ranged from one to ten.Endoscopic retrograde cholangiopancreatography(ERCP)was most frequently performed in combination with stent placement(82.9%),followed by percutaneous transhepatic cholangiodrainage(31.4%)and ERCP without stent placement(22.9%).In 14.3%of cases,magnetic resonance cholangiopancreatography was performed.A total of eight patients received a biliary stent.A comparison of biochemical hepatic function parameters at first diagnosis between patients who had or had not undergone intervention revealed that these were significantly elevated in six patients who had undergone intervention.Complications(cholangitis,pancreatitis)occurred in six patients during and in 12patients following the intervention.The average survival following onset of hepatobiliary complications was 8.8years.CONCLUSION:Hepatobiliary complications occur in about 10%of patients.A significant increase in hepatic transaminase concentrations facilitates the diagnosis.Interventional methods represent viable management options.