Journal of Medicine and Pharmacy - No.5 17
ROLE OF ENDOSCOPY ULTRASOUND IN THE
DIAGNOSIS OF PANCREATICO-BILIARY DISEASES
AT HUE UNIVERSITY HOSPITAL
Tran Van Huy1, Vinh Khanh2, Phan Trung Nam2, Tran Quang Trung2, Le Minh Tan2
(1) Internal Department – Hue University of Medicine and Pharmacy, Vietnam
(2) Gastrointestinal Endoscopic Center, Hue University Hospital, Vietnam
Background and aim: To evaluate the efficacy of endoscopy ultrasound for diagnosis of the diseases
of pancreatico-biliary system. Patients and methods: A cross - sectional study was conducted on 78
patients undergoing endoscopy ultrasound to diagnose pancreatico-biliary diseases. Results: Study on a
total 78 patients who have been hospitalized at the Gastrointestinal Endoscopic Center – Hue University
Hospital. EUS has been used to diagnose pancreatico – biliary in the period from 5/2013 to 7/2014.
We have some following results: (i) The age of patients is from: 22 to 80, medium age is 49 ± 19. The
percentage of the lesions at biliary duct is 49.5%, pancreatic diseases comprise of 40% and gall-bladder
diseases make up 10.5%. Biliary and gall-bladder diseases: The lesion at gall-bladder: Gall-bladder
stones constitute 66.7%, gall-bladder tumor is 22.2% and polyp represents 11.1%; The lesion at biliary
system: Tumors at biliary comprise of 11.9%, bile duct stones make up 88.1% and stones located at
the proximal common bile duct represent 45.2%; Pancreatic diseases: The lesion of pancreas: Chronic
pancreatitis account for 67.2%, pancreatic stones make up 16.4%, pancreatic cyst constitute 12.3% and
pancreatic tumors represent 4.1%; EUS – FNA to diagnosis IPMN constitutes 66.7% and pancreatic
cancer makes up 33.3%. Conclusions: Endoscopic ultrasound is a highly effective method of diagnosis
for pancreatico-biliary diseases.
Key words: endoscopy ultrasound, diagnosis, pancreatico-biliary diseases.
1. BACKGROUND
The pancreatico-biliary diseases are very popular
in the Central Vietnam in general and Hue City in
particular. In the 1980s, Endoscopic Ultrasound
(EUS) was invented, and then rapidly EUS has
become a medium diagnosis in pancreatico – biliary
diseases. At present, in the Central Vietnam, EUS
is a highest medium in diagnosis for pancreatico
– billiary diseases. Most of scientific researches in
the world has demonstrated the specificity of EUS
in diagnosis for gastrointestinal and pancreatico –
billiary diseases [5], [7]. For pancreatico – billiary
diseases, EUS was proven to be a safe and accurate
technique in parenchyma and pancreas duct by
the scientific research of Akane Yamabe [21].
According to Chen’s research on 2673 patients,
EUS has the sensitivity at 94% and specificity at
95% in diagnosis of CBD stones, particularly EUS
has its distinctive strength in cases in which stone
is less than 5mm and located at head of pancreas
– common bile duct [4]. The study found that
detection of tumor of extra hepatic duct was superior
by EUS (94%) in comparison with CT-Scanner
(only 30%) and MRI (42%) [15]. Endoscopic
Ultrasound Fine Needle Aspiration (EUS-FNA)
was evaluated to have the highest specificity and
sensitivity in diagnosis and follow up pancreatico
– billiary diseases [22]. According to Mitsuhiro
Kida, EUS-FNA has specificity ranging from 76%
to 90% for pancreatic diseases [24]. This result
is also similar to Matsuyama’s research with the
specificity at 94.6% for malignant pancreas diseases
[11]. Therefore, it has an enormous significance in
development and completion of the EUS procedure
in Vietnam in general, as well as the Central
Vietnam and Western Highlands in particular. This
new medical procedure is highly practicable in the
pancreatico- billiary diagnosis in the early period.
In addition, the introduction of this new technique
will help to reduce the burden for medical demand
in the region.
Until now, there have not been any studies
and researches focusing on the effectiveness and
the accuracy of EUS in the Central Vietnam.
- Corresponding author: Tran Van Huy, email: bstranvanhuy@gmail.com
- Received: 8/5/2014 * Revised: 15/6/2014 * Accepted: 25/6/2014 DOI: 10.34071/jmp.2014.1e.3
Journal of Medicine and Pharmacy - No.5
18
This reality has motivated us to implement the
research “Role of Endoscopy Ultrasound (EUS)
in Pancreatico-Biliary Disease Diagnosis at Hue
University Hospital. Our research has two major
purposes.
1. Assessing the role of EUS for bile duct –
gallbladder diseases.
2. Assessing the role of EUS for pancreas
diseases
2. OBJECTIVES AND RESEARCH
METHODOLOGY
2.1. Objects
There are 78 patients in total who have been
hospitalized at the Gastrointestinal Endoscopic
Center – Hue University Hospital. EUS have
been used to diagnose pancreatico – billiary in the
period from 5/2013 to 7/2014.
Choice standards
All patients have been indicated to examine
esophagogastroduodenoscopy (EGD) and EUS
[8], [9]
- Diagnosis and staging of pancreatic cancer
- Evaluating the abnormalities of pancreas
(suspect tumor; differential diagnosis of pancreatic
solid mass and cystic mass, diagnosis and staging
of chronic pancreatitis, etc.)
- Evaluating the abnormalities of the bile
duct and gall-bladder (suspect tumor; diagnosis
of the gall-bladder and common bile duct stone,
staging of cancer of common bile duct and gall-
bladder, etc.)
- Diagnosis and staging of ampullary
carcinoma.
Exception standards:
- The patients do not agree to do
esophagogastroduodenoscopy
- Contraindication with esophagogastroduode-
noscopy such as: stenosis pylorus or esophagus,
serious collateral diseases: myocardial infarction…
- Contraindication with midazolam.
2.2. Research methodology
2.2.1. Research design: A cross - sectional
study
2.2.2. Data collection method:
All patients are required for medical history and
clinical and para-clinical exams and abdominal
ultrasound is performed. They have been indicated
to do EUS.
Endoscopic Ultrasound:
- Equipments: Radial scope EG 530UT2 of
Fujifilm from Japan.
- Preparation for patients: Patients and their
families are explained clearly by doctors about
EUS, advantages as well as complications that can
happen.
Take antibiotic depending on each patient.
Patients need to be starved before 8 hours.
Remove fake teeth if any.
- Collection the data by protocol
2.2.3. Control data
Epitable of EPI – INFO 6.0 software of WHO
3. RESULT
3.1. Common characteristics among the patients
3.1.1. Age
Patients aging from 22 to 88. Median age is 49 ± 19.
3.1.2. Characteristic of the lesion
Table 3.1. Characteristic of the lesion
Lesion Gall-bladder
diseases
Bile duct
diseases
Pancreatic
diseases Total
Number 9 42 34 85
Rate (%) 10.5 49.5 40.0 100.0
Remark: The diseases at the common bile duct are highest proportion 49.5%, pancreatic diseases
40.0% and gall-bladder diseases 10.5%.
3.2. The lesion at the gall-bladder
Table 3.2. The lesion at the gall-bladder
Lesion Gall-bladder
tumor Gall-bladder stone Gall-bladder
polyp Total
Number 2 6 1 9
Rate (%) 22.2 66.7 11.1 100.0
Journal of Medicine and Pharmacy - No.5 19
Remark: The gall-bladder stone is the highest proportion 66.7%, gall-bladder tumor is 22.2% and
gall-bladder polyp is at 11.1%.
3.3. The lesion at the common bile duct
Table 3.3. The lesion at the common bile duct
Lesion CBD tumor CBD stone Total
Number 5 37 42
Rate (%) 11.9% 88.1% 100%
Remark: The common bile duct stone is the highest proportion 88.1%, common bile duct tumor is 11.9%.
3.4. Results of common bile duct stones characteristic by endoscopic ultrasound
Table 3.4. Characteristic of common bile duct stones
Position
Diameter
Proximal CBD Middle CBD Distal CBD
Total
n (%) n (%) n (%)
≤ 5mm 8 42.2 7 43.8 2 28.5 17
6 – 10mm 7 36.8 4 25.0 2 28.5 13
> 10mm 4 21.0 5 31.2 3 43.0 12
Total 19 100.0 16 100.0 7 100.0 42
Remark: Common bile duct stone diameter ≤ 5mm makes up the highest proportion (40.4%), and
stones position at the proximal common bile duct is highest proportion 45.2%
3.5. Pancreatic diseases
Table 3.5. The lesion at the pancreas
Lesion Chronic
pancreatitis
Main pancreatic
stone
Pancreatic
cyst
Pancreatic
tumor Total
Number 32 8 6 2 48
Rate (%) 67.2 16.4 12.3 4.1 100.0
Remark: Chronic pancreatitis has the highest proportion of 67.2%, the second is main pancreatic
stone, representing 16.4%, pancreatic cyst is 12.3% and the lowest rate belongs to pancreatic tumor,
making up for 4.1%.
3.6. EUS-FNA evaluated pancreatic lesion
Table 3.6. EUS-FNA evaluated pancreatic lesion
Lesion Pancreatic cancer IPMN Total
Number 1 2 3
Rate (%) 33.3 66.7 100.0
Remark: IPMN lesion constitutes 66.7% and pancreatic cancer accounts for 33.3%
4. DISCUSSION
4.1. Common characteristics of patient
In this research, number of samples is 78
patients, with the age from 22 to 88. Median age
49 ± 19. The bile duct and pancreatic diseases
have the highest proportions of 49.5% and 40%
respectively, the lowest rate at the gall-bladder
is 10.5%. It can be explained by the remarkable
accuracy of EUS in evaluating organ lying in
depth in the body while other technical methods
are imposisble to detect. Reasonably, a majority
of patients who are suspected of having the tumor
at the pancreatic head and CBD stones at the
proximal CBD are indicated for EUS [14]
4.2. Lesion at the gall-bladder
According to the Table 3.2, the gall-bladder
stone has the largest proportion of 66.7%, gall-
bladder tumor is 22.2% and gall-bladder polyp is
Journal of Medicine and Pharmacy - No.5
20
11.1%. In reviewing of the cases of gall-bladder
stones, stones with sizes > 10mm lie in one patient,
stones with sizes from 6 – 10mm fall into three
patients and two patients have stones with size
< 5mm. According to Kola, EUS has the sensitivity
at 94% and specificity at 95% in diagnosis gall-
bladder stones [10]. In our research, one patient
is identified to have gall-bladder polyp with size
of 7mm.
About gall-bladder tumor, we have two
patients suffering from gall-bladder cancer
and adenomyomatosis. About the patient’s
adenomyomatosis, the abdominal ultrasound
could not detect the tumor and CT-Scanner
detected dilation CBD. Consequently, depending
on such information, the tumor at the CBD or CBD
stones were generally thought of. However, in the
implementation of EUS, a different outcome was
generated, the position of the gall-bladder tumor
was near the cystic duct with having highdoppler
effect and we diagnose the adenomyomatosis
of the gallbladder. The scientific research in the
world, comparing EUS and abdominal ultrasound
about sensitivity and specificity in diagnosis the
gall-bladder tumor are 92% - 88% and 54% - 54%,
and EUS is very useful for detecting small tumor
when the scope position at the duodenum buld [8].
4.3. Lesion at the common bile duct
In this research, the highest proportion is
occupied by the common bile duct stones, making
up 88.1%, common bile duct tumor is 11.9%. The
bile duct tumor leads to jaundice and cholethiasis.
Under these medical conditions, EUS detects
the stenosis at the proximal and middle common
bile duct, and then ERCP is performed, putting
plastic stent come across position stenosis to
reduce pressure for the patient. According to nine
scientific researches, EUS has the sensitivity at
78% and specificity at 84% in diagnosis malignant
CBD diseases [6]. In another research, EUS has
sensitivity from 80% to 100% and specificity from
88% to 96.6% in diagnosis stenosis CBD [17].
4.4. Characteristic of common bile duct
stones
In our research, bile duct stones with size
≤ 5mm make up 40.4%, from 6 to 10mm is
30.9% and those with size > 28.7%. The highest
percentage is found in stones which located at
the proximal common bile duct, reaching up to
45.2%. Sensitivity and specificity contributes to
such high percentage. While in most of common
cases of stones which located at distal common
bile duct, it is applicable to use ultrasound
machine and CT-Scanner for diagnostic tests, in
the different cases related to proximal common
bile duct, the tests from ultrasound machine and
CT-Scanner have low level in both sensitivity
and specificity. However, the clinical suspicion of
CBD stones at the proximal is high among these
cases; therefore, EUS is applied for diagnosis.
According to other researches in the world, EUS
demonstrates a high specificity in diagnosis of
CBD stones, particularly in the cases of stones
having small size and locating in position which
is difficult to access. A research by Tse reveals that
EUS has sensitivity of 94% and specificity of 95%
in diagnosis of CBD stones. In one comparison of
indicators of EUS diagnosis for CBD stones and
other cases of stenosis common bile duct made by
Garrow, it shows that EUS has sensitivity of 89%
and specificity of 94% [6], [18]. Through seven
various researches, the results have come to one
conclusion that both EUS and MRCP (Magnetic
resonance cholangiopancreatography) share the
similar sensitivity and specificity in diagnosis for
CBD stones which are approximately between 90
and 95%. However, EUS has higher indicators in
specific cases of miniature stones and locating at
the proximal common bile duct, especially when it
is located near ampulla of Valter [19].
4.5. Pancreatic diseases
In our research, chronic pancreatitis comprises
the largest segment of 67.2%, and standing the
second and the third position are main pancreatic
stones with 16.4% and pancreatic cyst with
12.3%. The lowest segment is accounted by
pancreatic tumor with 4.1%. In 32 cases of chronic
pancreatitis, there are five cases of pancreatic
stones, three cases of pancreatic cyst, two cases
pancreatic tumor and two cases of pancreatic
stones and pancreatic cyst. In order to make
diagnosis of chronic pancreatitis by utilizing EUS,
we have depended on the Rosemont criteria [3]. A
correlation study on EUS and pathologic histology
by Albashir shows that EUS has sensitivity of 84%
and specificity of 100% in diagnosis of chronic
pancreatitis [1]. The findings of Akane Yamabe
affirms that EUS is a safe and effective technique
in assessing pancreatic parenchyma, pancreatic
duct and has a high diagnostic precision as well
as monitoring of patient suffering from chronic
pancreatitis [21]. In mentioned-above eight cases
of pancreatic stones, the detection was not made
by CT-Scanner. By using EUS, it detects three
patients having stones in both head and body
pancreatic, four patients having stones in head
Journal of Medicine and Pharmacy - No.5 21
pancreatic and one patient having stone in body
pancreatic with pancreatic duct stenosis at the
head pancreatic.
Many different researches in the world have
recognized the important role of EUS in diagnosis
and pathologic monitoring, particularly among the
circumstances of pancreatic cyst. Pancreatic cyst is
categorized into three types: pseudocysts, congenital
cysts and cystic neoplasms [8]. In our research, there
are six patients with pancreatic cyst including two
patients with two pancreatic cysts and four patients
with one pancreatic cyst. A majority of pancreatic
cysts is found in head and body pancreatic. As for
dimension, the size of the smallest pancreatic cyst
is 4mm and that of the largest pancreatic cyst is
18mm. Among these six patients diagnosed with
pancreatic cyst, three patients are detected to have
pseudocyst, comprising 50% and three patients
are diagnosed with IPMN, making up 50%. This
outcome properly matches with the common
results revealed by other international researches,
specifically congenital cysts makes up 5-10%,
pseudocysts with 80-90% and cystic neoplasms
with 5-10% [8]. EUS is capable of detecting the
lesion which is pancreatic cyst despite the small
size about 3mm with the precision varying between
92% and 96% [16]. EUS has sensitivity of 94% and
specificity of 85% for the cases related to pancreas
having parenchymal abnormal findings suggests
a pseudocyst. Pancreatic pseudocyst generally
appears to be single, without wall and have small
tissue in cyst [8], [12]. Medical literature defines
that intraductal papillary mucinous neoplasms
(IPMN) is a cystic lesion of the pancreas caused
by two enlarged variants of branch duct and main
duct. In our research, three patients are diagnosed
with IPMN in which two cases of pancreatic cyst
is closely related to main duct, and the other is not
so. In the circumstances associated with the branch
duct, two cysts are with sepations and their sizes are
8 mm and 16mm respectively. In the circumstances
associated with the main duct, two cysts are with
sepations and their sizes are 8 mm and 18mm
respectively. Endoscopic ultrasound-guided fine
needle aspiration (EUS-FNA) is used in these two
circumstances. According to one study by Bardales
and colleagues, sensitivity and specificity of EUS-
FNA are 80 - 90%; 85 - 100% respectively [2]. This
has proved the important role of EUS in pathologic
diagnosis for pancreatic cysts and suspected cases
of malignancy with the assistance of EUS-FNA.
Samples are taken for tests and diagnosis. This is
a modern and sophisticated technique in EUS with
a low complication rate varying from 0 to 4%. In
most of cases, the complications are often mild and
temporary [13].
The findings of our research have showed
that there are two tumors located in the head of
pancreatic. One tumor has a small size of 8mm
and is under follow up, and the other is proven
pancreatic cancer. In the case of pancreatic
cancer, the patient has been admitted into
hospital many times and been diagnosed with
chronic pancreatitis. The patient has medical
history for evidence of alcohol abuse. However,
visual images from ultrasound machines and
CT-Scanners are not able to suspect lesion.
Therefore, with the help of EUS usage, we
were able to identify the lesion sized 14mm in
the head of pancreas, and then performed the
technique of EUS-FNA for surgical operation
and pathologic assessment in post-operative
period. To some extent, this only case possibly
proves the effectiveness of EUS in diagnosis of
lesion related to pancreatic lesion, particularly
the lesion in the head of pancreas. Moreover,
with its outstanding advantage of cooperation
with EUS – FNA, the guidance for operation
has been defined clearly and outcomes after
surgery are totally satisfactory. It has been
confirmed by many international researchers.
According to the statistics published in the
world, EUS has a high precision, reaching up
to 90% when calculating the size of tumor if
the size of the lesion is less than 3 cm, and
standing by only 30% if the size of the lesion
is larger than 3cm. The difficulty in estimating
the size of a large pancreatic tumor by EUS
was due to the limited depth of penetration by
high frequency transducers [8]. In comparison
with other visual diagnostic tools, EUS has
a higher precision when measuring the size
and identifying the position of the tumors,
lympho note metastatic and vessel metastatic
[8]. However, the lesions belonging to chronic
pancreatitis often lead to diagnosis error even
when EUS is applied; therefore, it is necessary
to take advantage of EUS – FNA to diagnose
the suspected malignant lesion [20]. It reflects
the significant role of EUS in pathologic
diagnosis of pancreas located in the head and
neck of pancreas. More than that, EUS – FNA
allows us to take sample which helps to make
a precise diagnosis serving as a fundamental
step of treatment, monitoring, and prediction
for patients.