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Undiagnosed abdominal pain can be a perplexing problem for the physician and patient.
We have previously briefly discussed the role of EUS in the evaluation of abdominal pain suspected to be originating from the biliary tract (http://www.vhjoe.org/Volume3Issue2/3-2-1.htm). As noted in that article and in some selected references1-3 there is a body of literature on that subject.
Another indication for EUS in the evaluation of abdominal pain is to help determine if the symptoms may be pancreatic in origin. This issue features an article on EUS in the assessment of chronic pancreatitis by Drs Noh and Wallace. This review is important for endosonographers and non-endosonographers alike because it gives a pictorial reference for EUS criteria of chronic pancreatitis as well as a discussion of the sensitivity and specificity of EUS testing.
However, it is important to realize that EUS is not the end of the story. A more difficult question may be "What to do when the EUS shows 3,4 or 5 findings consistent with chronic pancreatitis in someone undergoing a chronic abdominal pain examination?".
In some cases the EUS findings of pancreatic damage are expected as in the case of the alcoholic with a long standing history of recurrent bouts of pancreatitis as shown in Video 1. However, shown in Videos 2 and 3 are examples of patients recently evaluated for abdominal pain. Neither had an obtainable history of alcohol overuse. (Radial array EUS images of the pancreatic body from the stomach). For reference, Video 4 shows a relatively normal pancreas from a patient who also underwent an EUS evaluation for chronic abdominal pain thought to be pancreatic or biliary in origin.
The clinical questions raised in patients with the findings in Video 2 and 3 include:
1) Is there actually a pancreatic injury?
2) Do these EUS findings explain the presenting symptoms,
3) What caused the images to look this way? Should an evaluation for autoimmune or inherited pancreatopathy be pursued? Should a biopsy be performed?
Studies are ongoing in which tissue confirmation of chronic pancreatitis are being compared to EUS4-10, new work in the etiology of chronic pancreatitis, including genetic and immune causes all suggest that this area of medicine is still evolving.
References
1. Mirbagheri SA, Mohamadnejad M, Nasiri J, Vahid AA, Ghadimi R, Malekzadeh R.
Prospective evaluation of endoscopic ultrasonography in the diagnosis of biliary microlithiasis in patients with normal transabdominal ultrasonography. J Gastrointest Surg. 2005 Sep-Oct;9(7):961-4.
2. Varadarajulu S, Wilcox CM, Eloubeidi MA. Impact of EUS in the evaluation of pancreaticobiliary disorders in children. Gastrointest Endosc. 2005 Aug;62(2):239-44.
3. Liu CL, Lo CM, Chan JK, Poon RT, Fan ST. EUS for detection of occult cholelithiasis in patients with idiopathic pancreatitis. Gastrointest Endosc. 2000 Jan;51(1):28-32.
4. Catalano MF, Lahoti S, Geenen JE, Hogan WJ. Prospective evaluation of endoscopic ultrasonography, endoscopic retrograde pancreatography, and secretin test in the diagnosis of chronic pancreatitis.Gastrointest Endosc. 1998 Jul;48(1):11-7.
5. Farrell JJ, Garber J, Sahani D, Brugge WR. EUS findings in patients with autoimmune pancreatitis. Gastrointest Endosc. 2004 Dec;60(6):927-36.
6. Hollerbach S, Klamann A, Topalidis T, Schmiegel WH. Endoscopic ultrasonography (EUS) and fine-needle aspiration (FNA) cytology for diagnosis of chronic pancreatitis. Endoscopy. 2001 Oct;33(10):824-31.
7. Kahl S, Glasbrenner B, Leodolter A, Pross M, Schulz HU, Malfertheiner P. EUS in the diagnosis of early chronic pancreatitis: a prospective follow-up study. Gastrointest Endosc. 2002 Apr;55(4):507-11.
8. Hastier P, Buckley MJ, Francois E, Peten EP, Dumas R, Caroli-Bosc FX, Delmont JP. A prospective study of pancreatic disease in patients with alcoholic cirrhosis: comparative diagnostic value of ERCP and EUS and long-term significance of isolated parenchymal abnormalities. Gastrointest Endosc. 1999 Jun;49(6):705-9.
9. Bhutani MS. Endoscopic ultrasonography: changes of chronic panreatitis in asymptomatic and symptomatic alcoholic patients. J Ultrasound Med. 1999 Jul;18(7):455-62
10. Deshpande V, Mino-Kenudson M, Brugge WR, Pitman MB, Fernandez-del Castillo C, Warshaw AL, Lauwers GY. Endoscopic ultrasound guided fine needle aspiration biopsy of autoimmune pancreatitis: diagnostic criteria and pitfalls. Am J Surg Pathol. 2005 Nov;29(11):1464-71.
11. Levy MJ, Reddy RP, Wiersema MJ, Smyrk TC, Clain JE, Harewood GC, Pearson RK, Rajan E, Topazian MD, Yusuf TE, Chari ST, Petersen BT. EUS-guided trucut biopsy in establishing autoimmune pancreatitis as the cause of obstructive jaundice. Gastrointest Endosc. 2005 Mar;61(3):467-72.
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