ULTRASONOGRAPHY (US) PLUS ENDOSCOPY – IN GENERAL AND IN BILIOPANCREATIC DISEASE
Is it possible to simply look at the gallbladder and at all parts of the biliary tract? And to decide with this look into the abdomen within a few minutes whether the biliary system is healthy or not? And if not: quickly planing the need for specific treatment as e.g. antibiotics, endoscopic intervention, or operation? And this with a minimum of expense, equipment, effort and with a reasonable invest in learning and training?
This dream has become true – by abdominal ultrasonography, performed by the gastroenterologist himself.
It might be unbelievable for younger colleagues, but it is true: it is only 30 years ago that the surgeon was the only one to have insight into the abdomen – so it was him to find and to tell the others what really was the diagnosis in a patient with abdominal problems.
Things have changed considerably – due to the combined use of first sectional imaging – especially abdominal ultrasonography (US), and second due to gastrointestinal endoscopy. So today the surgeon – if needed – is provided with an optimum of pre-operative information.
In many european countries, not only endoscopy, but as well ultrasonography is performed by the gastroenterologist himself. This is the most appropriate way of having immediate, precise, and highly informative insight into the abdomen by the responsible physician himself/herself.
So – what means clinical ultrasonography – as the first or the other eye in modern gastroenterology?
After the patient‚s history taken, ultrasonography is an integrated part of the physical examination of the patient – rendering realtime sectional images from all abdominal organs; the multiple slices of these images give – as a whole – an actuarial threedimensional status of the individual anatomy and pathology.
Simply, one can look into the abdomen and read it like an open book.
And basically, this is not difficult, especially with up to date ultrasound machines of the middle or high end class.
This US-equipment renders detailled realtime pictures from all parenchymatous organs – liver, pancreas, spleen/lymphnodes, and from all fluid containing organs and tubular structures / gallbladder, urinary bladder, abdominal and parenchymal vessels of all types, including the gut – irrespective to their fluid content – blood, bile, pancreatic juice, urine, and intestinal fluid contents. Moreover, the conventional B-scan and the colour-coded informations allow the analysis of flow phenomena, and of active and passive movements.
Ultrasonography gives an insight into all abdominal organs in normal and in pathological conditions unequalled by any other imaging modality, due to the extremely high local resolution capability of US and due to the realtime imaging modality in the living perfused organs and their structures. This exceeds the aspects of the normal and of the pathological gross anatomy even in the sense of the use of a magnification glass enhancement.
Thus ultrasound examination preceeding endoscopy proofs or rules out numerous potential pathological conditions in biliopancreatic disease and directs the indication and use of endoscopy. Ultrasonography fully substitutes the diagnostic component of ERCP, giving immediate information about the need or non-need of therapeutic side view intervention. Only as an exception, other imaging modalities (CT, MR/MRCP) are really helpful once ultrasonography has been performed. Postinterventionally, ultrasound follow up shows the success (aerobilia, normalisation of duct diameter, etc.) or the failure of endoscopic intervention, including the monitoring of complications.
Elevated serum concentrations of alkaline phosphatase and g-glutamyl-transferase with or without elevated bilirubine-levels – defining the cholestatic syndrome – can be caused by either parenchymatous liver disease or by biliary obstruction.
US and endoscopy are ideal partners in revealing and treating the reason of cholostasis: – in parenchymatous (diffuse) liver disease
such as liver cirrhosis and hepatitis, US is either diagnostic alone or highly suggestive (cirrhosis, acute and chronic hepatitis); US offers a resolution capacity of liver tissue and vascular structures inequaled by any other imaging modality. As a rule, carefully performed clinical expert US is diagnostic for parenchymatous liver disease, making endoscopic diagnosis a debatable adjunct method; – in obstructive choleostatic disease, again US is the first and usually leading diagnostic modality to reveal first the site of obstruction (intrahepatic, in the liver hilum, prepancreatic or intrapancreatic) and second the reason of obstruction (benign – e.g., lithiasis, or malignant); ERCP (endoscopic retrograde cholangiopancreaticography) will usually confirm the US-based findings and diagnoses, so endoscopy has rather become a therapeutic method in the sense of EST (endoscopic sphincterotomy) than a first line diagnostic modality.The short and long time follow-up studies after EST are preferably performed by US alone (searching for normal bile duct diameter, erobilia etc.), minimizing the need for control endoscopy.
The combination of US plus endoscopy (ERC + EST plus maybe stent implantation or stone extraction) must be performed by one and the same physician. Other diagnostic imaging modalities (CT-, MRI-scanning) are rarely of additional benefit.
The same considerations hold true in pancreatic disease. Ultrasound sectional imaging of the pancreas safely reveals in any given patient the head and the body region of this organ – again concerning the parenchymatous and the tubular structures; the tail region of the pancreas, however, is somewhat difficult to depict in routine US.
US reveals sincere diagnostic informations about the pancreas with respect to acute or chronic inflammation, tumours, concretions, and obstructions of the main pancreatic duct.
Interventional ultrasonography for diagnostic and for therapeutic reasons is another most helpful feature (and a chapter of its own) in ultrasonography and in biliopancreatic disease.
Combining endoscopy and miniaturized ultrasound-probes in one instrument in endoscopic ultrasonography (EUS) sounds promising with respect to two options: first, the use of higher ultrasound frequencies with a better resolution capacity in the near field (e.g., intestinal wall structures or organs and tissues adjacent to esophagus, stomach, duodenum, papilla, or rectum); second, the use of transintestinal EUS-guided intervententions (e.g., fine needle puncture) with specific EUS-equipment. Compared with US and in summarizing the experiences and published data in biliopancreatic indications, one might say that
– EUS must not be performed without a profound knowledge in conventional transcutaneous US, which always must be performed by one and the same physician prior to EUS;
– EUS needs a good expertise in conventional endoscopy as well;
– EUS diagnostic information is by far not as often as exspected more detailed or more specific/sensitive as compared to conventional transcutaneous US; this is especially true in tumours of the pancreas and the papilla of Vater;
– EUS guided interventions in pancreatic masses are – as a rule – more difficult as compared to US guided percutaneous interventions.
Maybe, EUS is somewhat overestimated in comparison to (expert--performed) clinical US. The implications of this conclusion with respect to cost-effectiveness, diagnostic invasiveness and patient compliance should be discussed and considered.
In biliary disease, US is the first diagnostic tool to prove or to exclude biliary calculi (especially in the gallbladder with a close to 100% sensitivity and specificty), to prove or to exclude acute or chronical cholcystitis or tumours, to prove or to exclude biliary obstruction (including the level and the reason of obstruction with or without jaundice). Moreover, US allows an immediate and sincere decision making about the further diagnostic and therapeutic course in a given patient, and to follow up a patient’s further course after e.g. antibiotics, or endoscopically or US-guided interventions. US is indispensable in any form of biliary disease, and it should be performed by the responsible clinical physician him- or herself – to see and to know better the diagnostic and therapeutic targets.
In biliopancreatic disease (as everywhere else in gastroenterology), the combined use of ultrasound as the first and of endoscopy as the second step by one and the same clinically orientated doctor gives an immediate and and complete fusion of all patient data (history, physical and labaratory values, endoscopic findings) in the diagnostic and therapeutic course – and this fusion will take place in one doctor´s responsible brain.
Especially the combination of ultrasound imaging and subsequent endoscopy by one and the same gastroenterologist turned out to be highly benficial for the patient, the clinician in charge, and the national health budgets. High quality endoscopy is well established and performed in many GI-centres around the globe. The second part – clinical ultrasonography – still deserves a more detailled consideration.
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