(1) Is there a role for EUS as one of the initial imaging modalities?

(2) Can EUS replace other diagnostic procedures, especially

ERCP? (3) In which period of the acute attack may EUS and EUS-
FNA play a role?

The published studies about these issues are quite limited. They
mainly focused on the role of EUS in cause finding. A potential is-
sue which has not really been addressed is the role of EUS in the
early management of complications of an acute pancreatitis such
as pancreatic fluid collections and infection.

The definition of an acute attack especially with regard to the

exact time frame has not clearly been defined yet. Clinically
the acute attack is present as long as the pancreatic enzymes

Invited papers
are elevated. However, from our experience even though the
enzymes have returned to normal values, the pancreas paren-

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chyma can be still edematous and fluid collections may be pres-
ent. EUS may provide information about the status of the par-
enchymatous stage of inflammation in addition to laboratory
findings. This information can be important for further man-
agement of patient and predicting the further progress of the
attack.

CT has been the gold standard imaging to access the severity of

acute pancreatitis using the Balthazar computed tomography in-
dex which grades the severity based on pancreatic inflammation
and necrosis. There are no published studies comparing EUS and
CT in grading the severity of the disease. EUS provides good lo-
coregional visualization, however extension of the necrosis is
still best visualized by CT. Therefore EUS cannot replace CT as
the index imaging. The situation is supposed to be different
with regards to cause finding.
S21

Studies on yield of EUS

Frossard et. al. managed to determine the cause of acute pan-

creatitis in 77 % of 168 patients by EUS. They misdiagnosed idio-
pathic pancreatitis as having biliary stones in 5 patients and
IPMT in 1 patient [1].

Acute pancreatitis: The acute attack. In a study of Tandon et al. with 31 patients, EUS demonstrated an
etiology in two-thirds of patients with idiopathic acute pancrea-
Acute recurrent pancreatitis
titis. All these patients had undergone transabdominal ultra-
S. Seewald, S. Omar, N. Soehendra sound and CT scan before EUS. Especially in microlithiasis, pan-
Dept. of Interdiscipl. Endoscopy, Univ. Hospital Hamburg-Eppendorf creatic cancer and chronic pancreatitis, EUS was very accurate.
The missed diagnoses were pancreatic duct stones, pancreas di-
visum, intraductal papillary mucinous tumor and sphincter of
Due to the well accessibility of the pancreatobilary system, the Oddi dysfunction [2]. A criticism of this paper was that patients
potential role of EUS and EUS-FNA in an acute attack of a first ep- with significant consumption of alcohol were included into this
isode or recurrent idiopathic pancreatitis seems to be an issue. study together with patients with first attack of acute pancreati-
Since EUS is competing with other imaging modalities such as tis, who will usually not have any further attacks [3, 4].
CT, MRCP and ERCP, the following questions have to be raised.
However, in a prospective study of EUS in primary vs. recurrent
idiopathic acute pancreatitis by Yusoff et al., the yield of EUS in
Correspondence: Dr. med. Stefan Seewald ´ Dept. of Interdiscipl. Endoscopy ´
Univ. Hospital Hamburg-Eppendorf ´ Martinistr. 52 ´ 20246 Hamburg ´ Phone: primary acute pancreatitis was not significantly different from
+49 40 42 803 5423 ´ Fax: +49 40 42 803 4420 ´ E-mail: [email protected] recurrent idiopathic pancreatitis. Therefore it was reasonable to
burg.de
perform EUS after the first attack. In this study the overall yield
Bibliography: Endoscopy 2006; 38 (S1): S21±S22  Georg Thieme Verlag KG
of positive finding was 29.2 %. The lower rate compared to other
Stuttgart ´ New York ´ ISSN 0013-726X ´ DOI 10.1055/s-2006-946646
studies can be explained by the fact that authors excluded pa-
 tients with significant alcohol consumption. Furthermore, EUS in the management of early complication
chronic pancreatitis noted by EUS were not included as a positive
finding [5]. EUS may play a potential role in the management of early com-
plication of acute pancreatitis such as acute fluid collections and
A study by Coyle et al. determined the diagnostic utility of ERCP infection. Due to the good accessibility of EUS, infected necrosis
with sphincter of Oddi manometry, bile analysis and EUS in pa- or fluid collections could be punctured and drained. However, in
tients with acute and acute recurrent idiopathic pancreatitis [6]. this early stage, the necrosis and acute fluid collections are more
Authors concluded that EUS was useful in detecting biliary dis- diffuse and not encapsulated, so an effective irrigation is almost
ease and anatomic anomalities and valuable in detecting early impossible. The only possible role of EUS-FNA is to confirm the
changes of chronic pancreatitis. EUS identified all the tumors. In presence of infection if clinically indicated. As far as we know
this study, 31 % of the patients had sphincter Oddi dysfunction, there is no study comparing EUS-FNA with CT guided aspiration.
which logically cannot be diagnosed by EUS.

Conclusion
Invited papers

Can EUS preclude ERCP

EUS can be an initial imaging modality in the first attack or recur-

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A clinically important question is if EUS is able to avoid inappro- rent idiopathic pancreatitis for cause finding, especially if pa-
priate cannulation of the papilla. In the management of patients tients were suspected to have biliary etiology. There is a role of
with suspected biliary pancreatitis, the role of emergency ERC is EUS in preventing unnecessary ERC. EUS guided transgastric
still controversial and EUS theoretically could help to restrict ERC FNA may be performed to confirm infection. EUS guided trans-
to patients with documented stones or sludge in the biliary tract. gastric drainage of necrosis or fluid collections do not play a ther-
apeutic role in the acute attack.
In a study of Prat et al. the value of early EUS of the bile duct be-
fore endoscopic sphincterotomy for acute biliary pancreatitis
was investigated. One hundred twenty three patients with sus- References
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vator with a single frequency of 7.5 MHz. This combination pro-
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provements EURCP might have a role as first line management
for patients with suspected biliary pancreatitis [9].

Seewald S et al. Acute pancreatitis ¼ Endoscopy 2006; 38 (S1): S21 ± S22