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Curriculum based clinical reviews
Advancing the diagnostic and therapeutic role of EUS in pancreaticobiliary disease: Hopkins Lecture 2016
  1. Kofi Oppong
    1. Correspondence to Dr Kofi Oppong, HPB Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne NE7 7DN, UK; kofi.oppong{at}nuth.nhs.uk

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    Introduction

    Linear endoscopic ultrasound (EUS) has become established as a key diagnostic and therapeutic tool in pancreaticobiliary medicine over the last 20 years. EUS/EUS-fine needle aspiration (FNA) is used in the diagnosis and staging of pancreatic and biliary masses, the diagnosis of unexplained dilatation of the bile and pancreatic ducts and the diagnosis of pancreatic cysts. Interventional EUS has developed rapidly with the EUS-guided drainage of pancreatic fluid collections, now the most commonly used EUS-guided intervention. In this article, I will set out the results of a series of studies performed over the last 12 years that have

    1. helped develop the role and establish the utility of diagnostic linear EUS/EUS-FNA

    2. developed and refined the techniques for EUS-guided pancreatic necrosectomy.

    Diagnosis

    The question of whether to further investigate patients with asymptomatic unexplained duct dilatation (after CT and/or magnetic resonance cholangiopancreatography (MRCP)) and normal liver function tests (LFT) is controversial and a growing problem due to the increase in the incidental finding in patients undergoing cross-sectional imaging. In a study that I initiated, a significant and clinically relevant yield was demonstrated in 17% of such patients with unexplained common bile duct (CBD) dilatation.1 We also demonstrated that previous cholecystectomy is significantly associated with no cause found on EUS in those with isolated CBD dilatation, and that the yield in those with CBD and pancreatic dilatation was low. This study helps to elucidate which asymptomatic patients, with normal LFT and unexplained dilated ducts, should undergo further investigation with EUS.

    Elastography is an ultrasound technique that allows assessment of the elasticity or firmness of a given tissue relative to that of adjacent normal tissue by measuring the strain or displacement generated in response to compression or vibration. The magnitude of the strain generated reflects the histological composition; inflammation is generally softer, that is, more strain, and malignancy …

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