Dicision Tree In Patient with Suspected Pancreatic Disease ERCP, ANGIOGRAPHY AND COMPUTED TO- MOGRAPHY IN THE DIAGNOSIS OF PANCR- EATIC DISEASE SEIKOH

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2 Dicision Tree In Patient with Suspected Pancreatic Disease ERCP, ANGIOGRAPHY AND COMPUTED TO- MOGRAPHY IN THE DIAGNOSIS OF PANCR- EATIC DISEASE SEIKOH SHIMAGUCHI AND JOE ARIYAMA Department of Gastroenterology, Juntendo University, Tokyo, Japan The relative efficacy of ERCP, angiography and computed tomography (CT) was studied in 22 patients with proven pancreatic disease. Twenty-two patients include 7 patients with pancreatic carcinoma, 5 patients with pancreatic cyst, 8 patients with pancreatic calcification and 2 patients with chronic pancreatitis. Qualitative evaluation of the diagnostic efficacy of each modality revealed that ERCP was the most reliable method for detecting pancreatic carcinoma. Even very small tumor was detected by ERCP. ERCP permitted to demonstrate fine abnormality of the pancreatic duct. It was difficult to assess extent of pancreatic disease with ERCP. CT was suited to demonstrate pancreatic calcification and cyst. Large unresectable pancreatic carcinoma was readily diagnosed by CT. Small pancreatic carcinoma measuring 1.3 ~1.2 ~1.2cm was not detected with CT. Size of pancreatic carcinoma, its extent and resectability were accurately defined by angiography. Angiography was also useful to exclude pancreatic carcinoma in patients with abnormal pancreatogram and/or computed tomogram. From these results diagnostic approach to pancreatic disease has been evolved (Table).

3 DIAGNOSTIC UTILITY OF CT AND ERCP HAJIME WATAHIKI AND SATORU NAKANO 2nd clinic of Internal Medicine (Department of Gastroenterology) Ogaki Municipal Hospital Computed tomography (CT), Ultrasonography (US) and Radioisotope examinations (RI) made a great progress in the diagnosis for the hepato-, pancreato- Gastroenterological Endoscopy

4 U Vol. 22(10), Oct biliary diseases in addition to conventional examinations as ERCP and PTC. This study is to clarify the ability and limitation of the diagnosis for these diseases by CT comparing with ERCP or PTC. I. Diagnosis by CT (3rd Generat GE CT/ T) a. Of fifty four cases with obstructive jaundice, the dilatation of the intrahepatic duct and sometimes of the common bile duct with enlarged gall bladder were detected in 90.7% by CT. Thus, CT was useful for the differential diagnosis of the jaundice, obstructive or not. b. A correct and suspicious diagnosis in 14 cases with carcinoma of the bile duct were made in 35.7% and 28.6% respectively. As for the resected cases, it decreased to 28.6%. The malignancy in the upper part of the biliary tract was more easier to be diagnosed than other parts showing 50.0% in correct diagnosis. In twenty four cases with carcinoma of the gall bladder, correct and suspicious diagnosis were established in 62.5% and 25.0% respectively. Even in the resected cases, the correct diagnosis was obtained in a half of them. In twenty cases with carcinoma of the pancreas, correct diagnosis was made in 55.0%, but all of them were in unresectable stages. All of six cases with papillary cancer remained in suspicious diagnosis. As mentioned above, diagnosis for the malignancies of pancreato-biliary system by CT were useful but it was difficult to make a correct diagnosis in the early, resectable stages. c. CT was also useful for the diagnosis of the intrahepatic stones, pancreatolithiases and cystic lesions as liver cyst and pancreatic cyst. In all six cases with intrahepatic stones, the cystic dilatation of the introhepatic biliary tree with high density area were observed. CT demonstrated clearly the lesion in the cases with pancreatic cyst even though diagnosis remained suspicious by ERCP. Hepatic lesions including liver cyst, fatty liver and malignant tumors became more detectable by CT. A correct diagnosis was established in 94.0% of 3 cases with liver malignancies.. Comparison of the diagnostic value between CT and ERCP. For the diagnosis of the cases with carcinoma of the gall bladder, CT was superior to ERCP. (Correct diagnosis; 62.5%, 48.3% respectively) On the contrary, ERCP was superior to CT in the cases with carcinoma of the biliary tract and the pancreas. (Correct diagnosis; 76.0%, 50.% respectively for the former, 78.1%, 55.0% respectively for the latter) Endoscopic observation and biopsy were useful for the diagnosis of papillary cancer. Conclusion: Diagnostic usefulness of CT was confirmed in such cases as liver cyst, fatty liver, intrahepatic stones and liver malignancies including hepato-cellular carcinoma and metastatic liver cancer. As for pancreato-biliary diseases, pancreatolithiases and pancreatic cyst became detectable more easily by CT and ERCP was superior to CT in the diagnosis for carcinoma of those organs except for carcinoma of the gall bladder. As CT is non-invasive examination, it is reasonable to undergo in the patient, lying in end stages of malignancies and can make a great progress in the correct diagnosis by combination of conventional examinations though early diagnosis in the resectable cases of malignancies is no promising.

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6 REAL-TIME ULTRASONOGRAPHY IN PANCRE- A TIC DIAGNOSIS \COMPARATIVE APPRAI- SAL WITH ENDOSCOPIC RETROGRADE CHO- LANGIOPANCREATOGRAPHY \ HIROMITSU SAISHO AND Eli KARASAWA The First Department of Internal Medicine Ultrasonography of he panrcreas was performed in 169 patients including 51 with pancreatic carcinoma, 31 with chronic pancreatitis and 87 with normal pancreas. Commercially available linear-array real-time ultrasound equipment with 3.5 MHz transducer was employed for the examination. Based on the results and pancreatic carcinoma were analyzed concerning to pancreatic duct dilatation, pancreatic size and shape, and pancreatic tissue echo pattern. Beaded dilatation of the pancreatic duct, partial enlargement of the pancreas, nodular tissue echopattern and focal decrease of echogenicity were the chararteristic sonographic signs of pancreatic carcinoma. In all of the 51 patients with pancreatic carcinoma, US showed pancreatic abnormality. Especially, 48 patients (94 0) had the characteristic signs. Irregular dilatation of the pancreatic duct and echogenic heterogenous echo pattern with scattered strong echo spots were the characteristic sonographic signs of chronic panrceatitis. In 27 (87 0) of 31 patients with chronic pancreatitis, abnormal sonographic findings were shown. Among them, 18 patients had the characteristic signs. In the 93 patients who underwent both US and ERCP, the results of US were compared with those of ERCP. Of the 26 patients with pancreatic carci noma, 9 ERCP studies failed in cannulation and other one failed to provide abnormality. In contrast, US could provide diagnostic information in all of the patients with pancreatic carcinoma. Additionally, US was superior to ERCP for the differentiation of pseudocysts from solid tumors. In the 22 patients with chronic pancreatitis, false negative diagnosis was provided in 3 US studies and in one ERCP study; in every patient, however, either of both studies could show abnormality. In the patients with ampullary carcinoma, ERCP including duodenoscopy could provide the definite diagnosis, while pancreatic duct dilatation was shown by US. It is concluded that US is a very reliable screening and diagnostic technique for the pancreas, so that the complementary use of US and ERCP constituted powerful diagnostic combination for the patients suspected of pancreatic disease. of these patients, ultrasound diagnosis of the pancreas was assessed. Furthermore, both ultrasonography (US) and endoscopic retrograde cholangiopancreatography (ERCP) were performed in 93 patients; both studies were always done within one week of each other. In these patients, US was compared with ERCP for the pancreatic evaluation. The sonographic features of chronic pancreatitis

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8 Vol22(10),Oct.1980 シ ン ポ ジ ウ ムⅣ 1489 な 例 もあ った. 膵癌36例 で は,ERCPで は主 膵 管 の 閉像,狭 辺 縁 不 整 像,造 影 剤 不整 貯 溜像 に よ り81%に USで 窄像, 正 診 した. は,限 局 性 腫 大,減 衰 を伴 な う腫 大,不 整 内 部 エ コ ー を もつ 腫 大,膵 影 内 の低 エ コ ー レベ ル域 等 に よ り, 89%に 正 診 で きた.ま たERPで 部 癌 では,USガ 膵 管 像 の得 られ な い頭 イ ドに尾 側拡 張 膵 管 を穿 刺 造 影 す る方 法 が 有 効 で あ る こ と も認 め た.USは 無 侵 襲 に行 な え る 点 で ス ク リー ニ ン グ法 と して最 適 とい え る. 癌 腫 以 外 の 膵 腫 瘍4例 の う ち,2例 は 出 血性 嚢胞 を形 成 して い たが,細 網 肉腫 の1例 は 膵 管 の圧 排 像 とUSで の 特 異 な腫 瘍 像,膵A細 胞 癌 の!例 で は不 整 貯 溜 を伴 な う膵 管 圧排 像 と,一 部 大 小 多 発 の 嚢胞 像 を もつ 混合 性 腫 に よ り,い ず れ も膵 癌 とは 異 な る腫 瘍 との 診 断 が可 能 で あ った, 以 上 の如 く,USは 肝 胆 膵 の ス ク リー ニ ム グ検 査 と して最 適 で あ る と共 に,腫 瘤 の 直 接 像,ERCPで Figure2膵 の非 造 影 部 の 情 報 が 得 られ る利 点 を持 っ.他 方,ERCPは, 体 部 癌切 除 例 胆管,膵 管 の よ り詳 細 な所 見 が得 られ,USで の胆 管像 や 膵 管 像 で も って それ にか え る こ とは で きな い と い え る. ENDOSCOPIC RETROGRADE CREATOGRAPHY IN THE DIAGNOSIS PANCREATIC EIZO AND OF HEPATOBILIARY KIMOTO AND SABURO graphy 症 例 のERCP (ERCP) diseases, 可 欠 だ った.USで は100%に 嚢 胞 像 そ の もの が得 られ, 内腔 の 変 化 も識 る こ とが で き,し か も,偶 発 症 の 心 配 の 無 い利 点 も有 して い た. 膵 炎 非 石 化群39例 り72%を で は,USで チ ェ ック で きた.ECRPで も72%に が 正 常 で あ る例 に 多 か った.膵 石 症11例 で91%に 82%に were 狭 窄,拡 で は,US 膵 石 エ コ ーを示 す こ とが で きた.ERCPで は 膵 管 像 を得 た が,造 影 剤 の過 剰注 入 へ の 注 意 を要 from ERC ERCP made in or pancreatic and ultrasonography also each differentiate solid (SOL) of the only in 16%. While, not only detect of intrahepatic of ERC tumor, them in 100%, cyst 所 見 を併 せ る こ とに よ り鑑 別 し得 た例 もあ り,鑑 別 困難 themselves, and rigidity biliary was 71%, was also 71%. of any of the intrahepatic Endoscopy lesion and abscess other. accuracy sonography out SOLs could し た.限 局 性 膵 炎 で は膵 癌 との 鑑別 が重 要 だが,而 検 査 Gastroenterological was hepatobiliary of space occupying could point In 7 cases nostic cholangiopancreato- ultrasonography both Nagoya Japan. performed. ultrasonography but and in whom medicine, Nagoya, endoscopic with suspected In 25 cases liver 腫 大 や膵 管 拡 張 像 に よ 張 や辺 縁 硬化 像 を認 め た.主 膵 管 の変 化 の軽 い もの は, US像 between 257 patients NAKAZAWA of internal school of medicine, Comparison Figure3同 AND DISEASES. The second department University, CHOLANGIOPANULTRASONOGRAPHY ERC calculi, the diag- and that revealed bile ducts or biliary of the contour of ultra- obstruction calculi of bile ducts

9 Ultrasonography delineated strong echoes accompanying acoustic shadows in the liver. In one of the cases, ultrasonically-guided percutaneous transhepatic cholangiography proved to be of great value. In 24 cases of choledocholithiasis, ERC correctly diagnosed in Ultrasonography, however, could diagnose only in 33%. In 58%, it revealed biliary dilatation but failed to find any calculous. In 61 cases of gall stone, the accuracy of ERC was 40%, and that of ultrasonography reached 93%. ERC correctly diagnosed 57% of 7 cases of gallbladder carcinoma, and ultrasonography did 86 0 of them. However, all of them were far advanced. In the diagnosis of bile duct carcinoma, ERC was superior to ultrasonography. In 16 cases of choledochal cyst ultrasonography well delineated cystic dilatation of extrahepatic bile duct in 81% of them, but abnormal cholangio-pancreatico anastomoses were demonstrated only by ERCP. Investigation of concomitant lesions, such as biliary calculi and carcinoma, were successfully accomplished by ultrasonography. In patients with pancreatic diseases, both ERCP and ultrasonography proved to be efficacious diagnostic tools. In all of 13 cases of cyst of the pancreas, ultrasonography made it possible to visualize cyst itself. ERP demonstrated obstruction of the pancreatic duct, pooling o contrast media within the cyst or pressure effect to the pancreatic duct. It should be investigated by ERP whether the pancreatic duct communicated with the cyst or not. It was possible to investigate the inflammatory process of the pancreas both with ERCP and ultrasonography. Pancreatic calculi were also visualized by ultrasonography. It was difficult, however, to differentiate localized pacreatitis from carcinoma. Aspiration biopsy was regarded to be useful in this respect. In 36 patients with carcinoma of the pancreas. ERCP revealed obstruction or stenosis of the main pancreatic duct with or without irregular pooling of contrast media within the gland, and obstruction or stenosis of the bile duct. The overall accuracy with ERCP was 81%. Ultrasonography demonstrated localizedenlargement of the pancreas with or without attenua tion, localized enlargement with central echoes or lowecho level area within the gland, and its overall accuracy was 89%. It was considered that some difficulty existed in detecting smaller lesions and in differentiating from localized pancreatitis. Both ERCP and ultrasonography gave usefull infomations in diagnosing pancreatic tumors other than carcinoma. It might well be concluded that ultrasonography was best suited for investigation of hepatobiliary and pancreatic diseases because of its noninvasiveness and relative diagnostic accuracy. Frequently it offered valuable informations which ERCP failed to. On the other hand, only ERCP made it possible to appreciate more detailed changes of bile and pancreatic duct. Thus, both modalities should be employed in conbination in the diagnosis of hepatobiliary and pancreatic diseases.

10 Figure 2 COMPARISON between PANCREATO- SCINTIGRAM and ERCP

11 A COMPARATIVE STUDY OF E. R. C. P. AND SCINTIGRAPHY WITH REFERENCE TO LIVER, BILIARY AND PANCREATIC DISEASE SHUNICHI AND KENZO TATSUMI KOBAYASHI 3rd Dept. of Internal Medicine, Osaka City University Medical School We discussed about the diagnostic value of scintigraphy and endoscopic retrograde choledochopancreatography (ERCP) in disease of the liver, the biliary tract or the pancreas. (1) The liver We approached the liver shape obtained by liver scan in diffuse liver disease such as chronic hepatitis or liver cirrhosis which was diagnosed histologically. As the result, chronic hepatitis was revealed in 94% of patients indicated normal liver shape or enlargement of the right lobe. Liver cirrhosis was revealed in 60% of patients indicated enlargement of the left or both lobe and in all patients indicated atrophy of the right lobe. The varying liver shape in liver scan was often associated with the progress of the liver disease. In addition, when the disease was advanced the liver scintigram indicated diffuse decrease together with increased radioactivity in the spleen and bone marrow of the spine. On the other hand, in ERCP performed patients with chronic hepatitis it showed local narrowing of the peripheral hepatic duct. In liver cirrhosis it showed either the few-branched and tapered hepatic duct or displacement and narrowing of the hepatic duct and a faint visualization of the peripheral hepatic duct. In localized liver disease such as hepatoma, metastatic liver tumor or abscess, the liver scintigram showed focal defect of the activity, and it was possible to differentiate hepatoma from other malignant lesions and benign lesions. We examined ERCP in 7 patients with hepatoma. 5 patients indicated stenosis of the common hepatic duct. 2 patients indicated obstruction, elongation or displacement due to tumor of the liver. (2) The biliary tract 99mTC-PI, 99mTC-HIDA has been used in scintigaphic examination of the biliary tract. These isotopes transfer speedily from the liver to the biliary tract and its image is sharp. So they provide the imf ormation about dilatation of the bile duct. it is possible to examine the contruction bladder used egg. In addition, of the gall The diagnosis of biliary obstruction can be performed if the radioactivity has appeared not in the gut but in the kidney. We obtained the biliary tree in 60% of 70 patients with the impared hepatic function (it is over both 2.0mg/dl in total bilirubin and 20 K.A. units in alkaliphosphatase). In such cases, it was possible to differentiate whether intrahepatic or extrahepatic cholestasis and to admit dilatation of the intrahepatic bile duct in patients with extrahepatic obstruction such as stones or tumor. On the other hand. ERCP provides the imformation in the biliary tract. about biliary disease. distinct of obstruction, stenosis or filling defect In choledochal cyst both biliary So it leed to accurate diagnosis scan and ERCP are usefull examination. Our 11 patients showed cystic dilatation of the biliary tract in biliary scan. 9 of these patients was diagnosed by ERCP in addition to the information of choledocho-pancreatic communication. (3) The pancreas We examined both scintigraphy and ERCP in 180 patients. 126 patients had pancreatic visualization in pancreatic scan. In those cases, the decreased radioactivity in pancreatic scan was proportionate to abnormality of the pancreatic duct in ERCP. Patients with glucose intolerance or acute pancreatitis revealed more decreased pancreatic view than abnormality the pancreatic duct. Residual patients revealed partial visualization (21 patients) and complete nonvisualization (34 patients) in pancreatic scan. They contained pancreatic cancer in 60%. Pancreatic cancer was diagnosed by ERCP as obstruction stenosis (7 patients) or cystic formation of (14 patients), (2 patients). 40 o were chronic pancreatitis and pancreatic cyst. In 21 patients with pancreatic cyst, 1 patient had positive visualization in pancreatic scan. Other were Gastroenterological Endoscopy

12 decreased visualization (10 patients) and partial visualization (5 patients) and complete nonvisualization (5 patients). ERCP obtained visualization of cyst in 11 patients. Especially, in 2 patients of chronic pancreatitis with pleural effusion ERCP was usefull procedure to prove pancreatic fistel or pancreatic large cyst throughout esophageal hiatus to pleural cavity. Figure 1 Result of Pancreatic Scintigram Figure 2 New Classification of Pancreatic Cancer in ERCP

13 cancer were analyzed to approach an early detection of pancreatic cancer. ERCP has been perormed in them. As shown in Figure 1, the true negative rate tomography has been carried out in 8 of them. There scintigraphy was evaluated in comparion with the results of ERCP and CT findings of resectable pancreatic 509 patients in the past five years and pancreatic scintigraphy has been performed in about 20% of of pancreatic scintigraphy was about 80%, while the true positive rate was 40%. Pancreatic scintigraphy failed to detect 5 pancreatic cancers with a false negative rate of 10% and the false positive rate (50%) was unexpectedly high. In view of high cost of pancreatic scintigraphy and a long half life of radiopharmaceutical, the diagnostic results of scintigraphy are not satisfactory. 13 patients have been found to have resectable pancreatic cancer in the past 12 months, and computed was no pathognomonic CT findings for small resectable pancreatic cancer, but computed tomography displayed useful information on surgical resectability by visualizing large vessels around the pancreas (aorta, ERCP AND IMAGING DIAGNOSIS TIC CANCER OF PANCRA- KAZUHIKO OHHASHI* AND KUNIO TAKAGI** *Department of Internal Medicine **Department of Surgery, Cancer Institute Hospital, Tokyo, Japan. In spite of the development of diagnostic modalities for pancreatic cancer, the surgical resectability and prognosis of pancreatic cancer have remained discouraging. Small pancreatic cancers are hardly detctable firstly because the clinical symptoms are commoly so vague that careful attention cannot be paid to the pancreas and secondly because ERCP could not have been performed in all but a few rare cases. Therefore, we need to urgently find out the noninvasive screening filter for pancreatic cancer. Body imaging technigues such as ultrasonography, computed tomography be suitable for this purpose. In this paper, a diagnostic or pancreatic scintigraphy seem to acuracy of pancreatic inferior vena cava, superior mesenteric artery and superior mesenteric vein). The direct CT findings of pancreatic cancer such as irregular contour enlargement and low density were rarely visualized in cases of small resectable pancreatic cancer, but the indirect CT findings such as dilatation of the main pancreatic duct or parenchymal atrophy distal to the tumor were demonstrated. 46 cases of pancreatic cancer with abnormal pancreatogram were divided into 3 types based on the site of tumor and appearance of pancreatic duct as shown in Figure 2. Type I is the commonest type of pancreatic cancer with marked dilatation of the main pancreatic duct and parenchymal atrophy. This type of pancreatic cancer may be detected by imaging techniques for both direct and indirect findings. Type U is very rarely seen but this type could be an early appearance of so called cancer of the pancreas head. In this type, either Wirsungi's or Santorini's duct is only involved and indirect findings cannot be seen. ERCP must be only the diagnostic modality to pickup this type of pancreatic cancer. Type V is a spe- Gastroenterological Endoscopy

14 cial form of pancreatic cancer with polypoid tumor inside the dilated main pancreatic duct. This type may be detected by imaging techniques. Thus, Type II pancreatic cancer can be only detected by ERCP and it must be indispensable as a screening filter at the moment.

15 ASSESSMENTS OF ERCP, US, CT AND RI IN THE DIAGNOSIS OF PANCREATICOBILIARY DISEASES NOBUYOSHI KUNO AND CHOICHIRO KIDO Departments of Iniernal Medicine, and Radiology, Aichi Cancer Center Hospital, Nagoya, Japan Assessments of the diagnostic value of 4 tests in 51 patients with proven carcinoma of the pancreas (22 patients) chronic pancreatitis (3), carinoma of the biliary tracts (5), and calculi of the biliary tracts (21) were made. ERCP, US, CT and RI were judged suspicious and undiagnostic discribed previously by us and others. ERCP as correct, according to the criteria and CT were most sensitive in diagnosing patients with pancreatic cancer (77.3 0, , respectively). These 4 tests offered complementary corrert or suspicious information cancer. in the evaluation of pancreatic An indirect sign on US and CT is dilatation intrahepatic biliary tree. All 4 tests are useful in patients with or without jaundice. Most of tumors are not diagnosed at a resectable stage. In this series only 4 patients had resectable pancreatic cancer. ERCP gave the correct diagnosis in these 4 patients. ERCP is the best means of diagnosing resectable tumors. of Most patients, however, experienced vague, nonspecific symptoms at an early stage in the disease process. If an effecive diagnostic Gastroenterological Endoscopy

16 procedure were used at this earlier stage, not only would the prognosis after resection be improved, but also a further group of patients who would otherwise progress to non-resctable disease could be identified and offered radical surgical treatment. We proposed decision tree for the diagnosis of pancreatic cancer. The diagnosis of pancreatitis was accepted following the criterion of Japan panreatic disease society. In all 3 patients with chronic pancreatitis, almost of all 4 tests gave the correct diagnosis. Despite many efforts, our detection of resectable tumor of the gallbladder by 4 tests was not effective. In 2 patients with carcinoma of the bile duct and in 3 patients with choledochocholelithiasis or choledocholithiasis, the ERCP diagnosis was definite and correct. In 10 of 18 patients with cholelithiasis, the ERCP diagnosis was suspicous, because the gallbladder could not be visualized in spite of sufficient opacification of the intrahepatic bile duct. In many of these patients, CT showed a high density in the area of the gallbladder or a low density in the area of the gallbladder with contrast enhancement. A more sensitive diagnostic modality for the correct diagnosis of pancreatico-biliary diseases remains to be established. CT associated with angiography, RI with subtraction and direct magnification during ERCP are under investigation. References 1) Kuno, N., Kasugai, T., Oguri, T.' Matsuura, A., Fujiwara, K. and Kato, O.: Endoscopic diagnosis of pancreatic diseases. Gendai Igaku 24:24, 1977 (In Japanese). 2) Doust, B. D.: The use of ultrasound in the diagnosis of gastroenterological disease. Gastroenterology 70: 602, ) stanley, R. J., Sagel, S. S., and Levitt, R. G.: Computed tomography evaluation of the pancreas. Radiology 124 : 715, ) Uno, K., Uchiyama, A., Hotta, T., and Kuniyasu, Y.: The diagnosis of the pancreatic cancer on pancreatic scintigram. Naika 43 : 782, 1979 (in Japanese).

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18 the diagnosis of pancreatic and hepato-biliary diseases was performed in order to disclose the usefulness of each diagnostic procedures. Materials consist of 4 cases of ampullary cancer, 21 cases of pancreatic cancer, 14 cases of calcifying chronic pancreatitis, 13 cases of non-calcifying chronic pancreatitis, 7 cases of pancreatic pseudocyst, 38 cases of cholecystolithiasis, 7 cases of choledocholithiasis, 4 cases of cancer of the sions; 5) malignancy of the lesions. "Suspect" means that the findings obtained are diag- nostic in terms of only some of the above items. Diagnostic accuracy and efficiency of each procedure were evaluated according to lesions. Results and comments: 1) ERCP was definite in all cases of ampullary cancer; CT was suspect in 2 cases and non-diagnostic in 2; US was non-diagnostic in all. ERCP is the best procedure for the diagnosis of ampullary cancer. 2) In pancreatic cancer, ERCP was definite in 62% and suspect in 33%; CT was definite in 86% and suspect in 7%; US was definite in 57% and suspect in 36%; RI was definite in none and suspect in 88%. ERCP was interpreted as sus- CORRELATIVE EVALUATION OF FRCP, CT SCANNING, ULTRASOUND SONOGRAPHY, AND RADIO-ISOTOPE SCANNING IN DIAGNOSIS OF PANCREATIC AND HEPATO-BILIARY DIS- EASES. KUNIKI MISHIMA AND MASAHIKO TAKEDA. Second Department of Int. Med., Okayama Uninersity Medical School, Okayama, Japan Correlative evaluation of ERCP, CT, US, and RI in gallbladder, 5 cases of cancer of the common bile duct, 7 cases of hepatoma, and 37 cases of normal controls. Diagnostic efficiency was categorized into three: definite, suspect, and non-diagnostic. "Definite" means that the findings obtained are diagnostic in terms of 1) presence of lesions; 2) location of the lesions; 3) size of the lesions; 4) number of the le- pect in 33% due to the lack of convincing evidence of malignancy and inability to disclose the extent of a space-taking lesion. One case showed extrapancreatic growth which was disclosed only by CT and US. US and RI were interpreted as suspect mostly due to the lack of convincing evidence of malignancy of a lesion. 3) In pancreatolithiasis, ERCP was definite in 86% and suspect in 7%; US and CT were definite in all; RI was suspect in all. ERCP, when satisfactorily opacified, gives the best information in terms of an indication for operation as well as diagnosis. 4) In non-calcifying chronic pancreatitis, ERCP was definite in 92% and suspect in 8%; CT was definite in 8% and non-diagnostic in 92%; US was non-diagnostic in all. ERCP in the

19 best procedure in detecting mild degree of chronic pancreatitis. 5) In pancreatic pseudocyst, ERCP was definite in 29% and suspect in 290; CT was definite in all; US was definite in 20% and suspect in 80% (due to difficulty in establishing the origin of the cyst). Pancreatic pseudocyst is most accurately diagnosed by CT and/or US. 6) In cholecystolithiasis, ERCP was definite in 53% and suspect in 13%; US was definite in 79% and suspect in 11%; CT was definite in 36% and non-diagnostic in 640. Cholecystolithiasis is best diagnosed by US. ERCP, when opacified, gives most accurate information but the success rate of cholangiography is somewhere between 75 to 85%. 7) In choledocholithiasis, ERCP was definite in all; US was definite in 71%. US can be definite in almost all cases with recent improved technique. CT is useful only to disclose the presence of biliary dilation. 8) In cancer of gallbladder, ERCP was definite in 50% and suspect in 25%; US was suspect in all; CT was non-diagnostic in all. All four cases underwent curable operation. US is a simplest and most useful procedure for detecting a tumor of gallbladder but diagnosis of malignancy is difficult. 9) In cancer of the choledochus, ERCP was definite in 80%; CT was suspect in 60%. ERCP gives most accurate information. US and CT are helpful mostly in disclosing the bile duct dilation. 10) In hepatoma, ERCP was suspect in 71% and non-diagnostic in 29%; CT was definite i n 33% and suspect in 50%; US was definite in 40% and suspect in 40%; RI was definite in 14% and suspect in 71%. 11) False positive results were obtained in 4% by ERCP, 14% by CT, and 3% by US. Conclusion: Combined use of ERCP, CT, US and RI is useful in establishing not only the diagnosis of pancreatic and hepato-biliary diseases but also an operative indication. ENDOSCOPIC RETROGRADE CHOLANGIOGRA- PHY (ERCP), ULTRASONOGRAPHY AND RI- SCANNING FOR CONGENITAL ANOMALAS OF PANCREATICO KATSUMI AND HIDEYO BILIARY SYTEM IN CHILDREN NAKAJIMA TAKAHASHI Depts. of Pediatric Surgery, Chiba University Hospital ERCP was attempted in our department 29 times for 26 children suspected biliary tract disease from 1975 through April 1980, and 16 out of 29 times were succeeded. Success rate was 55.2%. Final diagnosis of those patients were 9 cases congenital choledochal dilation, 1 case of anomalous junction of pancreatico biliary ductrl system without of Gastroenterological Endoscopy

20 choledochal dilation, 1 case of cholecystolithiasis and 5 cases of nomal biliary system. The age of the successful 4mo to 15yr 5mo. cases ranged from lyr In this series three types of endoscope were used, namely JF-B2 (OLYNPUS), FGS-PE (MACHIDA), and other. FGS-PE was a trial production for the pediatric use. All cases except one were performed under general anesthesia. Transient pancreafitis was observed in 2 cases after ERCP. The diagnostic rate of congenital choledochal dilation was 88.9% in ultrasonogr phy, 54.5% in RIscanning, 71.4% in PTC and 66.7% in ERCP. could not find any anomalous junction of pancreatico biliary ductal system in ultrasonography We and RI-scanning, but could get the true diagnosis in 71.4% by PTC and 64.3% by ERCP. We concluded that the ERCP was relatively safe prodedure even in children if it was performed with greate care, and that it was very useful to investigate the unction of pancreatico-biliary ductal system.

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