J Med Ultrasonics (2010) 37:117–121 DOI 10.1007/s10396-010-0262-y
ORIGINAL ARTICLE
Clinical experience with newer electronic radial-type endoscopic color Doppler ultrasonography in the diagnosis of esophageal varices Takahiro Sato • Katsu Yamazaki • Jouji Toyota • Yoshiyasu Karino • Takumi Ohmura • Jun Akaike
Received: 26 December 2008 / Accepted: 18 February 2010 / Published online: 14 April 2010 Ó The Japan Society of Ultrasonics in Medicine 2010
Abstract Purpose Endoscopic color Doppler ultrasonography (ECDUS) is a method for obtaining color images of flow in blood vessels. In this study, we report the utility of a newer electronic radial ECDUS for evaluating cases with esophageal varices. Methods Nineteen patients with esophageal varices were selected. The ECDUS was performed using a Pentax EG-3670URK (forward-view) with a distal tip diameter of 12 mm. A Hitachi EUB 7500, which provides a 360° view, was used for display. Results The newer electronic radial ECDUS more clearly delineates images of vessels in patients with esophageal varices. We found two chief advantages over the old probe, i.e., it is easier to manipulate in the distal esophagus than the old probe and it produces 360° images instead of 60° or 270° images. Conclusion Forward-view optics and an extended 360° viewing angle enabled clear color flow images to be obtained from all cases of esophageal varices examined.
Introduction Endoscopic color Doppler ultrasonography (ECDUS) is a useful method for obtaining color flow images of blood vessels, and we have used it to obtain graphic depictions of esophageal varices, paraesophageal veins, palisade veins, and perforating veins in patients with esophageal varices. We previously reported the utility of ECDUS (convex-type scanning instruments with forward-oblique viewing) for evaluating the hemodynamics of esophago-gastric varices [1–3], and mentioned the improved performance of electronic radial ECDUS, relative to the convex type, in evaluating the hemodynamics of esophageal varices [4]. In this paper we report the use of a newer electronic radial ECDUS system for evaluating the hemodynamics of esophageal varices.
Materials and methods Patients
Keywords Esophageal varices Endoscopic ultrasonography Color Doppler
T. Sato (&) K. Yamazaki J. Toyota Y. Karino T. Ohmura J. Akaike Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo, Hokkaido 060-0033, Japan e-mail:
[email protected]
The study included 19 patients (11 males and 8 females), ranging in age from 51 to 84 years (mean 61.2 years), with a history of esophageal varices. Fifteen of these patients with varices evident at the time of ECDUS were classified into Group A, whereas four patients with no evident varices following treatment were classified into Group B. Endoscopic findings of esophageal varices were: large and coilshaped, red color-positive varices in three patients; enlarged and tortuous, red color-positive varices in seven patients; small and straight, red color-positive varices in five patients; and five cases with cardiac varices (Group A). Underlying pathologies of portal hypertension included liver cirrhosis in 15 patients, cirrhosis associated with
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hepatocellular carcinoma in three patients, and idiopathic portal hypertension in one patient. In terms of the clinical staging of cirrhosis, 13 patients were graded Child–Pugh class A and six patients class B. The etiologies of liver cirrhosis were: hepatitis B surface antigen (HBs Ag)-positivity in three patients, antibody to hepatitis C virus (antiHCV)-positivity in nine patients, alcoholic liver disease in five patients, and unknown in one patient. Newer electronic radial ECDUS ECDUS was performed using a Pentax EG-3670 URK (Pentax, Tokyo, Japan) (forward-view) with a distal tip diameter of 12 mm and a working length of 1250 mm (Fig. 1a). This electronic radial array instrument has a curved-array scanning transducer with adjustable frequency (5, 7.5, or 10 MHz) and B mode/color Doppler/ color flow angio. The range of tip reflection is 130° up and 60° down/right/left. A Hitachi EUB 7500 (Hitachi, Tokyo, Japan), which provides 360° images, was used for display. The earlier echoendoscopes are also shown (FG-36UX, Fig. 1b; EG-3630UR, Fig. 1c). We evaluated ECDUS color flow images of esophageal varices, paraesophageal veins, palisade veins, perforating veins, and cardiac intramural veins using fast-Fourier transform (FFT) analysis. Perforating veins were defined as communicating vessels between esophageal varices and paraesophageal veins. Passageways of esophageal varices
Fig. 1 a The tip view of the EG-3670URK, b the tip view of the FG-36UX, c the tip view of the EG-3630UR
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are mainly associated with the left gastric vein, short gastric vein, and palisade vein, and perforating veins are recognized as additional passageways. Perforating veins detected by ECDUS were classified into one of three types according to the direction of flow: inflowing (i.e., flow from paraesophageal veins to the esophageal varices); outflowing (i.e., flow from esophageal varices to paraesophageal veins); and mixed (i.e., both inflow and outflow) [1]. The color gain was adjusted to eliminate background noise. The study was performed according to the tenets of the Declaration of Helsinki. Written informed consent was obtained from all patients before the procedure.
Results Among the 15 patients in Group A, color flow images of esophageal varices and paraesophageal veins were obtained for all patients (100%), whereas images of perforating veins and images of palisade veins were obtained for 10 patients (66.7%) and 11 patients (73.3%), respectively, and images of cardiac intramural veins were obtained for 13 patients (86.7%). This newer scope showed the advantage of a wider view (Fig. 2a) and clearly delineated the continuity of vessels from the cardiac intramural veins to esophageal varices (Fig. 2b), resulting in clear and fine color flow images of blood vessels being
J Med Ultrasonics (2010) 37:117–121
Fig. 2 a Images depicting esophageal varices (arrow) and paraesophageal veins (arrowhead) were obtained. b The continuities of vessels from the cardiac intramural veins (arrow) to the esophageal
obtained in all cases. The color flows of these vessels were depicted as a continuous wave on FFT analysis (Fig. 2c). Among the four patients in Group B, no color flow images of esophageal varices, perforating veins, or cardiac intramural veins were obtained; however, color flow images of paraesophageal veins and palisade veins were obtained in all four patients. Vessel images of esophageal varices and perforating veins were not detected in a cirrhotic patient with no varices after treatment. On the other hand, color flow images of palisade veins were clearly obtained in this case (Fig. 3). Forward-viewing optics were used to facilitate insertion of the instrument, which was considered easy in all cases; however, the stiffness of the distal tip was found to limit the flexibility of the scope, particularly during efforts to obtain J-turn or U-turn views with the newer probe, a Pentax EG-3670 URK. We found two chief advantages over the old probe, i.e., it is easier to manipulate in the distal esophagus than the old probe and it produces 360° images instead of 60° or 270° images.
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varices are delineated clearly. c Color flow images of these vessels exhibit a continuous wave on fast-Fourier transform analysis
Fig. 3 Color flow images of palisade veins
Case presentation The case was a 66-year-old woman with cirrhosis (HCV) and enlarged and tortuous, red color-positive esophageal
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Fig. 4 a Enlarged and tortuous, red color-positive esophageal varices. b An inflowing perforating vein (arrow) from paraesophageal veins to esophageal varices is delineated clearly in vessel images.
c Esophageal varices and paraesophageal veins, and an outflow-type perforating vein (arrow) from esophageal varices to paraesophageal veins were all detected in vessel images
varices (Fig. 4a). The inflowing perforating vein, from paraesophageal veins to esophageal varices, was delineated clearly on electronic radial ECDUS color flow images (Fig. 4b). Vessel images of esophageal varices and paraesophageal veins were detected, and an outflow-type perforating vein from the esophageal varices to paraesophageal veins was detected at the oral site of the inflowing perforating vein (Fig. 4c). Endoscopic injection sclerotherapy (EIS) was performed in this case for the purpose of obliterating esophageal varices and the inflowing perforating vein with blockade of the outflow-type perforating vein by use of an inflated attached balloon.
ECDUS in predicting recurrence of gastroesophageal varices, found that recurrence could be related both to the presence of cardiac intramural veins and the absence of paraesophageal veins. Hino et al. [9] also mention that risk factors for recurrence of esophageal varices could be analyzed in detail using convex-type ECDUS. The Pentax FG-36UX (Pentax, Tokyo, Japan) convextype instrument that was used in our previous reports [1–3] was difficult to insert and to apply in obtaining images. In another previous study, an instrument with forward-viewing optics (i.e., electronic radial ECDUS, EG-3630UR) facilitated insertion relative to the FG-36UX instrument [4] and provided 270° images. We discovered that obtaining J-turn or U-turn views was difficult owing to the stiffness of the distal tip, which limited the flexibility of the scope. Another disadvantage of this instrument was the impossibility of obtaining 360° views. Nevertheless, the scope was manipulated easily for observations of the lower esophagus and gastroesophageal junction. In this study, we evaluated a newer electronic radial ECDUS instrument with forward-viewing optics and an increased viewing radius of 360°. The scope was easy to manipulate in order to observe the lower esophagus and
Discussion Evaluating the hemodynamics of a portal venous system with hypertension is important for determining the optimum treatment. While endoscopic ultrasonography (EUS) has become a useful modality for the diagnosis of esophago-gastric varices [5–7], ECDUS provides more detailed data on the hemodynamics of esophageal varices. Senjyu et al. [8], who reported the use of linear-type
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gastroesophageal junction, and the instrument provided clear and fine color flow images of blood vessels in all cases. There is no difference in spatial resolution and Doppler sensitivity between the newer electronic radial ECDUS and the earlier EG-3630UR. Another scope (Olympus GF type UM2000) provides a 360° view, but we cannot comment on this scope because there are no clinical data on esophageal varices. Perforating veins are recognized as additional passageways of esophageal varices [10, 11]. Although perforating veins can be visualized via EUS [12–14], the direction of their blood flow cannot be determined with this method. The direction of blood flow in perforating veins is an important consideration in the therapeutic management of esophageal varices. Therefore, we should perform EIS in cases of an inflowing-type perforating vein for the purpose of obliterating esophageal varices and the perforating vein. On the other hand, an outflow-type perforating vein is associated with diversion of esophageal variceal blood flow into paraesophageal veins. Palisade veins, which are normally seen in the lamina propria at the lower end of the esophagus, have been called sudare-like veins. The palisade veins ran through the lamina propria, and most of them finished draining into the submucosal veins in the critical area [15, 16]. Palisade veins that remain after endoscopic therapies may be related to variceal recurrence, and endoscopic follow-up is necessary in such cases. The newer electronic radial ECDUS clearly delineates perforating veins and palisade veins in esophageal varices. The shortcomings of this newer electronic radial ECDUS are the stiffness of the distal tip and insufficient detection of slow blood flows. In conclusion, the newer electronic radial ECDUS is useful for evaluating the hemodynamics of esophageal varices. Because of the wider view (360°) and the easy manipulation of the scope with forward-viewing optics for observing the lower esophagus and gastro-esophageal junction, vessels in esophageal varices can be delineated more clearly.
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