In a recent case series we discovered that patients with autoimmune
pancreatitis show typical signs of hypervascularization in contrast-enhanced
high mechanical index endoscopic ultrasound (CEHMI EUS) [1]. Contrast-enhanced low mechanical index endoscopic
ultrasound (CELMI EUS) is a newly developed technique that should show a
different contrast-enhancing effect.
To explore the effect of CEHMI EUS (picture acquisition
[Fig. 1 a] and [1 b]) and CELMI EUS, we further combined each
technique with the newly developed method of three-dimensional (3D)
endosonography. 3D endosonography has already been shown to improve the
visualization of unenhanced gastrointestinal structures [2], and has recently been performed in combination with
CELMI EUS [3]. However, 3D endosonography has not
previously been done in association with CEHMI EUS or in patients with
autoimmune pancreatitis.
We used the commercial platform of the Hitachi Preirus ultrasound
machine in connection with a longitudinal endosonography scanner from Pentax.
CEHMI EUS was performed as recently described [4]. CELMI
EUS was performed with an additional injection of 4.5 mL Sonovue after
the CEHMI EUS data acquisition. A 3D scan was done with each method
30 – 40 s after injection of the contrast
enhancer.
The difference in vascularization with autoimmune pancreatitis
compared with that in a normal pancreas was impressively shown using the 3D
CEHMI EUS technique. [Fig. 1 a, b]
show images acquired during 3D CEHMI EUS, in a patient with autoimmune
pancreatitis and from a normal pancreas, and [Fig. 2 a, b] show the 3D
reconstructions. Furthermore, 3D CELMI EUS ([Fig. 2 c, d]) also provided a striking
improvement in the contrast-enhancing effect in the pancreatic tissue.
Fig. 1 a Acquisition of a
three-dimensional (3D) image in high mechanical index color Doppler mode from a
patient with autoimmune pancreatitis. The rich vascularization is clearly seen,
but not as impressively as in the 3D reconstruction. b
Acquisition of a 3D image from a normal pancreas. Normal vascularization is
shown; the large vessel below the pancreas is the splenic vein.
Fig. 2 a Three-dimensional (3D)
reconstruction of contrast-enhanced high mechanical index endosonography (CEHMI
EUS) images from a patient with autoimmune pancreatitis. The vascularization
pattern of the pancreas is strikingly shown. b 3D CEHMI
EUS reconstruction for a normal pancreas. While vessels can be detected with
this technique their extent is, however, notably reduced compared with those
seen in autoimmune pancreatitis.
c 3D reconstruction of contrast-enhanced
low mechanical index endosonography (CELMI EUS) in the same patient as in
[Fig. 2 a]. The contrast-enhanced
parenchyma of autoimmune pancreatitis is shown strikingly. d 3D CELMI EUS reconstruction in a normal pancreas. The
contrast-enhancing effect in the pancreatic parenchyma shows a clear difference
from that in autoimmune pancreatitis.
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