Purpose: The purpose of this study was to evaluate the rates of unacceptable diagnosis and clinically significant diagnostic discrepancy in radiology sections and imaging modalities through a peer review of teleradiology. Materials and Methods: Teleradiology peer reviews in a Korean teleradiology clinic in 2018 and 2019 were included. The peer review scores were classified as acceptable and unacceptable diagnoses and clinically insignificant and significant diagnostic discrepancy. The diagnostic discrepancy rates and clinical significance were compared among radiology sections and imaging modalities using the chi-square test. Results: Of 1312 peer reviews, 117 (8.9%) cases had unacceptable diagnoses. Of 462 diagnostic discrepancies, the clinically significant discrepancy was observed in 104 (21.6%) cases. In radiology sections, the unacceptable diagnosis was highest in the musculoskeletal section (21.4%) (p < 0.05), followed by the abdominal section (7.3%) and neuro section (1.3%) (p< 0.05). The proportion of significant discrepancy was higher in the chest section (32.7%) than in the musculoskeletal (19.5%) and abdominal sections (17.1%) (p < 0.05). Regarding modalities, the number of unacceptable diagnoses was higher with MRI (16.2%) than plain radiology (7.8%) (p < 0.05). There was no significant difference in significant discrepancy. Conclusion Peer review provides the rates of unacceptable diagnosis and clinically significant discrepancy in teleradiology. These rates also differ with subspecialty and modality.

Accurate diagnosis of autoimmune pancreatitis (AIP) is important to clinicians since it is difficult to differentiate AIP from pancreatic malignancies. Furthermore, unlike pancreatic malignancies, AIP has dramatic response to steroids. A 61-years-old man presented with acute pancreatitis. Imaging studies showed two separate pancreatic masses, irregular narrowing of main pancreatic duct, and a renal mass that highly suggested AIP. Endoscopic ultrasound-guided core needle biopsy of the pancreatic masses and ultrasound-guided biopsy of the renal mass revealed peripheral T-cell lymphoma. The patient is currently undergoing chemotherapy. We present a case of pancreatic lymphoma masquerading as AIP with literature review.
Biopsy ; Biopsy, Large-Core Needle ; Diagnosis ; Drug Therapy ; Humans ; Lymphoma* ; Lymphoma, T-Cell, Peripheral ; Pancreatic Ducts ; Pancreatic Neoplasms ; Pancreatitis* ; Steroids

Actinomycosis is a chronic, slowly progressive, and suppurative disease caused by filamentous anaerobic bacteria Actinomyces, which results in characteristic sulfur granules. Clinically, actinomycosis can present with a mass-like lesion, and this bacterial nidus has been frequently mistaken for a malignancy. For that reason many patients undergo surgical resection before the correct diagnosis is established. We report a case of a 63-year-old man with a solitary, asymptomatic pancreatic actinomycosis that masqueraded as pancreatic cancer. He did not have any other concurrently infected organs and did not have any signs or symptoms of infection. All radiologic images of the patient favored a malignancy to a great extent rather than an inflammatory mass. He was finally diagnosed with actinomycosis by endoscopic ultrasound (EUS)-guided fine needle aspiration biopsy without surgery. After one month of treatment with antibiotics, the pancreatic head mass was completely resolved on the follow-up computed tomography (CT).
Actinomyces ; Actinomycosis* ; Anti-Bacterial Agents ; Bacteria, Anaerobic ; Biopsy ; Biopsy, Fine-Needle ; Diagnosis ; Follow-Up Studies ; Head ; Humans ; Middle Aged ; Pancreas ; Pancreatic Neoplasms* ; Sulfur ; Ultrasonography

BACKGROUND/AIMS: Endoscopic ultrasonography (EUS)-guided ethanol ablation is gaining popularity for the treatment of focal pancreatic lesions. The aim of this study was to evaluate the safety, feasibility, and treatment response after EUS-guided ethanol injection for small pancreatic neuroendocrine tumors (p-NETs). METHODS: This was a retrospective analysis of a prospectively collected database including 11 consecutive patients with p-NETs who underwent EUS-guided ethanol injection. RESULTS: EUS-guided ethanol injection was successfully performed in 11 patients with 14 tumors. The final diagnosis was based on histology and clinical signs as follows: 10 non-functioning neuroendocrine tumors and four insulinomas. During follow-up (median, 370 days; range, 152 to 730 days), 10 patients underwent clinical follow-up after treatment, and one patient was excluded because of loss to follow-up. A single treatment session with an injection of 0.5 to 3.8 mL of ethanol resulted in complete responses (CRs) at the 3-month radiologic imaging for seven of 13 tumors (response rate, 53.8%). Multiple treatment sessions performed in three tumors with residual viable enhancing tissue increased the number of tumors with CRs to eight of 13 (response rate, 61.5%). Mild pancreatitis occurred in three of 11 patients. CONCLUSIONS: EUS-guided ethanol injection appears to be a safe, feasible, and potentially effective method for treating small p-NETs in patients who are poor surgical candidates.
Diagnosis ; Endosonography ; Ethanol* ; Follow-Up Studies ; Humans ; Insulinoma ; Neuroendocrine Tumors* ; Pancreatitis ; Pilot Projects* ; Prospective Studies ; Retrospective Studies

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) can be an effective treatment for bile leakage after liver transplantation. We evaluated the efficacy of endoscopic treatment in liver transplantation in patients who developed bile leaks. METHODS: Forty-two patients who developed bile leaks after liver transplantation were included in the study. If a bile leak was observed on ERCP, a sphincterotomy was performed, and a nasobiliary catheter was then inserted. If a bile leak was accompanied by a bile duct stricture, either the stricture was dilated with balloons, followed by nasobiliary catheter insertion across the bile duct stricture, or endoscopic retrograde biliary drainage was performed. RESULTS: In the bile leakage alone group (22 patients), endoscopic treatment was technically successful in 19 (86.4%) and clinically successful in 17 (77.3%) cases. Among the 20 patients with bile leaks with bile duct strictures, endoscopic treatment was technically successful in 13 (65.0%) and clinically successful in 10 (50.0%) cases. Among the 42 patients who underwent ERCP, technical success was achieved in 32 (76.2%) cases and clinical success was achieved in 27 (64.3%) cases. CONCLUSIONS: ERCP is an effective and safe therapeutic modality for bile leaks after liver transplantation. ERCP should be considered as an initial therapeutic modality in post-liver transplantation patients.
Adult ; Anastomotic Leak/etiology/*surgery ; *Bile ; Biliary Tract Diseases/etiology/*surgery ; Cholangiopancreatography, Endoscopic Retrograde/*methods ; Constriction, Pathologic/therapy ; Drainage ; Female ; Humans ; *Liver Transplantation ; Male ; Middle Aged ; Stents ; Treatment Outcome ; Young Adult

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) can be an effective treatment for bile leakage after liver transplantation. We evaluated the efficacy of endoscopic treatment in liver transplantation in patients who developed bile leaks. METHODS: Forty-two patients who developed bile leaks after liver transplantation were included in the study. If a bile leak was observed on ERCP, a sphincterotomy was performed, and a nasobiliary catheter was then inserted. If a bile leak was accompanied by a bile duct stricture, either the stricture was dilated with balloons, followed by nasobiliary catheter insertion across the bile duct stricture, or endoscopic retrograde biliary drainage was performed. RESULTS: In the bile leakage alone group (22 patients), endoscopic treatment was technically successful in 19 (86.4%) and clinically successful in 17 (77.3%) cases. Among the 20 patients with bile leaks with bile duct strictures, endoscopic treatment was technically successful in 13 (65.0%) and clinically successful in 10 (50.0%) cases. Among the 42 patients who underwent ERCP, technical success was achieved in 32 (76.2%) cases and clinical success was achieved in 27 (64.3%) cases. CONCLUSIONS: ERCP is an effective and safe therapeutic modality for bile leaks after liver transplantation. ERCP should be considered as an initial therapeutic modality in post-liver transplantation patients.
Adult ; Anastomotic Leak/etiology/*surgery ; *Bile ; Biliary Tract Diseases/etiology/*surgery ; Cholangiopancreatography, Endoscopic Retrograde/*methods ; Constriction, Pathologic/therapy ; Drainage ; Female ; Humans ; *Liver Transplantation ; Male ; Middle Aged ; Stents ; Treatment Outcome ; Young Adult

Background/Aims: There are limitations in treating ampullary adenomas with intraductal extension using conventional endoscopic modalities. Endoscopic intraductal radiofrequency ablation (ID-RFA) may be useful for treating intraductal (common bile duct [CBD] and/or pancreatic duct [PD]) extensions of ampullary adenomas, but long-term data are lacking. We thus evaluated the long-term outcomes of endoscopic ID-RFA for managing ampullary adenomas with intraductal extension. Methods: Prospectively collected endoscopic ID-RFA database at Asan Medical Center was reviewed to identify consecutive patients with ampullary adenoma who underwent ID-RFA for intraductal extension between January 2018 and August 2021. Technical success, short-term and long-term clinical success, and adverse events were evaluated. Results: A total of 29 patients (14 CBD, 1 PD, and 14 CBD and PD) were analyzed. All patients had undergone endoscopic snare papillectomy prior to ID-RFA. A median of one session of IDRFA (range, 1 to 3) for residual or relapsed intraductal extension of ampullary adenoma were successfully performed (technical success=100%). Both biliary and pancreatic stenting were routinely performed after ID-RFA to prevent ductal stricture. After a median follow-up of 776 days (interquartile range, 470 to 984 days), the short-term and long-term clinical success rates were 93% and 76%, respectively. Seven patients experienced procedural adverse events and three patients developed ductal strictures. Conclusions Endoscopic ID-RFA showed good long-term outcomes in treating residual or relapsed ampullary adenomas with intraductal extension. Repeated ID-RFA may be considered as an option for managing recurrence. Further studies are needed to standardize the procedure.

Objective: : Nontraumatic subdural hematoma (SDH) is a common disease, and spinal cerebrospinal fluid (CSF) leakage is a possible etiology of unknown significance, which is commonly investigated by several invasive studies. This study demonstrates that heavily T2-weighted magnetic resonance myelography (HT2W-MRM) is a safe and clinically effective imaging modality for detecting CSF leakage in patients with nontraumatic SDH. Methods: : All patients who underwent HT2W-MRM for nontraumatic SDH workup at our institution were searched and enrolled in this study. Several parameters were measured and analyzed, including patient demographic data, initial modified Rankin Scale (mRS) score upon presentation, SDH bilaterality, hematoma thickness upon presentation, CSF leakage sites, treatment modalities, followup hematoma thickness, and follow-up mRS score. Results: : Forty patients were identified, of which 22 (55.0%) had CSF leakage at various spinal locations. Five patients (12.5%) showed no change in mRS score, whereas the remaining (87.5%) showed decreases in follow-up mRS scores. In terms of the overall hematoma thickness, four patients (10.0%) showed increased thickness, two (5.0%) showed no change, 32 (80.0%) showed decreased thickness, and two (5.0%) did not undergo follow-up imaging for hematoma thickness measurement. Conclusion : HT2W-MRM is not only safe but also clinically effective as a primary diagnostic imaging modality to investigate CSF leakage in patients with nontraumatic SDH. Moreover, this study suggests that CSF leakage is a common etiology for nontraumatic SDH, which warrants changes in the diagnosis and treatment strategies.

Percutaneous transhepatic gallbladder drainage is an effective treatment for acute cholecystitis in poor surgical candidates. Endoscopic gallbladder drainage procedures, such as endoscopic ultrasound-guided gallbladder drainage, endoscopic gallbladder stenting, and endoscopic naso-gallbladder drainage, have been used as alternative treatments for acute cholecystitis. These procedures are associated with increased patient comfort and physiologic drainage. We report a case of endoscopic gallbladder stenting for acute cholecystitis in a 62-year-old male undergoing chemotherapy for metastatic pancreatic cancer. After endoscopic gallbladder stenting, the patient’s acute cholecystitis resolved and he was able to undergo scheduled chemotherapy. The inserted double-pigtail plastic stent will be left in situ permanently. The choice of drainage modality for acute cholecystitis will generally be based on resources, patient preferences, local expertise, and clinical context.