This case does not seem so easy to me. It is a pancreatic adenocarcinoma with metastasis, so the treatment should be palliative, so we remove options 1 and 5. In principle she is a patient in moderately good general condition, so the ideal would be to perform a permanent biliary diversion and chemotherapy, option 4 being the one I consider most correct.

This case does not seem so easy to me. It is a pancreatic adenocarcinoma with metastasis, so the treatment should be palliative, so we remove options 1 and 5. In principle she is a patient in moderately good general condition, so the ideal would be to perform a permanent biliary diversion and chemotherapy, option [HIDDEN].

A 76-year-old woman with no history other than hypertension consults for painless jaundice and pruritus with anorexia. Laboratory tests show bilirubin of 12 mg/dl (9.5 direct). Ultrasound shows intrahepatic and extrahepatic biliary dilatation together with a single hepatic nodule smaller than 2 cm located peripherally on the anterior aspect of the left lobe. The CT scan confirms these findings also demonstrating the presence of a pancreatic mass of 3.5 cm. In the pancreatic head. The aspiration puncture of the hepatic nodule is conclusive for adenocarcinoma. Indicate the best therapeutic option:

Neoadjuvant chemo/radiotherapy, conditioning the option of radical surgery on initial response.

Percutaneous external biliary drainage with palliative character with eventual reconversion to internal drainage in case of intolerance or complications.

Palliative surgical biliary bypass with or without prophylactic gastrojejunostomy depending on intraoperative findings.

Metallic biliary prosthesis by endoscopic retrograde cholangiopancreatography with the option of palliative chemotherapy.

Cephalic duodenopancreatectomy, with percutaneous ablation by radiofrequency or alcoholization of the hepatic lesion.

Endoscopic Ultrasound-Guided Biliary Drainage in Two Patients with Difficult Biliary Access.

Endoscopic retrograde cholangiopancreatography is the method of choice for biliary drainage, although in some cases standard biliary access is difficult or even impossible. Endoscopic ultrasound (EUS)-guided endoluminal procedures are an alternative in these cases, although experience with these techniques is still limited. We present two cases of successful EUS-guided biliary drainage. In the first case, a hepaticogastrostomy was performed in a patient with stage IV gastric adenocarcinoma with obstructive jaundice due to compression of the hilum, where malignant gastric stenosis and previous palliative gastrojejunostomy precluded access to the second part of the duodenum. In the second case, a patient with a pancreatic head adenocarcinoma with duodenal invasion that precluded major papillae identification was submitted to a choledochoduodenostomy. Both procedures occurred without immediate or delayed adverse events, with technical and clinical success. Although experience with EUS-guided biliary drainage is still limited, its efficacy and safety is favorable when compared with percutaneous and surgical drainage, and should be considered an alternative to these techniques where sufficient expertise exists.

[Percutaneous transhepatic biliary drainage in obstructive jaundice. Report of 19 cases (author's transl)].

The development of percutaneous transhepatic techniques of access to biliary tree with the fine needle made possible the wide diffusion of percutaneous biliary drainage. Results of 19 attempts of biliary drainage are presented; success rate in positioning external or external-internal drainage was 79% (92.3% in the last year). The technique employed is described and discussed comparing it with the methods proposed by other authors. Early therapeutic effects and long-term benefits on bilirubin levels and survival were good. Only 2 major complications were observed (hepatic abscess and biliary subcapsular cyst) but they did not require surgery. Cholangiocarcinomas and ilar hepatic metastases appeared to be elective indications to definitive palliative drainage, but pre-surgical or palliative drainage is also recommended in all cases of obstructive jaundice. Careful follow-up and check of patients with the biliary drainage improves the drainage function and reduces the complications.

[Interventional radiology in the palliative treatment of pancreatic cancer].

Pancreatic carcinoma often involves the head of the pancreas and obstructive jaundice is its earliest sign. It sometimes extends to celiac plexus and duodenum causing pain and bowel obstruction respectively. Only 20% of cases are totally resectable (stage I) at the time of diagnosis. Palliative treatment is the only available therapeutic option when the tumor extends surrounding organs or has given lymphatic metastases (stage II, III, IV). The aim of this study is to evaluate effectiveness of interventional radiology procedures on unresectable cancer palliative treatment. Between Jan 90 and Sep 98, 195 patients with unresectable pancreatic carcinoma received percutaneous treatments. They were 104 males and 91 females with mean age of 74 years (range, 48-95). One hundred eighty four patients underwent biliary drainage, six patients underwent celiac plexus block, two patients were treated by bowel stenting. Two patients received both biliary and bowel stents, one patient underwent biliary drainage and celiac plexus block. Jaundice treatment was performed by placement of drainage catheters in 48 patients, polymeric endoprostheses in 58 and metallic stents in 77 (67 Wallstents). Biliary drainage was successful in all cases obtaining appreciable bilirubin serum levels reduction and jaundice regression in 175 patients (95%). In 44 patients Wallstents were placed during a single PTC session time ("one step" technique). In 21 cases (11%) peri-procedural complications occurred. Follow-up related to 85 patients shows survival rate covered between 30 and 570 days (mean, 142). Best survival values occurred in patients who underwent "one step" technique. Celiac plexus block was successful in 5/7 cases (71%) with no complications, total pain relief and withdrawal of pharmacological treatment. Bowel stenting achieved complete recanalization of intestinal loop in 2 cases but showed troubles related to management of these patients. In patients with unresectable pancreatic carcinoma palliation is the only therapeutic option and has the purpose to achieve biliary tree decompression and eliminate jaundice associated symptoms, improving quality of life and reducing hospitalization. Jaundice relief is reachable by surgical, endoscopic or percutaneous approach. Surgical palliation is characterized by disadvantageous cost-effectiveness rate. Endoscopic and percutaneous palliations are alternative, although, in selected patients, percutaneous Wallstents placement by one step technique is perhaps the most successful procedure, showing high rate of technical outcome with low complications and short time spent in hospital. Celiac plexus block under CT guidance constitutes a reliable method for management of pain. At present bowel stricture treatment is surgical.

Percutaneous transhepatic cholangiography

Cholangiography during a biliary drainage intervention is called perioperative or primary choloangiography, and when performed later in the same drain it is called secondary cholangiography. Indications Cholestatic jaundice, to exclude extra hepatic bile duct obstruction, prior to biliary drainage procedure. If endoscopic retrograde cholangiopancreatography has failed and/or there is an obstruction in the proximal biliary tree. Contraindications Bleeding tendency Biliary tract sepsis Being unfit for surgery Hydatid cysts Ascites CLD (Chronic liver disease)

Technique It is predominantly now performed as a therapeutic technique. There are less invasive means of imaging the biliary tree including transabdominal ultrasound, magnetic resonance cholangiopancreatography, computed tomography and endoscopic ultrasound. If the biliary system is obstructed, percutaneous transhepatic cholangiography may be used to perform biliary drainage until a more permanent solution for the obstruction is performed (e.g. surgery). Additionally, self expanding metal stents can be placed across malignant biliary strictures to allow palliative drainage. Percutaneous placement of metal stents can be utilised when therapeutic endoscopic retrograde cholangiopancreatography has been unsuccessful, anatomy is altered precluding endoscopic access to the duodenum, or where there has been separation of the segmental biliary drainage of the liver, allowing more selective placement of metal stents.

Percutaneous transhepatic cholangiography, percutaneous hepatic cholangiogram, or percutaneous transhepatic cholangiography and drainage is a radiological technique used to visualize the anatomy of the biliary tract. A contrast medium is injected into a bile duct in the liver, after which X-rays are taken. It allows access to the biliary tree in cases where endoscopic retrograde cholangiopancreatography has been unsuccessful. Initially reported in 1937, the procedure became popular in 1952.

[Palliative surgical and endoscopic therapy of malignant bile duct occlusion].

Cholestatic jaundice is the result of a malignancy of the bile duct itself, of the gallbladder, of the ampulla or (as in most cases) of the pancreas. Patients without evidence of metastases or other signs of advanced cancer (e.g. ascites) are candidates for explorative laparotomy. In the vast majority of cases resection of a tumor is not feasible and the surgeon is faced with the objective of providing palliation. To date there exists not only one palliative procedure, and the surgeon has to take into account the following: In patients with pancreatic cancer palliation can be given with biliary bypass with or without gastroenterostomy. This carries an operative mortality of almost 20% and means a survival of only 5-6 months. Nonsurgical procedures as transpapillary stenting play an increasing role in the management of patients with obstructive jaundice due to pancreatic cancer. In some cases however resectable tumors perhaps will be overlooked. The results of controlled studies comparing endoscopic stenting and surgical bypass are encouraging for stenting techniques (lower morbidity and mortality (< 10%), technical success rates exceeding 90%). The availability of different palliative treatment modalities for carcinoma of the bile ducts suggests that no approach is definitely superior. Operative biliary-enteric anastomosis gives a tolerable operative mortality rate in younger patients, less morbidity, than external biliary drainage by better quality of life of the patients. In retrograde placement of prosthetic stents, in patients with high bile duct obstruction difficulties are frequently. In such cases the percutaneous drainage should be reserved for endoscopic failures, in cases the endoscopic and percutaneous approaches can be combined in the 'rendezvous' procedure. In recent years several reports have advocated extensive surgery for biliary neoplasms. Preoperative staging of these patients remains an issue as none of the commonly modalities are accurate in predicting resectability.

ICD-9-CM Volume 3

() Repair of liver () Other operations on liver () Operations on gallbladder and biliary tract () Cholecystotomy and cholecystostomy () Diagnostic procedures on biliary tract () Endoscopic retrograde cholangiopancreatography (ERCP) () Cholecystectomy () Anastomosis of gallbladder or bile duct () Incision of bile duct for relief of obstruction () Other incision of bile duct () Local excision or destruction of lesion or tissue of biliary ducts and sphincter of Oddi () Repair of bile ducts () Other operations on biliary ducts and sphincter of Oddi () Other operations on biliary tract () Operations on pancreas () Pancreatotomy () Diagnostic procedures on pancreas () Local excision or destruction of pancreas and pancreatic duct () Marsupialization of pancreatic cyst () Internal drainage of pancreatic cyst () Partial pancreatectomy () Total pancreatectomy () Radical pancreaticoduodenectomy () Transplant of pancreas () Other operations on pancreas

InternalMed_Harrison

Tissue Diagnosis and Cytology Preoperative confirmation of malignancy is not always necessary in patients with radiologic appearances consistent with operable pancreatic cancer. However, EUS-guided fine-needle aspiration is the technique of choice when there is any doubt, and also for use in patients who require neoadjuvant treatment. It has an accuracy of approximately 90% and has a smaller risk of intraperitoneal dissemination compared with the percutaneous route. FIGURE 112-1 Coronal computed tomography showing pancre-atic cancer and dilated intrahepatic and pancreatic ducts (arrows). showing contrast in dilated pancreatic duct (arrows). Percutaneous biopsy of the pancreatic primary or liver metastases is only acceptable in patients with inoperable or metastatic disease. ERCP is a useful method for obtaining ductal brushings, but the sensitivity of ERCP for diagnosis ranges from 35 to 70%.

Endoscopic sphincterotomy in the management of posttraumatic biliary fistula.

Complications after nonoperative management of hepatic trauma are rare but include persistent biliary fistula in 4% of cases. Therapy usually involves surgical drainage or hepatic resection to control the fistula. The authors present a case of hepatic biliary fistula treated nonoperatively with percutaneous drainage and endoscopic sphincterotomy. A 16-year-old girl suffered a grade III parenchymal liver fracture to the right lobe in an automobile accident. She was hemodynamically stable with no coexistent injuries and was treated nonoperatively. Over 2 weeks her total bilirubin rose to 3.2 mg/dL, and alkaline phosphatase was 463 U/L. Ultrasound showed free intraperitoneal fluid, and 2 L of bilious fluid were retrieved by paracentesis. A radionuclide scan confirmed massive extravasation of isotope from the right lobe. Two drains percutaneously placed over the parenchymal fracture produced 500 to 600 mL of bile daily. Endoscopic retrograde cholangiopancreatography (ERCP) 1 week later showed a normal extrahepatic biliary system. A 1-cm sphincterotomy was performed without difficulty. Within 72 hours, percutaneous drains produced only 35 mL per day. The follow-up radionuclide scan showed no evidence of extrahepatic biliary extravasation, and 3 weeks later the drains were removed. Six months after the accident, results of the computerized tomography scan and liver function tests were normal. It was believed that endoscopic sphincterotomy reduced fistula output by decreasing the intrabiliary pressure caused by the ampulla, thus favoring internal drainage. This case demonstrates the effectiveness of endoscopic sphincterotomy as an alternative to direct surgical intervention for the management of posttraumatic biliary fistula.

Recent advances regarding endoscopic biliary drainage for unresectable malignant hilar biliary obstruction.

Biliary drainage for unresectable malignant hilar biliary obstruction (UMHBO) is still associated with a number of controversies to be resolved. The superiority of bilateral drainage in comparison to unilateral drainage has not been proven obviously yet. However, bilateral drainage is necessary to treat obstructive jaundice in some UMHBO patients, and this may be connected with preservation of the functional liver volume. The partial stent-in-stent (SIS) method and side-by-side (SBS) method developed as bilateral drainage methods. There is no significant difference in the technical or clinical success rates of the SIS and SBS methods. In addition, these methods are comparable in terms of adverse events, patency period, and survival period. On the other hand, reintervention for recurrent biliary obstruction (RBO) after the SBS method seems to be easier in comparison to cases with RBO after the SIS method; however, there is no remarkable difference in the clinical results of these procedures. Endoscopic ultrasound (EUS)-guided biliary drainage also has become an option for patients with UMHBO. Left hepatic drainage using EUS-guided hepaticogastrostomy (EUS-HGS) has become common; however, few studies have reported the results of bridging drainage for the right lobe using the EUS-HGS route or EUS-guided hepaticojejunostomy. A few studies addressed the results of newly designed stents, such as the 6-mm braided metal stent and inside stent. The development of various drainage methods and new devices is necessary for the further advancement of endoscopic biliary drainage for patients with UMHBO, further studies to evaluate those methods and devices are warranted.

Endoscopic ultrasound-guided hepaticogastrostomy for advanced cholangiocarcinoma after failed stenting by endoscopic retrograde cholangiopancreatography.

Cholangiocarcinoma is common in Thailand. There are many palliative treatments available for patients with unresectable tumor, such as endoscopic retrograde cholangiopancreatography (ERCP) with stents, percutaneous transhepatic biliary drainage, or surgery. In cases in which ERCP has failed, we propose an alternative technique: the use of endoscopic ultrasound with fluoroscopy to perform hepaticogastrostomy for palliative drainage instead of percutaneous transhepatic biliary drainage. A case series study was conducted between December 2005 and December 2009 of 10 patients (4 male and 6 female, average age: 57 years) who presented with severe jaundice caused by advanced cholangiocarcinoma, who were treated with this procedure after failure to drain by ERCP. We used an electronic convex curved linear-array fluoroscopy-guided echoendoscope to drain the left dilated intrahepatic duct to the stomach by metallic wallstent. We performed the procedure with the first six patients under general anesthesia and with the other four under conscious sedation. Follow-up liver function tests were done, and clinical symptoms and survival times were recorded. Hepaticogastrostomy was unsuccessful on the first two patients (success rate = 8/10; 80%), and effective drainage was obtained in only seven patients. Average total bilirubin reduction was 14.96 mg/dL (58.75%) and 18.13 mg/dL (71.20%) after 2 weeks and 4 weeks, respectively, with good quality of life. One patient was not effectively drained because of malposition of the stent. There were two patients whose stent migrated into the stomach; one needed a second session with a second wallstent, and the other needed a double pigtail stent inside the second wallstent. Follow-up survival rates were 32-194 days (average: 123 days). Endoscopic-ultrasound-guided hepaticogastrostomy is safe and can be a good palliative option for advanced malignant biliary obstruction because it drains internally and is remote from the tumor site, promoting a long patency period of prosthesis and better quality of life.

Outcomes and limitations of endoscopic ultrasound-guided hepaticogastrostomy in malignant biliary obstruction.

Transpapillary biliary drainage in ERCP is an established method for symptomatic treatment of patients with unresectable malignant biliary obstruction. Percutaneous transhepatic biliary drainage frequently remains the treatment of choice when the transpapillary approach proves ineffective. Recently, EUS-guided extra-anatomical anastomoses of bile ducts to the gastrointestinal tract have been reported as an alternative to percutaneous biliary drainage. To assess the usefulness of extra-anatomical intrahepatic biliary duct anastomoses to the gastrointestinal tract as endotherapy for unresectable malignant biliary obstruction and to determine factors affecting the efficacy of treatment. A prospective analysis of the treatment results of all patients with unresectable biliary obstruction treated with EUS-guided hepaticogastrostomy at our institution in the years 2016-2019. Transmural intrahepatic biliary drainage (EUS-guided hepaticogastrostomy) was performed due to the ineffectiveness of ERCP in 53 patients (38 males, 15 females; mean age 74.66 [56-89] years) with unresectable biliary obstruction. Technical success of EUS-guided hepaticogastrostomy was achieved in 52/53 (98.11%) patients. Complications of endoscopic treatment were observed in 10/53 (18.87%) patients. Clinical success of EUS-guided hepaticogastrostomy was achieved in 46/53 (86.79%) patients. Bismuth type II-IV cholangiocarcinoma, hepatic metastases, ascites, suppurative cholangitis, and high blood bilirubin levels exceeding 30 mg/dL were independent factors for increased complications and inefficacy of EUS-guided hepaticogastrostomy. In the event of transpapillary biliary drainage proving ineffective, extra-anatomical anastomoses of intrahepatic bile ducts to the gastrointestinal tract provide an effective method for the treatment of patients with malignant biliary obstruction.

Indirect biliary drainage as an alternative solution for biloma due to complicated biliary drainage.

Pancreas cancer has increased morbidity and mortality. It generally result in biliary obstruction which life threatening importance. Main biliary drainage method is endoscopic retrograde cholangiopancreatography. When endoscopic retrograde cholangiopancreatography is not successful, second preferred method is percutaneous biliary drainage. Percutaneous biliary drainage has some complications which is an invasive procedure. A complication of percutaneous biliary drainage due to patient iatrogenity which was not ever reported in the literature biliary drainage according to our literature research. In these circumstances an alternative solution is indirect biliary drainage.

[Obstruction icterus--our experience].

The most common causes of extrahepatic obstruction are choledocholithiasis, malignant and benign stenosis of biliary ducts, pancreatic head carcinoma, and chronic cephalic pancreatitis. Differentiation between hepatocellular icterus with intrahepatic obstruction and extrahepatic mechanical obstruction is of utmost importance. Differential diagnosis usually includes a combination of clinical examination, biochemical testing, ultrasonography, endoscopic retrograde cholangiopancreatography (ERCP), transhepatic cholangiography, computed tomography (CT), nuclear magnetic resonance (NMR) and endoscopic ultrasonography (EUS). Choledocholithiasis mostly develops due to concrement migration from the gallbladder. The treatment of choice is operative therapy by either conventional method with laparotomy or endoscopic concrement extraction, the latter being preferred in case of residual concrements. Malignant stenoses of extrahepatic ducts can involve any segment of the biliary ducts or the gallbladder. The main symptom is so-called painless icterus. The condition is treated surgically by radical (various types of resection) or palliative (biliodigestive anastomoses) methods. Intraoperative lesion occurring on biliary duct procedures is generally involved in the etiology of benign stenoses of extrahepatic biliary ducts. The treatment is surgical and consists of the creation of hepaticojejunal anastomosis. The study included 151 patients admitted during a 5-year period (1999-2003) to Department of Surgery, Zabok General Hospital. Icterus was caused by choledocholithiasis in 112, carcinoma of extrahepatic biliary ducts in seven, carcinoma of the gallbladder in five, and carcinoma of the head of pancreas in 18 patients. Cephalic pancreatitis, malposition of a clamp placed during laparoscopic procedure, postoperative choledochus stricture, stricture of choledochoduodenal anastomosis and multiple cystic liver disease caused icterus in nine patients. In 106 choledocholithiasis patients, the concrement was removed by choledocholithotomy; duodenotomy and papillotomy in addition to choledochotomy were required in four patients; and creation of biliodigestive anastomosis was needed in two patients due to impossible concrement removal. Biliodigestive anastomosis was created in another 20 patients with the findings of inoperable tumor of the head of pancreas, inoperable tumor of the papilla of Vater, postoperative choledochus stenosis, stenosis of choledochoduodenal anastomosis, and chronic cephalic pancreatitis. Cephalic duodenopancreatectomy was performed in two patients, whereas other methods consistent with the etiologic substrate were employed in 17 patients. The following complications were observed in 151 patients operated on: T drain fall off (n = 2), lesion of retroduodenal choledochus (n = 1), and loosening of the cholecystojejunal anastomosis suture line (n = 1). The hospital mortality rate was 3.31% (n = 5). Impairment in the biliary duodenal drainage is an etiologic factor in the development of obstructive icterus. It is of utmost importance to differentiate hepatocellular icterus with intrahepatic obstruction from extrahepatic mechanical obstruction. The treatment depends on the etiologic factor involved. Operative treatment can be fully successful in cases caused by lithiasis or benign stenosis, whereas in cases due to malignant disease a variety of radical and operative procedures associated with a variable level of success are available. Mechanical obstructive icterus of extrahepatic biliary ducts ranks high in the morbidity and mortality in the Krapina--Zagorje County. Timely diagnosis, well planned and properly performed operative procedures could considerably improve the results achieved by the operative treatment of the disease.

[Extrahepatic biloma secondary to choledocholithiasis].

We present a case of extrahepatic biloma in a patient who was an emergency admission to the hospital and had a clinical pattern of obstructive jaundice secondary to choledocholithiasis. The diagnosis was made by echography and needle aspiration (PAAF). Due to the unfavorable evolution of the patient in the 48 hours after admission, she underwent surgery, which confirmed the diagnosis. Cholecystectomy was performed, with removal of the choledochal gallstone and side-to-side choledochoduodenostomy, and the postoperative evolution was satisfactory. We review the pathophysiologic characteristics of this entity and its etiology, symptomatology, diagnosis and treatment.

Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction.

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary biliary drainage method whenever possible. Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method if ERCP fails. Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method where one of the methods is EUS guided Hepaticogastrostomy (EUS-HGS). Here we describe the EUS-HGS technique in a case of unresectable malignant hilar biliary obstruction to achieve biliary drainage. Presented here is the case of a 71-year-old female with painless jaundice and weight loss for 2 weeks. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor with lymphadenopathy and liver metastasis. EUS fine needle biopsy (FNB) of the lesion was consistent with cholangiocarcinoma. Her bilirubin levels were 212 µmol/L (<15) during presentation. A linear echoendoscope was used to locate the left dilated intrahepatic ducts (IHD) of the liver. The segment 3 dilated IHD was identified and punctured using a 19 G needle. Contrast was used to opacify the IHDs under fluoroscopic guidance. The IHD was cannulated using a 0.025-inch guidewire. This was followed by the dilation of the fistula tract using a 6 Fr electrocautery dilator along with a 4 mm biliary balloon dilator. A partially covered metallic stent of 10 cm in length was deployed under fluoroscopic guidance. The distal part opens in the IHD and the proximal part was deployed within the working channel of the echoendoscope that subsequently released into the stomach. The patient was discharged three days after the procedure. Follow up performed in the second and fourth weeks showed that the bilirubin levels were 30 µmol/L and 14 µmol/L, respectively. This indicates that EUS-HGS is a safe method for biliary drainage in unresectable malignant biliary obstruction.

Feasibility of endoscopic ultrasound-guided hepaticogastrostomy using a 22-gauge needle.

This study aimed to evaluate the feasibility of performing endoscopic ultrasound-guided hepaticogastrostomy using a 22-gauge fine-needle aspiration needle. This was a single-center retrospective study. Fourteen patients who underwent endoscopic ultrasound-guided hepaticogastrostomy with a 22-gauge fine-needle aspiration needle were examined. Fourteen eligible patients were included in this study. The age of patients ranged from 55 to 93 years, with a median of 76 years. Of patients with existing underlying diseases, there were 8 cases of pancreatic cancer (57.1%), 2 cases of metastatic liver tumor (14.3%), 2 cases of bile duct stones (14.3%), 1 case of hilar cholangiocarcinoma (7.1%), and 1 case of gallbladder cancer (7.1%). Regarding gastrointestinal anatomy, there were 11 cases (78.6%) of normal and 3 cases (21.4%) of gastric resection with Roux-en-Y. Reasons for endoscopic ultrasound-guided hepaticogastrostomy were duodenal obstruction in 7 cases (50.0%), surgically altered anatomy in 3 cases (21.4%), and 4 cases (28.6%) of failed endoscopic retrograde cholangiopancreatography. Technical success was achieved in 11 cases (78.6%). Subsequently, 11 cases of technical success were analyzed. There were 5 cases of puncturing B2 (45.5%). The puncture bile duct diameter ranged from 3.1 to 5.7 mm, with a median of 4.4 mm. endoscopic ultrasound-guided antegrade procedures was combined with endoscopic ultrasound-guided hepaticogastrostomy in 2 cases (18.2%). Clinical success was achieved in all the cases. The procedure time ranged from 15 to 93 minutes, with a median duration of 35 minutes. Regarding the type of stent placed in hepaticogastrostomy, a plastic stent was placed in 10 cases (90.9%) and a metal stent was placed in 1 case (9.1%). Early adverse events occurred in 4 cases (36.4%), and all of these cases developed biliary peritonitis, late adverse events occurred in 1 case (9.1%), this was biloma. A change to a 0.025-inch guidewire during the procedure was required in 8 cases (72.7%). Esophageal puncture was not performed. endoscopic ultrasound-guided hepaticogastrostomy using a 22-gauge fine-needle aspiration needle is effective. However, in 72.7% of the cases started using the 0.018-inch guidewire, the guidewire was exchanged for a 0.025-inch guidewire during procedure.

Extrahepatic biliary stenoses after hepatic arterial infusion (HAI) of floxuridine (FUdR) for liver metastases from colorectal cancer.

Hepatic arterial infusion of floxuridine is an effective treatment for unresectable hepatic metastases from colorectal cancer. Despite its pharmacological advantage of higher tumor drug concentration with minimal systemic toxicity, hepatic arterial infusion of floxuridine is characterized by regional toxicity, including hepatobiliary damage resembling idiopathic sclerosing cholangitis (5-29% of treated cases). Unlike previous reports describing biliary damage of both intrahepatic and extrahepatic ducts, a case series of extrahepatic biliary stenosis after hepatic arterial infusion with floxuridine is herein described. Between September 1993 and February 1999, 54 patients received intraarterial hepatic chemotherapy based on continuous infusion of floxuridine (dose escalation 0.15-0.30 mg/kg/day for 14 days every 28 days) plus dexamethasone 28 mg. Twenty-seven patients underwent laparotomy to implant the catheter into the hepatic artery, the other 27 patients receiving a percutaneous catheter into the hepatic artery through a transaxillary access. Five patients (9.2%) developed biliary toxicity with jaundice and cholangitis (3 cases), alterations of liver function tests and radiological features of biliary tract abnormalities. They received from 9 to 19 cycles (mean 14.5 +/- 6.3 cycles) of floxuridine infusion with a total drug delivered dose ranging from 20.3 to 41.02 mg/kg (mean: 31.4 +/- 13.5 mg/kg). Extrahepatic biliary sclerosis was discovered by computed tomography scan and ultrasound, followed by endoscopic retrograde cholangiopancreatography and/or percutaneous cholangiography in 3 cases. Radiological findings included common hepatic duct complete obstruction in 1 case, common hepatic duct stenosis in 2 cases, common bile duct obstruction in 1 case, and intrahepatic bile ducts dilation without a well-recognized obstruction in 1 case. Two patients were treated by sequentially percutaneous biliary drainage and balloon dilation while 1 patient had an endoscopic transpapillary biliary prosthesis placed. Percutaneous or endoscopic procedures obtained the improvement of hepatic function and cholestatic indexes without subsequent jaundice or cholangitis. In two patients suppression of floxuridine infusion allowed the improvement of hepatic function. The present series suggests that in some patients receiving hepatic arterial infusion of floxuridine extrahepatic biliary stenosis may represent the primary event leading to a secondary intrahepatic biliary damage that does not correlate with specific floxuridine toxicity but results from bile stasis and infection, recurrent cholangitis and eventually biliary sclerosis. Aggressive research for extrahepatic biliary sclerosis is advised, since an early nonsurgical treatment of extrahepatic biliary stenosis may prevent an irreversible intrahepatic biliary sclerosis worsening the prognosis of metastatic liver disease.

[Role of interventional radiography in the treatment of the hepato-pancreato-duodenal area, complicated by obstructive jaundice].

We assessed the role of interventional radiological procedures used in the treatment of patients with hepatopancreatobiliary cancer complicated by obstructive jaundice. Between 1990 and 2000, 71 patients underwent percutaneous transhepatic biliary drainage (PTBD): external drainage--18 (group A); external-internal drainage or stenting (group B), and external-internal drainage or stenting plus chemoinfusion or chemoembolization of the hepatic artery--15 (group C). Mean survival (M(SD) calculated for patients who died was 2.1(0.5 mo for group A; (pb,c(0.01), 7.9(6.7 mo (group B), and 16.6(14.8 mo for group C (NS with B). The actual one-year survival was 10, 25, and 45%, respectively. External-internal PTBD and stenting are safe effective palliative procedures for patients with malignant obstructive jaundice. Survival in patients with hepatopancreatobiliary cancer doubled after chemoinfusion or chemoembolization, without grave complications or lethality.

Non-surgical and non-chemical attempts to treat echinococcosis: do they work?

Cystic echinococcosis (CE) and alveolar echinococcosis (AE) are chronic, complex and neglected diseases. Their treatment depends on a number of factors related to the lesion, setting and patient. We performed a literature review of curative or palliative non-surgical, non-chemical interventions in CE and AE. In CE, some of these techniques, like radiofrequency thermal ablation (RFA), were shelved after initial attempts, while others, such as High-Intensity Focused Ultrasound, appear promising but are still in a pre-clinical phase. In AE, RFA has never been tested, however, radiotherapy or heavy-ion therapies have been attempted in experimental models. Still, application to humans is questionable. In CE, although prospective clinical studies are still lacking, therapeutic, non-surgical drainage techniques, such as PAIR (puncture, aspiration, injection, re-aspiration) and its derivatives, are now considered a useful option in selected cases. Finally, palliative, non-surgical drainage techniques such as US- or CT-guided percutaneous biliary drainage, centro-parasitic abscesses drainage, or vascular stenting were performed successfully. Recently, endoscopic retrograde cholangiopancreatography (ERCP)-associated techniques have become increasingly used to manage biliary fistulas in CE and biliary obstructions in AE. Development of pre-clinical animal models would allow testing for AE techniques developed for other indications, e.g. cancer. Prospective trials are required to determine the best use of PAIR, and associated procedures, and the indications and techniques of palliative drainage.

[The surgical treatment of carcinoma of the extrahepatic bile ducts].

The authors have carried out a retrospective analysis of 157 patients with Ca in the extrahepatic biliary system, treated at the Clinic for Hepato-Biliary and Pancreatic Surgery within the period 1982-1992. From them 68 patients (43.31%) were with Ca in vesicule biliary and with Ca in the biliary tracts--89 patients (56.69%). The ratio men:women was respectively 1:4.67 and 1.12:1. The medium age of the patients was 63.08 years. In the group of the patients with Ca in biliary tracts the carcinoma was located in the upper third in 20.22% of the cases, in the middle third--in 24.72%, in the distal third--in 55.06%. Radical operations were made in 31.46% of the patients, with lethality 28.57%, whereas the postoperative lethality of the patients with duodeno-hemipancreatectomy was 6.67%, and the average postoperative survival was 32 months. The palliative operated patients constituted 65.17% in the general series, with lethality 15.52% and average postoperative survival 10.4 months. The explorative laparatomies constitute 3.37% from the operated patients. The total operative lethality was 19.1%. In the article the authors discussed the diagnostical methods, stated the preference for echography, computer axial tomography and retrograde cholangio-pancreatography in the mentioned sequence. The endoscopic procedures were discussed as and alternative for the non-resectable carcinomas of the biliary tracts.

Palliative Measures with Ethanol Gallbladder Ablation and Endobiliary Radiofrequency Ablation Followed by Endoscopic Biliary Stent Placement in an Advanced Case of Common Bile Duct Cancer: A Case Report.

Endobiliary radiofrequency ablation (RFA) is a procedure performed widely to induce locoregional tumor control by the transfer of thermal energy to the lesion and subsequent tumor necrosis. A 72-year-old male with a prior history of acute calculous cholangitis and perforated cholecystitis was admitted to the Kyungpook National University Hospital complaining of fever and nausea. He had an indwelling percutaneous transhepatic gallbladder drainage (PTGBD) catheter from the previous episode of perforated cholecystitis. An abdominal CT scan showed marked dilation of both the intrahepatic and extrahepatic bile ducts. Common bile duct cancer was confirmed histologically after an endobiliary biopsy. A surgical resection was considered to be the initial treatment option. During open surgery, multiple metastatic nodules were present in the small bowel mesentery and anterior abdominal wall. Resection of the tumor was not feasible, so endobiliary RFA was performed prior to biliary stenting. Cholecystectomy was required for the removal of the PTGBD catheter, but the surgical procedure could not be performed due to a cystic ductal invasion of the tumor. Instead, chemical ablation of the gallbladder (GB) with pure ethanol was performed to breakdown the GB mucosa. Palliative treatment for a biliary obstruction was achieved successfully using these procedures. In addition, a PTGBD catheter was removed successfully without significant side effects. As a result, an improvement in the patient's quality of life was accomplished.

InternalMed_Harrison

Endoscopic ultrasonography (EUS) produces high-resolution images of the pancreatic parenchyma and pancreatic duct with a transducer fixed to an endoscope that can be directed onto the surface of the pancreas through the stomach or duodenum. EUS and MRCP have largely replaced ERCP for diagnostic purposes in many centers. EUS allows one to obtain information about the pancreatic duct as well as the parenchyma and has few procedure-related complications associated with it, in contrast to the 5–10% of post-ERCP pancreatitis observed. EUS is also helpful in detecting common bile duct stones in acute pancreatitis. Pancreatic masses can also be biopsied via EUS in cases with suspected pancreas cancer, and one can deliver nerve-blocking agents through EUS fine-needle injection in patients suffering from pancreatic pain from chronic pancreatitis or cancer. EUS has been studied as a diagnostic modality for chronic pancreatitis. Criteria for abnormalities on EUS in severe chronic pancreatic

Ascending cholangitis

Percutaneous biliary drainage In cases where a person is too ill to tolerate endoscopy or when a retrograde endoscopic approach fails to access the obstruction, a percutaneous transhepatic cholangiogram (PTC) may be performed to evaluate the biliary system for placement of a percutaneous biliary drain (PBD). This is often necessary in the case of a proximal stricture or a bilioenteric anastomosis (a surgical connection between the bile duct and small bowel, such as the duodenum or jejunum). Once access across the stricture is obtained, balloon dilation can be performed and stones can be swept forward into the duodenum. Due to potential complications of percutaneous biliary drain placement and the necessity of regular drain maintenance, a retrograde approach via ERCP remains first-line therapy.

Autoimmune pancreatitis or pancreatic cancer? A dilemma in a pregnant woman.

Autoimmune pancreatitis is now a defined entity and it could mimic a pancreatic malignancy. True oncological emergencies in pregnant patients are rare. A 39 years-old pregnant woman was admitted to our emergency unit due to right upper quadrant abdominal pain and evidence of obstructive jaundice. Since computed tomography-scan and endoscopic retrograde cholangiopancreatography are contraindicated in pregnant woman, a cholangio-Nuclear Magnetic Resonance was performed, confirming the biliary tract dilatation with stenosis of the intrapancreatic portion of the common bile duct and a shaded image of a mass in the pancreatic head. An endoscopic ultrasound with fine needle aspiration biopsy were performed. US-guided external percutaneous trans-hepatic biliary drainage was successfully performed. The cytological examination showed the presence of erythrocytes, granulocytes, histiocytes and rare lymphocytes; a diagnosis of AIP was supposed, and steroid therapy with metilprednisolone was started. Laboratory tests and jaundice were normalized within 15 days, and the fetus was born in very good health, 22 weeks after. The follow-up was uneventful and a CT-scan confirmed the complete normalization of the pancreatic gland, 12 months after hospital discharge. Autoimmune pancreatitis should be taken into account in the differential diagnosis of a not well defined pancreatic mass; in the event of pancreatic mass-forming disease in pregnancy, the differential diagnosis should be early and accurate, because destructive surgery involves an high rate of morbidity and may interrupt pregnancy. A US-guided FNAB and the response to the corticosteroid therapy should lead to a correct diagnosis.

Percutaneous transhepatic biliary drainage may be the preferred preoperative drainage method in hilar cholangiocarcinoma.

<bBackground and study aims</b  Preoperative biliary drainage of hilar cholangiocarcinoma (HC) is controversial. The goal of this study was to compare the clinical outcome and associated complications for types II, III, and IV HC managed by percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP). <bPatients and methods</b  Between January 2011 and June 2017, a total of 180 patients with II, III, and IV HC were enrolled in this retrospective cohort study. According to the drainage method, patients were divided into two groups: PTBD (n = 81) and ERCP (n = 99). This study was registered with ClinicalTrials.gov, NCT03104582, and was completed. <bResults</b  Compared with the PTBD group, the ERCP group had a higher incidence of post-procedural cholangitis (37 [37.37 %] vs. 18 [22.22 %], <iP</i  = 0.028) and pancreatitis (17 [17.17 %] vs. 2 [2.47 %], <iP</i  = 0.001); required more salvaged biliary drainage (18 [18.18 %] vs. 5 [6.17 %], <iP</i  = 0.029), and incurred a higher cost ( <iP</i  < 0.05). Patients with type III and IV HC in the ERCP group had more cholangitis than those in the PTBD group (26 [36.62 %] vs. 11 [18.03 %], <iP</i  = 0.018). The rate of cholangitis in patients who received endoscopic bilateral biliary stents insertion was higher than patients with unilateral stenting (23 [50.00 %] vs. 9 [26.47 %], <iP</i  = 0.034), and underwent PTBD internal-external drainage had a higher incidence of cholangitis than those with only external drainage (11 [34.36 %] vs. 7 [14.29 %], <iP</i  = 0.034). No significant difference in the rate of cholangitis was observed between the endoscopic unilateral stenting group and the endoscopic nasobiliary drainage group (9 [26.47 %] vs. 5 [26.32 %], <iP</i  = 0.990). <bConclusion</b  Compared to ERCP, PTBD reduced the rate of cholangitis, pancreatitis, salvage biliary drainage, and decreased hospitalization costs in patients with types II, III, and IV HC. Risk of cholangitis for patients with types III and IV was significantly lower in the PTBD group.

Endoscopic ultrasound-guided hepaticogastrostomy for hilar cholangiocarcinoma: the first trial in Thailand.

There are many palliative treatments for patients with unresectable malignant biliary obstruction, e.g. endoscopic retrograde cholangiopancreatography (ERCP) with stents, percutaneous transhepatic biliary drainage (PTBD) or surgery. We propose a new technique by using endoscopic ultrasound (EUS) with fluoroscopy to perform hepaticogastrostomy for palliative drainage far from the site of tumor to avoid tumor obstruction. Between December 2005 and June 2006, two patients with severe jaundice by hilar cholangiocarcinoma were treated with this new procedure. The first case was a 44-year female post partial resection of tumor and Roux en Y hepaticojejunostomy and the second case was a 48-year male post ERCP and right hepatic stent. We used an electronic convex curved linear-array echo-endoscope with fluoroscope guided to drain left dilated intrahepatic duct to the stomach by inserting 8 Fr 60 mm metallic wallstent via lesser curvature. We performed under general anesthesia and followed-up every two weeks. There were former two patients failed to place the stents. Hepaticogastrotomy of both patients were our first successful trial but stent site of the first case was not good because the insertion was at esophagogastric junction. Total bilirubin of first and second case fell from 38.4 mg/dl to 27.3 mg/dl and 22.0 mg/dl to 3.4 mg/ dl in two weeks, respectively. No immediate complication was found and oral diet was well succeeded on the next day after procedure in both cases. The first case was dead after 32 days of operation from sepsis and hepatic failure. The second case was clinically much improved after 3 months and died from liver failure after 6 months and 10 days. This new interventional EUS-guided hepaticogastrostomy is safe, feasible and may provide an alternative to surgery or PTBD or failed ERCP. It can improve the palliative treatment in hilar lesions because it's internal drainage and far from tumor site that promote fast recovery. However, long term study is still necessary to evaluate the results and cost-effectiveness of this technique.

[Clinical signs, diagnosis and surgical treatment of extrahepatic biliary duct tumors].

Experience of surgical treatment of 271 patients the extrahepatic biliary ducts tumor for the 1992-1999 yrs period is presented. Indirect signs of extrahepatic biliary ducts tumor were revealed in 84% of observations. Depending on the tumor localization the trustworthiness of the endoscopic retrograde pancreatocholangiography method had constituted from 79.8 to 96.4%. Correct diagnosis was established before the operation in 94.3% of patients. Radical operation was done in 93 (34.3%) of patients, including 22 with proximal localization of tumor, 13--with central one, 10--distal, 48--terminal. Palliative operation was performed in 178 patients, in 76 of them biliodigestive anastomosis was done. Total postoperative mortality was 14.8%.

Percutaneous transhepatic cholangiography

Contraindications Bleeding tendency Biliary tract sepsis Being unfit for surgery Hydatid cysts Ascites CLD (Chronic liver disease) Complications Percutaneous transhepatic cholangiography may increase the incidence of metastasis, tube dislocation, and bleeding when compared to endoscopic biliary drainage. However, it has lower rate of cholangitis, pancreatitis when compared to endoscopic biliary drainage, probably because the latter has higher chance of incomplete drainage of infected bile, or accidental resection of papilla that causes the backflow of infected bile from the duodenum into the biliary system. References External links Medline page Projectional radiography Digestive system imaging

Diagnostic challenges and management of choledochal cyst in an 11-year-old child: a delayed diagnosis (a case report).

Choledochal cyst are rare congenital disease of the biliary tree. It presenting as cystic dilatations of the biliary tree can involve the extrahepatic biliary radicles, the intrahepatic biliary radicles or both. They are typically a surgical problem of infancy and childhood, but less than a quarter of the patients the diagnosis is delayed until adulthood as it presenting with vague and nonspecific signs and symptoms. In a case with biliary symptoms, abdominal ultrasound scan is the initial imaging modality of choice. Precise and accurate delineation of the biliary system mandates cholangiography with the advantage of non-invasive magnetic resonance cholangiopancreatography (MRCP) over endoscopic retrograde cholangiopancreatography. A case report of 11-year-old Tanzania girl with abdominal swelling and jaundice presented to a health facility for evaluation. She complained of abdominal swelling that her mother noticed when she was 3 years old, located above the umbilicus and since then it was not changed its size until 8 years later when it rapidly increased in size associated with non-specific dull pain. Abdominal computed tomography (CT) scan was done showed A well-defined hypo-attenuated non-enhancing retro-gastric cyst. Percutaneous transhepatic cholangiopancreatography (PTC) was performed due to inconclusive findings from CT-scan showed extrahepatic huge cystic dilatation, dilated central right hepatic ducts, left intrahepatic ducts failed to be visualize. Diagnosis of choledochal cyst type isovaleric acidaemia (IVA) was made. Explorative laparotomy was done, huge cystic mass occupying common bile duct was seen below the liver with distended gallbladder covered with visceral peritoneum. Second part of duodenum, pancreases and transverse colon was adhered to the inferior surface of the mass that further make difficult for cyst excision and reconstruction. Cyst was decongested and cholangioenterostomy with Roue-en-Y reconstruction was made. Cholecystectomy was done, hemostasis archived abdomen closed and patient sent to Intensive care units (ICU). Despite of advanced diagnostic modalities, delayed diagnosis of choledochal cyst can be a challenge due to its vague and nonspecific signs and symptoms. Excision of the cyst and reconstruction by hepatojejunostomy as the standard therapy could be difficult due to its biliary complications such as adhesion and infection and hence cyst-enterostomy drainage procedure can be done as option for relief of patient discomfort and prevent further complications.

Efficacy of primary drainage by endoscopic ultrasound-guided biliary drainage for unresectable pancreatic adenocarcinoma.

Obstructive jaundice induced by pancreatic adenocarcinoma is typically treated with biliary drainage with endoscopic retrograde cholangiopancreatography (ERCP)-guided biliary drainage (ERCP-BD). Recently, endoscopic ultrasonography-guided biliary drainage (EUS-BD) was employed as an alternative method after ERCP-BD failed. We aimed to determine the efficacy and safety of EUS-BD for primary biliary drainage. Between December 2011 and February 2019, at Kawasaki General Medical Center, we retrospectively enrolled 33 patients who had undergone endoscopic biliary drainage with a metal stent, in a first attempt to relieve obstructive jaundice caused by unresectable pancreatic adenocarcinoma. We compared the technical and clinical outcomes between ERCP-BD and EUS-BD. Twenty-three patients underwent ERCP-BD and 10 underwent EUS-BD. Both groups achieved 100% technical success. The clinical success rates were similar between the groups: 91% (21/23 patients) for ERCP-BD and 100% (10/10 patients) for EUS-BD (<iP</i = 0.48). Biliary obstruction recurred in 6/23 patients (26%) treated with ERCP-BD and 1/10 patients (10%) treated with EUS-BD (<iP</i = 0.40). Other adverse events occurred in 4/23 patients (17%) in the ERCP-BD group and 1/10 patients (10%) in the EUS-BD group (<iP</i = 0.99). We suggest that EUS-BD could be employed for primary biliary drainage in patients with obstructive jaundice caused by unresectable pancreatic adenocarcinoma.


Since the most frequent cause of vaginal bleeding in postmenopausal women is urogenital atrophy, the existence of an endometrial pathology cannot be ruled out. According to the SEGO: "Abnormal genital bleeding is the main sign of suspicion that should lead us to rule out an endometrial neoplastic pathology, particularly in postmenopausal patients, or those with associated risk factors (...) Given the sign of suspicion, the performance of a transvaginal ultrasound, or in its absence transrectal, allows us to: rule out organic pathology (fibroids, polyps); measurement of endometrial thickness in a longitudinal cut. It is recommended to use a cut-off point of 3mm for endometrial biopsy in the symptomatic patient".

A 64-year-old woman. Menopause at 54 years of age. Two pregnancies and eutocic deliveries. She does not take any medication. She comes to the emergency department reporting two days of vaginal bleeding with discomfort in the hypogastrium. The clinical examination performed by the gynecologist does not show any lesions in the external genitalia, vagina or cervix. Vaginal examination is inconclusive. Which of the following seems to you to be the most appropriate first diagnostic approach?

Transvaginal ultrasound and measurement of endometrial thickness. Depending on this, an endometrial biopsy should be taken or not.

Endometrial biopsy by aspiration in consultation. With it I can get the diagnosis very reliably and it is inexpensive.

Hysteroscopy with sedation and directed biopsy if a lesion is seen.

I would perform a microbleed, since it is the test that would provide me with the definitive diagnosis.

Heavy menstrual bleeding

Diagnosis The NICE guidelines states that: "Many women presenting to primary care with symptoms of HMB can be offered treatment without the need for further examination or investigation. However, investigation via a diagnostic technique might be warranted for women for whom history or examination suggests a structural or endometrial pathology or for whom the initial treatment has failed." Diagnosis is largely achieved by obtaining a complete medical history followed by physical exam and vaginal ultrasonography. If need be, laboratory tests or hysteroscopy may be used. The following are a list of diagnostic procedures that medical professionals may use to identify the cause of the abnormal uterine bleeding. Pelvic and rectal examination to ensure that bleeding is not from lower reproductive tract (i.e. vagina, cervix) or rectum Pap smear to rule out cervical neoplasia Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities.

Endometrial biopsy

Transvaginal ultrasonography is generally done before obtaining an endometrial biopsy as it may help in the gynecologic diagnosis, or even make the taking of a biopsy superfluous if the lining is thin. If the endometrial lining is less than 5 mm thick on sonography, it is highly unusual to encounter endometrial cancer. The test is usually done in women over age 35. A more thorough histologic evaluation can be obtained by a dilatation and curettage, which requires anesthesia. Contraindications The procedure is contraindicated in pregnancy. Therefore, women in the reproductive years may need a pregnancy test before a biopsy is taken to assure that the test is not done during a pregnancy. Other contraindications are pelvic inflammatory disease and coagulopathies.

Vaginal bleeding

Diagnostic evaluation The cause of the bleeding can often be discerned on the basis of the bleeding history, physical examination, and other medical tests as appropriate. The physical examination for evaluating vaginal bleeding typically includes visualization of the cervix with a speculum, a bimanual exam, and a rectovaginal exam. These are focused on finding the source of the bleeding and looking for any abnormalities that could cause bleeding. In addition, the abdomen is examined and palpated to ascertain if the bleeding is abdominal in origin. Typically a pregnancy test is performed as well. If bleeding was excessive or prolonged, a CBC may be useful to check for anemia. Abnormal endometrium may have to be investigated by a hysteroscopy with a biopsy or a dilation and curettage.

Endometrial cancer

Transvaginal ultrasound to examine the endometrial thickness in women with postmenopausal bleeding is increasingly being used to aid in the diagnosis of endometrial cancer in the United States. In the United Kingdom, both an endometrial biopsy and a transvaginal ultrasound used in conjunction are the standard of care for diagnosing endometrial cancer. The homogeneity of the tissue visible on transvaginal ultrasound can help to indicate whether the thickness is cancerous. Ultrasound findings alone are not conclusive in cases of endometrial cancer, so another screening method (for example endometrial biopsy) must be used in conjunction. Other imaging studies are of limited use. CT scans are used for preoperative imaging of tumors that appear advanced on physical exam or have a high-risk subtype (at high risk of metastasis). They can also be used to investigate extrapelvic disease. An MRI can be of some use in determining if the cancer has spread to the cervix or if it is an endocervical

Gynecology_Novak

Diagnosis of Postmenopausal Abnormal Bleeding Pelvic examination to detect local lesions and a Pap test to assess cytology are essential first steps in finding the cause of postmenopausal bleeding. Pelvic ultrasonographic examination and, in particular, transvaginal ultrasonography or sonohysterography can suggest the cause of bleeding (250,254). Endometrial sampling, through office biopsy, hysteroscopy, or D&C, is usually considered essential. An endometrial thickness of less than 5 mm measured by transvaginal ultrasonography is unlikely to indicate endometrial cancer, although some authors suggest that the diagnostic accuracy is overestimated and recommend a cutoff of 3 mm (250,255). Management of Postmenopausal Abnormal Bleeding

Postmenopausal bleeding should be referred urgently.

Postmenopausal bleeding is an episode of bleeding 12 months or more after the last menstrual period. It occurs in up to 10% of women aged over 55 years. All women with postmenopausal bleeding should be referred urgently. Endometrial cancer is present in around 10% of patients; most bleeding has a benign cause. The peak incidence for endometrial carcinoma is between 65 and 75 years of age. Causes of postmenopausal bleeding include: endometrial carcinoma; cervical carcinoma; vaginal atrophy; endometrial hyperplasia +/- polyp; cervical polyps; hormone-producing ovarian tumours; haematuria and rectal bleeding. The aim of assessment and investigation of postmenopausal bleeding is to identify a cause and exclude cancer. Assessment should start by taking a detailed history, with identification of risk factors for endometrial cancer, as well as a medication history covering use of HRT, tamoxifen and anticoagulants. Abdominal and pelvic examinations should be carried out to look for masses. Speculum examination should be performed to see if a source of bleeding can be identified, assess atrophic changes in the vagina and look for evidence of cervical malignancy or polyps. Ultrasound scan and endometrial biopsy are complementary. Ultrasound scan can define endometrial thickness and identify structural abnormalities of the uterus, endometrium and ovaries. Endometrial biopsy provides a histological diagnosis. The measurement of endometrial thickness aims to identify which women with postmenopausal bleeding are at significant risk of endometrial cancer. If the examination is normal, the bleeding has stopped and the endometrial thickness is < 5 mm on transvaginal ultrasound scan, no further action need be taken.

Endometrial biopsy

Procedure Generally, an endometrial biopsy follows this process: The patient is asked to lie on the table with her feet in the stirrups for a pelvic examination. She may or may not be given localized anesthesia. A speculum will be inserted into the vagina to spread the walls of the vagina apart to expose the cervix. The cervix will then be cleansed with an antiseptic solution. A tenaculum, a type of forceps, will hold the cervix steady for the biopsy. The biopsy curette will be inserted into the uterine fundus and with a scraping and rotating motion some tissue will be removed. The removed tissue will be placed in formalin or equivalent for preservation. The tissue will be sent to a laboratory, where it will be processed and tested. It will then be read microscopically by a pathologist who will provide a histologic diagnosis.

[Ultrasonographic diagnosis of endometrial disorders: correlation with the histological results in 112 patients].

The diagnosis of endometrial lesions hitherto was mainly made on the basis of histological examination. The objective of this study was the assessment of the diagnostic accuracy of transvaginal ultrasound investigation by comparison with the usual histological investigation, which implies painful endometrial sampling. 112 perimenopausal women with irregular vaginal blood loss were examined by transvaginal ultrasound. Shortly afterwards endometrial sampling was performed by means of aspiration, conventional curettage or hysteroscopically guided biopsies. The group of 112 patients included 11 women who had previously received hormone substitution therapy (10%). The other patients (without previous hormone substitution therapy) were divided into a premenopausal group (n = 47) and a postmenopausal group (n = 54). In case of an endometrial thickness (single layer) of less than 3 mm in postmenopausal patients, no (pre)malignant lesions were found. In the pre- and postmenopausal group, using this cut-off-level two of the five endometrial hyperplasias were ultrasonographically missed. All fourteen endometrial carcinomas in 112 patients were ultrasonographically detected by an endometrial thickness > or = 4 mm. In the postmenopausal group specificity was 73% (16/22) using a cut-off-level of 3 mm, in the premenopausal patients it was only 36% (11/31). Regular echo-density or a clear alignment between endo- and myometrium hardly had any value in the diagnosis of (pre)malignant lesions of the endometrium. If our patients with an endometrial thickness of less than 3 mm would not have had an endometrial curettage, 38 of 112 (34%) endometrial samplings might have been avoided. According to our view, transvaginal endometrial examination can be of distinct value in the detection of (pre)malignant endometrium.

Gynecology_Novak

Symptoms Endometrial carcinoma most often occurs in women in the sixth and seventh decades of life, at an average age of 60 years; 75% of cases occur in women older than 50 years of age. About 90% of women with endometrial carcinoma have vaginal bleeding or discharge as their only presenting symptom. Most women recognize the importance of this symptom and seek medical consultation within 3 months. Some women experience pelvic pressure or discomfort indicative of uterine enlargement or extrauterine disease spread. Bleeding may not have occurred because of cervical stenosis, especially in older patients, and may be associated with hematometra or pyometra, causing a purulent vaginal discharge. This finding is often associated with a poor prognosis (69). Less than 5% of women diagnosed with endometrial cancer are asymptomatic. In the absence of symptoms, endometrial cancer usually is detected as the result of investigation of abnormal Pap test results, discovery of cancer in a uterus

Adenomyosis

Histopathology The diagnosis of adenomyosis is through a pathologist microscopically examining small tissue samples of the uterus. These tissue samples can come from a uterine biopsy or directly following a hysterectomy. Uterine biopsies can be obtained by either a laparoscopic procedure through the abdomen or hysteroscopy through the vagina and cervix. The diagnosis is established when the pathologist finds invading clusters of endometrial tissue within the myometrium. Several diagnostic criterion can be used, but typically they require either the endometrial tissue to have invaded greater than 2% of the myometrium, or a minimum invasion depth between 2.5 and 8mm.

Obstetrics and gynaecology

Colposcopy: If the results of a cervical cancer screening test, such as Pap smear or HPV test, are abnormal this more thorough examination of the cervix and vaginal tissues may be needed. Loop electrical excision procedure (LEEP): a procedure to quickly remove abnormal vaginal tissue within the cervix. A local anesthetic and a solution to enhance the points of removal visually is administered during the process. There is a chance of experiencing watery, pinkish discharge, brownish discharge, and mild cramping. Endometrial biopsy: a procedure that collects a tissue sample from the endometrium lining of the uterus. The sample is tested and checked under a microscope for abnormals cells or indicators of cancer. IUD insertion: an intrauterine device that is T-shaped and is placed in the uterus through the cervix. It is a reversible contraceptive that can be done in a doctor's office.

Endometrial cancer

Dilation and curettage or an endometrial biopsy are used to obtain a tissue sample for histological examination. Endometrial biopsy is the less invasive option, but it may not give conclusive results every time. Hysteroscopy only shows the gross anatomy of the endometrium, which is often not indicative of cancer, and is therefore not used, unless in conjunction with a biopsy. Hysteroscopy can be used to confirm a diagnosis of cancer. New evidence shows that D&C has a higher false negative rate than endometrial biopsy. Before treatment is begun, several other investigations are recommended. These include a chest x-ray, liver function tests, kidney function tests, and a test for levels of CA-125, a tumor marker that can be elevated in endometrial cancer. Classification Endometrial cancers may be tumors derived from epithelial cells (carcinomas), mixed epithelial and mesenchymal tumors (carcinosarcomas), or mesenchymal tumors.

Gynecology_Novak

Diagnosis Office endometrial aspiration biopsy is the accepted first step in evaluating a patient with abnormal uterine bleeding or suspected endometrial pathology (76). The diagnostic accuracy of office-based endometrial biopsy is 90% to 98% when compared with subsequent findings at dilation and curettage (D&C) or hysterectomy (77–79).

Endometrial biopsy

Medical uses There are a number of indications for obtaining an endometrial biopsy in a non-pregnant woman: Women with chronic anovulation such as the polycystic ovary syndrome are at increased risk for endometrial problems and an endometrial biopsy may be useful to assess their lining specifically to rule out endometrial hyperplasia or cancer. In women with abnormal vaginal bleeding the biopsy may indicate the presence of abnormal lining such as endometrial hyperplasia or cancer. In patients with suspected uterine cancer, the biopsy may discover the presence of cancer cells in the endometrium or cervix. In female infertility the assessment of the lining can determine, if properly timed, that the patient ovulated, however, the same information can be obtained by a blood test of the progesterone level.

Modern evaluation of the endometrium.

Abnormal uterine bleeding in women older than age 35 years, and certainly in menopausal patients, mandates evaluation, mainly to exclude cancer and hyperplasia, but also to better diagnose the source of the bleeding to appropriately manage the patient. In the past, dilation and curettage was the mainstay of diagnosis. This gave way to in-office suction pump-generated biopsies. Most recently, disposable biopsy instruments with their own internal piston to generate suction have become the standard of care. Rarely has such a technique received such widespread acceptance with such limited validation. Transvaginal ultrasonography, when technically feasible, is a noninvasive way to image the endometrial cavity. Saline-infusion sonohysterography is a subset of transvaginal ultrasonography reserved for patients in whom an adequate endometrial echo is not seen or when an endometrial echo is seen but not sufficiently thin. Appropriate understanding and use of transvaginal ultrasonography and addition of sonohysterography when necessary can allow a clinical algorithm that can triage patients with abnormal uterine bleeding to 1) no anatomic pathology best treated expectantly; 2) a global endometrial process, in which case random blind endometrial sampling is appropriate; or 3) a focal endometrial abnormality in which case endometrial sampling should be done with the visualization offered by hysteroscopy. Finally, the incidence of thick endometrial echo found incidentally in postmenopausal women with no bleeding is extremely high (10-17%) and should not trigger invasive endometrial sampling automatically.

Endometrial Biopsy -- Introduction

Endometrial biopsy is frequently used to evaluate abnormal uterine bleeding. It is a relatively quick and cost-effective way to sample the endometrium to allow for direct histological evaluation of the endometrium. It is an essential skill to have as endometrial cancer is the fourth most common cancer among women. The American Cancer Society estimates there will be 65,950 new uterine cancer cases and 12,550 related deaths in 2022 [American Cancer Society. Facts & Figures, 2022]. The patient does not need to undergo more invasive procedures as endometrial biopsies have a high sensitivity and specificity for detecting endometrial hyperplasia and endometrial malignancy, equal to the diagnostic accuracy of dilatation and curettage (D&C) procedure. [1]

[Assessment of the reliability of different methods in diagnosing endometrial cancer].

Endometrial cancer is the most common gynecologic malignancy. The purpose of the study was to compare the reliability of different methods for diagnosing endometrial cancer. A prospective study from January 1996 to September 1998. 264 women at risk of endometrial cancer with clinical indications for hysteroscopy with curettage participated in the study. They underwent different diagnostic methods: endometrial cytology (121 cases), endometrial biopsy (150) or ultrasonography (200). The accuracy of these methods was related to the following results obtained from hysteroscopy with curettage. The results of the study suggest higher reliability of endometrial biopsy from cytology. The hysteroscopic diagnosis conforms with the histologic examination showed by the curettage. Endometrial cancer as the cause of post-menopausal bleeding can be excluded in cases with endometrial thickness of < or = 5 mm measured by vaginal ultrasonography. We concluded that the combination of hysteroscopy and endometrial biopsy may substitute for curettage and become the method of choice for the endometrium.

Gynecology_Novak

Endometrial Cancer Screening in the General Population Screening for endometrial cancer should not be undertaken because of the lack of an appropriate, cost-effective, and acceptable test that reduces mortality (31–33). Routine Papanicolaou (Pap) testing is inadequate, and endometrial cytologic assessment is too insensitive and nonspecific to be useful in screening for endometrial cancer, even in a high-risk population. A progesterone challenge test reveals whether the endometrium is primed by estrogen, but it does not identify abnormal endometrial pathology. Transvaginal ultrasonographic examination of the uterus and endometrial biopsy are too expensive to be employed as screening tests.

Vaginal bleeding

Postmenopausal bleeding In postmenopausal vaginal bleeding, the primary goal of any diagnostic evaluations is to exclude endometrial hyperplasia and malignancy. Transvaginal ultrasonography and endometrial sampling are common methods for an initial evaluation. Guidelines from the American College of Obstetricians and Gynecologists (ACOG) recommend transvaginal ultrasonography as an appropriate first-line procedure to identify which patients are at higher risk of endometrial cancer. Endometrial sampling is indicated if having the following findings and/or symptoms: Endometrial thickness greater than 4 mm Diffuse or focal increased echogenicity (heterogeneity) Failure to visualize the endometrium Persistent or recurrent bleeding regardless of endometrial thickness Endometrial sampling can be obtained either by an endometrial biopsy using an endometrium sampling device such as a pipelle or by dilation and curettage (D&C) with or without a hysteroscopy. FIGO classification

Endometrial biopsy

The endometrial biopsy is a medical procedure that involves taking a tissue sample of the lining of the uterus. The tissue subsequently undergoes a histologic evaluation which aids the physician in forming a diagnosis.

Gynecologic Examination -- Introduction

The gynecological exam traditionally includes an examination of the external and internal genitalia. Under some conditions, it may be necessary to perform a rectal examination as well. A gynecological exam is typically needed for females with gynecological complaints or for screening for cervical cytology at 21 years of age. [1]

Endometrial sampling and general practice.

Endometrial sampling is an 'office' technique that has gained widespread acceptance in the United States (US). It is as accurate as dilatation and curettage (D&C) in the diagnosis of endometrial atypia and carcinoma. It appears to be the most suitable method of endometrial assessment for general practice. It has the potential for the earlier detection of endometrial abnormality and for increasing the number of women with abnormal vaginal bleeding who can be wholly managed within primary care. However, research is lacking on the effect of the widespread introduction of the technique into general practice. This paper puts forward recommendations for the use of endometrial sampling by general practitioners (GPs) based on current evidence.

Gynecology_Novak

endometrial cancer are asymptomatic. In the absence of symptoms, endometrial cancer usually is detected as the result of investigation of abnormal Pap test results, discovery of cancer in a uterus removed for some other reason, or evaluation of an abnormal finding on a pelvic ultrasonography examination or computed tomography (CT) scan obtained for an unrelated reason. Women who are found to have malignant cells on Pap test are more likely to have a more advanced stage of disease (70).

Endometrial cancer

Diagnosis Diagnosis of endometrial cancer is made first by a physical examination, endometrial biopsy, or dilation and curettage (removal of endometrial tissue; D&C). This tissue is then examined histologically for characteristics of cancer. If cancer is found, medical imaging may be done to see whether the cancer has spread or invaded tissue. Examination

[Diagnostic accuracy in transvaginal echography in benign endometrial diseases and its comparison with hysteroscopic biopsy].

Abnormal uterine bleeding is one of the main indications for hysteroscopy in peri-menopausal age. Transvaginal ultrasound allows for an accurate study of the endometrium through the evaluation of thickness, homogeneity. The aim of this retrospective study was the evaluation of transvaginal ultrasound versus hysteroscopy in diagnostic approach to abnormal uterine bleeding in peri- and post-menopause. 130 Women referred to the Department of Obstetrics and Gynecology of the University of Pavia for abnormal uterine bleeding entered the study; all them underwent transvaginal ultrasound and hysteroscopy with directed biopsy, with histological diagnosis of benign endometrial disease. On the basis of endometrial thickness measured at ultrasound, premenopausal patients were divided into two groups, post menopausal patients into three groups, and for each group a comparison between hysteroscopic findings, histological diagnosis and echographic aspect was performed. A 100% correspondence between ultrasound, hysteroscopy and histology was found in the group of subjects with endometrial atrophy, with an endometrial thickness of 2.9 +/- 0.68 at ultrasound; in the remaining groups sensibility and specificity of transvaginal ultrasound seem to be lower. In our experience a cut-off of 4 mm can be established for endometrial thickness measured by transvaginal ultrasound. Values that are below this cut-off point are diagnostic for endometrial atrophy, precluding the need for more invasive examinations: a medical treatment can then be administered. On the contrary, an endometrial thickening of 4 mm or more requires an hysteroscopic examination with directed biopsy and histological diagnosis.

[Comparison of the measurement line cervical and endometrial ultrasound techniques using two].

Cervical and endometrial measurement in the gynecological and obstetric patients is of vital importance. There is no consensus for the correct way in which should be made the measurement, more than anything is for an opinion of some experts. To determine whether there are differences in measurement of endometrial or sagittal cross section of the uterus and cervix in the measurement of fractional linear fashion or along the cervical canal. Using a transvaginal ultrasound, was measured in a transverse and longitudinal endometrial lining. And by fractional measuring along the cervical canal and a linear manner from the internal to the external. We studied a total of 63 patients. The mean endometrial transversal measurement in a cross was 7.1. mm (SD +/- 3.3) The mean endometrial longitudinally measured were: 7.9 mm (SD +/- 3.4). The mean cervical measurement was fractionally 3.3 cm (SD +/- 0.4) Mean cervical linear measurement was 3.9 cm (SD +/- 0.4). Using student's t test where the value of p in the endometrial measurement was 0.0871 and p value in cervical measurement was 0.009, the latter being statistically significant. With respect to the measurement of the endometrial lining, there is no significant difference do any of the two different techniques. However, measurement of the cervix, another significant difference (p = 0.009), so it should be further investigated which of these two techniques is the right way to establish more accurate diagnoses.

Gynecology_Novak

Endometrial Sampling Endometrial sampling should be performed to evaluate abnormal bleeding in women who are at risk for endometrial pathology, including polyps, hyperplasia, or carcinoma. Such sampling is mandatory in the evaluation of anovulatory bleeding in women older than 35 to 40 years of age, in younger women who are obese, and in those who do not respond to medical therapy or those with a history of prolonged anovulation (143). The technique of D&C, which was used extensively for the evaluation of abnormal bleeding, was largely replaced by endometrial biopsy in the office. The classic study in which a D&C was performed before hysterectomy with the conclusion that less than one-half of the endometrium was sampled in more than one-half of the patients led to questioning the use of D&C for endometrial diagnosis (176,177). Hysteroscopy, either diagnostic or operative, with endometrial sampling, can be performed either in the office or operating room (178).

Transvaginal ultrasonography and hysteroscopy in the diagnosis of endometrial abnormalities.

To investigate the value of transvaginal ultrasonography, aspiration biopsy, and hysteroscopy combined with curettage or directed biopsy in detecting endometrial pathology in women with abnormal uterine bleeding. Prospective, nonrandomized study. A university-affiliated hospital. One hundred twenty-two premenopausal and 78 postmenopausal women with abnormal uterine bleeding. The women underwent transvaginal ultrasonography (TVS) combined with aspiration Pipelle biopsy. They were scheduled for hysteroscopy and endometrial sampling by curettage or directed biopsy within 4 weeks. Ultrasonographic findings were evaluated on the basis of final diagnoses established by hysteroscopy and histologic examination. The endometrium was measured at its thickest part in the longitudinal plane. In premenopausal women, endometrial thickness was measured during the early proliferative phase of the cycle. Ultrasound examination was considered negative if single-layer thickness was less than 5 mm in the absence of endometrial projections. In all other cases it was classified as positive. For postmenopausal women the cutoff point was 4 mm (single layer). In postmenopausal women with endometrial thickness less than 4 mm, as well as in premenopausal patients with negative TVS, the combination of TVS and aspiration biopsy missed only one case of atypical hyperplasia. In premenopausal patients TVS clearly detected 73% of polyps and myomata, permitting diagnostic and surgical hysteroscopy to be performed at the same time. In postmenopausal women with endometrial thickness 4 mm or greater, aspiration biopsy failed to detect two cases of atypical hyperplasia and one of focal adenocarcinoma. Pipelle sampling was technically infeasible in a woman with endometrial cancer because of a stenotic cervix. It also missed the majority of benign lesions (polyps and myomas). Transvaginal ultrasound seems to be an excellent initial diagnostic method, with high sensitivity in diagnosing endometrial abnormalities. Its combination with aspiration biopsy seems to be safe in women with a thin endometrium. Hysteroscopy is necessary in postmenopausal women with an endometrium of 4 mm or more, as well as in premenopausal patients with endometrial thickness more than 5 mm (preovulatory phase of the cycle) and in those with suspected polyps or myomas.

Gynecology_Novak

for neoplasia and provide enough information to support an initial management strategy. In the absence of a satisfactory diagnosis or if unexplained bleeding continues without response to treatment, further investigation is appropriate, using one or a combination of ultrasound, endometrial sampling, SIS, or office hysteroscopy. For women in their earlier reproductive years who have AUB, medical or expectant management may be used initially, depending on the severity and inconvenience of the bleeding. For those who do not respond to medical treatments such as oral contraceptives, further diagnostic procedures such as transvaginal ultrasonography, SIS, or hysteroscopy with biopsy can be performed (165).

Ultrasonographic evaluation of the endometrium in postmenopausal vaginal bleeding.

Transvaginal ultrasound with SIS is a cost-minimizing screening tool for perimenopausal and postmenopausal women with vaginal bleeding. Its use decreases the need for invasive diagnostic procedures for women without abnormalities, and ultrasound increases the sensitivity of detecting abnormalities in women with pathologic conditions. Vaginal sonography is preferred over uniform biopsy of postmenopausal women with vaginal bleeding because it (1) is a less invasive procedure, (2) is generally painless, (3) has no complications, and (4) may be more sensitive for detecting carcinoma than blind biopsy. Transvaginal sonography is rarely nondiagnostic. Endometrial sampling is less successful in women with a thin endometrial stripe on ultrasound than in women with real endometrial pathologic condition. A limitation of ultrasound is that an abnormal finding is not specific: ultrasound cannot always reliably distinguish between benign proliferation, hyperplasia, polyps, and cancer. Although ultrasound may not be able to distinguish between hyperplasia and malignancy, the next step in the clinical treatment requires tissue sampling. Because of the risk of progression of complex hyperplasia to carcinoma, patients with this finding may benefit from hormonal suppression, dilatation and curettage, endometrial ablation, or hysterectomy, depending on the clinical scenario. The inability to distinguish these two entities based on ultrasound alone should not be seen as a limitation because tissue sampling is required in either case. Occasionally (in 5% to 10% of cases), a woman's endometrium cannot be identified on ultrasound, and these women also need further evaluation. Ultrasonography also may be used as a first-line investigation in other populations with abnormal uterine bleeding. In a multicenter, randomized, controlled trial of 400 women with abnormal uterine bleeding, the investigators found that transvaginal sonography combined with Pipelle endometrial biopsy and outpatient hysteroscopy was as effective as inpatient hysteroscopy and curettage. The subject, included women older than 35 years with PMB, menorrhagia, intermenstrual bleeding, postcoital bleeding, or irregular menses. Transvaginal sonography may be a cost-effective. sensitive, and well-tolerated method to evaluate most women with abnormal bleeding in combination with physical examination and endometrial biopsy and hysteroscopy us indicated. Hysteroscopy is likely to become the new gold standard in the future because of its ability to visualize directly the endometrium and perform directed biopsies as indicated. As office-based hysteroscopy becomes more practical and widespread, the technique may become more cost effective. An evaluation plan using transvaginal sonography as the initial screening evaluation followed by endometrial biopsy or, more likely, hysteroscopy is likely to become the standard of care (Fig. 12). It remains unproven whether certain patients at higher risk for carcinoma should proceed directly to invasive evaluation. Women on tamoxifen with persistent recurrent bleeding, women with significant risk factors for carcinoma, and women with life-threatening hemorrhage comprise this group. Further studies are still necessary to evaluate high-risk patients and determine whether ultrasound or biopsy is really the most cost-effective initial test.

[How I explore...a gynecologic pathology. Part 1: clinical history and examination].

After major technical advances in obstetrics and gynecology, one can unfortunately observe a decreased quality of the clinical history and gynecological examination, and of usual paraclinical tests. However, outpatient gynecological examination is the main component of a precise diagnosis and of possible medical or surgical treatments. In this article, we review the successive steps of outpatient clinic examination, with emphasis on the important parts of clinical examination. The complementary explorations will be detailed in the second part of this article, in a future issue of the Revue Médicale de Liège. The pathologies will not be exhaustively reviewed in this manuscript; only the diagnostic side of clinical examination will be detailed.

Gynaecological history, complaints and examinations in a middle-aged population.

A sample of women aged 40-56 years (n = 1349) was selected at random from the Census Register of Göteborg, Sweden. Altogether, 1095 (81%) filled out a questionnaire concerning gynaecological data. A control group (n = 170) was established and 135 women from this group (79%) underwent an extensive personal interview and pelvic examination. One aim was to investigate the representativity of the control group for the initial random sample and to compare the information obtained from the questionnaire with the information acquired by personal interview. An additional aim was to obtain information related to pelvic examination and FSH concentrations in the serum of middle-aged women. In general there was a good agreement between information from questionnaires and from personal interviews. The pelvic examination revealed that 53% of the post-menopausal women showed signs of genital atrophy and this condition was more common in sexually inactive than active women. Weakness of the pelvic floor was encountered in 16%. The uterus was of normal size in 94%, anteflexed in 76%, mid-positioned in 8% and retroflexed in 16%. There was a positive correlation between a pathological smear and cervical ectopy. Serum FSH values in menstruating women ranged from 6.4 to 47 IU/l. A cut-off value of 50 IU/l gave a complete separation between menstruating and post-menopausal subjects.