Gallstones represent the most frequent aetiology of acute pancreatitis in many statistics all over the world, estimated between 40%-60%. Accurate diagnosis of acute biliary pancreatitis (ABP) is of outmost importance because clearance of lithiasis [gallbladder and common bile duct (CBD)] rules out recurrences. Confirmation of biliary lithiasis is done by imaging. The sensitivity of the ultrasonography (US) in the detection of gallstones is over 95% in uncomplicated cases, but in ABP, sensitivity for gallstone detection is lower, being less than 80% due to the ileus and bowel distension. Sensitivity of transabdominal ultrasonography (TUS) for choledocolithiasis varies between 50%-80%, but the specificity is high, reaching 95%. Diameter of the bile duct may be orientative for diagnosis. Endoscopic ultrasonography (EUS) seems to be a more effective tool to diagnose ABP rather than endoscopic retrograde cholangiopancreatography (ERCP), which should be performed only for therapeutic purposes. As the sensitivity and specificity of computerized tomography are lower as compared to state-of-the-art magnetic resonance cholangiopancreatography (MRCP) or EUS, especially for small stones and small diameter of CBD, the later techniques are nowadays preferred for the evaluation of ABP patients. ERCP has the highest accuracy for the diagnosis of choledocholithiasis and is used as a reference standard in many studies, especially after sphincterotomy and balloon extraction of CBD stones. Laparoscopic ultrasonography is a useful tool for the intraoperative diagnosis of choledocholithiasis. Routine exploration of the CBD in cases of patients scheduled for cholecystectomy after an attack of ABP was not proven useful. A significant rate of the so-called idiopathic pancreatitis is actually caused by microlithiasis and/or biliary sludge. In conclusion, the general algorithm for CBD stone detection starts with anamnesis, serum biochemistry and then TUS, followed by EUS or MRCP. In the end, bile duct microscopic analysis may be performed by bile harvested during ERCP in case of recurrent attacks of ABP and these should be followed by laparoscopic cholecystectomy.

We read with great interest the recent ar− ticle by Jonas et al. [1] which described the endoscopic ultrasound− (EUS−)guided drainage of a cystic metastasis in the mediastinum, and also the article by Mohl et al. [2] reporting their experience of endoscopic transhiatal drainage of a mediastinal pancreatic pseudocyst. Both articles reported interesting cases of EUS− guided or EUS−assisted drainage of med− iastinal lesions. We recently managed a similar case, a patient with a large pancre− atic pseudocyst that extended through the diaphragmatic hiatus inside the me− diastinum, which was complicated by a left pleural effusion.A 30−year−old man, with a known history of heavy alcohol consumption, was ad− mitted in the Emergency Department complaining of intense epigastric pain, nausea, and vomiting. He was suspected to have acute pancreatitis. Computed to− mography revealed a large (15 cm) pan− creatic body pseudocyst that extended upward through the diaphragmatic hiatus into the posterior mediastinum, close to the descending aorta ( Figure 1). A large left pleural effusion with a high amylase content was also present, which persisted despite two drainage procedures and 1 month of conservative treatment.Because of the close proximity to the aor− ta and the absence of a clear bulge inside the stomach or esophagus, EUS−guided drainage of the mediastinal pancreatic pseudocyst was performed through the terminal esophagus using a large−channel linear ultrasound endoscope (Olympus GF−UC160T AL5; Olympus, Hamburg, Ger− many) and a one−step drainage system consisting of a diathermic catheter−guide− wire assembly and a mounted 5−cm, 10−Fr stent (Giovannini Needle Wire; Wilson− Cook, Limerick, Ireland). The procedure was technically successful, with good vi− sualization of the stent placement inside the mediastinal pancreatic pseudocyst ( Figure 2) and intermittent drainage of fluid inside the esophagus. After 24 hours, upper gastrointestinal endoscopy and computed tomography with coronal re− construction of the images showed that the stent had rolled over, with the upper esophageal end now inside the stomach, in a good downward−facing position that allowed drainage of the mediastinal col− lection directly into the stomach (Fig− ure 3).The clinical course was favorable and after 1 month there was complete disappear− ance of both the mediastinal pancreatic pseudocyst and the left pleural collection. On computed tomographic scans, the stent was visualized with the upper end in the mediastinum in close contact with the descending aorta, without any fluid collections (Figure 4). The stent was gent− ly pulled inside the stomach and subse− quently removed without any complica− tions. The patient was then followed up for 3 months without any evidence of re− currence.EUS−guided drainage of symptomatic pancreatic pseudocysts is currently con− Figure 4 Control contrast−enhanced axial computed tomographic image after 30 days, showing the stent with its upper end in the mediastinum in close contact with the des− cending aorta, and no flu...

Power Doppler EUS provides useful information for the differential diagnosis of pancreatic masses. The results were in concordance with previous studies that showed a hypovascular pattern of pancreatic carcinoma, as well as the formation of collaterals in advanced cases due to the invasion of the splenic or portal veins. Further studies of dynamic EUS with contrast agents are necessary to better characterize pancreatic masses.

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Tourism, through its components, can be found in all areas that relate to sustainable development principles. Although it should be encouraged due to the multiplier effect that it has in the development of a region, it creates pressure on the surrounding environment like any other economic activity in the process of specific potential capitalization. This paper is aimed at determining the degree of tourism pressure, its trend and impact on tourism's sustainable development and the Romanian economy. When this pressure exceeds the ecological support capacity, negative effects occur, both on the landscape in general, and on certain tourist objectives, in particular. The assessment of this pressure and its most accurate quantification imply the use, calculation, correlation and interpolation of indicators that may summarize certain aspects related to the density of tourist fittings, tourist traffic intensity and capitalization level. Hence, the approach would be considered regionally and in terms of tourism pressure dynamics, depending on the structure of available statistical data, as well as to get a clearer picture. The authors used methods specific to geography, as well as statistical and econometric methods. The interdependence between tourism, tourism pressure and sustainability is described in the Central region. The results and observations determined with reference to the factors and indicators shown underlie the coordination of the tourism activity in the other regions according to the processes of sustainability and tourism pressure mitigation.

Background: The new developments in imaging technology, including contrast enhanced ultrasound (CEUS), computed tomography (CT), and magnetic resonance imaging (MRI), allow a better diagnosis of both malignant and benign liver lesions. Material and methods: A retrospective trial of 126 patients was conducted in the Gastroenterology and Imaging Departments of the University of Medicine and Pharmacy Craiova, Romania. CEUS and MRI were the imaging techniques used for diagnosis of focal liver lesions (FLL), especially for hepatocellular carcinoma (HCC). Histopathology was used only in 15 cases. For each method of investigation we calculated the sensitivity, specificity, positive and negative predictive values (PPV and NPV), positive and negative likelihood ratio (+LR, -LR), accuracy and we compared the ROC curves. Statistical analysis also included the Chi-square and Kappa tests. Results: Seventy six cases were diagnosed as HCC, with average size of 5.2±3.3 cm in diameter. The sensitivity and specificity were 71.4% and 95.6% for CEUS and 91.4%, 98.9% respectively, for MRI. When comparing the ROC curves, we found a higher area under curve for MRI (0.952) then for CEUS (0.835) (p=0.005), and 95% confidence interval of 0.0343 to 0.199. No statistically significant difference in diagnosis of FLL was found between CEUS and MRI (p > 0.05) and the agreement between the two imaging techniques was good (k = 0.78). Conclusions: CEUS can be used as the first step in the diagnosis of liver lesions, but MRI remains the gold standard diagnostic method for liver tumors.

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