ERCP in acute pancreatitis.

BACKGROUND: The role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of acute pancreatitis has evolved over years since its introduction in 1968. Its importance in diagnosing the etiology of pancreatitis has steadily declined with the advent of less invasive diagnostic tools. The therapeutic implications of ERCP in acute pancreatitis are many fold and are directed towards management of known etiological factors or its related complications. This article highlights the current status of ERCP in acute pancreatitis. DATA SOURCES: An English literature search using PubMed database was conducted on ERCP in acute pancreatitis, the etiologies and complications of pancreatitis amenable to endotherapy and other related subjects, which were reviewed. RESULTS: ERCP serves as a primary therapeutic modality for management of biliary pancreatitis in specific situations, pancreatitis due to microlithiasis, specific types of sphincter of Oddi dysfunction, pancreas divisum, ascariasis and malignancy. In recurrent acute pancreatitis and smoldering pancreatitis it has a definite therapeutic utility. Complications of acute pancreatitis including pancreatic-duct disruptions or leaks, benign pancreatic-fluid collections and pancreatic necrosis can be beneficially dealt with. Intraductal ultrasound and pancreatoscopy during ERCP are useful in detecting pancreatic malignancy. CONCLUSIONS: The role of ERCP in acute pancreatitis is predominantly therapeutic and occasionally diagnostic. Its role in the management continues to evolve and advanced invasive procedures should be undertaken only in centers dedicated to pancreatic care.

Non-invasive predictors of esophageal varices.

BACKGROUND/AIM: Current guidelines recommend screening cirrhotic patients with an endoscopy to detect esophageal varices and to institute prophylactic measures in patients with large esophageal varices. In this study, we aimed at identifying non-endoscopic parameters that could predict the presence and grades of esophageal varices. PATIENTS AND METHODS: In a prospective study, 229 newly diagnosed patients with liver cirrhosis, without a history of variceal bleeding, were included. Demographic, clinical, biochemical and ultrasonographic parameters were recorded. Esophageal varices were classified as small and large, at endoscopy. Univariate analysis and multivariate logistic regression analysis were done to identify independent predictors for the presence and grades of varices. RESULTS: Of the 229 patients (141 males; median age 42 years; range 17-73 years) with liver cirrhosis, 97 (42.3%) had small and 81 (35.4%) had large varices. On multivariate analysis, low platelet count (Odd's Ratio [OR], 4.3; 95% confidence interval [CI], 1.2-14.9), Child Pugh class B/C (OR, 3.3; 95% CI, 1.8-6.3), spleen diameter (OR, 4.3; 95% CI, 1.6-11.9) and portal vein diameter (OR, 2.4; 95% CI, 1.1-5.3) were independent predictors for the presence of varices. Likewise, for the presence of large esophageal varices, low platelet count (OR, 2.7; 95% CI, 1.4-5.2), Child Pugh class B/C (OR, 3.8; 95% CI, 2.3-6.5) and spleen diameter (OR, 3.1; 95% CI, 1.6-6.0) were the independent risk factors. CONCLUSION: The presence and higher grades of varices can be predicted by a low platelet count, Child-Pugh class B/C and spleen diameter. These may be considered as non-endoscopic predictors for the diagnosis and management of large grade varices.

Distinguishing tuberculosis and Crohn's disease in developing countries: how certain can you be of the diagnosis?

Distinguishing tuberculosis and Crohn's disease in patients presenting with chronic abdominal pain and diarrhea is a huge diagnostic challenge, particularly in tuberculosis endemic countries. A large number of patients with Crohn's disease are initially misclassified as having Intestinal tuberculosis in places where tuberculosis is endemic before they are treated for Crohn's disease. Although a variety of endoscopic, radiological and histological criteria have been recommended for the differentiation, it often proves difficult in routine clinical practice. Future prospective studies are required in patients with granulomatous colitis to prevent unnecessary inappropriate anti tuberculous therapy for patients with Crohn's disease and appropriate early treatment for a patient with tuberculosis.

Carcinoma of the esophagus in Tamil Nadu (South India): 16-year trends from a tertiary center.

BACKGROUND: In the Western world, esophageal adenocarcinoma has surpassed in incidence squamous cell carcinoma. AIM: To determine the trend changes in histology and site distribution of esophageal malignancy between 1989 and 2004 in a southern state of the Indian subcontinent. METHOD: A retrospective study on 994 patient records with esophageal carcinoma esophagus. Age, gender, clinical presentation and duration of illness were recorded in a prestructured proforma. The site of the tumor was classified as upper, mid, lower esophagus and esophagogastric junction. The 16 year study period was divided into four equal cohorts. Statistical analysis was performed using the chi-square test and the one way ANOVA wherever appropriate; p < 0.05 was considered significant. RESULTS: Squamous cell carcinoma was the most common malignancy, seen in 912 (92%) patients. 82 patients (8%) had adenocarcinoma. 65 of these 82 patients (79%) had an esogastric junction malignancy and 17 (21%) a tumor in the distal third of the esophagus. No time trends were discernible with regard to the clinical presentation, frequency, mean age or gender. However, an increase in the number of patients below the age of 40 was noted (p=0.008). In squamous cell carcinoma of the esophagus, there was an overall increase in the mean age of occurrence (p=0.05), but no significant changes in the gender ratio. The lower esophageal cancers outnumbered the midesophageal cancers in the 4th cohort and the former represent the most common site of malignancy. CONCLUSION: Squamous cell carcinoma is the most common type of esophageal cancer in the Indian subcontinent, located with a predilection in the distal third. Adenocarcinoma is uncommon and affects more frequently men younger than 40.