Obstructive jaundice due to isolated tuberculosis of the pancreas: endoscopic treatment instead of surgery?

The optimal treatment for relieving biliary obstruction due to isolated pancreatic tuberculosis has not so far been defined, and most previously reported patients were treated surgically. We describe a 17-year-old, immunocompetent girl who was admitted with obstructive jaundice caused by a tuberculous mass in the head of the pancreas. Antituberculous therapy alone failed to alleviate the jaundice, and she was therefore treated by stent insertion and, subsequently, balloon dilation of the common bile duct stricture. At follow-up 5 years later, magnetic resonance cholangiopancreatography showed no evidence of stricture in the common bile duct.

Recurrent pancreatitis as a late complication of endoscopic sphincterotomy for common bile duct stones: diagnosis and therapy.

Although long-term complications of endoscopic sphincterotomy (ES) have often been reported, the possible effects of the procedure on the pancreatic duct orifice remain virtually unknown. Three women patients are described who developed attacks of recurrent pancreatitis at 2, 7, and 27 months after ES for bile duct stones. The attacks were apparently caused by a partial stenosis of the pancreatic orifice, arising from post-procedure fibrosis and scarring. The patients were evaluated and treated endoscopically. All three patients benefited from endoscopic therapy; two became symptom-free and one improved. Symptoms recurred in the three patients, after 26, 41, and 23 months. In one patient, re-stenosis was documented and repeat sphincterotomy resulted in complete relief of symptoms during the ensuing 5 months. In the remaining two patients, the symptoms were mild and no further intervention was needed. Concerning complications, one patient suffered a moderately severe pancreatitis without sequelae. Recurrent pancreatitis may emerge as a late complication after ES for common bile duct stones. It is probably causally related to stenosis of the pancreatic orifice brought about by fibrosis and scarring, which may exceptionally develop after the procedure. Endoscopic therapy should probably be considered in the first instance, but the optimal treatment for this condition remains to be determined.

Gastroesophageal acid reflux in patients with nutcracker esophagus.

BACKGROUND: Hypertensive esophageal contraction, called nutcracker esophagus (NE), is the most common motility abnormality associated with cardiac-like chest pain. However, its significance for the development of symptoms has been a matter of controversy for decades, and recently it has been suggested that NE might represent a primarily acid-related esophageal disorder. The frequency of acid-related esophageal dysfunction is studied in an unselected group of patients with NE. METHODS: During the period March 1993 to June 1998, 572 consecutive patients underwent esophageal manometry and 24-h pH monitoring. RESULTS: A motility pattern consistent with NE was found in 45 subjects referred because of chest pain (n = 35), reflux dyspepsia only (n = 8) or epigastric pain (n = 2). Acid-related esophageal dysfunction was noted in 30 (70%) of the NE patients; abnormal acid exposure time (n = 21), esophagitis (n = 2) or positive symptom index (n = 7). In addition, an increased number of reflux episodes were found in another three subjects. NE was more prevalent in subjects referred for chest pain than in those referred for other symptoms (14.3% versus 4.5%; P < 0.0001) and, conversely, 78% of the patients with NE were referred because of chest pain. CONCLUSIONS: Various aspects of acid-related esophageal dysfunction occur frequently in patients with NE, suggesting that acid may play a role in the development of symptoms in NE. Nonetheless, given its association with chest pain, NE could be a marker of a subgroup of patients with acid reflux, distinct from other reflux patients.

Endoscopic bile duct stent placement as a predictor of outcome following endoscopic sphincterotomy in patients with suspected sphincter of Oddi dysfunction.

OBJECTIVES: To determine whether symptomatic improvement following placement of endoscopic stent across the biliary sphincter could predict the longer-term clinical outcome after endoscopic sphincterotomy (ES). METHODS: Twenty-three post-cholecystectomy patients with suspected sphincter of Oddi dysfunction underwent, sequentially, sphincter of Oddi manometry, endoscopic stent placement, ES, and follow-up for a further 6-12 months. RESULTS: Eight (35%) patients either did not respond (n = 5), did not tolerate the stent (n = 1) or relapsed during stenting (n = 2). Only the patient who did not tolerate the stent from the outset (12%) improved after ES. Of five patients who responded to stenting and had ES within 8 weeks, only two (40%) remained asymptomatic. In contrast, of 10 patients who were pain-free during 12-14 weeks of stenting, nine (90%) continued to be asymptomatic after ES. All seven patients with an elevated sphincter of Oddi pressure responded to stenting and six benefited from sphincter ablation. Five (31%) of 16 patients who had normal sphincter pressure and had improvement after 12-14 weeks of stenting remained free from pain following ES. ES resulted in long-term freedom from pain in 12 of the 23 patients: six of the seven patients with elevated sphincter of Oddi pressure and six of the 16 subjects with normal manometry (P < 0.05). CONCLUSION: Freedom from symptoms during at least 12 weeks of stenting predicted a favourable outcome after ES, irrespective of sphincter of Oddi pressure. Patients who failed to improve or showed improvement only with short-term stenting were less likely to benefit.

Endoscopic treatment of anastomotic strictures in Crohn's disease.

The results of endoscopic balloon dilatation in 27 patients with anastomotic strictures caused by Crohn's disease are reported. All patients had obstructive symptoms not responding to corticosteroids and of such a degree that resection or strictureplasty was considered necessary. The patients were followed up for 7 to 38 months after their first dilatation. Eighteen patients were more or less free from obstructive symptoms while the results were less favourable in the remaining nine patients. The median time after the latest surgical intervention was seven years in the group with a successful outcome and 1.6 years in the group with a poor outcome, which may indicate that some patients have a more aggressive form of Crohn's disease where balloon dilatation is only of moderate value. However, all patients experienced at least a temporary effect, so that balloon dilatation can be considered for use in situations where it is desirable to postpone surgery.

Ampullary hamartoma: endoscopic diagnosis and treatment.

This study shows a patient who presented with intermittent biliary tract obstruction caused by ampullary hamartoma. Endoscopic retrograde cholangiopancreatography showed a large ulcerated papilla and dilated biliary ducts. Tissue diagnosis was established by a large particle biopsy obtained with a snare. The patient underwent a successful endoscopic sphincterotomy and has remained symptom free for 4 years.

Ampullary tumor caused by metastatic renal cell carcinoma.

In this paper we report the case of a renal cell carcinoma (RCC) metastatic to the ampullary region. The patient presented with severe anemia due to blood loss from the ampullary tumor 11 years after nephrectomy for the primary renal cancer. The diagnosis was established by means of endoscopy and biopsy.

Endoscopic management of pancreatic disease.

Since its introduction in 1968, ERCP has developed from being a purely diagnostic method, mostly used in the investigation of unexplained upper abdominal pain, to an invaluable tool for the management of patients with pancreatic disorders. In cases with severe gallstone pancreatitis, the biliary obstruction is disclosed and relieved by ERCP and ES. In patients with severe acute pancreatitis of other aetiologies, as well as in post-traumatic pancreatitis, ERCP is indispensable for revealing complications (e.g. pancreatic duct rupture) and/or for planning the treatment strategy. Furthermore, in cases of pancreatitis not related to alcohol or gallstones, it often demonstrates causes which may be treatable, and it is also useful for evaluation of the gland after massive pancreatic necrosis. Moreover, ERCP is helpful in establishing the diagnosis of chronic pancreatitis and its complications as well as in demonstrating morphological grounds for therapeutic intervention. Although the indications, limitations, and practicability of the different techniques of therapeutic ERCP in various pancreatic diseases still remain to be defined, the method appears to offer an alternative to surgery, particularly in cases in which operative treatment is technically difficult and the results are less favourable. Frequency and severity of complications associated with both diagnostic and therapeutic ERCP seem to be, at least in the hands of experts, reasonably low.

Intensive intravenous treatment of ulcerative colitis.

Two hundred four courses of intensive intravenous treatment were given to 158 patients with ulcerative colitis. The remission rates in the severe, moderate, or mild attacks were 55.7%, 86.9%, and 91.8%. Total colitis had a great impact on the results, especially in severe attacks. Of these patients, 52.8% were operated on within 3 wk. The relapse rate was exponential, and during the first year 48.1% of the patients in remission relapsed. The extent of the colitis, severity of the attack, or duration of intensive intravenous treatment had no influence on the time of relapse. Twelve patients with chronic continuous disease were given intensive intravenous treatment. No long-term benefit was seen in patients with total ulcerative colitis, but half of those with less extensive colitis showed a good to excellent response to treatment.

Occurrence of Clostridium difficile toxin in inflammatory bowel disease.

The occurrence of Clostridium difficile toxin in faeces has been studied in 53 inpatients with inflammatory bowel disease (IBD) at 57 admissions. Before faecal sampling of the patients had had sulphasalazine therapy--17 for more than 1 year--and 16 patients had taken antibiotics on 20 occasions within the last year. The toxin was found in 3 out of 57 samples (5%). In all cases it could be detected only in undiluted stool filtrate. None of the patients was treated for the C. difficile infection; remission was achieved in two of the patients, whereas the third patient with severe ulcerative colitis was referred to colectomy. Our results suggest that neither IBD as such nor long-term sulphasalazine therapy predisposes to occurrence of C. difficile toxin. Antibiotic therapy in these patients does not imply a higher risk of toxin occurrence than in other patients. In our region there is no need for routine screening for this in symptomatic patients with IBD.

C-peptide concentration in pancreatic juice obtained during endoscopic pancreatography in patients with and without insulinoma.

ERCP was performed in three patients with insulinoma. One had a large malignant tumor, while the remaining two had small tumours. In two of these patients pancreatic juice was collected for C-peptide determination. Pancreatography was performed and pancreatic juice was obtained in seven other subjects comprising: five control subjects and two patients in whom insulinoma was suspected because of symptoms suggestive of hypoglycaemia. Pancreatography was normal in all subjects except the patient with a large insulinoma in whom an obstruction of the main pancreatic duct was found. The maximal C-peptide concentrations in pancreatic juice of patients with insulinoma were found to be several-fold higher than in the control subjects and in one of the patients in whom insulinoma was suspected but unproven. The remaining patient with suspected insulinoma had a maximal C-peptide concentration comparable with those found in patients with proven insulinoma. Thus remarkable differences in maximal C-peptide concentrations obtained in patients with and without insulinoma were found. However, the clinical significance of the findings needs further evaluation. The value of ERP in patients with suspected insulinoma may be twofold: an obstruction of the main pancreatic duct may indicate a large, hardly resectable tumour; in patients in whom the duct is unaffected the relation between the tumour as visualized by angiography, and the duct, is of value for the surgeon when planning the operation.

Human pancreatic polypeptide (HPP) immunoreactivity in an infiltrating endocrine tumour of the papilla of Vater with unusual morphology.

Histological, histochemical and clinical features of an endocrine duodenal tumour situated in the papillary region were studied. The tumour had a remarkable mixed histological growth pattern, consisting of epithelial glandular structures which showed a gradual transition into a spindle-cell tumour, resembling a neurogenic tumour. The neoplasm was considered malignant since it had infiltrated into the muscular layer of the duodenal wall. The tumour was non-argentaffin and non-argyrophil. No serotonin could be demonstrated histochemically. Immunoreactive pancreatic polypeptide (HPP) was detected by indirect immunofluorescence in the majority of tumour cells of the epithelial glandular structures, whereas areas with a spindle-cell pattern were almost unreactive to the HPP-antiserum. No reaction was found with antibodies against gastrin, insulin, glucagon, vasoactive intestinal polypeptide or somatostatin. The patient had no endocrine symptoms that could be ascribed to the production of HPP by the neoplasm. Twenty-four months postoperatively, the patient's serum HPP concentration had begun to rise, suggesting recurrence of the tumour.

Hypotonic duodenography and secretin-CCK test in the diagnosis of pancreatic disease.

Sixty-five patients with possible pancreatic disease or long-lasting upper abdominal symptoms were examined by means of the secretin-CCK test and hypotonic duodenography. Both examinations were performed after one duodenal intubation. In patients with pancreatitis functional abnormalities were revealed in 85 per cent while the duodenography was abnormal in 43 per cent. In patients with carcinoma, 77 per cent had abnormal exocrine pancreas function and 70 per cent had abnormalities demonstrated at duodenography. The value of the two examinations for assessment of patients with upper abdominal symptoms and pancreatic disease is discussed.

Hypotonic duodenography and endoscopic retrograde pancreatography in the diagnosis of pancreatic disease.

Hypotonic duodenography and endoscopic retrograde pancreatography were performed in 45 non-icteric patients with suggested pancreatic disease or long-standing upper gastrointestinal symptoms. The accuracy of each method in the diagnosis of pancreatic disease was compared. Hypotonic duodenography revealed pancreatitis in 48 per cent and ERP in 83 per cent of the cases. All 6 pancreatic tumours were detected at ERP and 3 at duodenography. The role of hypotonic duodenography and endoscopic retrograde pancreatography in the diagnosis of pancreatic disease is discussed.

Effect of secretin and cholecystokinin-pancreozymin on plasma CEA concentration in patients with pancreatic carcinoma and pancreatitis.

Plasma CEA concentration before and after administration of secretin and cholecystokinin-pancreozymin has been determined in 89 patients with neoplastic or inflammatory pancreatric disease and other neoplastic and nonneoplastic disorders. The purpose of the study was to expore the specificity and sensitivity of such a provocation tests. Some rise of the plasma CEA concentration after hormonal stimulation could be observed in several patients in the various groups. However, none of the 37 patients with nonpancreatic disease who had a basal CEA concentration of 6 micrograms/l or less had a maximal CEA concentration above 13 micrograms/l after the stimulation whereas 7 out of 31 patients with pancreatic disease (3 with pancreatic carcinoma and 4 with chronic pancreatitis) showed such an elevation of plasma CEA concentration. Thus, the provocation test showed a satisfactory specificity for pancreatic disease but a low sensitivity. It is suggested that the possibility of an effect of physiologically released gastrointestinal hormones should be considered when "unexplained" high CEA values are found in plasma samples from nonfasting patients.