Idiopathic acute recurrent pancreatitis.

Acute recurrent pancreatitis (ARP) results most commonly from alcohol abuse or gallstone disease. Initial evaluation fails to detect the cause of ARP in 10-30% of patients, and as a result the diagnosis of "idiopathic" ARP is given. In these patients, a more extensive evaluation including specialized labs, ERCP, endoscopic ultrasound, or magnetic resonance cholangiopancreatography typically leads to a diagnosis of microlithiasis, sphincter of Oddi dysfunction, or pancreas divisum. Less commonly, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatobiliary tumors, or chronic pancreatitis are diagnosed. Determining the etiology is important, as it helps to direct therapy, limits further unnecessary evaluation, and may improve a patient's long term prognosis.

Benign pancreatic duct strictures: medical and endoscopic therapy.

Pancreatic duct strictures usually reflect underlying pancreatic disease and are likely caused by one or more of the following: acute or chronic pancreatitis, benign or malignant pancreatic neoplasm, pseudocyst and trauma. The characteristics of pancreatic strictures are identified, and medical and endoscopic therapy options are reviewed.

Evaluation of metastatic celiac axis lymph nodes in patients with esophageal carcinoma: accuracy of EUS.

BACKGROUND: Endosonography (EUS) is the most accurate modality for assessing depth of tumor invasion and local lymph node metastasis. However, its accuracy in the identification of metastatic (celiac axis) lymph nodes is less well defined. Our objective in this study was to determine the accuracy of Eus in detecting celiac axis lymph node metastasis in patients with esophageal carcinoma. METHODS: Two hundred fourteen patients with esophageal carcinoma underwent preoperative EUS. Of these, 145 underwent attempted surgical resection and staging, and 4 underwent EUS-guided fine-needle aspiration of mediastinal and celiac lymph nodes. Local (mediastinal) and distant (celiac axis) lymph nodes were assessed for malignancy on the basis of four criteria (larger than 1 cm, round, homogeneous echo pattern, sharp borders). Accuracy of EUS was determined by means of correlating histopathologic findings for the resected lymph nodes or results of EUS-guided fine-needle aspiration cytologic examination. RESULTS: Surgical exploration (n = 145) and fine-needle aspiration cytologic examination (n = 4) revealed metastatic celiac axis lymph nodes in 23 and metastatic mediastinal (local) lymph nodes in 93 of 149 patients with esophageal carcinoma. According to defined criteria for malignant lymph nodes, there were 19 true-positive and 4 falsenegative results. Sensitivity for the diagnosis of celiac lymph node metastasis with EUS was 83% with a 98% specificity. For the diagnosis of mediastinal lymph node metastasis, sensitivity was 79% and specificity was 63%. All patients with malignant celiac axis lymph nodes had local T3 (tumor breaching adventitia) or T4 (tumor invading adjacent organs) disease. CONCLUSION: EUS is an excellent modality in the evaluation of metastatic celiac axis lymph nodes in patients with esophageal carcinoma. These findings should be used in selecting options for treatment. Sensitivity for detecting malignancy is consistent with that of prior studies, and local and regional lymph nodes and specificity is significantly higher.

Prospective evaluation of endoscopic ultrasonography, endoscopic retrograde pancreatography, and secretin test in the diagnosis of chronic pancreatitis.

BACKGROUND: Chronic pancreatitis in its early stages may defy diagnosis despite existing diagnostic modalities. Endoscopic retrograde pancreatography (ERCP), secretin test, and conventional ultrasound are insensitive in detecting the early stages of chronic pancreatitis. The aim of this study was to determine whether endoscopic ultrasonography (EUS) high-resolution imaging allows for the detection of chronic pancreatitis as compared with clinical history, ERCP, and secretin test. METHODS: Eighty consecutive patients with recurrent pancreatitis underwent ERCP, EUS, and secretin test. EUS evaluated parenchymal changes: echogenic foci (calcification), prominent interlobular septae (fibrosis), small cystic cavities (edema), lobulated outer gland margin (fibrosis/atrophy), and heterogeneous parenchyma; and ductal changes: dilation, irregularity, echogenic wall (fibrosis), side-branch ectasia, and echogenic foci (stones). EUS criteria for chronic pancreatitis included mild (1 to 2 features), moderate (3 to 5 features), and severe (more than 5 features). RESULTS: Abnormal studies were EUS = 63, ERCP = 36, and secretin test = 25. Secretin test had 100% agreement with normal and severe chronic pancreatitis by EUS criteria, but agreement was poor for mild (13%) and moderate (50%) disease. Alternatively, the agreement between ERCP- and EUS-specific criteria was excellent for normal (100%), moderate (92%), and severe (100%) chronic pancreatitis and poor for mild (17%) disease. When the 2-test modality (ERCP and secretin test) was compared with EUS alone, no enhancement in agreement was seen. CONCLUSION: Using the above criteria EUS may assist in the diagnosis of chronic pancreatitis not established by ERCP or secretin test. Excellent agreement can be expected between EUS and ERCP in the diagnosis of chronic pancreatitis with the exception of mild changes noted on EUS (kappa statistics = 0.82: 95% CI [0.70, 0.95]). Long-term follow-up of the patients with mild EUS changes will determine the validity of EUS in diagnosing the early stages of chronic pancreatitis.

Endoscopic retrieval of proximally migrated biliary and pancreatic stents: experience of a large referral center.

BACKGROUND: Proximal migration of a biliary or pancreatic stent is an infrequent event but its management can be technically challenging. METHODS: Review of all cases of proximally migrated biliary and pancreatic stents over a 10-year period at a referral pancreatic-biliary center. Data abstracted from patient records included indication for stenting, method of presentation, success of attempt, and method used. Successful methods were determined by reviewing procedure reports. Follow-up was attempted in all patients in whom stent retrieval had failed. RESULTS: Thirty-three proximally migrated bile duct stents, and 26 proximally migrated pancreatic duct stents were identified. Most of the patients were without symptoms. Eighty-five percent of common bile duct stents and 80% of pancreatic duct stents were successfully extracted endoscopically. Seventy-one percent (34 of 48) were retrieved with a basket or balloon. Of the stents not retrieved, two patients did not return for repeat ERCP, three patients with malignant common bile duct strictures were managed with placement of a second stent, three patients with pancreatic duct stents have remained without symptoms with no further retrieval attempts, and three patients with proximally migrated pancreatic duct stents required surgery because of pain and failure of multiple endoscopic retrieval attempts. CONCLUSION: Over 80% of proximally migrated bile duct and pancreatic duct stents may be extracted endoscopically. Few patients will require surgery.

Endoscopic sphincterotomy for stones by experts is safe, even in younger patients with normal ducts.

OBJECTIVE: To provide current information on the risks of endoscopic sphincterotomy for stone. SUMMARY BACKGROUND DATA: In recent years (since the popularity of laparoscopic cholecystectomy), endoscopic sphincterotomy has been used increasingly for the management of bile duct stones in relatively young and healthy patients. The validity of this trend has been questioned using data on short-term complications derived from earlier decades that involved more elderly and high-risk patients. METHODS: Seven academic centers collected data prospectively using a common database. Complications within 30 days of the procedures were documented by standard criteria. RESULTS: Of 1921 patients, 112 (5.8%) developed complications; two thirds of these events were graded as mild (<3 days in hospital). There was no evidence of increased risk in younger patients or in those with smaller bile ducts. There was only one severe complication and there were no fatalities in 238 patients age <60, with bile duct diameters of <9 mm. CONCLUSION: Sphincterotomy for stones can be performed very safely by experienced endoscopists.

Treatment of pancreatic pseudocysts with ductal communication by transpapillary pancreatic duct endoprosthesis.

BACKGROUND: Endoscopic treatment of pancreatic pseudocysts via cystenterostomy has been recognized as a successful treatment option in carefully selected patients. Pancreatic transpapillary stenting as an alternative treatment option in patients with pancreatic pseudocysts directly communicating with the main duct has received little consideration. The aim of the current study was to assess the safety and utility of transpapillary pancreatic endoprosthesis in the treatment of communicating pseudocysts. METHODS: Twenty-one patients underwent placement of 33 transpapillary endoprostheses for the treatment of symptomatic pancreatic pseudocysts. All pseudocysts communicated with the main pancreatic duct and ranged in size from 3 to 9 cm (mean 6 cm). Eight patients had associated pancreatic duct strictures. RESULTS: Stent placement was successful in all cases: 13 directly into the pseudocyst, 8 beyond the stricture but not into the pseudocyst. Initial resolution of pseudocysts was seen in 17 patients, with 16 patients free of pseudocyst recurrence at mean follow-up of 37 months. All patients with associated strictures were treated successfully. Factors predictive of success included presence of strictures, size of pseudocyst greater than or equal to 6 cm, location in the body of the pancreas, and duration of pseudocyst less than 6 months. Complications included one episode of mild pancreatitis. CONCLUSIONS: Endoscopic treatment of symptomatic pancreatic pseudocysts with ductal communication by transpapillary pancreatic duct stenting is a safe, effective modality and should be considered a first line therapy.

Treatment of non-extractable common bile duct stones with combination ursodeoxycholic acid plus endoprostheses.

Despite widely available technology for removal of bile duct stones, endoscopists currently encounter approximately 3% of patients with stones that defy extraction. After sphincterotomy and unsuccessful attempts at extraction of "defiant" stones, biliary stents were placed in 22 patients. Ten patients were treated with ursodeoxycholic acid, and 12 patients treated only with stent served as control subjects. Ductal strictures preventing stone extraction were present in eight control patients and in six patients treated with ursodeoxycholic acid. The number of total calculi in the ursodeoxycholic acid group was slightly higher (4.2 per patient) than the number in the control group (3.3 per patient). Stone and bile duct dimensions were similar in each group. Nine of 10 patients in the ursodeoxycholic acid group had complete stone clearance, and 41 of 42 stones were removed during a follow-up period of 9 +/- 2 months; in contrast, no patient in the control group had complete clearance and only 6 of 40 stones were removed after a follow-up period of 31 +/- 6 months. Oral ursodeoxycholic acid facilitates extraction of defiant bile duct stones. This treatment is an effective alternative to high-tech extraction methods for large biliary stones.

Endoscopic treatment of problems encountered after laparoscopic cholecystectomy [corrected].

With the advent of laparoscopic cholecystectomy, a number of patients with various postprocedure problems have been referred for endoscopic management. Thirty-five patients were evaluated. The group included 26 women and 9 men, ages 24 to 90 years (mean, 50 years). Twenty-five patients with retained common bile duct stones were successfully treated with endoscopic sphincterotomy and balloon or basket removal. Three patients with bile duct strictures had balloon dilation and endoprosthesis placement and were free of signs of obstruction on 9-month follow-up. Bile leaks were treated successfully with endoscopic sphincterotomy and endoprosthesis placement. Two patients with bile duct leaks and biloma formation required percutaneous or surgical drainage in addition to endoscopic treatment. Three patients had more than one complication. Two patients had strictures with retained stones above the stricture; dilation of the stricture was performed and the stones were removed. One patient with the complication of biliary leak and a long, irregular stricture was treated temporarily by sphincterotomy and stent placement while awaiting surgery. Therapeutic biliary endoscopy is a valuable, minimally invasive alternative to surgery in patients with problems arising after laparoscopic cholecystectomy.

Incidence and risk factors for biliary and pancreatic stent migration.

Endoprostheses are commonly used in the treatment of biliary and pancreatic disorders. The frequency of and potential risk factors for stent migration, however, remain largely unknown. From January 1986 to June 1990, 807 biliary and pancreatic stents were placed at our institution. Our study analyzed the occurrence of stent migration among the 589 stents for which follow-up data were available. Results demonstrated incidence rates of 4.9 and 5.9% for proximal (into the duct) and distal (out of the duct) biliary stent migration, respectively. Likewise, incidence rates of 5.2 and 7.5% were observed for proximal and distal pancreatic stent migration, respectively. Malignant strictures, larger diameter stents, and shorter stents were significantly associated with proximal biliary stent migration. Sphincter of Oddi dysfunction and longer stents were associated with proximal pancreatic stent migration. Migration of stents out of the common bile duct occurred more frequently in papillary stenosis. No other significant risk factors for distal migration were found. These results indicate that stent migration is an important complication. Multiple risk factors were associated with stent migration and need to be considered in the development of new stent types.

Endoscopic sphincterotomy complications and their management: an attempt at consensus.

Despite its relative safety (in comparison with surgery), and undoubted role in many clinical circumstances, biliary sphincterotomy is the most dangerous procedure routinely performed by endoscopists. Complications occur in about 10% of patients; 2 to 3% have a prolonged hospital stay, with a risk of dying. This document is an attempt to provide guidelines for prevention and management of complications, based on a workshop of selected experts, and a comprehensive review of the literature. We emphasize particularly the importance of specialist training, disinfection, drainage, and collaboration with surgical colleagues.

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.

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.