Autoimmune pancreatitis, pancreatic mass, and lower gastrointestinal bleed.

Autoimmune pancreatitis (AIMP) is a recently described clinical entity causing chronic pancreatitis. It often presents with diffuse enlargement of the pancreas and/or a focal mass at the head of the pancreas causing common bile duct obstruction and jaundice. In most instances, AIMP is mistaken for pancreatic cancer. A number of laboratory abnormalities such as positive antinuclear antibody, hypergammaglobulinemia, and antibody to carbonic anhydrase are often present in these patients. Currently, pancreatic biopsy demonstrating characteristic histopathologic changes is essential to establish the diagnosis. We report the first case of AIMP presenting as a pancreatic tail mass and lower gastrointestinal bleed.

Self-expandable metal stents for malignant gastric outlet obstruction: a modified technique.

BACKGROUND AND STUDY AIMS: Endoscopic palliative treatment may be effective in the management of malignant gastric outlet obstruction. However, experience in this area is limited, and the techniques vary widely. In this retrospective study, a uniform technique using nearly identical self-expandable metal stents was employed to assess technical feasibility, safety, and outcome. PATIENTS AND METHODS: Eight patients presenting with clinical findings of gastric outlet obstruction confirmed by upper gastrointestinal radiography underwent endoscopic placement of expandable metal stents. All patients had primary or metastatic malignancy involving the pylorus or duodenum. Endoscopic and Gastrografin-enhanced upper gastrointestinal radiographic evaluations were carried out immediately after stent placement. Complications and clinical outcomes were assessed in each patient. RESULTS: Five patients had extrinsic compression of the descending duodenum due to pancreatic cancer, two had pyloric stenosis from metastatic cancer, and one patient had primary duodenal cancer. Stent placement was successful in all patients, and was followed by clinical improvement. There was one death within 30 days, related to pneumonia. CONCLUSION: Endoscopic self-expandable stent placement appears to be a reasonable therapeutic alternative in patients with malignant gastric outlet obstruction.

Brush cytology for pancreatic carcinoma: an analysis of factors influencing results.

BACKGROUND: Despite recent advances in cytology brush design, yield of endoscopic brush cytology in suspected pancreatic carcinoma remains low. METHODS: We prospectively evaluated 32 such patients by ERCP to analyze differences in yield based on anatomic location of the pancreatic stricture, and the role of concurrent biliary stricture brush cytology, in improving the overall yield. Endoscopic brush cytology was performed on all strictures following ERCP. A final diagnosis of pancreatic carcinoma was confirmed in all patients. RESULTS: Twenty-three of the 32 patients had positive cytology for pancreatic malignancy (71.9%). Eight patients had positive brushings from biliary strictures alone (25%) and 15 had positive brushings obtained from pancreatic strictures (46.9%). The yield varied widely depending on the anatomic location of the stricture; ampullary, genu, and tail regions had low rates of positive cytology, in part due to technical factors and brush design (1 of 8, 2 of 6, and 1 of 4, respectively). Strictures of the head and body yielded high rates of positive cytology (7 of 8 and 4 of 6, respectively). CONCLUSIONS: The yield of endopancreatic brush cytology is related to the location of malignancy, with overall yield enhanced by concurrent brushing of bile duct strictures.

Saline injection needle-knife sphincterotomy: a preliminary report.

BACKGROUND AND STUDY AIMS: Needle-knife sphincterotomy is an established technique in the management of some patients with biliary tract obstruction. However, the technique can be technically difficult in patients with very small papillae, specially when associated with distorted ampullary and duodenal anatomy. We present here a technique that may enhance successful needle-knife sphincterotomy in this situation. PATIENTS AND METHODS: Eight patients with biliary tract obstruction who had small papillae and distorted ampullary or duodenal anatomy were evaluated. All patients had undergone one or more unsuccessful cannulations prior to referral. All eight patients underwent saline injection of their papillae, creating a bulging papilla, prior to needle-knife sphincterotomy. RESULTS: Seven of the eight patients had successful needle-knife sphincterotomy following saline injection, and endoscopic therapy during the first attempt. In one patient, the procedure was successful at a second attempt 48 hours later. There were no instances of significant complications. CONCLUSION: Saline injection into the papilla prior to needle-knife sphincterotomy may improve success rates in patients with unusually small papillae and distorted ampullary or duodenal anatomy. However, at present this technique should only be attempted by experienced endoscopists. Further studies with larger numbers of patients are required before the safety of this technique can be fully evaluated.

Periampullary disorders: review of pathophysiology.

The ampulla of Vater is strategically located at the confluence of the terminal end of the bile duct and the pancreatic duct. It is entwined by smooth muscle fibers often referred to as the sphincter of Oddi. As a result, the ampulla demonstrates dynamic motor activity. A variety of structural and functional abnormalities can involve the ampulla and the periampullary region. Disorders involving the ampulla often produce remarkably similar clinical features, such as acute pancreatitis, biliary colic, or jaundice. Therefore, it is important that patients with periampullary disorders are systematically studied using endoscopic retrograde cholangiopancreatography, sphincter of Oddi manometry, and endoscopic ultrasonography. Common disorders involving the periampullary region and state-of-the-art techniques for diagnosis and treatment of these disorders are discussed.

Cutting the defiant lower esophageal ring.

A symptomatic lower esophageal ring generally responds to standard bougienage therapy. However, a subset of patients with a lower esophageal ring defy dilation therapy. We have evaluated the efficacy of electrocautery incision of "defiant" lower esophageal rings, the data of which forms the basis of this report. Seven of 75 patients with a lower esophageal ring failed to respond to conventional esophageal dilation. All seven patients underwent electrocautery incision of a "defiant" lower esophageal ring with alleviation of dysphagia. One patient had recurrence of dysphagia that occurred 6 months after initial electrocautery incision. No major complication occurred, although one patient had transient chest pain. Subsequently, all patients have remained without symptoms at a mean follow-up of 36 months. Electrocautery incision of "defiant" lower esophageal ring is efficacious, safe, and results in long-term relief of dysphagia.

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.

Assessment of ampulla of Vater pathology. An endoscopic approach.

One hundred eighty-nine endoscopic biopsies of the papilla of Vater were obtained from 125 patients during a 10-year period. Chronic inflammation was the most common histologic change identified. Of the 44 patients with papillary neoplasia, 42 were diagnosed by endoscopic biopsy. Sixteen of the 18 patients with invasive carcinoma were diagnosed by biopsy. Follow-up biopsies in patients endoscopically managed demonstrated recurrent tumors in 6 of 11 patients. With advances in instrumentation and techniques, pathologists can expect to see increasing numbers of ampullary biopsies. When multiple biopsy fragments are obtained and step sectioned, the diagnostic reliability of endoscopic biopsies in patients with tumors and carcinoma is greater than 90%. The morphologic spectrum of papillary lesions is similar to that seen in the colon with some significant exceptions. Tumor morphology varied considerably from area to area. Variations were seen in the basic architecture (villous-tubular), grade of dysplasia, presence of malignancy, and invasion from fragment to fragment, and in some cases from microscopic field to field. Another notable difference between the ampulla and colon is the rich mucosal lymphatic network of the ampullary region. Thus, any carcinoma invading the lamina propria was diagnosed as invasive carcinoma.

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.