Endoscopic ultrasound guided transmural drainage of walled off pancreatic necrosis using a "step - up" approach: A single centre experience.

BACKGROUND: Walled off necrosis (WON) can be treated endoscopically using multiple transmural plastic stents or fully covered self-expandable metallic stent (FCSEMS) and direct endoscopic necrosectomy (DEN). We evaluated the efficacy of "step-up" endoscopic transmural approach for treatment of WON. METHODS: Retrospective analysis of data of 86 patients with WON who were treated with attempted endoscopic ultrasound (EUS) guided "step up" transmural drainage during last 5 years was done. Initially multiple plastic stents were placed and patients not responding underwent FCSEMS placement and/or DEN. RESULTS: Patients presented 10.8 ± 2.8 weeks after an acute attack of acute pancreatitis and mean size of WON was 10.7 ± 2.9 cm. EUS guided transmural drainage was technically successful in 85/86 (98.8%) patients and 70 (82.4%) were drained with multiple 7/10Fr plastic stents alone while DEN was needed in 9 (10.6%) and FCSEMS was inserted in 6 (7%) patients. All patients had successful outcome with none requiring surgery. The patients who needed DEN/FCSEMS presented earlier and had large size collection with more solid necrotic debris as compared to patients treated with multiple plastic stents alone. The complications were pneumoperitoneum (n = 1), bile leak following cholecystecomy (n = 1), development of external pancreatic fistula following percutaneous drainage (n = 1) and gastrointestinal bleed (n = 1). CONCLUSIONS: "Step up" endoscopic transmural drainage using multiple plastic stents as an initial therapy is safe and effective treatment of WON and avoids more aggressive DEN in majority of patients. Large size WON with more necrotic debris may require DEN.

Extra-pancreatic necrosis alone: Contours of an emerging entity.

Acute pancreatitis is of two morphologic types: interstitial edematous pancreatitis that is not associated with any tissue necrosis and necrotizing pancreatitis wherein the pancreatic parenchyma with or without varying amount of extra-pancreatic tissue/fat undergoes necrosis. Necrotizing pancreatitis has a worse outcome compared with interstitial pancreatitis because of increased severity related to a heightened systemic response and cytokine storm associated with tissue necrosis. Increasingly, an entity of extra-pancreatic necrosis (EPN) alone, wherein the pancreatic parenchyma is normal on an enhanced computed tomographic scan but the peri-pancreatic tissues undergo necrosis, is being recognized. Available data suggest that the outcomes in patients with EPN alone are between the excellent prognosis of patients with interstitial and adverse prognosis of patients with necrotizing pancreatitis. The extent of EPN also seems to determine the outcome. This review summarizes the currently available literature on this entity and various radiological scores that have been suggested to determine the presence and stage of EPN.

Pancreatic tuberculosis.

Pancreatic tuberculosis is very rare, but recently, there has been a spurt in the number of reports on pancreatic involvement by tuberculosis. It closely mimics pancreatic cancer, and before the advent of better imaging modalities it was often detected as a histological surprise in patients resected for a presumed pancreatic malignancy. The usual presentation involves abdominal pain, loss of appetite and weight, jaundice which can be associated with cholestasis, fever and night sweats, palpable abdominal lump, and peripheral lymphadenopathy. Computed tomography (CT) of the abdomen is an important tool for evaluation of patients with pancreatic tuberculosis. This CT imaging yields valuable information about the size and nature of tubercular lesions along with the presence of ascites and lymphadenopathy. However, there are no distinctive features on CT that distinguish it from pancreatic carcinoma. Endoscopic ultrasound provides high resolution images of the pancreatic lesions as well as an opportunity to sample these lesions for cytological confirmation. The presence of granulomas is the most common finding on histological/cytological examination with the presence of acid fast bacilli being observed only in minority of patients. As there are no randomized or comparative studies on treatment of pancreatic tuberculosis it is usually treated like other forms of tuberculosis. Excellent cure rates are reported with standard anti tubercular therapy given for 6-12 months.

Naso-jejunal fluid resuscitation in predicted severe acute pancreatitis: Randomized comparative study with intravenous Ringer's lactate.

INTRODUCTION: Early management of severe acute pancreatitis (SAP) includes intravenous fluid resuscitation. AIM: To confirm feasibility of naso-jejunal (NJ) fluid resuscitation using oral hydration solution (ORS) and compare its efficacy with intravenous (IV) fluid resuscitation using Ringer Lactate (RL) in predicted SAP. PATIENTS AND METHODS: All patients of predicted SAP (presence of SIRS or BISAP > 2) without significant co morbidities were randomized to NJ group (ORS: 20 ml/kg bolus and then 3 mL/kg/h) or IV group (RL infusion at same rate). The groups were compared vis-à-vis persistent organ failure (POF), pancreatic necrosis, and mortality. RESULTS: Seventy-seven patients were assessed and after exclusion, 49 patients were randomized to either NJ (24 patients) or IV group (25). The demographic and baseline clinical profile of both groups including BISAP score (2.25 ± 0.73 and 2.32 ± 0.56), hematocrit (40.2 ± 6.8 and 38.3 ± 6.6), blood urea nitrogen (16.88 ± 6.69 and 21.44 ± 17.56 mg/dL), and intra-abdominal pressure (14.55 ± 4.8 and 14.76 ± 5.5 cm of water) were similar. NJ resuscitation had to be stopped in two patients because of abdominal discomfort and distension. The change in intra abdominal pressure after 48 h of hydration was comparable in both groups. The occurrence of POF (66.67% and 68%), pancreatic necrosis (69.5% and 76%), intervention (5 each), surgery (1 each), and mortality (16.5% and 8%) were comparable (P > 0.05). CONCLUSION: In select group of patients with SAP, NJ fluid resuscitation with ORS is feasible and is equally efficacious as IV fluid resuscitation with RL.

Clinical significance of presence and extent of extrapancreatic necrosis in acute pancreatitis.

BACKGROUND AND AIM: Extrapancreatic necrosis (EPN) alone represents a subgroup of pancreatitis with better outcome than patients with pancreatic parenchymal necrosis (PN). However, data on clinical significance of EPN is limited, and significance of the extent of EPN is not known. METHODS: Two hundred thirteen patients (136 [63.8%] males; mean age: 39.8 ± 13.2 years) with acute pancreatitis were prospectively enrolled and followed up till recovery or death. Contrast-enhanced computed tomography of each patient was retrospectively evaluated for presence of PN and EPN, pleural effusion and ascites. EPN was termed extensive if it extended to paracolic gutters or pelvis. RESULTS: Twenty-one (9.9%) patients had interstitial pancreatitis, seven (3.3%) patients had PN alone, 48 (22.5%) patients had EPN alone, and 137 (64.3%) patients had combined PN and EPN. Patients with EPN alone had significantly higher frequency of organ failure than patients with interstitial pancreatitis. Compared with patients with EPN alone, the patients with combined necrosis had significantly higher frequency of pleural effusion (88.2% vs. 75%), ascites (41% vs. 20.8%), and need for intervention (32.6% vs. 14.6%). Patients with extensive EPN (n = 57) had significantly higher frequency of pleural effusion, ascites, and multi-organ failure than those with limited EPN. CONCLUSION: EPN alone should be considered as a separate category of acute pancreatitis as it has less severe course than PN but has more severe course than interstitial pancreatitis. Patients with extensive EPN in spite of having increased frequency of ascites, pleural effusion, and multi-organ failure had similar outcome as compared to patients with limited EPN.

Gastrointestinal bleeding in acute pancreatitis: etiology, clinical features, risk factors and outcome.

BACKGROUND: There is paucity of data on the effect of interventions on risk of gastrointestinal bleeding (GIB) in acute pancreatitis (AP). METHODS: Retrospective study of records of patients with AP and GIB. RESULTS: 16 (3.7%) patients (14 males; mean age 39.3 ± 12.8 years) had gastrointestinal bleeding. Two patients had peptic ulcer disease related GIB. The cause of GIB in remaining patients was: pseudoaneurysms in 5, gastrointestinal fistulization in 4, and no identifiable lesion in 5. Two patients with pseudoaneurysms were treated with angioembolisation whereas 3 needed surgery. The patients with gastrointestinal fistula had complicated course and 3 of these 4 patients died due to sepsis and multi organ failure. Rest 5 patients with no identifiable lesion were managed conservatively and there was no recurrence of GIB. Of the 14 patients with AP related GIB, a previous intervention had been done in 11(79%) patients. Fifty-three patients (12.7%) without GIB died whereas 5 (31.2%) patients with GIB succumbed to the illness (p = 0.04). CONCLUSIONS: The majority of our patients of AP with GIB had antecedent history of interventions. The mortality was higher in patients with GIB, which was not due to hemorrhage but to sepsis and related complications.

Comparison of encapsulated versus nonencapsulated (14) C-urea breath test for the detection of Helicobacter pylori infection: a scintigraphy study.

BACKGROUND AND AIMS: (14) C-urea breath test ((14) C-UBT) is considered as "gold standard" for detection of active gastric H. pylori infection. However, till date no comparative study using encapsulated and non-encapsulated (14) C-UBT protocols has been conducted in same subjects in identical conditions. We monitored gastric fate of capsule containing (14) C-urea with real time display and compared sensitivities of these protocols at different time points of breath collection. METHODS: Non-encapsulated (14) C-UBT was performed using 74 kBq of (14) C-urea in 100 dyspeptic patients by collecting breath samples at 10, 15 and 20 minutes. Thereafter, within 2 days a gelatin capsule containing (14) C-urea along with 6.0 MBq of (99m) Tc-diethylene triamine penta-acetic acid was administered to each patient for real time display of capsule movement and its fate in gastrointestinal tract by gamma camera. Simultaneously, breath samples were collected for (14) CO2 measurement during image acquisition. RESULTS: Employing non-encapsulated (14) C-UBT, 74 out of 100 dyspeptic patients were found to be H. pylori positive. Discordant (14) C-UBT results were obtained in 4/74 (5.4%) cases using these two protocols. By employing encapsulated and nonencapsulated (14) C-UBT protocols, sensitivities of (14) C-UBT were found to be 90.5 versus 98.6% at 10 and 91.8 versus 97.2% at 15 minutes respectively; while these were 94.6 versus 100, 90.7 versus 98.6 and 83.7 versus 93.2% considering any one, two or all three positive values respectively. CONCLUSIONS: Incomplete/non-resolution of (14) C-urea capsule in stomach during the phase of breath collections appears to decrease sensitivity of encapsulated (14) C-UBT as compared to nonencapsulated protocol for detection of H. pylori infection.

Pancreatic encephalopathy: an unusual cause of asterixis.

CONTEXT: Pancreatic encephalopathy is the occurrence of neuropsychiatric abnormalities in setting of acute pancreatitis which is not otherwise explained by presence of electrolyte abnormities, or organic lesions. The pathogenesis of pancreatic encephalopathy is incompletely understood. The clinical presentation is variable. CASE REPORT: A 60 year old male, a diabetic for 5 years, was admitted with three days of abdominal pain associated with vomiting and complicated by altered sensorium for one day. He developed asterixis during the course of his hospital stay. Other workup was non-contributory and patient improved with supportive management. CONCLUSION: Asterixis has not hitherto been reported in pancreatic encephalopathy.

Bone mineral metabolism and bone mineral density in alcohol related and idiopathic chronic pancreatitis.

BACKGROUND: There is limited information on the bone mineral metabolism in patients with chronic pancreatitis (CP). METHODS: 103 patients with CP (all males: mean age 38.6 ± 20.64 yrs) and 40 age matched control males (mean age: 36.7 ± 20.70 yrs) were prospectively studied. Serum levels of 25 (OH) Vitamin D3, alkaline phosphatase (ALP), and parathyroid hormone (PTH) were measured. Bone mineral density (BMD) was measured using adual-energy X-ray absorptiometry (DEXA) scanner. RESULTS: Seventy two (70%) patients had alcohol related chronic pancreatitis (ACP), 30 (29.1%) patients had idiopathic chronic pancreatitis (ICP) and one patient had post-traumatic chronic pancreatitis. Fifty nine (59.8%) patients had chronic calcific pancreatitis (CCP) and 39 (37.8%) patients were diabetic. Steatorrhea was noted in 21 (20.4%) patients. On comparison with controls, patients with chronic pancreatitis had significantly lower 25 (OH) Vitamin D3 levels (p = 0.01). On evaluation of bone mineral density (BMD) at lumbar spine, 46% patients were osteopenic and 12% patients were osteoporotic. On evaluation of BMD of femur, 30.1% patients were osteoporotic and 39.8% patients were osteopenic. No significant difference was found in the frequency of metabolic osteopathy between alcoholic and idiopathic groups (p = 0.108), calcific and non-calcific groups (p = 0.410), diabetic and non-diabetic groups (p = 0.126). smokers and non-smokers (p = 0.198), and patients with and without history of steatorrhea (p = 0.265) and indifferent severity groups ofupancreatitis (p = 0.910) CONCLUSIONS: Majority of patients with both ACP and ICP had low BMD and similar frequency of bone changes between various groups suggests that systemic inflammation may play an important role in its pathogenesis. Further detailed metabolic studies are necssary to define the pathogenic mechanism of metabolic osteopathy associated with chronic pancreatitis.

Comparative evaluation of barium meal follow-through and barium enteroclysis before capsule endoscopy in obscure gastrointestinal bleeding.

BACKGROUND/AIMS: Small bowel radiological investigations have lower diagnostic yield in comparison to capsule endoscopy (CE) and are inaccurate in predicting capsule impaction. Most studies have used barium meal follow-through (BAMFT) and more sensitive barium enteroclysis (BE) is infrequently used. This study was done to retrospectively compare results of performing BAMFT or BE before CE in patients with obscure gastrointestinal bleeding. METHODOLOGY: Sixtyfive patients with obscure gastrointestinal bleeding underwent barium examination (BE or BAMFT depending upon patient's preference) and CE was performed if barium examination was normal. The demographic data, barium examination results and CE findings were retrospectively collected. RESULTS: Sixteen patients underwent BAMFT and 49 patients underwent BE prior to CE. BAMFT was normal in all 16 patients whereas CE was normal in only 1/16 patient. Seven of 49 (14.2%) patients had stricture or mass on BE. In these 7 patients CE was not performed. In contrast to BAMFT, 22/41 (53.6%) patients with normal BE had normal CE findings also. The capsule got stuck in one patient with NSAID induced diaphragm disease who had normal BE and required surgical removal. CONCLUSIONS: BE should be preferred over BAMFT as the radiological imaging technique for evaluation of small bowel before CE in patients with obscure gastrointestinal bleeding as it may detect unexpected strictures and intraluminal masses. However, radiological findings either on BAMFT or BE cannot predict passage of capsule endoscope through small bowel.

Superiority of non-capsulated 14C-urea breath test over capsule based method for detection of Helicobacter pylori infection - a preliminary report.

BACKGROUND: 14C-urea breath test (14C-UBT) is employed as a 'gold standard' technique for the detection of active gastric Helicobacter pylori infection and is recommended as the best option for "test-and-treat" strategy in primary health care centers. AIM: To compare the performance of capsulated and non-capsulated 14C-UBT protocols for the detection of H. pylori infection in patients. METHODS: Fifty eight H. pylori infected patients underwent routine upper GI endoscopy and biopsies were processed for rapid urease test (RUT) and histopathology examination. Capsulated 14C-UBT was done in a novel way by using 74 kBq of 14C-urea along with 6.0 MBq of 99mTc-diethylene triamine penta-acetic acid (99mTc-DTPA) to simultaneously monitor the movement and the fate of ingested capsule after delineating the stomach contour by using 20.0 MBq of 99mTechnetium pertechnetate (99mTcO4-) under dual head gamma camera. Non-capsulated 14C-UBT was performed within 2 days of the previous test and the results of these protocols were compared. RESULTS: In 3 out of 58 H. pylori positive cases (5.17%), 14C-UBT results were found to be negative by using the capsulated method. Interestingly, on monitoring the real time images of the capsule in these cases it was found that misdiagnosis of H. pylori infection occurred mainly due to either rapid transit of the 14C-urea containing capsule from the upper gastric tract or its incomplete resolution in the stomach during the phase of breath collection. CONCLUSION: Use of non-capsulated '4C-UBT protocol appears to be a superior option than the conventional capsule based technique for the detection of H. pylori infection.

Colonic lesions in patients undergoing small bowel capsule endoscopy.

PURPOSE: Capsule endoscopy by enabling direct visualization of small bowel mucosa has conquered the last frontier of diagnostic endoscopy. However, its ability to simultaneously detect colonic lesions has not been evaluated. This study was done to evaluate frequency of detection of colonic abnormalities in patients undergoing small bowel capsule endoscopy and its impact on the clinical management. PATIENTS AND METHODS: Eighty-seven patients (60 males; mean age: 51.2 ± 18.6 years) who had obscure gastrointestinal bleeding or unexplained abdominal pain or unexplained diarrhea underwent capsule endoscopy. The demographic data and capsule endoscopy findings were retrospectively evaluated. RESULTS: Capsule endoscopy was normal in 26 (29.8%) patients and small bowel abnormalities were noted in 49 (56.3%) patients. Capsule endoscope did not reach the cecum during the battery life period of the capsule in five (5.7%) patients. Colonic abnormalities were noted in eight (9.1%) patients. These included cecal angiodysplasia (four), cecal carcinoma (one), transverse colon polyp (one), sigmoid colon ulcerations with histological diagnosis of Crohn's colitis (one), and cecal ulcers with final diagnosis of amebic colitis (one). CONCLUSION: The colon should also be carefully evaluated in patients undergoing small bowel capsule endoscopy as significant lesions can be detected that helps in appropriate management.

Endoscopic ultrasound (EUS) features of mediastinal tubercular lymphadenopathy.

BACKGROUND/AIMS: Endoscopic ultrasound (EUS) findings in mediastinal tubercular lymphadenopathy have not been well characterized. This study aims to assess the accuracy of EUS findings of patchy anechoic or hypoechoic areas and hyperechoic foci in mediastinal lymph nodes for the diagnosis of mediastinal tuberculosis. METHODOLOGY: Forty-two patients with enlarged mediastinal lymph nodes who underwent EUS guided FNA were included. EUS findings were retrospectively reviewed for size, patchy anechoic or hypoechoic areas and hyper echoic foci. The final diagnosis was based on cytological examination of aspirate as well as clinical follow-up. RESULTS: Final diagnosis was tuberculosis in 22 patients and non-tubercular diagnosis in the rest. Hyperechoic foci in the lymph nodes was seen in 77.2% of patients with tubercular mediastinal lymphadenopathy and in 5% of patients with non-tubercular mediastinal lymphadenopathy (p=0.00). Patchy anechoic or hypoechoic areas were seen in 40.9% patients with tubercular mediastinal lymphadenopathy whereas none of the patients with non-tubercular mediastinal lymphadenopathy presented these (p=0.01). The patchy anechoic or hypoechoic areas or hyperechoic foci in the mediastinal lymph nodes had accuracies of 69.0% and 85.7%, respectively, for the diagnosis of tuberculosis. CONCLUSIONS: Patchy anechoic or hypoechoic areas or hyperechoic foci in the mediastinal lymph nodes on EUS are important signs of mediastinal tubercular lymphadenopathy and EUS guided FNA is a useful modality for diagnosis of mediastinal tuberculosis.