EUS-guided pseudocyst drainage: prospective evaluation of early removal of fully covered self-expandable metal stents with pancreatic ductal stenting in selected patients.

BACKGROUND: EUS-guided pseudocyst drainage with fully covered self-expandable metal stents (FCSEMSs) was recently described. The appropriate period for stent removal is not known. OBJECTIVE: To assess the safety and efficacy of EUS-guided FCSEMS placement for 3 weeks, along with pancreatic ductal stenting in selected patients. STUDY DESIGN: Prospective, single-center evaluation. SETTING: Tertiary referral center. PATIENTS: Symptomatic pseudocysts in the body and tail region of the pancreas. INTERVENTIONS: EUS-guided transgastric placement of FCSEMS. MRCP was performed after 3 weeks. Patients with a suspected pancreatic duct leak underwent ERCP and plastic stent placement. The FCSEMSs were removed at 3 weeks. MAIN OUTCOME MEASUREMENTS: Success of FCSEMS placement, adverse events, and recurrence rate. RESULTS: Forty-seven patients met the eligibility criteria. Technical and functional success was achieved in 43 patients (intention to treat, 91.48% and 95.34% patients [per protocol, 41/43, respectively]). Adverse events occurred in 2 patients (cyst infections, 4.6%). Follow-up of 42 patients at 3 weeks was performed. MRCP detected a ductal leak in 3 patients (7.1%) and a disconnected duct in 2 patients (4.7%). ERCP and stenting were successful in all 3 patients with a ductal leak. During a median follow-up of 306 days in 42 patients, 2 recurrences (4.7%) were detected, both in patients with disconnected duct. Multivariate analysis showed that pancreatic ductal leak or disconnection was an independent factor affecting pseudocyst resolution at 3 weeks (P = .0001). LIMITATIONS: Single-center study. CONCLUSION: Short-term placement of FCSEMSs with pancreatic ductal stenting in selected patients appears safe and effective for the treatment of pseudocysts.

Recurrent acute pancreatitis in a patient with wirsungocele and neuroendocrine tumor of ampulla of Vater.

CONTEXT: Wirsungocele has recently been shown to be associated with acute recurrent, severe necrotizing pancreatitis and chronic pancreatitis or chronic pain in abdomen. Till to date there is no report on association of wirsungocele with an ampullary neuroendocrine tumor, and recurrent pancreatitis. CASE REPORT: We report a first ever case of wirsungocele diagnosed on EUS, its association with neuroendocrine tumor of ampulla and recurrent acute pancreatitis. CONCLUSION: This case report highlights the diagnostic utility of EUS in diagnosing small ampullary pathology like wirsungocele and neuroendocrine tumor.

Massive Liver Trauma-Multidisciplinary Approach and Minimal Invasive Surgery can Salvage Patients.

Management of massive liver trauma (grades IV-VI) is associated with high morbidity and mortality. It can pose serious challenges to treating physician and requires multimodality interventions. For a successful outcome, timing of intervention is crucial. We report a case of grade V hepatic injury treated successfully with angioembolization, laparoscopic lavage, and endoscopic stenting during a time period from admission to discharge on the 24th day. Angioembolization was performed at admission after resuscitation as CT scan showed active extravasation in the arterial phase. Laparoscopic lavage and drainage was performed on the fifth day as abdominal inflammatory response failed to respond to medical management. There was biliary component of abdominal fluid noticed during laparoscopy, which manifested by postoperative localized biliary fistula; hence endoscopic stenting of the bile duct was performed on the seventh day. The patient recovered well with timely minimal invasive approach and was fine at 1 year follow-up.

Comparison of transhepatic and extrahepatic routes for EUS-guided rendezvous procedure for distal CBD obstruction.

BACKGROUND: EUS-guided rendezvous procedure (EUS-RV) can be done by the transhepatic (TH) or the extrahepatic (EH) route. There is no data on the preferred access route when both routes are available. STUDY AIM: To compare the success, complications, and duration of hospitalization for patients undergoing EUS-RV by the TH or the EH route. PATIENTS AND METHODS: Patients with distal common bile duct (CBD) obstruction, who failed selective cannulation, underwent EUS-RV by the TH route through the stomach or the EH route through the duodenum. RESULTS: A total of 35 patients were analysed (17 TH, 18 EH). The mean procedure time was significantly longer for the TH group (34.4 vs. 25.7 min; p = 0.0004). There was no difference in the technical success (94.1 vs. 100%). However, the TH group had a higher incidence of post-procedure pain (44.1 vs. 5.5%; p = 0.017), bile leak (11.7 vs. 0; p = 0.228), and air under diaphragm (11.7 vs. 0; p = 0.228). All bile leaks were small and managed conservatively. Duration of hospitalization was significantly higher for the TH group (2.52 vs. 0.17 days; p = 0.015). CONCLUSIONS: EUS-RV has similar success rate by the TH or the EH route. However, the TH route has higher post-procedure pain, longer procedure time, and longer duration of hospitalization. The EH route should be preferred for EUS-RV in patients with distal CBD obstruction when both access routes are technically feasible.

Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access (with videos).

BACKGROUND: Precut papillotomy after failed bile duct cannulation is associated with an increased risk of pancreatitis. EUS-guided rendezvous drainage is a novel alternative technique, but there are no data comparing this approach with precut papillotomy. OBJECTIVE: To evaluate the safety and efficacy of EUS-guided rendezvous drainage of the bile duct and compare its outcome with that of precut papillotomy. DESIGN: Retrospective study. SETTING: Tertiary care referral center. PATIENTS: Consecutive patients with distal bile duct obstruction, in whom selective cannulation of the bile duct at ERCP failed after 5 attempts with a guidewire and sphincterotome, underwent an EUS-guided rendezvous procedure. The outcomes were compared with those in a historical cohort of patients who underwent precut papillotomy. INTERVENTIONS: Patients in whom selective cannulation failed underwent EUS-guided rendezvous drainage by use of the short wire technique or precut papillotomy by use of the Erlangen papillotome. At EUS, after the extrahepatic bile duct was punctured with a 19-gauge needle, a hydrophilic angled-tip guidewire 260 cm long was passed in an antegrade manner across the papilla into the duodenum. The echoendoscope was then exchanged for a duodenoscope, which was introduced alongside the EUS-placed guidewire. The transpapillary guidewire was retrieved through its biopsy channel, and accessories were passed over the wire to perform the requisite endotherapy. MAIN OUTCOME MEASURES: Comparison of the rates of technical success and complications between patients treated by the EUS-guided rendezvous and those treated by precut papillotomy techniques. Treatment success was defined as completion of the requisite endotherapy in one treatment session. RESULTS: Treatment success was significantly higher for the EUS-guided rendezvous (57/58 patients) than for those undergoing precut papillotomy technique (130/144 patients) (98.3% vs 90.3%; P = .03). There was no significant difference in the rate of procedural complications between the EUS and precut papillotomy techniques (3.4% vs 6.9%, P = .27). LIMITATIONS: Retrospective nonrandomized study design; highly selective patient cohort. CONCLUSIONS: In this study, the EUS-guided rendezvous technique was found to be superior to precut papillotomy for single-session biliary access. Prospective randomized trials are needed to confirm these preliminary but promising findings.

Single-operator cholangioscopy-guided laser lithotripsy in patients with difficult biliary and pancreatic ductal stones (with videos).

BACKGROUND: Scant data exist on the utility of the holmium:yttrium-aluminum-garnet laser for the treatment of biliary or pancreatic duct stones. OBJECTIVE: To evaluate the efficacy and safety of fiberoptic probe and catheter system-guided holmium laser lithotripsy of difficult biliary and pancreatic duct stones. DESIGN: Prospective study. SETTING: Tertiary-care referral center. PATIENTS: This study involved 64 patients who underwent holmium laser stone fragmentation. INTERVENTION: A total of 64 patients (60 bile duct stones, 4 pancreatic duct stones) underwent endoscopic retrograde stone fragmentation with a holmium laser and a fiberoptic probe and catheter system. The inclusion criterion for bile duct stones was stones not amenable to retrieval by mechanical lithotripsy and/or balloon sphincteroplasty or standard techniques. Pancreatic duct stones included in this study were not amenable to removal by stone retrieval basket or balloon. MAIN OUTCOME MEASUREMENTS: Rates of ductal clearance and procedural complications. RESULTS: All 64 patients had successful fragmentation of biliary and pancreatic duct stones with the holmium laser. Fifty of 60 patients (83.3%) had complete biliary duct clearance after a single session; 10 patients required an additional session. All pancreatic duct stones were fragmented in a single session. Mean duration of ERCP sessions was 45.9 minutes (range 30-90 minutes). Complications were mild and were encountered in 13.5% of patients; fever (n = 3), transient abdominal pain (n = 4), and biliary stricture (n = 1). LIMITATIONS: No comparative treatment group. CONCLUSION: The fiberoptic probe and catheter system facilitates transpapillary access for holmium laser fragmentation of difficult biliary and pancreatic duct stones. The technique is safe and highly effective for single-setting duct clearance. Complications are minimal and transient.

Endosonography-guided fine needle aspiration cytology of intra-abdominal lymph nodes with unknown primary in a tuberculosis endemic region.

BACKGROUND AND AIM: Intra-abdominal lymphadenopathy poses a diagnostic and management challenge in highly endemic regions for tuberculosis. Opting for empirical anti-tuberculosis treatment raises the risk of wrong or delayed treatment. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the procedure of choice for tissue acquisition from peri-luminal lymph nodes. We studied the utility of EUS-FNA in evaluating intra-abdominal lymph nodes of unknown etiology, in the setting of high endemicity of tuberculosis. METHODS: Consecutive patients with intra-abdominal lymph nodes of unknown etiology underwent EUS-FNA using a 22-gauge needle. Final diagnosis was made on surgical histology or on 6-months follow-up. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic yield were calculated. RESULTS: Sixty-six patients were included. Final diagnoses were tuberculosis, 35 (53%); metastatic adenocarcinoma, 11 (16.7%); lymphoma, three (4.5%); carcinoid, one (1.5%) and reactive nodes, 16 (24.2%). EUS-FNA provided a diagnosis in 61 patients (92.4%). Sensitivity, specificity, PPV and NPV for diagnosing tuberculosis via EUS-FNA were 97.1%, 100%, 100% and 96.9%, respectively. In 10 (15.2%) patients receiving empirical anti-tuberculosis treatment, the final diagnoses were metastatic adenocarcinoma (5), lymphoma (2), carcinoid (1) and reactive adenopathy (2). CONCLUSION: Despite being in a highly endemic area, almost half of the patients studied have a non-tuberculosis etiology. EUS-FNA is a safe and accurate procedure for establishing the diagnosis of unexplained intra-abdominal lymphadenopathy.

EUS-guided biliary rendezvous using a short hydrophilic guidewire.

BACKGROUND AND STUDY AIMS: EUS-guided rendezvous technique for biliary access requires expert manipulation of the guidewire across the downstream stricture or papilla. Published literature reports usage of the long-wire system to prevent loss of wire during scope exchange. We studied the efficacy of using a short hydrophilic guidewire in EUS-guided rendezvous. PATIENTS AND METHODS: This is a retrospective study conducted in a tertiary care referral centre. 15 patients underwent EUS-guided biliary rendezvous with short wire. EUS-guided transduodenal/transgastric puncture of the biliary system was performed, followed by anterograde placement of a hydrophilic short-wire (260 cm) across the downstream stricture and/or papilla. Retrograde access was then achieved by retrieving the trans-papillary wire, followed by standard ERCP intervention. Main outcome measurements were rates of procedural success and complications. RESULTS: EUS-guided biliary rendezvous was successful in 14 patients (93.3%). Failure was seen in one patient due to a tight malignant biliary stricture. One patient had peri-choledochal bile tracking which did not require any specific treatment. CONCLUSIONS: Short-wire system in EUS-guided biliary rendezvous is highly effective and safe. It is a useful salvage procedure for biliary cannulation in patients with accessible papilla.

Endoscopic balloon sphincteroplasty for extraction of large radiolucent pancreatic duct stones (with videos).

BACKGROUND: Although radiopaque pancreatic duct stones can be targeted by extracorporeal shock wave lithotripsy (ESWL) and extracted by ERCP, large and radiolucent stones remain a therapeutic challenge. OBJECTIVE: To evaluate the technical success and safety of endoscopic balloon sphincter dilation technique (sphincteroplasty) for extraction of large radiolucent pancreatic duct stones. DESIGN: Case series. SETTING: Tertiary referral center. PATIENTS: Four symptomatic patients with large (> or =1 cm) radiolucent stones occluding the main pancreatic duct that could not be retrieved by standard endoscopic maneuvers. INTERVENTIONS: Pancreatic sphincterotomy followed by balloon dilation of the pancreatic orifice to aid retrieval of large radiolucent stones occluding the main pancreatic duct. MAIN OUTCOME MEASUREMENTS: Technical success and safety of the balloon dilation (sphincteroplasty) technique. Technical success was defined as the ability to achieve pancreatic duct clearance in 1 endoscopic encounter. Complications were assessed according to consensus criteria. RESULTS: The procedure was technically successful in all 4 patients. Pancreatic duct clearance was achieved in all 4 patients in 1 endoscopy session with complete symptom relief at 12-month follow-up. Mild post-ERCP pancreatitis developed in 1 patient, and minor bleeding developed in another patient; both were managed conservatively. LIMITATION: Small number of patients. CONCLUSIONS: Endoscopic balloon dilation of the pancreatic orifice after sphincterotomy is a safe technique that facilitates the removal of large radiolucent stones from the main pancreatic duct in 1 endoscopic session. More studies with larger numbers of patients are required before this technique can be adopted routinely as a treatment alternative for patients with large radiolucent pancreatic duct stones.

Relation of insulin-like growth factor-1 and insulin-like growth factor binding protein-3 levels to growth retardation in extrahepatic portal vein obstruction.

BACKGROUND: Growth retardation has been described in patients with extrahepatic portal vein obstruction (EHPVO). An abnormal growth hormone (GH)-insulin-like growth factor (IGF) axis has been postulated as a possible etiology. We compared anthropometric parameters and IGF-1 and insulin-like growth factor binding protein-3 (IGFBP-3) levels in patients with EHPVO with their siblings as controls. METHODS AND PATIENTS: Consecutive patients diagnosed with EHPVO who presented to out-patient clinic in Department of Gastroenterology between February 2005 and February 2006 were enrolled along with their siblings whenever possible. After detailed history and clinical examination, anthropometric parameters such as age, height, weight, and mid-parental height were measured in patients and controls. IGF-1 and IGFBP-3 levels were also estimated. RESULTS: Fifty-two patients (40 males, 32 adults) were enrolled. Sibling controls were available for 28 patients. Variceal bleeding was the presenting symptom in 41 of 52 (78.8%) patients. Target height was not achieved in 7 of 32 (22.6%) adults and 6 of 20 (30%) children, showing evidence of growth retardation. The mean IGF-1 levels in patients and controls were 124.71 +/- 65.49 ng/ml and 233 +/- 76.98 ng/ml (P < 0.01), respectively. The mean IGFBP-3 levels in patients and controls were 2.90 +/- 1.07 mug/ml and 4.22 +/- 0.77 mug/ml (P < 0.01), respectively. Hormonal levels between those with and without evidence of growth retardation did not differ significantly. Duration of symptoms, spleen size, platelet count, and age of presentation did not correlate with anthropometry and hormonal levels. CONCLUSIONS: Growth retardation by anthropometry was documented in a quarter of patients with EHPVO. All patients had significantly low IGF-1 and IGFBP-3 levels in comparison with controls despite normal anthropometry in majority of patients (75%).

Hypercoagulable state in idiopathic ulcerative colitis: role of hyperhomocysteinemia and hyperfibrinogenemia.

BACKGROUND: Previous reports on hypercoagulable factors in inflammatory bowel diseases involve heterogeneous populations and patients on various medications. AIMS: To determine the frequency of thrombotic complications in ulcerative colitis (UC); to evaluate for hyperhomocysteinemia and its relationship to vitamin B12 and folate levels and methylene tetrahydrofolate reductase (MTHFR) mutation; and to evaluate for hyperfibrinogenemia and factor V Leiden mutation. METHODS: Eighty-six adult patients with UC were seen during the study period; 28 of them underwent blood tests and constituted the study population. Patients who received medications that affect these factors were among the 58 excluded. Tests were obtained at baseline and after 2 months during remission. Patients received folic acid in addition to treatment for UC. RESULTS: Vascular thrombotic events were noted in 4 patients during follow up. Hyperhomocysteinemia was detected in 11 (39.3%) patients (controls 15/100, p=0.007). Heterozygous state for MTHFR C677T mutation was found in 5 (17.9%) patients (controls: 0.2% homozygous, 13.6% heterozygous, p>0.05). Plasma homocysteine did not correlate with extent, severity or duration of disease, or with MTHFR C677T heterozygous state, but correlated with serum folic acid level (p=0.003) and BMI (p=0.03). With folate supplementation, homocysteine decreased significantly in patients who had hyperhomocysteinemia at baseline. Hyperfibrinogenemia was detected in 3 patients (none in 100 controls). Plasma fibrinogen was not affected by duration, extent or severity of UC and did not decrease with remission of disease. Only one patient had heterozygous factor V Leiden mutation. CONCLUSION: Vascular thrombosis occurred in less than a fifth of the UC population studied. Hyperhomocysteinemia reversible by folate supplementation and hyperfibrinogenemia were observed, but their contribution and that of factor V Leiden mutation appear to be insignificant.

Effect of liver disease on maternal and fetal outcome--a prospective study.

BACKGROUND: Liver disease in pregnancy can have serious consequences. Its prevalence, profile and effect on outcome of pregnancy have not been documented systematically in India. We prospectively determined the frequency, causes and outcome of liver disease in pregnant women. SETTING: Tertiary-care teaching hospital. METHODS: Consecutive pregnant women with liver disease attending the inpatient or outpatient services of the Departments of Gastro-enterology and Obstetrics and Gynecology between December 2002 and October 2004 were evaluated and followed up till 2 weeks postpartum or death. RESULTS: Liver disease was found in 107 (0.9%) of 12,061 pregnancies. Of these, fifty six (52.3%) had pregnancy-specific liver disorders (pregnancy-induced hypertension [PIH]-associated liver dysfunction 36--including HELLP syndrome 22 and pre-eclamptic liver dysfunction 14; intrahepatic cholestasis of pregnancy 10; hyperemesis gravidarum 7; acute fatty liver of pregnancy 3). Liver disorders not specific to pregnancy included hepatitis E (16), hepatitis B, non A-E hepatitis and chronic liver disease (5 each) and others (14); in 6 patients no cause could be found. Ninety-six patients completed follow up. Overall maternal and perinatal mortality rates were 19.7% and 35.4%, respectively. CONCLUSIONS: PIH-associated liver dysfunction was the most common cause of liver disease in pregnancy. This is associated with significant maternal and perinatal morbidity and mortality.

Endoscopic biliary drainage in patients with amebic liver abscess and biliary communication.

BACKGROUND: Percutaneous drainage or surgery is required when amebic liver abscess (ALA) fails to respond to medical management. In some of these patients, non-response may be due to communication of ALA with the biliary tree. This report describes our experience with the use of endoscopic biliary draining in such patients. METHODS: Medical records of patients with ALA undergoing either needle aspiration or percutaneous pigtail drainage were retrieved; the indications for drainage were: abscess volume exceeding 250 mL, a thin rim of tissue (< 1 cm thick) around the abscess, systemic toxic features and failure to improve on medical treatment. Patients with abscess drain output >25 mL/day persisting for 2 weeks or presence of bile in the drain fluid underwent endoscopic biliary drainage. RESULTS: A total of 115 patients with ALA underwent percutaneous treatment. None of the 25 patients with needle aspiration needed any further treatment. Of the 90 who underwent catheter drainage, the catheter could be removed within one week in 77 patients; the remaining 13 patients (median age 42 years, range 24-65; all men) had an abscess-biliary communication. In them, the median catheter output was 88 mL/day (range 45-347) and 54 mL/day (28-177) at 2 days and 2 weeks after catheter placement. The drain fluid contained bile in all 13 patients and in addition contained pus in 10 patients. Eleven patients had a solitary abscess and two had multiple abscesses. Cholangiogram showed biliary communication in all 13 patients. All patients were treated with placement of 10F biliary endoprosthesis or 10F nasobiliary drain. Pigtail catheter was removed within 1 week in 11 of 13 patients. CONCLUSION: In patients with amebic liver abscess communicating with the biliary tree, biliary stenting may hasten clinical recovery and allow early removal of liver abscess catheter drain.

Thrombophilic conditions in non-cirrhotic portal vein thrombosis.

OBJECTIVE: To study the prevalence of thrombophilic conditions in patients with acute and chronic portal vein thrombosis (PVT) and to compare it with those in patients suffering from deep vein thrombosis (DVT) after lower limb arthroplasty and in healthy subjects. METHODS: Twenty-six patients with spontaneous PVT (20 chronic, 6 acute) with normal liver function and not receiving anticoagulants were evaluated for thrombophilic conditions. Levels of protein C, protein S and antithrombin were compared with those in 50 healthy controls. Factor V gene 'Leiden' mutation (FVL) and high homocysteine levels were looked for in patients with PVT and in 18 patients developing post-arthroplasty lower limb DVT despite anticoagulation. RESULTS: Of 26 patients with PVT, 19 had at least one thrombotic condition (acute PVT 5/6, chronic PVT 14/20) and 12 had more than one such condition; in comparison, of 18 patients with DVT, eight had one thrombophilic condition and one had two such conditions (p=0.03). Patients with PVT had significantly lower levels of protein C, protein S and antithrombin than healthy subjects and those with DVT. Six patients had Factor VIII levels above 150%; four had elevated homocysteine levels and three had detectable anti-cardiolipin antibodies. Three patients with PVT (acute 2, chronic 1) were heterozygous for FVL mutation. CONCLUSIONS: Underlying thrombophilic conditions are common in Indian patients with spontaneous PVT. In many patients, multiple thrombophilic conditions are present and these may play a role in the pathogenesis of PVT.

Intraluminal duodenal diverticulum presenting as gastrointestinal bleeding after NSAID use.

Intraluminal duodenal diverticuli are rare. They usually present with obstruction; presentation with GI bleeding is very rare. We report a 51-year-old man who presented with melena after NSAID intake; the diverticulum was excised surgically.

Familial clustering of hepatitis B infection: study of a family.

Familial clustering of hepatitis B virus infection has been reported infrequently. We report a family of 27 members, where 13 members were HBsAg-positive. This included 7 of 10 members in one linear family across four generations. Nine subjects who were tested were HBeAg-negative. Of these nine, three subjects had elevated ALT; histology in one of them showed activity index <3. One subject received lamivudine therapy elsewhere; ALT levels returned to normal in two months.