RESUMEN
BACKGROUND: Biliary disease in pregnancy is a relatively uncommon condition; the diagnosis of this condition is not standardized. Furthermore, the use of radiographic imaging studies and therapeutic approaches in pregnancy is limited because of the possibility of fetal exposure. STUDY DESIGN: During a 2-year interval of 2001 to 2002, we successfully performed endoscopic retrograde cholangiopancreatography (ERCP) studies in 6 pregnant women between 6 and 30 weeks of gestation with symptomatic acute cholangitis or pancreatitis without irradiation exposure or major maternal complications. Five of the women had classic symptoms of severe right upper quadrant abdominal pain, gallbladder stones, jaundice, and dilated bile ducts on ultrasonic evaluation. One woman had severe recurrent pancreatitis during early pregnancy 4 years after a cholecystectomy. The cases are compiled to provide a descriptive review of ERCP without the use of radiation imaging treatment for these conditions. RESULTS: Maternal outcome: After ERCP, jaundice resolved in all cases. No further episodes of pancreatitis occurred during the 1 affected pregnancy. No post-ERCP complications occurred during this series. Two patients required cholecystectomy later, one in the postpartum period and the other 5 weeks post-ERCP. Fetal outcome: Two infants were born at term without complications. Two infants were born prematurely at 35 weeks, 1 with significant growth retardation and pulmonary complications and 1 without developmental problems or complications. Two mothers were lost to follow-up; the outcomes of their pregnancies are unknown. CONCLUSION: The use of ERCP in pregnancy is limited because of the undesirable effects of radiation exposure to the fetus.
Asunto(s)
Colangiopancreatografia Retrógrada Endoscópica/métodos , Colangitis/diagnóstico , Pancreatitis/diagnóstico , Complicaciones del Embarazo/diagnóstico , Resultado del Embarazo , Adulto , Colangitis/terapia , Femenino , Edad Gestacional , Humanos , Edad Materna , Pancreatitis/terapia , Embarazo , Complicaciones del Embarazo/terapia , Embarazo de Alto Riesgo , Radiación , Factores de Riesgo , Muestreo , Sensibilidad y Especificidad , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND AND STUDY AIMS: Unexplained pancreatitis represents a diagnostic challenge. The aim of this study was to determine the diagnostic utility of endoscopic retrograde cholangiopancreatography (ERCP) with sphincter of Oddi manometry (SOM), bile analysis, and endoscopic ultrasound (EUS) in evaluating such patients. PATIENTS AND METHODS: Of 162 patients referred for evaluation of pancreatitis, 72 with a known cause were excluded. The remainder ( n=90) was classified as having prior acute ( n=24) or recurrent acute pancreatitis ( n=66). Bile sampling and SOM were performed at the time of ERCP. EUS was used to assess for tumors and for chronic pancreatitis. Clinical outcomes were evaluated by questionnaire. RESULTS: ERCP was successful in 88/89 patients (99 %). Manometry was successful in 63/67 patients (94 %), and 56 patients underwent EUS. Findings were categorized into five distinct etiologies: sphincter of Oddi dysfunction (SOD) ( n=28; 31 %), pancreas divisum ( n=18; 20 %), biliary ( n=18; 20 %), idiopathic ( n=18; 20 %) and tumor-related ( n=8; 9 %). Features of moderate or severe chronic pancreatitis by EUS and ERCP criteria were found in 18 patients (21 %); an additional nine patients had chronic pancreatitis by EUS criteria alone. EUS identified all the tumors. The condition was improved in 96 % of all patients undergoing endoscopic therapy. CONCLUSION: An etiology was identified in the majority of patients with unexplained pancreatitis. SOD represented the most common finding. Moderate to severe chronic pancreatitis was found in over one-fifth of these patients. Bile analysis, SOM, and EUS are useful tools in the evaluation of unexplained acute pancreatitis.
Asunto(s)
Colangiopancreatografia Retrógrada Endoscópica , Enfermedades del Conducto Colédoco/complicaciones , Endosonografía , Manometría/métodos , Pancreatitis/diagnóstico , Esfínter de la Ampolla Hepatopancreática/fisiología , Enfermedad Aguda , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Bilis/química , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pancreatitis/etiología , RecurrenciaRESUMEN
Cytokines play an important role in the regulation of inflammation and fibrosis in the development of chronic pancreatitis. In this study, transforming growth factor beta (TGFbeta), interleukin (IL)-6, IL-10, and tumor necrosis factor alpha (TNFalpha) were measured in pure pancreatic juice obtained through pancreatic duct cannulation. Twenty patients with chronic pancreatitis were compared with six patients thought to be free of pancreatic disease who were undergoing endoscopic retrograde cholangiopancreatography for biliary tract disorders. TGFbeta was detected in 17 of 20 patients with chronic pancreatitis tested (85%), compared with only one patient in the control group (17%). There was no measurable amount of IL-10, IL-6, or TNFalpha in any of the pure pancreatic juice samples from any of the patients. These data indicate that TGFbeta may play an active role in the advancement of pancreatitis by causing local inflammation and inducing fibroblasts to secrete collagen. This finding may be relevant in the future for identifying patients whose conditions may advance to chronic pancreatitis, and blocking the effects of TGFbeta could have therapeutic effects.
Asunto(s)
Jugo Pancreático/química , Pancreatitis/metabolismo , Factor de Crecimiento Transformador beta/análisis , Adolescente , Adulto , Anciano , Femenino , Humanos , Interleucina-10/análisis , Interleucina-6/análisis , Masculino , Persona de Mediana Edad , Factor de Crecimiento Transformador beta/química , Factor de Necrosis Tumoral alfa/análisisAsunto(s)
Simulación por Computador , Endoscopía Gastrointestinal , Modelos Biológicos , Animales , HumanosRESUMEN
BACKGROUND: The use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is increasing in the management of pancreatobiliary diseases in children. METHODS: Over a 32-month period, we performed 34 ERCP procedures for the treatment of pancreatitis in 22 children at two university hospitals. Demographics and clinical data and ERCP findings were documented. Clinical status was assessed 6 months before the first ERCP and 6 months after the last ERCP, according to general condition, severity and frequency of pain, and health care encounters (emergency department visits, clinic visits, and hospital admissions related to the pancreatitis). RESULTS: Mean age of the patients was 10.7 years (range 1.5 to 17 years). Abdominal pain was the main presenting symptoms with hyperamylasemia and hyperlipasemia. Clinical diagnoses included acute pancreatitis (6), recurrent pancreatitis (5), and chronic pancreatitis (11). The mean follow-up was 16.4 months. Nine patients had sphincter manometry, with abnormal results leading to biliary sphincterotomy in 4. Fifteen patients underwent a total of 23 therapeutic ERCP procedures unrelated to sphincter dysfunction. There were 2 complications of 34 procedures (6%), both being mild pancreatitis after sphincter manometry. There were no deaths. There was a significant reduction in frequency (p < 0.01) and severity of pain (p < 0.01) after intervention. Patients without pancreatographic changes of chronic pancreatitis had the most marked clinical improvement (p < 0.05). In those with ductal changes of chronic pancreatitis, clinical improvement was not predicted by the extent of ductal changes. There was a significant decrease in health care encounters (p < 0.05) and improvement in general condition (p < 0.01) after endoscopic therapy, especially in those with a normal pancreatogram. CONCLUSIONS: Therapeutic ERCP is safe in pediatric patients with pancreatitis. Significant clinical improvement is achieved in patients with biliary or pancreatic stone disease. Prospective studies with long-term follow-up are needed to determine the impact of endoscopic therapy in patients with chronic pancreatitis and sphincter of Oddi dysfunction.
Asunto(s)
Colangiopancreatografia Retrógrada Endoscópica/métodos , Pancreatitis/diagnóstico , Pancreatitis/terapia , Enfermedad Aguda , Adolescente , Análisis de Varianza , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Modelos Logísticos , Masculino , Índice de Severidad de la Enfermedad , Resultado del TratamientoAsunto(s)
Colangiopancreatografia Retrógrada Endoscópica/normas , Imagen por Resonancia Magnética/normas , Adulto , Conductos Biliares/patología , Niño , Colangiopancreatografia Retrógrada Endoscópica/economía , Colangiopancreatografia Retrógrada Endoscópica/instrumentación , Colangiopancreatografia Retrógrada Endoscópica/métodos , Seguridad de Equipos , Estudios de Evaluación como Asunto , Humanos , Lactante , Imagen por Resonancia Magnética/economía , Imagen por Resonancia Magnética/instrumentación , Imagen por Resonancia Magnética/métodos , Sensibilidad y Especificidad , Estados UnidosAsunto(s)
Endoscopía Gastrointestinal/efectos adversos , Control de Infecciones/métodos , Infecciones/transmisión , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/prevención & control , Equipos de Seguridad/normas , Costos y Análisis de Costo , Endoscopía Gastrointestinal/métodos , Seguridad de Equipos , Estudios de Evaluación como Asunto , Guías como Asunto , Humanos , Control de Infecciones/economía , Infecciones/etiología , Equipos de Seguridad/economía , Sensibilidad y Especificidad , Sociedades Médicas , Estados UnidosAsunto(s)
Remoción de Dispositivos/instrumentación , Endoscopios Gastrointestinales , Instrumentos Quirúrgicos , Evaluación de la Tecnología Biomédica , Sistema Digestivo , Diseño de Equipo , Cuerpos Extraños/cirugía , Neoplasias Gastrointestinales/cirugía , Humanos , Pólipos/cirugía , Estados UnidosRESUMEN
Lateral pancreaticojejunostomy has demonstrated variable success in the management of chronic pancreatitis associated with ductal dilation, but its role in patients with nondilated ducts is poorly defined. The aim of this study was to assess the outcome of lateral pancreaticojejunostomy in chronic pancreatitis with nondilated pancreatic ducts. The records of all patients who underwent lateral pancreaticojejunostomy with a pancreatic duct measuring less than 7 mm in diameter were reviewed. Seventeen patients underwent lateral pancreaticojejunostomy for chronic pancreatitis and intractable pain between 1995 and 1996. Endoscopic retrograde cholangiopancreatography demonstrated features of chronic pancreatitis that were mild in seven patients, moderate in five, and severe in four. Postoperative complications occurred in two patients (11.7%). There were no deaths. Mean length of follow-up was 10.3 months (range 3 to 16 months). Rehospitalization for recurrent pancreatitis or pain was necessary in 59% of patients. Emergency room visits were reported by 76%. Narcotic use continued in 88%, with 76% of the patients reporting their pain as the same or worse than before the operation, and 65% continuing to view their health status as poor. In chronic pancreatitis patients with a nondilated pancreatic duct, lateral pancreaticojejunostomy appears to be of little benefit with respect to pain relief, subsequent hospitalization, continued narcotic use, or overall health status.
Asunto(s)
Cuidados Paliativos , Conductos Pancreáticos/patología , Pancreatoyeyunostomía , Pancreatitis/cirugía , Adulto , Niño , Colangiopancreatografia Retrógrada Endoscópica , Enfermedad Crónica , Femenino , Estudios de Seguimiento , Humanos , Cuidados Paliativos/métodos , Pancreatoyeyunostomía/métodos , Pancreatitis/patología , Factores de Tiempo , Insuficiencia del TratamientoRESUMEN
BACKGROUND & AIMS: Patients with sphincter of Oddi dysfunction are at high risk of developing pancreatitis after endoscopic biliary sphincterotomy. Impaired pancreatic drainage caused by pancreatic sphincter hypertension is the likely explanation for this increased risk. A prospective, randomized controlled trial was conducted to determine if ductal drainage with pancreatic stenting protects against pancreatitis after biliary sphincterotomy in patients with pancreatic sphincter hypertension. METHODS: Eligible patients with pancreatic sphincter hypertension were randomized to groups with pancreatic duct stents (n = 41) or no stents (n = 39) after biliary sphincterotomy. The primary measured outcome was pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Pancreatic stenting significantly decreased the risk of pancreatitis from 26% to 7% (10 of 39 in the no stent group and 3 of 41 in the stent group; P = 0.03). Only 1 patient in the stent group developed pancreatitis after sphincterotomy, and 2 others developed pancreatitis at the time of stent extraction. Patients in the no stent group were 10 times more likely to develop pancreatitis immediately after sphincterotomy than those in the stent group (relative risk, 10.5; 95% confidence interval, 1.4-78.3). CONCLUSIONS: Pancreatic duct stenting protects significantly against post-ERCP pancreatitis in patients with pancreatic sphincter hypertension undergoing biliary sphincterotomy. Stenting of the pancreatic duct should be strongly considered after biliary sphincterotomy for sphincter of Oddi dysfunction; pancreatic sphincter of Oddi manometry identifies which high-risk patients may benefit from pancreatic stenting.
Asunto(s)
Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Pancreatitis/etiología , Pancreatitis/prevención & control , Esfínter de la Ampolla Hepatopancreática/fisiopatología , Esfinterotomía Endoscópica/efectos adversos , Stents , Adulto , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Our aim was to verify endoscopic ultrasound (EUS) accuracy to diagnose, rule out, and establish the severity of chronic pancreatitis found by endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Patients undergoing ERCP for unexplained abdominal pain and/or suspected chronic pancreatitis underwent EUS. EUS was performed by experienced operators who were aware of the history but blinded to ERCP results. Chronic pancreatitis was defined using the Cambridge classification: 0 to 1 = "normal," 2 to 4 = "all chronic pancreatitis," 3 to 4 = "moderate to severe chronic pancreatitis." The number of EUS criteria required to obtain sensitivity, specificity, positive and negative predictive values > or = 85% was determined. EUS criteria for chronic pancreatitis are hyperechoic foci, hyperechoic strands, lobularity, hyperechoic duct, irregular duct, visible side-branches, ductal dilation, calcification, and cysts. RESULTS: One hundred twenty-six patients underwent EUS and ERCP. EUS was highly sensitive and specific (> 85%) depending on the number of criteria present. Chronic pancreatitis is likely (PPV > 85%) when more than two criteria (for "all chronic pancreatitis") and more than six criteria (for "moderate to severe chronic pancreatitis") are present. "Moderate to severe chronic pancreatitis" is unlikely (NPV > 85%) when fewer than three criteria are present. Independent predictors of chronic pancreatitis were "calcification" (p = 0.000001), history of alcohol abuse (p = 0.002), and the total number of EUS criteria (p = 0.008). CONCLUSIONS: EUS can accurately diagnose, rule out, and establish the severity of chronic pancreatitis found by ERCP.
Asunto(s)
Colangiopancreatografia Retrógrada Endoscópica , Endosonografía , Pancreatitis/diagnóstico , Adulto , Enfermedad Crónica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Prospectivos , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Clinical evaluation of intraoperative endoscopy with electrohydraulic lithotripsy (EHL) in the management of 13 patients with pancreatobiliary lithiasis was undertaken. METHODS: Ten patients with chronic pancreatitis with intraductal lithiasis in the head and three with biliary lithiasis (one choledochal, one cystic, one right intrahepatic) underwent intraoperative endoscopy with EHL. Shock waves were applied by visual contact with a 3-Fr gauge EHL probe until all stones were fragmented and irrigated free. All pancreatitis patients had failed ERCP attempts to stent their pancreatic ducts secondary to ductal lithiasis. Patients with pancreatic stones underwent lateral pancreatojejunostomy. Biliary stone patients underwent laparoscopic cholecystectomy with common duct exploration (two cases) and open cholecystectomy with choledochoduodenostomy (one case). RESULTS: Intraductal stone eradication was successful in all patients. Transampullary visualization of the duodenum was achieved in eight cases. Average EHL time was 65 min. There was no evidence of postoperative pancreatitis, cholangitis, or retained common duct stones. CONCLUSION: Intraoperative pancreatobiliary endoscopy with EHL is safe and effective in the eradication of pancreatic and bile duct stones. This novel technique represents a valuable adjunct in the management of chronic fibrocalcific pancreatitis with ductal lithiasis in the head region and in the open and laparoscopic management of intra- and extrahepatic bile duct stones.