Fluid analysis prior to surgical resection of suspected mucinous pancreatic cysts. A single centre experience.

OBJECTIVE: EUS-FNA cytology and fluid analysis are frequently utilized to evaluate pancreatic cysts. Elevated cyst fluid CEA is usually indicative of a mucinous pancreatic cyst but whether CEA or amylase values can subclassify various mucinous cysts is unknown. The purpose of this study is to determine whether cyst fluid CEA and amylase obtained by EUS-FNA can differentiate between mucinous cystic neoplasms (MCNs) and intraductal papillary mucinous neoplasms (IPMNs). METHODS: Using our prospective hospital EUS and surgical databases, we identified all patients who underwent EUS of a pancreatic cyst prior to surgical resection, in the last 10 years. Cysts were pathologically sub-classified as MCNs or IPMNs; all other cysts were considered non-mucinous. Values of cyst fluid CEA and amylase were correlated to corresponding surgical histopathology and compared between the two groups. RESULTS: 134 patients underwent surgery for pancreatic cysts including 82 (63%) that also had preoperative EUS. EUS-FNA was performed in 61/82 (74%) and cyst fluid analysis in 35/61 (57%) including CEA and amylase in 35 and 33 patients, respectively. Histopathology in these 35 cysts demonstrated nonmucinous cysts in 10 and mucinous cysts in 25 including: MCNs (n=9) and IPMNs (n=16). Cyst fluid CEA (p=0.19) and amylase (p=0.64) between all IPMNs and MCNs were similar. Between branched duct IPMNs and MCNs alone, cyst fluid CEA (p=0.34) and amylase (p=0.92) were also similar. CONCLUSION: In this single center study, pancreatic cyst fluid amylase and CEA levels appeared to be of limited value to influence the differential of mucinous pancreatic cysts. Larger studies are recommended to evaluate this role further.

Role of endoscopic ultrasound for evaluating gastrointestinal tract disorders in pediatrics: a tertiary care center experience.

BACKGROUND: Endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA) has a well-established role in the evaluation of various gastrointestinal (GI) tract disorders in adults. The clinical impact of EUS on the management of the pediatric population remains less clear. This study evaluates the feasibility, safety, and applications of EUS ± FNA in pediatric GI tract disorders. PATIENTS AND METHODS: Using a prospectively maintained EUS database, all patients 18 years of age or younger referred for EUS at our institution were identified. Retrospective chart review was conducted to document procedure indications, type of anesthesia used, EUS findings, final FNA cytology results, and clinical impact of EUS ± FNA on the subsequent management of pediatric patients. RESULTS: Fifty-eight EUS procedures were performed in 56 patients (35 girls). Median age was 16 years (range 4-18 years). The main indications for EUS were acute or recurrent pancreatitis, abdominal pain of suspected pancreatobiliary origin, suspected biliary obstruction, upper GI mucosal/submucosal lesions, and evaluation of pancreatic abnormalities seen on prior imaging. Sedation used included nurse-administered propofol sedation in 38 (73%), general anesthesia in 9 (17%), and fentanyl with meperidine in 3 (6%). Five therapeutic procedures performed included celiac plexus blocks in 4 and 1 EUS-guided pancreatogram. In 44 (86%) patients, EUS provided a new diagnosis. The procedure was successfully completed in all patients with no reported complications. CONCLUSIONS: EUS ± FNA is feasible and safe and makes a significant impact on most pediatric patients. Nurse-administered propofol sedation appears to be safe and well tolerated in this group.

Safety of endoscopic retrograde cholangiopancreatography during pregnancy.

BACKGROUND: The risk of choledocholithiasis is expected to be higher during pregnancy. This is attributed to alteration in bile composition as well as biliary stasis that take place during gestation. There is significant concern regarding application of endoscopic procedures especially the more invasive ones for treatment of choledocholithiasis during pregnancy. Our aim was to provide an additional support to the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in the management of biliary diseases during pregnancy. METHODS: The medical records of 10 pregnant patients who underwent ERCP at King Abdullah University Hospital, during the period from 2002 to 2007 were reviewed. Pregnancy course and outcomes were followed up in all cases. Results were analysed and compared with published data on safety and efficacy of this procedure. RESULTS: The mean age for mothers was 24.3 years. The mean duration of gestation was 18.4 weeks. Two patients were in the first trimester, five were in their second trimester and another three in the third trimester. The main indication for ERCP was obstructive choledocholithiasis on ultrasound and liver function tests. Fetal radiation exposure was not routinely measured. During, or after, the procedure there was no need for tocolytic agents. Also there was no intrauterine fetal distress. Screening for congenital anomalies was negative in all cases. CONCLUSION: Major complications of biliary obstruction have been prevented through this procedure. Short-term follow up for all neonates whom mothers underwent ERCP during pregnancy supports its safety. However, specific long-term fetal complications of radiation exposure have not been investigated yet.

Usefulness of fatty meal-stimulated cholescintigraphy in the diagnosis and treatment of chronic acalculous cholecystitis.

OBJECTIVE: Fatty meal cholescintigraphy (fatty meal CS) is a potential physiologic alternative for cholecystokinin (CCK) CS in the diagnosis and treatment of chronic acalculous cholecystitis (CAC). However, there are limited data in the literature to support this assumption. Our objective was to determine the usefulness of fatty meal CS in the diagnosis and treatment of CAC. METHODS: We retrospectively reviewed the medical records of 198 patients who had undergone fatty meal CS for presumed CAC. Data retrieved focused on symptom improvement following management. Gallbladder ejection fraction (GBEF) of 50% or less was considered abnormal. Patients were divided into groups on the basis of test results and management. RESULTS: In group 1a, patients with low GBEF and cholecystectomy, 88% (54 of 61) reported symptom improvement, whereas the remaining 12% (7 of 61) retained their symptoms. Group 1b consisted of patients with low GBEF and who were managed medically. Persistence of symptoms was noted in 76% (32 of 42) of patients, whereas the remaining 24% (10 of 42) had symptom improvement. Group 2 consisted of patients with normal GBEF. Follow-up showed that 60% (47 of 78) of patients had symptom improvement either spontaneously or on medical treatment, whereas the remaining 40% (31 of 78) retained their symptoms. CONCLUSIONS: Fatty meal CS is a very useful technique in the diagnosis of CAC. It predicts a good surgical outcome once GBEF is low in patients with high pre-test probability for CAC. Moreover, fatty meal CS may be a good alternative to CCK CS.

Is maintenance acid suppression necessary to reduce the rate of reinfection with Helicobacter pylori?

BACKGROUND/AIMS: Helicobacter pylori (HP) infection can recur even after eradication by triple therapy. We hypothesize that maintenance acid suppression treatment after standard eradication therapy would be necessary to further reduce ulcer recurrence in Jordanian population. METHODOLOGY: This is a retrospective study that was conducted at King Abdullah University Hospital (KAUH), a major University hospital, and tertiary care facility (> 400 beds) located in North Jordan. Endoscopic and histologic results and medication history were reviewed for each patient who has prescribed eradication therapy for HP over the period from July 2003 until May 2006. RESULTS: Maintenance acid suppression treatment after standard eradication therapy markedly reduced the recurrence rate of peptic ulcer from 58.3% (with out maintenance acid suppression treatment) to 1.45% (with maintenance acid suppression treatment). CONCLUSIONS: Our results indicate that treatment of HP infection by eradication regimen (triple therapy only) is not enough to prevent recurrence of ulcer in the Jordanian population. Thus, we recommend maintenance acid suppression following standard H. pylori eradication regimen to maintain remission.

Risk factors for post-ERCP pancreatitis: a prospective multicenter study.

OBJECTIVES: Pancreatitis is the most common and serious complication of diagnostic and therapeutic ERCP. The aim of this study is to examine the potential patient- and procedure-related risk factors for post-ERCP pancreatitis in a prospective multicenter study. METHODS: A 160-variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study evaluating whether prophylactic corticosteroids will reduce the incidence of post-ERCP pancreatitis. Data were collected prior to the procedure, at the time of procedure, and 24-72 h after discharge. Post-ERCP pancreatitis was diagnosed and its severity graded according to consensus criteria. RESULTS: Of the 1,115 patients enrolled, diagnostic ERCP with or without sphincter of Oddi manometry (SOM) was performed in 536 (48.1%) and therapeutic ERCP in 579 (51.9%). Suspected sphincter of Oddi dysfunction (SOD) was the indication for the ERCP in 378 patients (33.9%). Pancreatitis developed in 168 patients (15.1%) and was graded mild in 112 (10%), moderate in 45 (4%), and severe in 11(1%). There was no difference in the incidence of pancreatitis or the frequency of investigated potential pancreatitis risk factors between the corticosteroid and placebo groups. By univariate analysis, the incidence of post-ERCP pancreatitis was significantly higher in 19 of 30 investigated variables. In the multivariate risk model, significant risk factors with adjusted odds ratios (OR) were: minor papilla sphincterotomy (OR: 3.8), suspected SOD (OR: 2.6), history of post-ERCP pancreatitis (OR: 2.0), age <60 yr (OR: 1.6), > or =2 contrast injections into the pancreatic duct (OR: 1.5), and trainee involvement (OR: 1.5). Female gender, history of recurrent idiopathic pancreatitis, pancreas divisum, SOM, difficult cannulation, and major papilla sphincterotomy (either biliary or pancreatic) were not multivariate risk factors for post-ERCP pancreatitis. CONCLUSION: This study emphasizes the role of patient factors (age, SOD, prior history of post-ERCP pancreatitis) and technical factors (number of PD injections, minor papilla sphincterotomy, and operator experience) as the determining high-risk predictors for post-ERCP pancreatitis.

Improved stent characteristics for prophylaxis of post-ERCP pancreatitis.

BACKGROUND & AIMS: Pancreatic stenting is an effective method to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in high-risk patients. This retrospective study evaluated the impact of modified stent characteristics on the rate of post-ERCP pancreatitis, spontaneous stent dislodgment, and stent-related sequelae. METHODS: A total of 2283 patients underwent 2447 ERCPs over a 6-year period with placement of 3-4F diameter, unflanged pancreatic stents. The indication for stenting was pancreatitis prophylaxis predominantly in suspected sphincter of Oddi dysfunction (SOD), pancreas divisum therapy, and precut sphincterotomy. An abdominal radiograph was obtained 10-14 days later to assess spontaneous stent passage. Post-ERCP pancreatitis was defined according to established criteria. A total of 479 patients underwent repeat ERCPs after an initial ERCP with pancreatic stent placement. The prestenting pancreatogram was then compared with follow-up studies. RESULTS: The pancreatitis rate with 3F, 4F, 5F, and 6F stents was 7.5%, 10.6%, 9.8%, and 14.6%, respectively (3F vs. 4F, 5F, 6F: P = 0.047). Spontaneous stent dislodgment was 86%, 73%, 67%, and 65%, respectively (3F vs. 4F, 5F, 6F: P < 0.0001). The frequency of ductal changes was 24% in patients with 3-4F stents compared with 80% with 5-6F stents. Ductal perforation from the stents occurred in 3 patients (0.1%). CONCLUSIONS: Small diameter (3-4F), unflanged pancreatic stents are more effective than the traditionally used stents (5-6F) in preventing post-ERCP pancreatitis. Stent-induced ductal changes and the need for endoscopic removal are also significantly less with 3-4F stents. The 3F stent appears to be superior in all aspects studied. Additional studies are needed to define the ideal method to eliminate post-ERCP pancreatitis.

Frequency of biliary crystals in patients with suspected sphincter of Oddi dysfunction.

BACKGROUND: The passage of gallstones (macro- or microlithiasis) is theorized to play a role in inducing sphincter of Oddi dysfunction. This study examined the frequency at which biliary crystals are found in patients with suspected type II and type III sphincter of Oddi dysfunction. METHODS: A total of 85 patients (66 women, 19 men; mean age 38 years) with unexplained abdominal pain of suspected pancreatobiliary origin and no prior episode of pancreatitis underwent ERCP with sphincter of Oddi manometry and bile collection for crystal analysis. Eighty-one patients had a gallbladder in situ. No patient had evidence of stones or sludge on prior abdominal imaging. Sphincter of Oddi manometry was performed in standard retrograde fashion by using an aspirating catheter. Patients were classified by sphincter of Oddi dysfunction type by using a modified Hogan-Geenen classification system. Patients with type I sphincter of Oddi dysfunction were excluded. Bile was collected directly from the gallbladder (n=23) or common bile duct (n=62) after an infusion of 3.5 microg of cholecystokinin and was examined by light and polarizing microscopy for cholesterol crystals or calcium bilirubinate granules. RESULTS: The proportion of patients with crystals was 3.5% (3/85). Thirty-five patients (41%) had elevated biliary and/or pancreatic sphincter pressure (type II, 16; type III, 19), of whom one (3%) had cholesterol crystals. Fifty patients had normal sphincter pressure, of whom two (4%) had cholesterol crystals (p=0.6). All 3 patients with cholesterol crystals had a gallbladder in situ. Calcium bilirubinate granules were not found in any patient. CONCLUSIONS: Microlithiasis appears to be rare in patients suspected to have type II or type III sphincter of Oddi dysfunction. Evaluation of bile for crystals appears unproductive in this group of patients.