Endoscopic retrograde cholangiopancreatography in pregnancy

BACKGROUND

Pancreaticobiliary disease in pregnancy is relatively uncommon. The frequency of choledocholithiasis in pregnancy requiring intervention has been reported to be as low as one in 1200 deliveries. Traditionally, intervention in these patients has been surgical. Although surgery has an overall low morbidity and mortality for the expectant mother, it carries with it a 4- to 6-wk recovery period and a possibly increased risk of fetal wastage. Published information regarding the role and safety of ERCP in pregnancy is limited. This series of 23 pregnant patients undergoing ERCP was collected from six different medical centers.

METHODS

Twenty-three pregnant patients with symptomatic pancreaticobiliary disease underwent a total of 29 ERCPs (three patients had diagnostic ERCP, and 20 had therapeutic ERCP). Fifteen, eight, and six procedures were performed in the first, second, and third trimesters, respectively. The only ERCP complication was pancreatitis in one patient. There was one spontaneous abortion (3 months after ERCP) and one neonatal death; however, casual relationship to ERCP was not apparent.

CONCLUSION

Diagnostic and therapeutic ERCP appears reasonably safe and effective in pregnancy. Cautious and selective use of this procedure offers a viable alternative to surgery or observation in patients with emergent pancreaticobiliary problems.

Flexible sigmoidoscopy plus air-contrast barium enema versus colonoscopy for evaluation of symptomatic patients without evidence of bleeding

One hundred forty-nine patients aged 40 years or more with symptoms suggestive of colonic disease but without evidence of gastrointestinal bleeding (absence of hematochezia, normal serum levels of hemoglobin, and at least one test negative for fecal occult blood) were randomized to undergo either initial colonoscopy or initial flexible sigmoidoscopy plus air-contrast barium enema. Patients with incomplete initial colonoscopy and certain patients with polyps seen on flexible sigmoidoscopy plus barium enema underwent the alternative procedure (barium enema or colonoscopy). The main results were as follows: First, the overall prevalence of cancer in the study was very low (0.67%). Second, initial flexible sigmoidoscopy plus barium enema detected more patients with diverticulosis than did initial colonoscopy (46% versus 31%; p = .01). Initial colonoscopy detected more persons with adenomas (p = .06) than did initial flexible sigmoidoscopy plus barium enema. Patients undergoing initial flexible sigmoidoscopy plus barium enema require the alternative procedure (24%) than were patients undergoing initial colonoscopy (6%; p = .002). Third, sensitivity analyses suggested that for most areas in the United States, initial colonoscopy would be more cost-effective for the outcomes of detection of adenomas and detection of large adenomas, although very few patients in the study had large adenomas. We conclude that the prevalence of colorectal cancer in persons with colonic symptoms but no evidence of bleeding is low and is comparable with the prevalence in an asymptomatic population. Cost-effective selection of imaging strategies in this population can be based on demographic factors such as age and sex, which are better predictors of the presence of adenomas than are symptoms.

Classification and treatment of local septic complications in acute pancreatitis

BACKGROUND

An international symposium on acute pancreatitis recently developed a clinical classification system for severe acute pancreatitis that classifies all local septic complications into three groups: infected necrosis (IN), sterile necrosis (SN), and pancreatic abscess (PA). Despite the appeal of having three distinct, well-defined labels for this complex process, the clinical utility of this schema has yet to be determined. The purpose of this study was to investigate the prognostic and therapeutic utility of applying this clinical classification system to a large group of surgical patients with local septic complication from acute pancreatitis.

PATIENTS AND METHODS

We reviewed the cases of 62 patients with complicated pancreatitis, classifying them into IN (n = 20), SN (n = 14), or PA (n = 28) groups. Ranson's score, APACHE II score, and computed tomography grading were calculated within the first 48 hours of admission. Information on patient demographics, etiology of pancreatitis, operative procedures, timing of intervention, bacteriology, blood loss, intensive care unit days, ventilator days, and morbidity and mortality were also accrued and analyzed.

RESULTS

Despite similar demographics and etiology of pancreatitis, patients with necrosis, both IN and SN, were more critically ill than were patients with PA (APACHE II score > 15, 21% versus 0%, respectively), required earlier operative intervention (mean 14 days versus 29 days, P = 0.02), required necrosectomy with drainage (65% versus 4%, P < 0.001) rather than simple drainage (3% versus 86%, P < 0.001), more reoperations (2.3 versus 1.1, P < 0.05), and had a significantly higher mortality rate (35% versus 4%, P < 0.05). In addition, patients with IN required significantly more hospital days, ventilator days, and blood transfusions than either patients with SN or PA (P < 0.05).

CONCLUSIONS

We conclude that this classification system allows for the stratification of patients into three distinct groups--infected necrosis, sterile necrosis, and pancreatic abscess--and has both therapeutic and prognostic usefulness.

Success and yield of second attempt ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be an accurate and reliable method to evaluate biliary and pancreatic disorders. When an attempt to perform ERCP fails, the managing physician must decide whether to repeat the procedure or rely on other alternatives. We tallied the data from 113 patients referred to our institution for repeat ERCP after a failed attempt at another hospital. This group represented approximately 5% of the total population studied during that period of time. All of the patients had undergone one or more unsuccessful ERCP(s) and were referred to our center for another attempt at ERCP. Using a variety of techniques, we were successful in cannulating the desired duct in 96% of attempts. Pathologic findings were present in 64% of cases, of which 22% were sphincter of Oddi dysfunction. Thus, second attempt ERCP is generally worthwhile if clinically indicated and ERCP expertise is geographically available.

Evaluation of submucosal upper gastrointestinal tract lesions by endoscopic ultrasound

The proper diagnosis of submucosal upper gastrointestinal tract mass lesions by endoscopy or barium study is difficult. Differentiation between submucosal tumors, vascular structures, and extrinsic organs is often impossible. We performed endoscopic ultrasound examination of 91 patients with upper gastrointestinal submucosal mass lesions. Endoscopic ultrasound was accurate in determining the site of origin in 48 of 50 cases where pathology or angiography comparison was available. Leiomyoma, lipoma, varices, and carcinoma had characteristic ultrasonographic findings. Endoscopic ultrasound is a useful procedure in the evaluation of upper gastrointestinal submucosal mass lesions.

Pancreas divisum. Diagnosis, clinical significance, and management alternatives

Pancreas divisum patients make up a small but problematic portion of ERCP cases. Minor papilla cannulation techniques have been refined. Recurrent pancreatitis patients generally will benefit from minor papilla therapy. Methods to select patients who are likely to respond to invasive therapy and further study need validation. Clinicians and endoscopists are strongly encouraged to be cautious and conservative with this patient group until stronger data indicate optimal management schemes.

Endoscopic management of recurrent and chronic pancreatitis

Endoscopic therapy is now being utilized in the setting of recurrent acute and chronic pancreatitis. This review analyzes the current state of the art of these new applications of endoscopy. Selection of appropriate candidates for the various treatment modalities appears important for optimal results of therapy. Patients with gallstone pancreatitis, pancreas divisum, obstructing main pancreatic duct stones, and bulging pseudocysts appear to be the best candidates for endoscopic therapy.

Wire-guided sphincterotomy

Guidewire-assisted techniques have acquired an important role in endoscopic interventions in the pancreaticobiliary tree. The wire-guided sphincterotome allows the endoscopist to maintain direct access to the biliary tree before or after the sphincterotomy. It has the additional advantages of allowing for more expeditious placement of accessories and being useful in combined percutaneous-endoscopic procedures. There are two basic designs of wire-guided sphincterotomes. The single-channel model has a single lumen for both the cutting wire and guidewire and requires guidewire removal before the application of power. The double-channel model has two separate lumens for the guidewire and stainless steel cutting wire. In vitro data suggest that significant capacitive coupling currents (or short circuits) may occur on the standard Teflon-coated guidewire when used with a double lumen sphincterotome, resulting in electrosurgical burns. Thus, the manufacturers of the double-lumen models recommend removing the Teflon-coated wire before performing sphincterotomy. Although limited data in humans have been published, it appears that wire-guided sphincterotomy and standard sphincterotomy have similar complication rates. More safety information in humans is awaited.

Intravenous cholangiography with helical CT: comparison with endoscopic retrograde cholangiography

PURPOSE

To determine whether helical computed tomography (CT) performed during intravenous cholangiography can provide useful images of the biliary tree and to compare this technique with endoscopic retrograde cholangiography (ERC).

MATERIALS AND METHODS

Eighteen adult patients with clinically suspected biliary disease who were referred for ERC were first examined with helical CT cholangiography performed 75 minutes after intravenous infusion of 100 mL of 10.3% iodipamide meglumine.

RESULTS

Helical CT cholangiography revealed good opacification of the biliary tree in 13 of 14 patients with serum bilirubin levels less than 2 mg/dL (34 mumol/L) and poor opacification in three of four patients with levels greater than 2 mg/dL. In six of seven patients with choledocholithiasis, the diagnosis was made by means of helical CT cholangiography.

CONCLUSION

Helical CT cholangiography may be a clinically useful method for visualization of the biliary tree in some patients with suspected biliary disease with normal bilirubin levels and in patients in whom attempts at ERC fail.

Post-ERCP pancreatitis: randomized, prospective study comparing a low- and high-osmolality contrast agent

Diagnostic and therapeutic ERCPs are complicated by pancreatitis in 1% to 10% of patients, and evidence suggests that the contrast agent used for ERCP may be important in the pathogenesis of such pancreatitis. This prospective, double-blind study was undertaken to determine whether the use of a low-osmolality, nonionic contrast agent (Omnipaque 300; iohexol, 672 mOsm/kg H2O) would reduce the frequency and severity of postprocedure pancreatitis as compared to a high-osmolality, ionic contrast agent (Hypaque 50%; diatrizoate sodium, 1515 mOsm/kg H20). Six hundred ninety patients undergoing diagnostic ERCP (pancreatogram, cholangiogram, or both) either with or without sphincter of Oddi manometry and therapy were randomized to iohexol or diatrizoate sodium. Postprocedure pancreatitis was diagnosed when the serum amylase or lipase level was elevated to at least four times the upper limits of normal at 18 hours and was associated with increased abdominal pain persisting for at least 24 hours after the procedure that required administration of narcotic analgesics. The pancreatitis was graded as mild, moderate, or severe depending on the length of hospital stay and the need for intervention. The overall frequency (7.2% versus 7.5%) and severity (4.3% mild, 2% moderate, 0.9% severe for the diatrizoate sodium group versus 4.3% mild, 2.6% moderate, and 0.6% severe for the iohexol group) of postprocedure pancreatitis and the frequency and severity within each procedure category were similar for the two contrast agent groups (p > .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Endoscopic antireflux techniques. Endoluminal and laparoscopic

Overall, endoscopic management of GER is an exciting new field of therapy or potential therapy. Endoluminal methods have developed slowly and remain experimental. Laparoscopic methods have developed rapidly and are being applied in clinical settings. The future looks bright and is open to the endoscopist's creativity. Continued scientific comparisons of techniques are needed to ultimately define optimal techniques and outcomes.

Treatment of bile leaks from the cystohepatic ducts after laparoscopic cholecystectomy

The cystohepatic ducts represent accessory bile ducts of variable size which frequently travel within the gallbladder fossa or in the posterior wall of the gallbladder. These ducts can be injured during laparoscopic cholecystectomy and can result in bile collections if transected. Successful treatment by operative means or radiologically guided percutaneous drainage is possible, but endoscopic management has several advantages. We describe cases managed by endoscopic retrograde cholangiopancreatography (ERCP) with stent placement and discuss the advantages of this method. Also discussed is the anatomy of these accessory bile ducts, additional management options, and techniques for avoiding this injury during open or closed cholecystectomy.

The yield of a second screening flexible sigmoidoscopy in average-risk persons after one negative examination

BACKGROUND/AIMS

The American Cancer Society recommends that asymptomatic persons aged > or = 50 years undergo sigmoidoscopy every 3-5 years. However, the yield of a second examination 3 years later in persons who are initially negative is unknown. The aim of this study was to determine the yield of a second flexible sigmoidoscopy in average-risk persons aged > or = 50 years after an initial negative examination.

METHODS

Two hundred fifty-nine asymptomatic, average-risk persons who had undergone a negative screening flexible sigmoidoscopy examination at age > or = 50 years underwent a second examination at least 2 years later (mean, 3.4 years).

RESULTS

The second examination found adenomas in 15 (6%) screenees, but no cancers or large (> 1 cm) or severely dysplastic adenomas were detected. Persons aged > or = 60 years at the time of the second examination were more likely (10%) to have adenomas than those < 60 years (3%) (odds ratio, 3.76; 95% confidence interval, 1.17-12.2), but no advanced lesions were found in persons aged > or = 60 years.

CONCLUSIONS

These data suggest that the American Cancer Society should consider changing its recommendation for screening flexible sigmoidoscopy in asymptomatic, average-risk persons to 5-year intervals after a negative examination.

Gallbladder ejection fraction and its relationship to sphincter of Oddi dysfunction

Theoretically, relative distal common bile duct obstruction due to sphincter of Oddi dysfunction may be a cause of poor gallbladder evacuation observed on quantitative cholescintigraphy. In this study, the relationship of sphincter of Oddi dysfunction to the gallbladder ejection fraction by quantitative cholescintigraphy was explored. Eighty-one patients with biliary-type pain and otherwise normal evaluations underwent quantitative cholescintigraphy, sphincter of Oddi manometry, and ERCP. Abnormalities of stimulated quantitative cholescintigraphy and/or sphincter of Oddi manometry were present in 70% of this study group. Manometric evidence of sphincter dysfunction was present in patients with similar frequency irrespective of the degree of gallbladder evacuation. In conclusion, abnormalities of quantitative cholescintigraphy and sphincter manometry appear to be independent factors, although frequent findings in this patient population.

Colonic adenomas in asymptomatic women with a history of breast cancer

One hundred ninety-three asymptomatic women with a personal history of breast cancer underwent screening colonoscopy. One hundred sixty-eight women had breast cancer as their only potential risk factor for colonic neoplasia, and 25 had a family history of colorectal neoplasia in addition to their personal history of breast cancer. Among women with breast cancer, increasing age and body weight were each predictive of an increasing prevalence of colonic adenomas. The prevalence of colonic adenomas in women aged 50-75 yr whose only potential risk factor was breast cancer was 18%, and was identical to the prevalence of colonic adenomas in 186 asymptomatic average-risk control women aged 50-75 yr (odds ratio 1.0, 95% CI 0.54-1.87). We conclude that a personal history of breast cancer does not predict a higher prevalence of colonic adenomas.

Prospective evaluation of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in patients with chronic abdominal pain of suspected pancreatic origin

Twenty asymptomatic paid volunteers (13 females, 7 males, mean age 34 years, range 21-52 years), underwent endoscopic ultrasonography (EUS) to assess variation in the appearance of ductular and parenchymal features of the pancreas. Following this investigation, 69 patients with chronic abdominal pain of suspected pancreaticobiliary origin were evaluated with EUS followed by endoscopic retrograde cholangiopancreatography (ERCP) and in 16 patients secretin stimulated intraductal pure pancreatic juice (PPJ) collection. Thirty patients were found to have chronic pancreatitis based on clinical, ERCP and/or PPJ data, and EUS was abnormal in 24 of these individuals. All of the 19 patients with abnormal pancreatograms also had an abnormal EUS. Twenty-two of the 30 patients with chronic pancreatitis had early disease (no or minimal changes on ERCP). In this subgroup of patients, the sensitivity of EUS was 86% versus 50% for ERCP (p = 0.01). For all patients, the sensitivity, specificity and accuracy of EUS in diagnosing chronic pancreatitis was 80%, 86% and 84% respectively. Using logistic regression analysis eight EUS features were found to be indicative of chronic pancreatitis including echogenic foci within the gland, focal regions of reduced echogenicity within the gland, increased thickness/echogenicity of the main pancreatic duct (MPD) wall, accentuation of the gland's lobular pattern, cysts, an irregular contour or dilation of the MPD and side branch dilation (p < or = 0.05). Generation of a receiver operating characteristic curve to assess the sensitivity and specificity of EUS in diagnosing chronic pancreatitis based on the number of abnormal findings demonstrated that sensitivity and specificity were optimal when three or more abnormal parenchymal and/or ductular features were found. These results suggest that EUS can play an adjunctive role to ERCP and PPJ in the diagnosis of early chronic pancreatitis.