Acute pancreatitis following endoscopic biopsy of the ampulla in a patient with Gardner's syndrome

Acute pancreatitis following endoscopic ampullary biopsy: A case report

BACKGROUND

Endoscopic biopsy is mandatory for the diagnosis of malignant and premalignant ampullary tumours. The commonly reported inadvertent complications following routine mucosal biopsy include perforation and haemorrhage. Acute pancreatitis is an extremely rare complication following this procedure.

CASE SUMMARY

This report details the case of a 59-year-old man who underwent biopsy of the ampulla for a suspected periampullary tumour. Following the procedure, the patient presented with symptoms of acute pancreatitis which was substantiated by laboratory and radiological investigations. He was conservatively managed and discharged following complete resolution of symptoms.

CONCLUSION

This case report serves to highlight the importance of this potential complication following routine endoscopic biopsy of the ampulla.

Readmission rate and complications following biopsy of the ampulla of Vater—A retrospective data analysis

Background and Aim

Obtaining endoscopic biopsies from the ampulla of Vater is important for the diagnosis of lesions that are suspicious for neoplasia. The clinical safety profile is not well defined in the literature. Our aim was to evaluate the procedure-related readmission rate and complications from ampullary biopsy in patients undergoing duodenoscopy and endoscopic retrograde cholangiopancreatography (ERCP).

Methods

A retrospective data analysis was performed on adult patients at Austin Hospital who underwent ampullary biopsies between 1 January 2010 and 1 March 12022. Medical records were identified using pathology databases. The electronic health record was reviewed for baseline characteristics including demographics, date, indication for ampullary biopsy, procedure type (duodenoscopy or ERCP), and procedural associated interventions during ERCP. Readmissions to the Austin Emergency Department within 30 days following the biopsy were identified, and complications were noted.

Results

A total of 506 records were reviewed and 246 episodes of ampullary biopsy met the inclusion criteria. The procedure-related readmission rate for all episodes was 6.1%, which included pain (3.3%), pancreatitis (2.0%), cholangitis (1.6%), and bleeding (0.8%). Ampullary biopsies with ERCP had a procedure-related readmission rate of 8.4%, whereas ampullary biopsies without ERCP had a rate of 2.2%. Increased readmissions and complications were associated with male sex (P = 0.01 and P = 0.05, respectively). There was no association between the number of biopsies taken and complications.

Conclusion

Performing an ampullary biopsy without an associated ERCP carries a low rate of clinical complications and procedure-related readmissions. The combination of ERCP and ampullary biopsy increases the risk four-fold.

Endoscopic retrograde cholangiopancreatography with ampullary biopsy vs ERCP alone: a matched-pairs controlled evaluation of outcomes and complications

Background and aims

Biopsy of the ampulla of Vater may be performed to evaluate for ampullary adenomas, suspected ampullary tumors and immunohistological staining for autoimmune pancreatitis. Ampullary biopsies are commonly performed at the time of endoscopic retrograde cholangiopancreatography (ERCP). Due to the well-established complication rate following ERCP, the contribution of ampullary biopsy as a potential independent risk factor would require a controlled comparison.

Methods

A matched-pairs, case-control analysis was performed for patients undergoing ERCP with or without ampullary biopsy. The analysis involved a retrospective review of adult patients at a tertiary-care center who underwent ampullary biopsies during ERCP compared (via procedural complexity) with a matched control group who underwent ERCP without ampullary biopsies.

Results

Of 159 procedures involving ampullary biopsy, 54 ERCPs that met the inclusion criteria were performed with ampullary biopsy and included in the analysis cohort. This cohort was compared with 54 patients undergoing ERCP without ampullary biopsy, matched by American Society for Gastrointestinal Endoscopy (ASGE) grade of procedural complexity. There were no patients with sphincter of Oddi dysfunction. Ampullary biopsies suggested a diagnosis in 75.9% of the procedures including 12 adenomas, 5 adenocarcinomas and 1 intraductal papillary mucinous neoplasm. Including major and minor complications, the overall complication rate with biopsy (9.3%) was equivalent to the complication rate in the control group without ampullary biopsy (9.3%, P>0.99). The incidence of post-procedure pancreatitis was not significantly different between the two groups (5.6% vs 3.7%, P=0.6). Age and pancreatic duct manipulation, but not ampullary biopsy, were associated with complications on multivariate analysis in the study population.

Conclusions

Ampullary biopsy performed during ERCP had a high diagnostic yield and was not associated with an increased rate of post-procedure complications or pancreatitis when compared with ERCP alone.

Acute Pancreatitis Following Endoscopic Ampullary Biopsies without Attempted Cannulation of the Ampulla of Vater

A 51-year-old man underwent diagnostic work-up for an abnormal-appearing ampulla of Vater. Three hours after biopsy of the ampulla, the patient presented with intense symptoms suggesting acute pancreatitis, which was later confirmed with laboratory and radiographic examinations. Other causes were excluded and the acute pancreatitis was considered a procedural complication. This is a rarely reported complication that must be taken into consideration when biopsies are performed in the ampulla of Vater.

Usefulness of white-light imaging-guided narrow-band imaging for the differential diagnosis of small ampullary lesions

BACKGROUND

Small ampullary tumors and inflammatory lesions have similar endoscopic findings and are difficult to differentiate. Narrow-band imaging (NBI) can visualize microvessels and mucosal microstructure clearly and is widely used to diagnose early gastric and colon cancer.

OBJECTIVE

To evaluate the usefulness of NBI for differentiating ampullary tumors from benign diseases.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care hospital.

PATIENTS

All 45 patients who had suspicious ampullary lesions (enlarged or protruded morphology) during duodenoscopy and underwent NBI between March 2010 and January 2011.

INTERVENTIONS

NBI.

MAIN OUTCOME MEASUREMENTS

NBI images were assessed for irregular villous arrangement, irregular villous size, ridge disappearance, demarcation with normal villi, and abnormal microvasculature. Histology of NBI-guided lesion biopsy specimens provided the final diagnoses. Agreement between NBI images and histologic findings was analyzed.

RESULTS

Of the 60 ampullary lesions, 11, 26, and 23 were adenocarcinomas, adenomas, and benign inflammatory diseases, respectively. Irregular villous arrangement, irregular villous size, ridge disappearance, demarcation with normal villi, and abnormal microvasculature were observed in 45%, 63%, 50%, 48%, and 58% of the lesions, respectively. Multivariate analysis revealed that irregular villous arrangement (odds ratio [OR] 15.76; 95% confidence interval [CI], 3.38-64.12; P < .001) and abnormal microvasculature (OR 86.63; 95% CI, 14.56-515.41; P < .001) were significant independent factors for identifying ampullary adenomas and adenocarcinoma. All tumors had at least one abnormal NBI feature.

LIMITATIONS

Retrospective design.

CONCLUSION

The NBI findings of irregular villous arrangement and/or abnormal microvasculature were useful for differentially diagnosing ampullary tumors. NBI may complement the accurate diagnosis of ampullary lesions by white-light imaging.

Diagnostic Accuracy of the Initial Endoscopy for Ampullary Tumors

Background/Aims

Ampullary tumors come in a wide variety of malignant forms. We evaluated the diagnostic accuracy of endoscopy for ampullary tumors, and analyzed the causes of misdiagnosis.

Methods

We compared endoscopic imaging and biopsy results to final diagnoses. Types of endoscope, numbers of biopsy specimens taken, and final diagnoses were evaluated as possible factors influencing diagnostic accuracy.

Results

Final diagnoses were 19 adenocarcinomas, 18 normal or papillitis, 11 adenomas, two adenomyomas, one paraganglioma, and one neuroendocrine tumor. The diagnostic accuracy of endoscopic imaging or the initial biopsy was identical (67.3%). At least one test was concordant with the final diagnosis in all except two cases. Compared with the final diagnosis, endoscopic imaging tended to show more advanced tumors, whereas the initial biopsy revealed less advanced lesions. The diagnostic accuracy of the initial biopsy was influenced by the type of endoscope used and the final diagnosis, but not by the number of biopsies taken.

Conclusions

Endoscopy has limited accuracy in the diagnosis of ampullary tumors. However, most cases with concordant endoscopic imaging and biopsy results are identical to the final diagnosis. Therefore, in cases where both of these tests disagree, re-evaluation with a side-viewing endoscope after resolution of papillitis is required.

A case of severe necrotising pancreatitis following ampullary biopsy

We present a case of necrotising pancreatitis following ampullary biopsy in a patient with Barrett's oesophagus. The patient needed multiple necrosectomies and several admissions to the intensive care unit. This report is only the third and most severe case of pancreatitis following ampullary biopsy, highlighting its importance as a complication.

A case of acute pancreatitis following endoscopic biopsy of the ampulla of Vater

Ampullary tumors are diagnosed by endoscopic biopsy of the ampulla of Vater. We encountered a rare case of acute pancreatitis following endoscopic biopsy of the ampulla. A 53-year-old man referred to our hospital for detailed examination of a suspected tumor of the ampulla of Vater. We conducted endoscopic biopsy from the ampulla. He developed severe abdominal pain four hours after the procedure. The serum amylase and serum lipase were elevated and abdominal computed tomography (CT) revealed pancreatic enlargement and diffuse stranding of the peri-pancreatic fat, compatible with the findings of acute pancreatitis. We diagnosed the patient as having acute pancreatitis caused by endoscopic biopsy of the ampulla of Vater. Conservative therapy improved his condition, however, a large pancreatic walled-off necrosis (WON) developed. Therefore, we performed endoscopic ultrasonography (EUS)-guided cyst drainage on the 74th day after admission. The WON diminished gradually in size and the symptoms disappeared, and the patient was discharged in good physical condition on the 137th day after admission. In this case, the ampullary biopsy may have caused mucosal edema or intraductal hematoma, resulting in pancreatic duct obstruction. It is important for endoscopists both to be aware of this potential complication following endoscopic biopsy of the ampulla and to inform the patients about possible complications of this procedure.

Endoscopic ampullectomy: a practical guide

Endoscopic ampullectomy is a minimally invasive method of treating superficial lesions of the ampulla of Vater. With careful patient selection and lesion assessment it is a safe and efficacious therapeutic procedure that can obviate the need for potentially major surgical intervention. Strategies for safe and successful endoscopic ampullectomy with a focus on resection technique and recognition and management of complications are presented.

Endoscopic ultrasound-guided fine-needle aspiration biopsy using linear array and radial scanning endosonography

BACKGROUND

Endoscopic ultrasound (EUS) accurately stages gastrointestinal malignancies but is less able to differentiate between neoplastic and inflammatory processes. EUS-guided fine-needle aspiration (EUS FNA) has been reported useful for obtaining a diagnosis in suspected gastrointestinal lesions. We report our entire experience with EUS FNA using both radial and linear array endosonography, including our diagnostic accuracy and complication rate.

METHODS

Two hundred eight consecutive patients (119 men, 89 women) referred for EUS evaluation of suspected gastrointestinal or mediastinal masses underwent EUS-guided FNA. We performed EUS FNA using radial scanning or linear array endosonography and a 23 gauge, 4 cm needle or a 22 gauge, 12 cm needle. Data collected included lesion types, number of passes, complications, and diagnostic accuracy.

RESULTS

Two hundred eight lesions were targeted, with a total of 705 FNA passes (mean 3.39 passes/patient). Overall diagnostic accuracy for our study population was 87% with a 89% sensitivity and 100% specificity. The diagnostic accuracy for each subgroup was 95% for mediastinal lymph node, 85% for intra-abdominal lymph node, 85% for pancreatic, 84% for submucosal, and 100% for perirectal masses. EUS FNA provided an adequate specimen in 90% of patients. The FNA results were similar for both types of endosonography. We observed immediate complications in 2% (4 of 208) of patients. All complications occurred with EUS FNA of pancreatic lesions and consisted of bleeding and pancreatitis in 2 patients each. For EUS FNA of pancreatic masses there was a 1.2% (2 of 121) risk of pancreatitis, 1% (1/121) risk of severe bleeding, and risk of death in less than 1%.

CONCLUSIONS

EUS-guided FNA appears to be technically feasible, safe, and accurate for obtaining diagnostic tissue of suspicious gastrointestinal and mediastinal lesions and provides important preoperative information.