EUS to detect evidence of pancreatic disease in patients with persistent or nonspecific dyspepsia

Helicobacter pylori-Toxoplasma gondii interplay with a possible role of IL-10

Parasites are known for their modulatory effects on the immune response. The impact of toxoplasmosis on the immune response towards H. pylori is being studied in terms of IL-10 levels. This study included 110 patients suffering from persistent dyspepsia and 50 apparently healthy controls. Stool samples were collected and tested for H. pylori using colloidal gold one step test. Sera were examined for anti-Toxoplasma IgM and IgG using ELISA. IL-10 was also tested in the sera using ELISA. We found that Toxoplasma IgM and IgG tested positive in 1.8 % and 40 % of H. pylori positive patients, respectively. H. pylori-infected patients displayed higher IL-10 levels than the healthy controls (84 versus 0.59 pg/ml, respectively, P < 0.001). Classification of H. pylori positive patients according to Toxoplasma IgG titers yielded three groups: negative (58, 52.7 %), equivocal (8, 7.3 %), and positive (44, 40 %) groups, with the highest IL-10 levels detected in the double positive than the negative and the equivocal group (215 pg/ml versus 43 and 112.5 pg/ml, respectively, P < 0.001). There was strong positive correlation between Toxoplasma IgG titers and IL-10 levels (rs = 0.82, P < 0.001). Toxoplasma enhances IL-10 production in response to H. pylori infection. This could ameliorate the inflammatory response in the gastric mucosa, and subsequently more colonization with the H. pylori is achieved, resulting in persistent infection.

Comparison of pancreatic enzyme abnormalities and protease-activated receptor-2-positive eosinophils in the duodenum of patients with functional dyspepsia-irritable bowel syndrome overlap with functional dyspepsia alone in Asian populations

BACKGROUND AND AIM

Some patients with functional gastrointestinal disorders exhibit pancreatic dysfunctions and pancreatic enzyme abnormalities. Thus, we aimed to clarify whether significant differences in clinical characteristics, prevalence of pancreatic enzyme abnormalities, duodenal inflammation, and protease-activated receptor 2 (PAR2) expression levels related to hypersensitivity exist between functional dyspepsia (FD) alone and FD-irritable bowel syndrome (IBS) overlap group.

METHODS

Ninety-three patients based on the Rome IV criteria, FD alone (n = 44) and FD overlapped with IBS (n = 49) group were enrolled. The patients scored their own clinical symptoms after consuming high-fat meals. Serum trypsin, PLA2, lipase, p-amylase, and elastase-1 levels were measured. PAR2, eotaxin-3, and TRPV4 mRNA levels in duodenum were determined using real-time polymerase chain reaction methods. PRG2- and PAR2 in the duodenum were evaluated using immunostaining.

RESULTS

FD score and global GSRS in patients with FD-IBS overlap were significantly higher than FD alone. Although the prevalence of pancreatic enzyme abnormalities in patients with FD alone was significantly (P < 0.01) higher than that in FD-IBS overlap, the ratio of aggravation of clinical symptoms following high-fat intake in patients with FD-IBS overlap was significantly higher (P = 0.007) than that in patients with FD alone. PAR2- and PRG2-double positive cells were localized in the degranulated eosinophils in the duodenum of patients with FD-IBS overlap. The number of PAR2- and PRG2-double positive cells in FD-IBS overlap was significantly (P < 0.01) higher than FD alone.

CONCLUSIONS

Pancreatic enzyme abnormalities and PAR2 expression on degranulated eosinophils infiltrations in the duodenum may be associated with the pathophysiology of patients with FD-IBS overlap in Asian populations.

Exocrine Pancreatic Insufficiency is Undiagnosed in Some Patients with Diarrhea-Predominant Irritable Bowel Syndrome Using the Rome IV Criteria

BACKGROUND AND AIMS

Irritable bowel syndrome (IBS) is one of the most frequent disorders in clinical practice, with a mean 7.6-10.8% worldwide prevalence. A study showed that 6.1% of patients with diarrhea-predominant IBS (IBS-D) had severe exocrine pancreatic insufficiency (EPI). We aimed to identify the prevalence of EPI based on fecal elastase stool testing (Fel-1) in IBS-D and the clinical characteristics that may predict the diagnosis of EPI.

METHODS

Patients aged > 18 years presenting to tertiary hospital outpatient clinics with IBS-D completed validated questionnaires and gave a stool sample where Fel-1 concentration was measured. Patients with Fel-1 < 100 µg/g represented EPI and > 100 to < 200 µg/g underwent testing for pancreatic pathology with laboratory and endoscopic ultrasound (EUS) evaluation.

RESULTS

One hundred forty patients (mean age 60 years, females 75.7%) were studied. EPI was found in 5% (95% CI 2.2-10.4), and pancreatic steatosis was the main EUS finding (71%). Dyspepsia was an independent factor associated with EPI (OR 34.7; 95% CI 4.95-366.37, p = 0.0007). After pancreatic enzyme replacement therapy (PERT), patients showed a significant improvement in the Bristol stool scale (p < 0.0001), bowel movements per day (p < 0.005), distension score (0.0009), pain score (0.0277) and IBS severity (0.0034).

CONCLUSION

EPI is present in 5% of patients who fulfill Rome IV criteria for D-IBS, and dyspepsia was an independent symptom strongly associated with EPI. Pancreatic steatosis was the main endoscopic ultrasound finding. After PERT therapy, patients had significantly improved stool frequency, stool consistency, abdominal pain, distension and IBS severity score.

Combination of high-density cholesterol level, elastic score, and severity of exocrine pancreatic dysfunction may be useful for a predictive factor for patients with early chronic pancreatitis

BACKGROUND

This study aimed to clarify whether any risk factors including clinical characteristics, endosonographic features, and exocrine pancreatic dysfunction may be useful for a predictive factor for patients with early chronic pancreatitis.

METHODS

A total of 163 consecutive patients that presented with functional dyspepsia with pancreatic enzyme abnormalities (FD-P) (n = 46), early chronic pancreatitis (ECP) (n = 47), and asymptomatic patients with pancreatic enzyme abnormalities (AP-P) (n = 70) based on the Rome III classification and the Japan Pancreatic Association were included in this study. The enrolled patients were evaluated using endosonography (EUS) and EUS elastography. The levels of the five pancreatic enzymes were measured. Pancreatic exocrine function was analyzed using N-benzoyl-l-tyrosyl-p-aminobenzoic acid (BT-PABA).

RESULTS

There were no significant differences in clinical characteristics such as age, gender, body mass index, alcohol consumption, and smoking among patients with AP-P, FD-P, and ECP. The ratio of BT-PABA test less than 35% in patients with ECP was significantly (P = 0.043) higher than in AP-P patients. Elastic score was a useful tool to differentiate the FD-P group from the ECP group. The high-density cholesterol levels in patients with ECP were significantly lower than those in AP-P. In addition, the combination of total and high-density cholesterol levels, BT-PABA test, and elastic score has a higher area under the curve value (0.708) of patients with ECP than in the other groups.

CONCLUSIONS

The combination of high-density cholesterol levels, elastic score, and severity of exocrine pancreatic dysfunction may be useful for a predictive factor for patients with ECP.

Trypsin may be associated with duodenal eosinophils through the expression of PAR2 in early chronic pancreatitis and functional dyspepsia with pancreatic enzyme abnormalities

BACKGROUND

Early chronic pancreatitis (ECP) has been reported to advance into chronic pancreatitis, it may be critical to differentiate the pathophysiology of ECP and functional dyspepsia (FD) in patients with pancreatic enzyme abnormalities (FD-P). This study aimed to clarify differences in the pathophysiology of ECP and FD-P and to determine whether duodenal inflammatory responses in the two diseases were associated with protease-activated receptor (PAR) 2, as the trypsin receptor.

METHODS

Eighty patients who presented with FD-P and ECP were enrolled. In duodenal specimens, PAR2 mRNA levels were determined using real-time PCR. Using immunostaining, CD68-, GLP-1-, PRG2-, and CCR2-positive cells, tight junction proteins, and PAR 2 were evaluated.

RESULTS

There were no significant differences in clinical symptoms and gastric motility between ECP and FD-P patients. The CD68-positive cells infiltrations and occludin expression levels in the duodenal mucosa of patients with FD-P were significantly (p<0.001 and p = 0.048, respectively) lower than those in patients with ECP. Although serum trypsin levels in ECP and FD-P patents were significantly (p<0.05 and p<0.001, respectively) associated with duodenal eosinophils counts, elevated trypsin levels were not significantly associated with degranulated eosinophils, occludin, claudin-1 and ZO-1 expression levels in the duodenum of either group. PAR2 mRNA levels were increased in the duodenum of patients with ECP and FD-P. PAR2 was localized in the epithelial cells of the duodenal mucosa and the surface of degranulated eosinophils in ECP and FD-P patients.

CONCLUSIONS

Elevated trypsin levels might be partly associated with duodenal inflammatory responses through PAR2-related degranulated eosinophils and the reduction of occludin in patients with ECP and FD-P.

State of anxiety may be associated with exocrine pancreatic insufficiency in functional dyspepsia patients with pancreatic enzyme abnormalities

We have reported that refractory functional dyspepsia patients with pancreatic enzyme abnormalities (FD-P). We tried to analyze the prevalence of exocrine pancreatic insufficiency (EPI) in FD-P patients to clarify whether the pathophysiology of FD patients including clinical symptoms and quality of life were associated with EPI. We enrolled forty-nine patients presenting with typical symptoms of FD-P patients (n = 20) and asymptomatic patients with pancreatic enzyme abnormalities (AP-P) (n = 29). Five pancreatic enzymes (p-amylase, lipase, elastase-1, trypsin, and PLA2) were measured and STAI-state/-trait and SF-8 were evaluated. Pancreatic exocrine function was analyzed using N-benzoyl-l-tyrosyl-p-aminobenzoic acid (BT-PABA). There were no significant differences in patient background between FD-P and AP-P patients. BT-PABA test scores for FD-P patients (61.67 ± 5.55) were significantly (p = 0.01) lower than in AP-P patients (95.38 ± 2.36). Physical component scale (PCS) in FD-P patients was significantly (p = 0.002) lower than that in AP-P patients. STAI-state was relatively (p = 0.054) associated with BT-PABA test in FD-P and AP-P patients by multiple logistic regression analysis. The prevalence of EPI in FD-P patients was significantly higher than that in AP-P patients and was relatively associated with state of anxiety. Further studies will be needed to clarify how EPI or pancreatic enzyme abnormalities are associated with the pathophysiology of FD-P patients.

Recent Advances in the Definition and Management of Functional Dyspepsia

In 2016, the Rome criteria were updated as Rome IV, and only minor changes were introduced for functional dyspepsia (FD). The major symptoms of FD now include not only postprandial fullness, but also epigastric pain and burning, and early satiation at above the "bothersome" level. Investigations into the effect of meal ingestion on symptom generation have indicated that not only postprandial fullness and early satiety but also epigastric pain and burning sensation and nausea (not vomiting) may increase after meals. Helicobacter pylori infection is considered to be the cause of dyspepsia if successful eradication leads to sustained resolution of symptoms for more than 6 months, and such a condition has been termed H. pylori-associated dyspepsia. Prompt esophagogastroduodenoscopy and H. pylori "test and treat" may be beneficial, especially in regions with a high prevalence of gastric cancer, such as east Asia. In terms of treatment, acotiamide, tandospirone, and rikkunshito are newly listed in Rome IV as treatment options for FD. Clinical studies in the field of FD should be strictly based on the Rome IV criteria until the next Rome V is published in 2026.

Evaluation and Management of Suspected Early Chronic Pancreatitis (ECP)

PURPOSE OF REVIEW

Chronic pancreatitis in the advanced stages leads to significant health care utilization because of the associated complications. Early-stage diagnosis could prevent the development of these complications by appropriate management. In this article, we reviewed the recent evidence pertaining to the diagnosis and management of early chronic pancreatitis (ECP).

RECENT FINDINGS

The working group for the International Consensus Guidelines for Chronic Pancreatitis has published consensus-based statements to streamline the diagnosis of ECP. There is no international consensus on the definition and diagnosis of ECP. The Revised Japanese Diagnostic Criteria for ECP based on clinical features and endoscopic ultrasound findings have been proposed. Large prospective cohort studies are needed to develop and validate internationally acceptable diagnostic criteria. ECP is recognized as a distinct stage in the development and progression of CP. Consensus-based definitions and diagnostic criteria need to be developed.

Diagnosis and Management of Chronic Pancreatitis: A Review

IMPORTANCE

Chronic pancreatitis (CP) is a chronic inflammatory and fibrotic disease of the pancreas with a prevalence of 42 to 73 per 100 000 adults in the United States.

OBSERVATIONS

Both genetic and environmental factors are thought to contribute to the pathogenesis of CP. Environmental factors associated with CP include alcohol abuse (odds ratio [OR], 3.1; 95% CI, 1.87-5.14) for 5 or more drinks per day vs abstainers and light drinkers as well as smoking (OR, 4.59; 95% CI, 2.91-7.25) for more than 35 pack-years in a case-control study involving 971 participants. Between 28% to 80% of patients are classified as having "idiopathic CP." Up to 50% of these individuals have mutations of the trypsin inhibitor gene (SPINK1) or the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Approximately 1% of people diagnosed with CP may have hereditary pancreatitis, associated with cationic trypsinogen (PRSS1) gene mutations. Approximately 80% of people with CP present with recurrent or chronic upper abdominal pain. Long-term sequelae include diabetes in 38% to 40% and exocrine insufficiency in 30% to 48%. The diagnosis is based on pancreatic calcifications, ductal dilatation, and atrophy visualized by imaging with computed tomography, magnetic resonance imaging, or both. Endoscopic ultrasound can assist in making the diagnosis in patients with a high index of suspicion such as recurrent episodes of acute pancreatitis when imaging is normal or equivocal. The first line of therapy consists of advice to discontinue use of alcohol and smoking and taking analgesic agents (nonsteroidal anti-inflammatory drugs and weak opioids such as tramadol). A trial of pancreatic enzymes and antioxidants (a combination of multivitamins, selenium, and methionine) can control symptoms in up to 50% of patients. Patients with pancreatic ductal obstruction due to stones, stricture, or both may benefit from ductal drainage via endoscopic retrograde cholangiopancreatography (ERCP) or surgical drainage procedures, such as pancreaticojejunostomy with or without pancreatic head resection, which may provide better pain relief among people who do not respond to endoscopic therapy.

CONCLUSIONS AND RELEVANCE

Chronic pancreatitis often results in chronic abdominal pain and is most commonly caused by excessive alcohol use, smoking, or genetic mutations. Treatment consists primarily of alcohol and smoking cessation, pain control, replacement of pancreatic insufficiency, or mechanical drainage of obstructed pancreatic ducts for some patients.

Comparison of clinical symptoms, gastric motility and fat intake in the early chronic pancreatitis patients with anti-acid therapy-resistant functional dyspepsia patients

Background

There was no available data concerning the clinical differentiation between the updated definition of early chronic pancreatitis (ECP) and anti-acid therapy-resistant functional dyspepsia (RFD).

Aims

We aimed to determine whether clinical symptoms, gastric motility, psychogenic factors and fat intake can help distinguish early chronic pancreatitis (ECP) from anti-acid therapy-resistant functional dyspepsia patients with pancreatic enzyme abnormalities (RFD-P) and anti-acid therapy-resistant functional dyspepsia (RFD) patients using endosonography.

Methods

We enrolled 102 consecutive patients presenting with typical symptoms of RFD patients (n = 52), ECP patients (n = 25) and RFD-P patients (n = 25). ECP patients were diagnosed based on the criteria recommended by the Japan Pancreatic Association. Gastric motility was evaluated by ¹³C-acetate breath tests. Severity of duodenal inflammation was examined.

Results

24.5% of RFD patients were determined as ECP using endosonography. Abdominal pain score in Gastrointestinal Symptom Rating Scale (GSRS) in the patients with ECP was significantly lower compared to that in the patients with RFD-P. There were no significant differences in State-Trait Inventory (STAI)-state/-trait scores, Self-Rating Questionnaire for Depression (SRQ-D) scores and clinical symptoms for fat intake among three groups. The early phase of gastric emptying (AUC₅; AUC₁₅) in ECP and RFD-P patients were significantly disturbed compared to those in RFD patients.

Conclusions

Evaluation of severity of abdominal pain and measurement of the early phase of gastric emptying will be useful tools to distinguish ECP patients from RFD patients. Accurate diagnosis of ECP patients may contribute to the prevention from advancing of chronic pancreatitis.

Association of Low Fecal Elastase-1 and Non-Ulcer Dyspepsia

Non-ulcer dyspepsia (NUD) is a term used to define a set of symptoms that are believed to originate from the gastroduodenal region, and no underlying organic, systemic, or metabolic reason can be found. The majority of patients suffer from chronic symptoms although half of the patients report improvement in symptoms with time. The potential role exocrine pancreatic insufficiency in NUD patients has not been clarified yet. We aimed to identify exocrine pancreas function with pancreatic fecal elastase-1 in patients diagnosed with non-ulcer dyspepsia and no typical exocrine pancreatic insufficiency (EPI) symptoms. Thirty-five patients referred to gastroenterology clinics with NUD and 35 people with no dyspeptic symptoms as a control group were included in this prospective study. Non-ulcer dyspepsia patients were classified as group 1 and control subjects classified as group 2. Upper gastrointestinal endoscopies were performed in both groups. Assessment of exocrine pancreatic function was performed by measuring fecal elastase-1 concentration with a commercial ELISA kit using polyclonal antibodies (BioServ Diagnostics) in NUD patients compared to control subjects. Mean fecal elastase-1 levels were significantly lower in group 1 patients compared with group 2 (367.47 ± 43.27; 502.48 ± 50.94 respectively; p = 0.04). The percentage of the patients with EPI was significantly higher in group 1 (p = 0.02). Patients with NUD should be re-evaluated if they do not show satisfactory improvement with treatment. Exocrine pancreatic insufficiency was significantly higher in patients with NUD in our study. Evaluation for the presence of EPI can be a cost effective approach in management of refractory patients during the process of ruling out organic reasons.

Morphological and functional changes of chronic pancreatitis in patients with dyspepsia: A prospective, observational, cross-sectional study

OBJECTIVE

Whether chronic pancreatitis (CP) may present with dyspepsia is controversial. We aimed at evaluating the frequency and risk factors of changes of CP in patients presenting with epigastric pain syndrome (EPS)-like symptoms.

DESIGN

A prospective, observational, cross-sectional study was carried out in patients with EPS-like symptoms. Patients underwent endoscopic ultrasound (EUS) evaluation of the pancreas, and changes of CP were defined as the presence of five or more EUS criteria of the disease. In patients with 3 or 4 EUS criteria, magnetic resonance dynamic evaluation of the pancreas (MRI/sMRCP) and endoscopic pancreatic function test (ePFT) were carried out to confirm or exclude the presence of changes of CP. A multivariate logistic regression analysis was performed to evaluate factors associated with CP findings, and results are shown as odds ratio (OR) and 95% confidence interval (CI).

RESULTS

213 patients were included. Changes of CP were confirmed by EUS (≥5 criteria) in 18 patients (8.4%). Thirty-four patients had 3-4 EUS criteria, and changes of CP were confirmed in 27 of them by MRI/sMRCP and ePFT (12.7%). Morphological and functional findings of CP were then present in 45 patients (21.1%). Male gender (OR 2.97; 95%CI 1.39-6.37) and alcohol and tobacco consumption (OR 6.56; 95%CI 1.97-21.85) were associated with the presence of changes of CP.

CONCLUSION

Morphological and functional changes of CP are frequent in patients with EPS-like symptoms. Whether these pancreatic changes explain EPS-like symptoms requires further investigation.

Epigastric pain syndrome accompanying pancreatic enzyme abnormalities was overlapped with early chronic pancreatitis using endosonography

There was not available data about the overlap between functional dyspepsia (FD) and pancreatic diseases. We aimed to determine whether epigastric pain syndrome (EPS) accompanying with pancreatic enzyme abnormalities were associated with early chronic pancreatitis proposed by Japan Pancreas Society (JPS) using endosonography. We enrolled 99 consecutive patients presenting with typical symptoms of FD, including patients with postprandial distress syndrome (PDS) (n = 59), EPS with pancreatic enzyme abnormalities (n = 41) and EPS without pancreatic enzyme abnormalities (n = 42) based on Rome III criteria. Gastric motility was evaluated using the ¹³C-acetate breath test. Early chronic pancreatitis was detected by endosonography and graded from 0 to 7. The ratio of female patients among EPS patients (34/41) with pancreatic enzyme abnormalities was significantly (p = 0.0018) higher than the ratio of female EPS patients (20/42) without it. Postprandial abdominal distention and physical component summary (PCS) scores in EPS patients with pancreatic enzyme abnormalities were significantly disturbed compared to those in EPS patients without it. Interestingly, AUC₅ and AUC₁₅ values (24.85 ± 1.31 and 56.11 ± 2.51, respectively) in EPS patients with pancreatic enzyme abnormalities were also significantly (p = 0.002 and p = 0.001, respectively) increased compared to those (19.75 ± 1.01 and 47.02 ± 1.99, respectively) in EPS patients without it. Overall, 64% of EPS patients with pancreatic enzyme abnormalities were diagnosed by endosonography as having concomitant early chronic pancreatitis proposed by JPS. Further studies are warranted to clarify how EPS patients with pancreatic enzyme abnormalities were associated with early chronic pancreatitis proposed by JPS.

Potential for Screening for Pancreatic Exocrine Insufficiency Using the Fecal Elastase-1 Test

The early diagnosis of pancreatic exocrine insufficiency (PEI) is hindered because many of the functional diagnostic techniques used are expensive and require specialized facilities, which prevent their widespread availability. We have reviewed current evidence in order to compare the utility of these functional diagnostic techniques with the fecal elastase-1 (FE-1) test in the following three scenarios: screening for PEI in patients presenting with symptoms suggestive of pancreatic disease, such as abdominal pain or diarrhea; determining the presence of PEI in patients with an established diagnosis of pancreatic disease, such as chronic pancreatitis or cystic fibrosis; determining exocrine status in disorders not commonly tested for PEI, but which have a known association with this disorder. Evidence suggests the FE-1 test is reliable for the evaluation of pancreatic function in many pancreatic and non-pancreatic disorders. It is non-invasive, is less time-consuming, and is unaffected by pancreatic enzyme replacement therapy. Although it cannot be considered the gold-standard method for the functional diagnosis of PEI, the advantages of the FE-1 test make it a very appropriate test for screening patients who may be at risk of this disorder.

Significance of normal appearance on endoscopic ultrasonography in the diagnosis of early chronic pancreatitis

Background and Objectives:

The Rosemont classification (RC) was developed as a consensus-based standard for the diagnosis of chronic pancreatitis (CP) by endoscopic ultrasonography (EUS), however, it is more complicated than the conventional scoring system. We have noticed that in the early stages of CP, it is not unusual to observe pancreas with abnormal appearance coexisting with the areas of normal parenchyma. The aim of this study was to investigate the validity of a “normal” pancreas appearance and to evaluate the usefulness of modified diagnostic criteria in comparison to the traditional EUS criteria and the RC.

Patients and Methods:

One hundred and seventy-seven patients who had undergone both EUS and endoscopic retrograde pancreatography (ERP) within 2 months were enrolled in the study, and patients with pancreatic cancer were excluded from the study. ERP findings were used as the gold standard for the diagnosis of CP. The EUS images obtained were classified according to both the RC and our new modified criteria. The latter includes an additional criterion to the modified traditional criteria: fine-reticular pattern (F-RP) was defined as a normal pancreatic parenchyma. We compared the accuracy between the new modified EUS criteria and the RC.

Results:

(1) Normal or equivocal findings on ERP were obtained for 132 patients; 113 patients had F-RP on EUS. In contrast, F-RP was found in only 6 out of 45 CP cases on ERP (P < 0.0001). (2) We investigated the diagnostic capability of our new criteria for endoscopic retrograde cholangiopancreatography normal/equivocal pancreas compared to the traditional criteria. In cases where fewer than two points were defined as normal, the incidence of normal pancreas was significantly higher based on the new criteria than on the traditional criteria (P = 0.002). (3) No significant differences were found between the new criteria and the RC across all ERP grades.

Conclusion:

Our new proposed “normal-added EUS criteria” for diagnosing CP was equivalent to the RC.

Efficacy of low-fat diet against dyspepsia associated with nonalcoholic mild pancreatic disease diagnosed using the Rosemont criteria

OBJECTIVES

The objective of this study was to examine the efficacy of low-fat diet against dyspepsia in patients who had endosonographic evidence of nonalcoholic mild pancreatic disease.

METHODS

Patients with unknown cause of upper abdominal pain suggesting pancreatic disease without a history of alcohol consumption were prescribed a low-fat diet (<20 g of fat/d) for 4 weeks. Based on endoscopic ultrasonographic findings and the Rosemont criteria, the patients were distributed into those with 5 or more minor features of chronic pancreatitis (suggestive group), those with 3 or 4 (indeterminate group), and those with 2 or less (control group). Patients with major features were excluded. Symptom severity was recorded before and after the diet therapy using a 10-cm visual analog scale. Improvement of symptoms was compared among the 3 groups.

RESULTS

Of 45 patients, 14 were in the suggestive group, 18 were in the indeterminate group, and 13 served as controls. Improvement of visual analog scale score was significantly greater in the suggestive group than in the indeterminate group (P < 0.001) and the control group (P < 0.001).

CONCLUSIONS

A low-fat diet may be effective in patients with dyspepsia associated with endosonographic evidence of mild pancreatic disease, who do not habitually drink alcohol.

Conventional versus Rosemont endoscopic ultrasound criteria for chronic pancreatitis: comparing interobserver reliability and intertest agreement

BACKGROUND

The Rosemont criteria (RC) were recently proposed by expert consensus to standardize endoscopic ultrasound (EUS) features and thresholds for diagnosing chronic pancreatitis (CP); however, they are cumbersome and are not validated.

OBJECTIVE

To determine interobserver agreement between RC and conventional criteria (CC), and to assess intertest agreement in the diagnosis of CP.

METHODS

Thirty-six consecutive patients who underwent EUS for abdominal pain or pancreatitis were retrospectively reviewed. Anonymized images were independently chosen as best representations of the pancreatic body and reviewed by three experts who recorded the presence of CC and RC features. Agreement (proportion and kappa statistic) between CC and RC was calculated. Interobserver agreement within the CC and RC was assessed. Secondary comparisons with endoscopic retrograde cholangiopancreatography were made where available.

RESULTS

Using CC, 60 readings (83.3%) were negative for CP, while 12 readings (16.7%) were positive. Using RC, 59 readings (81.9%) were negative for CP, while 13 (18.1%) were positive. The weighted kappa for interobserver agreement for CC (four categories: normal⁄low probability, indeterminate, high probability or calcific) was 0.50, with 80.0% overall agreement, versus 0.27 and 68.1% for the four RC categories (normal, indeterminate, suggestive of and consistent with). Agreement on a positive diagnosis with CC was 86.1% (P=0.38 [McNemar's exact test]), with a kappa of 0.47; for RC, agreement was lower at 80.6% (P=0.016 [McNemar's exact test]), with a kappa of 0.38. For patients who underwent endoscopic retrograde cholangiopancreatography (n=12), false-negative and false-positive rates between CC and RC did not appear to be different.

CONCLUSIONS

The RC do not appear to achieve the goals of improving accuracy and interobserver agreement for diagnosing CP.

The role of endoscopic ultrasound in the evaluation of chronic mesenteric ischaemia

INTRODUCTION

Doppler transabdominal ultrasound is a validated screening test for chronic mesenteric ischaemia, but gas and obesity are limitations. Endoscopic ultrasound has been proposed as a comprehensive test to evaluate chronic upper abdominal pain and is capable of Doppler measurement. We aim to evaluate the accuracy of Doppler endoscopic ultrasound (D-EUS) as a single screening test to rule out chronic mesenteric ischaemia in patients with abdominal pain and compare it with Doppler transabdominal ultrasound (D-TUS).

METHODS

We enrolled all patients ≥50 years with chronic upper abdominal pain and vascular risk referred for endoscopic ultrasound. All were scheduled for D-EUS and D-TUS plus a confirmatory test if one of the previous resulted positive. We estimated the accuracy of both techniques comparing them using McNemar test.

RESULTS

68 patients completed the study. Fifty-three (78%) underwent D-EUS, D-TUS, and a confirmatory test. Fifteen (38%) underwent follow-up after negative results. Three (4%) in the D-EUS group and 14 in the D-TUS (21%) were excluded due to artefacts. D-EUS presented a sensitivity of 63%, specificity of 84%, whilst D-TUS presented a sensitivity of 80% and a specificity of 78%. Specificity of D-EUS was not significantly different to D-TUS.

CONCLUSIONS

These results support the role of Doppler endoscopic ultrasound to exclude chronic mesenteric ischaemia as cause of chronic abdominal pain.

Current status of molecular markers for early detection of sporadic pancreatic cancer

Pancreatic cancer (PC) is a highly lethal malignancy with near 100% mortality. This is in part due to the fact that most patients present with metastatic or locally advanced disease at the time of diagnosis. Significantly, in nearly 95% of PC patients there is neither an associated family history of PC nor of diseases known to be associated with an increased risk of PC. These groups of patients who comprise the bulk of PC cases are termed as "sporadic PC" in contrast to the familial PC cases that comprise only about 5% of all PCs. Given the insidious onset of the malignancy and its extreme resistance to chemo and radiotherapy, an abundance of research in recent years has focused on identifying biomarkers for the early detection of PC, specifically aiming at the sporadic PC cohort. However, while several studies have established that asymptomatic individuals with a positive family history of PC and those with certain heritable syndromes are candidates for PC screening, the role of screening in identifying sporadic PC is still an unsettled question. The present review attempts to assess this critical question by investigating the recent advances made in molecular markers with potential use in the early diagnosis of sporadic PC - the largest cohort of PC cases worldwide. It also outlines a novel yet simple risk factor based stratification system that could be potentially employed by clinicians to identify those individuals who are at an elevated risk for the development of sporadic PC and therefore candidates for screening.

Endoscopic ultrasound in chronic pancreatitis: Where are we now?

Endoscopic ultrasonography (EUS) is well suited for assessment of the pancreas due to its high resolution and the proximity of the transducer to the pancreas, avoiding air in the gut. Evaluation of chronic pancreatitis (CP) was an early target for EUS, initially just for diagnosis but later for therapeutic purposes. The diagnosis of CP is still accomplished using the standard scoring based on nine criteria, all considered to be of equal value. For diagnosis of any CP, at least three or four criteria must be fulfilled, but for diagnosis of severe CP at least six criteria are necessary. The Rosemont classification, more restrictive, aims to standardize the criteria and assigns different values to different features, but requires further validation. EUS-fine needle aspiration (EUS-FNA) is less advisable for diagnosis of diffuse CP due to its potential side effects. Elastography and contrast-enhanced EUS are orientation in differentiating a focal pancreatic mass in a parenchyma with features of CP, but they cannot replace EUS-FNA. The usefulness of EUS-guided celiac block for painful CP is still being debated with regard to the best technique and the indications. EUS-guided drainage of pseudocysts is preferred in non-bulging pseudocysts or in the presence of portal hypertension. EUS-guided drainage of the main pancreatic duct should be reserved for cases in which endoscopic retrograde cholangiopancreatography has failed owing to difficult cannulation of the papilla or difficult endotherapy. It should be performed only by highly skilled endoscopists, due to the high rate of complications.

Endoscopic ultrasound for the diagnosis of chronic pancreatitis

Endoscopic ultrasound (EUS) has become a well accepted test for the diagnosis of chronic pancreatitis. Advantages include its ability to detect subtle and severe changes of the pancreatic duct and parenchyma, and its relative safety compared with endoscopic retrograde cholangiopancreatography. Limitations include inter- and intra-observer variability, operator dependence, and an incomplete understanding of its true accuracy. The Rosemont classification has recently been proposed as a weighted, standardized method that may improve EUS chronic pancreatitis scoring. This paper reviews the published evidence regarding the accuracy of EUS in chronic pancreatitis diagnosis, and enumerates the emerging technologies that have been recently studied which may ultimately improve endosonographic imaging of the pancreas.

Efficacy of camostat mesilate against dyspepsia associated with non-alcoholic mild pancreatic disease

BACKGROUND

The aim of the present study was to examine the potential efficacy of camostat mesilate, a protease inhibitor, against dyspepsia associated with non-alcoholic mild pancreatic disease.

METHODS

Patients with upper abdominal pain suggesting pancreatic disease (persistent over hours, pain aggravated by ingestion of food, epigastric pain radiating to the back), without a history of alcohol consumption and who exhibited no abnormalities regarding serum amylase and lipase, ultrasonography, CT and upper gastrointestinal endoscopy, were prescribed 200 mg camostat mesilate three times daily for 2 weeks. The patients were subjected to endoscopic ultrasonography (EUS) while under treatment and were distributed into those who had 4 or more suggestive findings of chronic pancreatitis (suspected pancreatic disease group), 2 or 3 (equivalent group) and those with 1 or no findings (control group). Symptom severity was recorded before and after treatment using a 10-cm visual analog scale (VAS).

RESULTS

Among 95 patients, 40 were in the suspected pancreatic disease group, 30 were in the equivalent group and 25 served as controls. A significant intra- and intergroup improvement of symptoms was observed not only in the suspected pancreatic disease group but also in the equivalent group.

CONCLUSIONS

Camostat mesilate may serve as a therapeutic agent for patients with dyspepsia associated with mild pancreatic disease, who do not habitually drink alcohol.

Evaluation and management of dyspepsia

Dyspepsia is a common clinical problem seen by both primary care physicians and gastroenterologists. Initial evaluation should focus on the identification and treatment of potential causes of symptoms such as gastroesophageal reflux disease (GERD), peptic ulcer disease, and medication side effects but also on recognizing those at risk for more serious conditions such as gastric cancer. This manuscript discusses the evaluation and management of dyspepsia including the role of proton-pump inhibitors, treatment of Helicobacter pylori, and endoscopy. Finally, treatment of refractory functional dyspepsia is addressed.

Endoscopic ultrasound in the evaluation of pancreaticobiliary disorders

The close proximity of the endoscopic ultrasound probe to the pancreas coupled with the ability to perform fine needle aspiration has made endoscopic ultrasound an extremely important technique for the evaluation of both benign and malignant pancreaticobiliary disorders. In parallel to the widespread importance of diagnostic endoscopic ultrasound, the therapeutic and interventional applications of this procedure are expanding and may become a major breakthrough in the management of pancreaticobiliary diseases. This article focuses on the utility and recent advances of endoscopic ultrasound in the diagnostic evaluation pancreaticobiliary disorders and analyses the data of well established interventional procedures such as celiac plexus neurolysis and pseudocyst drainage. Moreover, the more innovative procedures, such endoscopic ultrasound-guided biliary and pancreatic ducts access and drainage and the experimental use of direct endoscopic ultrasound-guided therapy of both solid and cystic pancreatic lesions will also be reviewed.

Diagnosis of mild chronic pancreatitis (Cambridge classification): Comparative study using secretin injection-magnetic resonance cholangiopancreatography and endoscopic retrograde pancreatography

AIM: To investigate the usefulness of secretin injection-MRCP for the diagnosis of mild chronic pancreatitis.

METHODS: Sixteen patients having mild chronic pancreatitis according to the Cambridge classification and 12 control subjects with no abnormal findings on the pancreatogram were examined for the diagnostic accuracy of secretin injection-MRCP regarding abnormal branch pancreatic ducts associated with mild chronic pancreatitis (Cambridge Classification), using endoscopic retrograde cholangiopancreatography (ERCP) for comparison.

RESULTS: The sensitivity and specificity for abnormal branch pancreatic ducts determined by two reviewers were respectively 55%-63% and 75%-83% in the head, 57%-64% and 82%-83% in the body, and 44%-44% and 72%-76% in the tail of the pancreas. The sensitivity and specificity for mild chronic pancreatitis were 56%-63% and 92%-92%, respectively. Interobserver agreement (κ statistics) concerning the diagnosis of an abnormal branch pancreatic duct and of mild chronic pancreatitis was good to excellent.

CONCLUSION: Secretin injection-MRCP might be useful for the diagnosis of mild chronic pancreatitis.

Endoscopic ultrasonography for evaluating patients with recurrent pancreatitis

Acute recurrent pancreatitis (ARP) is still a complex diagnostic and therapeutic challenge in clinical practice. In up to 30% of cases of ARP, it is not possible to establish the etiology of the disease. In the other 70%, many factors play an etiological role in ARP: microlithiasis, sphincter of Oddi dysfunction (SOD), pancreas divisum, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatic tumors or chronic pancreatitis are diagnosed. EUS should be useful in ARP as it is sensitive for diagnosing bile duct stones, gallbladder sludge, pancreatic lesions, ductal abnormalities and chronic pancreatitis. Endoscopic ultrasound (EUS) appears to be diagnostic in the majority of patients with previously unexplained pancreatitis, and offers an alternative to endoscopic retrograde cholangiopancreatography (ERCP) as the initial diagnostic test in patients with ARP.

Endoscopic ultrasound and IL-8 in pancreatic juice to diagnose chronic pancreatitis

BACKGROUND/AIM

Pancreatic juice (PJ) [IL-8] has been proposed as a marker for pancreatic diseases. We compared the accuracy of PJ [IL-8] and endoscopic ultrasound (EUS) to diagnose chronic pancreatitis (CP).

METHODS

79 patients with symptoms suspicious for CP were enrolled. PJ emptied into the duodenum was collected during an upper endoscopy with IV secretin and [IL-8] was measured. CP was diagnosed when PJ [IL-8] was >20 pg/ml. CP was diagnosed at EUS when >or=4 of the 9 established criteria were present. CP was diagnosed by using composite gold standard: ERCP, histology, CT or MRI, and clinical follow-up (mean 20 months).

RESULTS

38 patients had CP, whereas 41 patients had no pancreatic disease. To diagnose CP, PJ [IL-8] was significantly less sensitive compared to EUS (47 vs. 71%), but equally accurate (71 vs. 80%) and specific (93 vs. 88%). By combining PJ [IL-8] and EUS, sensitivity and specificity significantly increased to 82% (either IL-8 or EUS positive) and 100% (both IL-8 and EUS positive).

CONCLUSIONS

Both PJ [IL-8] and EUS are accurate diagnostic modalities for CP. PJ collection can be performed at the time of EUS. PJ [IL-8] and EUS are complementary with higher sensitivity and specificity when used together.

Comparison of endoscopic ultrasound chronic pancreatitis criteria to the endoscopic secretin-stimulated pancreatic function test

Endosonography (EUS) has emerged as a major diagnostic tool in pancreatic imaging. Direct tests of pancreatic function are considered the most sensitive and accurate method to establish a diagnosis of chronic pancreatitis (CP), particularly when imaging studies are inconclusive. The aim of this study was to compare current EUS CP criteria with our newly described, purely endoscopic, secretin-stimulated pancreatic function test (ePFT). Fifty-six patients (25 male, mean age = 44 years) who were referred for evaluation/treatment of chronic abdominal pain with or without CP underwent both EUS and ePFT. The EUS protocol included the following: (1) EUS images were obtained in a standardized fashion from both gastric and duodenal stations, and (2) EUS images were scored independently by one of three therapeutic endoscopists for 0--9 parenchymal/ductal criteria as follows: 0-3 = normal, 4-5 = equivocal, >/=6 = definite CP. Endoscopic pancreatic function test (ePFT) protocol included the following: (1) upper endoscopy, (2) intravenous synthetic porcine secretin (0.2 mcg/kg, ChiRhoClin, Inc.) after test dose, (3) duodenal fluid aspirated every 15 min for 1 h, and (4) autoanalyzed for [HCO3] cutpoint of 80 mEq/L. According to EUS, 33 were normal, 13 equivocal, and 10 definite for CP. The mean peak [HCO3 -] range (in mEq/L) for each group was normal CP (83.7, range = 58-118), equivocal CP (68, range = 30-88), and definite CP (56, range=19-84). Using a peak [HCO3 -] of </=80 mEq/L as diagnostic for CP, the referent values (sensitivity%/specificity%) for EUS in the diagnosis of CP were normal (60/72), equivocal (36/94), and definite (26/100), respectively. An EUS score or greater than 5 had the best specificity (100%) and negative predictive value (100%). We conclude that endoscopic pancreatic function testing with secretin confirms that as EUS score increases, the peak pancreatic fluid bicarbonate decreases. We also conclude that EUS has excellent statistical inferences for diagnosing CP when at least 6 or more criteria are present. EUS as a screening test in patients with chronic abdominal pain and equivocal imaging studies may be of limited value.

Accuracy of endoscopic ultrasonography and magnetic resonance cholangiopancreatography for the diagnosis of chronic pancreatitis: a prospective comparison study

BACKGROUND

The diagnosis of chronic pancreatitis (CP) remains challenging. Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) have been proposed as highly accurate diagnostic modalities. Although endoscopic retrograde cholangiopancreatography (ERCP) has been previously used as a gold standard, it is associated with a small but significant risk. We aim to compare the accuracy of EUS and MRCP with the composite gold standard using ERCP, surgical pathology, and/or long-term clinical follow-up.

METHODS

Ninety-nine patients with clinical signs and/or symptoms suggestive of CP were prospectively enrolled. The diagnosis of CP by MRCP was established when one or more of these features were present: main duct dilation without obstruction, dilated side branches, intraductal stones, ductal irregularity, reduced T1-signal intensity, parenchymal atrophy, and reduced secretory response to secretin administration. The diagnosis of CP by EUS was made when 4 or more of the established criteria were present. Accuracy of all criteria used ("EUS only," "MRCP only," "either EUS or MRCP," and "both EUS and MRCP") was compared with the composite gold standard.

RESULTS

Forty patients were diagnosed with CP by the composite gold standard whereas the remaining 59 patients were controls. EUS only seemed more sensitive but equally specific compared with MRCP only to diagnose CP. The combination of EUS and MRCP had a sensitivity of 98% for either EUS or MRCP and a specificity of 100% for both EUS and MRCP.

CONCLUSIONS

EUS and MRCP are highly accurate modalities for the diagnosis of CP and are complementary when used together. If confirmed in larger series, the diagnosis of CP by both EUS and MRCP is highly predictive and ERCP is unlikely to add any useful information.

International survey of knowledge of indications for EUS

BACKGROUND

The knowledge level for EUS indications among gastroenterologists across different locations and practices is not known. The aim of this study was to assess knowledge of EUS indications among a diverse group of gastroenterologists, both nationally and internationally.

METHODS

A web-based survey was designed to assess knowledge of EUS with respect to 4 organ systems: esophagus, gastroduodenum, hepatopancreatobiliary, and colorectum. The survey was distributed by electronic mail (e-mail) to members of the American Society for Gastrointestinal Endoscopy.

RESULTS

The survey was distributed to 3848 physicians, of whom 2848 had an active e-mail address. There were 323 respondents (11.3%), of whom 210 were U.S. members and 113 international. Overall, the mean score for the different organ systems for all respondents was highest for gastroduodenum (93% correct) and lowest for colorectum (71%) compared with esophagus (79%) and hepatopancreatobiliary (83%) systems. The mean total score was higher for U.S. respondents (84% correct) compared with international respondents (79%, p < 0.0001). Endosonographers fared better than those who were not endosonographers (85% vs. 81%, p = 0.0002).

CONCLUSIONS

Knowledge levels of colorectal applications of EUS are poorest among the 4 organ systems studied. Future educational initiatives should focus on applications of EUS in this category. Studies are required to assess the impact of this education on the appropriateness of EUS referral patterns.

Yield of EUS-guided FNA of pancreatic masses in the presence or the absence of chronic pancreatitis

BACKGROUND

Evaluation of a focal pancreatic mass in the setting of chronic pancreatitis (CP) is a diagnostic challenge. The objectives of the study were to compare the diagnostic yield and accuracy of EUS-guided FNA (EUS-FNA) in the evaluation of pancreatic-mass lesions in the presence or the absence of CP and to identify predictors of CP before EUS-FNA of pancreatic-mass lesions.

METHODS

The study design was analysis of data collected prospectively on all patients with solid pancreatic-mass lesions who underwent EUS-FNA at a tertiary referral center. A total of 282 consecutive patients underwent 300 EUS-FNA procedures of pancreatic-mass lesions over a 3-year period. The diagnostic yield and the accuracy of EUS-FNA was compared between patients with and without CP. CP was defined by the presence of more than 4 EUS criteria.

RESULTS

Final diagnosis was adenocarcinoma in 210 (70%), benign disease in 64 (21%), other pathology in 19 (6%), and indeterminate in 4 (2%); 3 patients (1%) were lost to follow-up. CP was noted in 75/300 (25%) patients. A lower sensitivity for EUS-FNA was observed in patients with CP than in those without CP (73.9% vs. 91.3%; p = 0.02). While patients with CP had a higher negative predictive value (88.9% vs. 45.5%; p < 0.001), no significant differences were observed for specificity (100% vs. 93.8%), positive predictive value (100% vs. 99.5%), and accuracy (91.5% vs. 91.4%) between those with and without CP. False-negative cytology was encountered in 24 cases: 6/71 (8%) with CP vs. 18/222 (8%) without CP. Patients with CP required more EUS-FNA passes to establish a diagnosis vs. those without CP (median, 5 vs. 2; p < 0.001). On multivariable analysis, age < 50 years (p < 0.001), male gender (p < 0.001), black race (p = 0.001), and the absence of jaundice (p = 0.005) were significantly associated with CP. The impact of EUS-FNA on long-term clinical management was not analyzed. The impact of individual EUS features of CP on sensitivity of EUS-FNA was not evaluated. By protocol, mass lesions that were benign required more passes to definitively exclude malignancy.

CONCLUSIONS

EUS-FNA has a low sensitivity for pancreatic-mass lesions in the setting of CP. This decreased sensitivity can be overcome by performing more numbers of passes at FNA, which improves diagnostic accuracy. Demographic features and clinical presentation are predictive of underlying CP in patients with pancreatic-mass lesions.

Guidelines for the management of dyspepsia

Dyspepsia is a chronic or recurrent pain or discomfort centered in the upper abdomen; patients with predominant or frequent (more than once a week) heartburn or acid regurgitation, should be considered to have gastroesophageal reflux disease (GERD) until proven otherwise. Dyspeptic patients over 55 yr of age, or those with alarm features should undergo prompt esophagogastroduodenoscopy (EGD). In all other patients, there are two approximately equivalent options: (i) test and treat for Helicobacter pylori (H. pylori) using a validated noninvasive test and a trial of acid suppression if eradication is successful but symptoms do not resolve or (ii) an empiric trial of acid suppression with a proton pump inhibitor (PPI) for 4-8 wk. The test-and-treat option is preferable in populations with a moderate to high prevalence of H. pylori infection (> or =10%); empirical PPI is an initial option in low prevalence situations. If initial acid suppression fails after 2-4 wk, it is reasonable to consider changing drug class or dosing. If the patient fails to respond or relapses rapidly on stopping antisecretory therapy, then the test-and-treat strategy is best applied before consideration of referral for EGD. Prokinetics are not currently recommended as first-line therapy for uninvestigated dyspepsia. EGD is not mandatory in those who remain symptomatic as the yield is low; the decision to endoscope or not must be based on clinical judgement. In patients who do respond to initial therapy, stop treatment after 4-8 wk; if symptoms recur, another course of the same treatment is justified. The management of functional dyspepsia is challenging when initial antisecretory therapy and H. pylori eradication fails. There are very limited data to support the use of low-dose tricyclic antidepressants or psychological treatments in functional dyspepsia.

Comparative analysis of direct pancreatic function testing versus morphological assessment by endoscopic ultrasonography for the evaluation of chronic unexplained abdominal pain of presumed pancreatic origin

OBJECTIVES

The diagnosis of "minimal change" chronic pancreatitis (MCCP) is often considered when conventional imaging studies are unrevealing in a patient population with abdominal pain of presumed pancreatic origin. Direct pancreatic function testing using secretin as a secretagogue (ST) has been considered the most sensitive method to diagnose MCCP but is not widely available to clinicians. Endoscopic ultrasound (EUS) allows detailed imaging of pancreatic architecture, but the sensitivity and specificity for MCCP remain to be determined. We sought to compare the accuracy of EUS and ST in patients with presumed MCCP.

METHODS

Seventy-four patients referred to our pancreas clinic with unexplained abdominal pain and previously negative imaging studies underwent an ST for evaluation of possible MCCP. Twenty-one of these also underwent EUS. EUS images were read by 1 of 2 experts blinded to ST results.

RESULTS

Using ST as the "gold standard," EUS had a maximum sensitivity of 71% when the cut-off for diagnosis was set at at least 3 EUS features. Conversely, maximum specificity (92%) was seen when the cut-off value was set at at least 6 EUS criteria. Diagnostic certainty was only 50% (positive predictive value = 0.5) when at least 6 criteria were used as the cut-off. MCCP was excluded with greater than 70% certainty when less than 3 criteria were present. At the best cut-off value of at least 4 features, EUS had a sensitivity of 57% and a specificity of 64%.

CONCLUSIONS

In this patient population with abdominal pain of presumed pancreatic origin, EUS and standard pancreatic function testing are often discordant. If ST is assumed to be the reference against which other tests are compared, EUS is less accurate than ST in diagnosing MCCP.

Chronic pancreatitis

In the past 20 years, endoscopic ultrasonography has been added to the already large armamentarium of diagnostic tests for chronic pancreatitis. This article discusses its potential and possible limitations.

The role of ultrasound in biliary and pancreatic diseases

The possibilities and the limits of transabdominal ultrasonography (US) in the diagnosis of bilio-pancreatic diseases are reviewed here in the light of the last 10 years' research. US remains the method of choice for the diagnosis of gallstones and is generally accepted as an initial imaging technique in gallstone complications, such as acute cholecystitis. Moreover the method can be useful for the detection of the biliary complications after laparoscopic cholecystectomy and after liver transplantation. US is still considered the first diagnostic procedure when stones are suspected in the common bile duct. The use of color Doppler can provide a differential diagnosis of gallbladder cancer with respect to other benign inflammatory or polypoid lesions. Color Doppler US allows to detect vascular complications of acute pancreatitis such as pseudoaneurysms. US is still considered useful for the initial screening of the pancreatic cancer. However, for staging other imaging techniques must be employed. With US useful informations are obtained in the diagnosis of cystic tumors of the pancreas and of pancreatic metastases. US is generally of little use for the diagnosis of endocrine tumors.

Proposal for a new grading system for chronic pancreatitis: the ABC system

BACKGROUND

A satisfactory classification, or staging system, for chronic pancreatitis is not available. Currently available systems use histologic proof or imaging data for assessment. Although the former is not available in all cases, the latter may not correlate well with the clinical presentation. Therapy for chronic pancreatitis depends on the clinical aspects of the disease, not purely on the duct morphology or histology.

GOALS

A staging/grading system is proposed that is applicable to all types of diagnosed chronic pancreatitis and that allows comparison of similar groups. It also provides therapeutic guidelines. The system divides patients into grades A, B, and C, depending on the presence or absence of abdominal pain or complications. Further subdivision is based on the presence or absence of deficiency in pancreatic function. This staging system permits accurate description of the disease with relevance to therapeutic approach and prognosis.

Cholecystokinin-stimulated peak lipase concentration in duodenal drainage fluid: a new pancreatic function test

OBJECTIVE

Hormonal stimulation with secretin or cholecystokinin (CCK) is the most sensitive means of assessing pancreatic function. Secretin is not available, and current CCK tests are cumbersome, requiring dual tube intubation and marker perfusion techniques. The aim of this study was to test the efficacy of a new CCK-stimulated pancreatic function test measuring peak lipase concentration.

METHODS

A Dreiling gastroduodenal tube was inserted to the ligament of Treitz, and fluid was collected on ice for 80 min in four 20-min aliquots. CCK was infused i.v. at a constant rate of 40 ng/kg/h. Gastric aspirations were discarded. Duodenal aspirates were analyzed for volume and enzyme concentration with a clinical laboratory autoanalyzer.

RESULTS

Nineteen healthy volunteers and 18 chronic pancreatitis patients were studied. Lipase concentration and secretory volume showed a peak response by 40 min of stimulation, whereas amylase response was variable. The mean peak lipase concentrations (+/-SEM) for normal volunteers and mild, moderate, and advanced chronic pancreatitis patients were 16.9+/-1.9, 7.9+/-1.7, 3.7+/-1.2, and 2.1+/-0.6 x 10 5 IU/L, respectively. Lower peak lipase concentrations were significantly associated with more advanced chronic pancreatitis (p < 0.001). The receiver operating characteristic curve area for all chronic pancreatitis patients was 0.944 (95% CI = 0.825-0.985). A peak lipase concentration of 780,000 IU/L provided a sensitivity and specificity of 0.833 and 0.867, respectively. This CCK test was well tolerated and without complications.

CONCLUSIONS

Lipase concentration in duodenal fluid increases nearly 3-fold from baseline after CCK stimulation in healthy volunteers but is markedly reduced in patients with chronic pancreatic disease. Peak lipase concentration is a significant predictor of chronic pancreatitis and correlates with severity of pancreatic disease. Aspiration of duodenal drainage fluid with a Dreiling tube and analysis with a laboratory autoanalyzer are less cumbersome than marker perfusion and back titration techniques. Measurement of enzyme concentration instead of output could lead to the development of an endoscopic or through-the-scope screening method for assessing patients with suspected chronic pancreatitis or chronic abdominal pain.

EUS in the diagnosis of early chronic pancreatitis: a prospective follow-up study

BACKGROUND

The aim of this prospective, follow-up study was to investigate the value of EUS in the diagnosis of alcohol-induced chronic pancreatitis.

METHODS

One hundred thirty patients with known (n = 51) or clinically suspected (n = 79) chronic pancreatitis were included. Patients with a history of chronic use of alcohol and recurrent abdominal pain underwent endoscopic retrograde pancreatography and EUS. The 38 patients with normal endoscopic retrograde pancreatography but signs of chronic pancreatitis on EUS were included in a follow-up program.

RESULTS

All patients with chronic pancreatitis confirmed by retrograde pancreatography (n = 92; 70.8%) had ductal or parenchymal changes detectable with EUS. Among 38 patients (29.2%) with normal retrograde pancreatography, 32 (84.2%) presented with morphologic features consistent with chronic pancreatitis by EUS. During follow-up (median 18 months, range 6-25 months) chronic pancreatitis was confirmed by repeat endoscopic retrograde pancreatography in 22 of these 32 patients (68.8%). On the basis of these follow-up data, the sensitivities of EUS and endoscopic retrograde pancreatography at the time of the first examination were, respectively, 100% and 80.7% (p < 0.001).

CONCLUSION

EUS detects chronic pancreatitis in all cases if endoscopic retrograde pancreatography was suggestive for chronic pancreatitis. However, EUS is more sensitive than endoscopic retrograde pancreatography in the detection of early morphologic changes of chronic pancreatitis in patients with abdominal pain and a history of chronic and continued ingestion of alcohol.

Chronic pancreatitis

An increasing number of novel mutations are associated with chronic pancreatitis. Some cause a high-penetrance, autosomal dominant type of clinical picture (eg, mutations at codons 29 and 122 of the cationic trypsinogen gene), whereas others have a low penetrance or are frequent in the general population (eg, mutations in Kazal type 1 [SPINK1] and in codons 16, 22, and 23 of the cationic trypsinogen gene) and act as disease modifiers. The results of recent studies indicate that smoking adversely affects the course and complications of chronic pancreatitis (more frequent and faster rate of calcification and higher risk of development of pancreatic cancer). Thus, regardless of the cause of chronic pancreatis, patients with this condition should not smoke. Using current diagnostic criteria, the accuracy of endoscopic ultrasound for the diagnosis of chronic pancreatitis is not good. For example, 39% of dyspeptic persons without any other evidence of chronic pancreatitis fulfilled the endoscopic ultrasound criteria for chronic pancreatitis. Diabetes frequently occurs in chronic pancreatitis, but it is not prevented or increased by pancreatic surgery. Islet cell autotransplantation holds promise for the prevention of diabetes in patients requiring total pancreatectomy if the pancreas is not extensively fibrotic. Splenic vein occlusion is present in 7% of patients undergoing surgery for chronic pancreatitis, but fewer than one fifth of these patients have variceal bleeding before or after surgery.

Dyspepsia: challenges in diagnosis and selection of treatment

BACKGROUND

Despite considerable study, the pathophysiology of dyspepsia remains obscure. This and other factors have impeded development of precise and effective treatment strategies.

OBJECTIVE

This paper provides a brief review of the clinical syndrome of dyspepsia and its pathophysiology, symptoms, diagnosis, and treatment.

METHODS

To identify articles for inclusion in this review, a search of MEDLINE was conducted using the key word dyspepsia. Because the literature on this topic is voluminous and duplicative, the search was limited primarily to literature from the last decade and to articles concerning dyspepsia in adults.

RESULTS

The symptoms of dyspepsia, which may include epigastric pain, heartburn. bloating, and early satiety, defy diagnosis in as many as 50% of patients, even after endoscopy and other appropriate studies. In the other half of patients, such causative disorders as gastroesophageal reflux disease (GERD), peptic ulcer disease, cholecystitis, pancreatitis, and gastric cancer may be diagnosed. Despite controversy regarding the selection of therapy, empiric treatment is common for apparent idiopathic dyspepsia. Histamine2-receptor antagonists, proton pump inhibitors (PPIs), promotility agents, and coating agents have all been used as empiric therapy for dyspeptic symptoms. With empiric treatment, subsequent management is directed by the therapeutic response. In the absence of a definitive diagnosis, treatment is usually selected on the basis of the type and severity of symptoms, a thorough history and physical examination, and factors such as age and the presence of Helicobacter pylori infection. Five PPIs are currently available--lansoprazole, omeprazole, rabeprazole, pantoprazole, and esomeprazole--all with established efficacy in GERD and other acid-mediated disorders. The PPIs can be expected to be useful in certain patients with dyspepsia, and may be prescribed for patients who are found to re- spond to potent antisecretory therapy. Patients' concern about their symptoms, practical considerations, and restrictions imposed by managed care organizations may all affect the choice between empiric therapy and early endoscopy in patients with dyspepsia.

CONCLUSIONS

Despite the variety of therapeutic options available for the symptoms of dyspepsia, the many presentations of this condition and the uncertainty of the response to the currently available therapeutic options continue to pose a substantial clinical challenge.