Pancreatic tuberculosis mimicking cystic tumor of pancreas

Isolated pancreatic tuberculosis is very rare, and it presents as a mass lesion and closely mimics pancreatic adenocarcinoma both clinically as well as on imaging. Further, pancreatic tuberculosis can also rarely mimic cystic tumor of the pancreas. We present an unusual case of pancreatic tuberculosis in a 42-year-old lady who presented with pain abdomen and had a cystic lesion with an enhancing mural nodule on computed tomography resembling a cystic tumor of the pancreas.

Frequency & predictors of pancreatitis in symptomatic primary hyperparathyroidism

Background & objectives:

The frequency and predictors of pancreatitis in primary hyperparathyroidism (PHPT) are not well understood. The objective of the present study was to evaluate the frequency of pancreatitis in patients with PHPT and its association with clinical and biochemical parameters of the disease.

Methods:

In this retrospective study all consecutive patients with PHPT registered in the PHPT registry (www.indianphptregistry.com) from the year 2004 to 2013 were included. The clinical, biochemical and radiological parameters related to pancreatitis were evaluated in histologically proven PHPT patients.

Results:

A total of 218 patients (63 men; mean age: 40.6±14.4 yr) underwent surgery for PHPT during the study. Pancreatitis occurred in 35 [16%, 18 acute and 17 chronic pancreatitis (CP)] patients and male:female ratio was 1:0.94. Skeletal manifestations were seen less frequently in PHPT with pancreatitis as compared to that of PHPT without pancreatitis. PHPT with pancreatitis had significantly higher serum calcium (12.4±2.0 vs. 11.7±1.5 mg/dl, P<0.05) in comparison to PHPT without pancreatitis. PHPT with acute pancreatitis (AP) had higher serum calcium (P<0.05) and parathyroid hormone (PTH) (P<0.05) levels than PHPT with CP. Curative parathyroidectomy improved the symptoms associated with pancreatitis as there was no recurrence in AP group, whereas recurrence was observed only in about 10 per cent patients of the CP group.

Interpretation & conclusions:

Pancreatitis was observed in 16 per cent of PHPT patients with male predominance in the study population. No recurrence of AP was observed after curative surgery. It may be proposed that serum amylase with calcium and PTH should be measured in all patients of PHPT with pain abdomen to rule out pancreatitis.

Capsule endoscopy in small bowel Crohn’s disease and Tuberculosis

Differentiation of small bowel tuberculosis (SBTB) from Crohn’s disease (CD) is a diagnostic challenge. We studied 52 patients with suspected SBTB or CD with terminal ileal involvement, who were prospectively enrolled. After confirming patency of the gastrointestinal tract, 26 patients underwent capsule endoscopy (CE). A final diagnosis of CD was found in 18 patients and SBTB in eight patients. All SBTB patients had involvment of the ileocecal valve (ICV) with large (n = 6) and aphthous (n = 2) ulcers in the ileal segment. In CD, ICV involvement was seen in five (33%) patients. Large and aphthous ulcers were observed in seven (47%) and 15 (100%) patients, respectively. On comparison with CD, patients with SBTB had increased frequency of ICV involvement ( P = 0.002) and lesser frequency of aphthous ulcers ( P = 0.007). CE can help in differentiating CD from SBTB by the position of its involvement and the type of ulcers present.

Spontaneous intra-gastric rupture of walled-off pancreatic necrosis: Endoscopic ultrasound features

Walled-off necrosis (WON) is a delayed local complication of acute pancreatitis. It is usually associated with acute necrotizing pancreatitis. It requires drainage if it is infected, associated with gastric or biliary obstruction or is painful. Asymptomatic WON are usually managed conservatively. Occasionally, WON may spontaneously fistulize into gastrointestinal lumen or may rupture into the peritoneum. We describe the endoscopic demonstration of a case of spontaneous rupture of WON into the stomach and its subsequent uncomplicated resolution. Spontaneous rupture of WON into gastrointestinal tract with uncomplicated resolution is a rare event.

Nonfluoroscopic endoscopic ultrasound-guided transmural drainage of pancreatic pseudocysts at atypical locations

Background: Pancreatic pseudocysts (PP) at atypical locations are a therapeutic challenge and are usually managed surgically. Objective: We evaluated safety and efficacy of nonfluoroscopic endoscopic ultrasound (NF-EUS)-guided transmural drainage in the management of PP at atypical locations. Patients and Methods: Retrospective analysis of 11 patients (all males; age range: 28–46 years) with PP at atypical locations who were treated with NF-EUS-guided transmural drainage during the last 18 months was done. Results: Four patients had intra/peri-splenic, three patients had mediastinal, three patients had intrahepatic, and one patient had renal PP. Nine patients had chronic pancreatitis whereas two patients had acute pancreatitis. Alcohol was the etiology of pancreatitis in ten patients. The size of PP ranged from 4 to 10 cm. All patients had abdominal pain, and two patients had fever whereas one patient with mediastinal PP also had dysphagia. NF-EUS-guided transmural drainage could be done successfully in all patients. 7 Fr transmural stent(s) was/were placed in six patients whereas single-time complete aspiration of PP was done in five patients. On endoscopic retrograde pancreatography, six patients had partial duct disruption whereas five patients had complete disruption. Bridging transpapillary stent (5 Fr) was placed in all patients with partial disruption. All PP healed in 10/11 (91%) patients within 2–4 weeks, and there has been no recurrence in 9 of these patients during a follow-up period of 4–18 months. One patient with splenic PP needed surgery for gastrointestinal bleed. Conclusion: PP at atypical locations can be effectively and safely treated with NF-EUS-guided transmural drainage.

Imaging of esophageal tuberculosis: A review of 23 cases

Purpose: To evaluate the various radiological abnormalities in patients with proven esophageal tuberculosis.

Material and Methods: The case records of 23 patients with proven esophageal tuberculosis were evaluated retrospectively for various radiological abnormalities. Twenty-two patients had secondary involvement of esophagus in the form of direct extension of mediastinal and pulmonary tuberculosis or spinal tuberculosis. Only 1 patient had primary involvement of the esophagus with no evidence of disease elsewhere. The diagnosis was confirmed by endoscopic and CT-guided biopsy/aspiration cytology in 7 and 6 cases, respectively. Diagnosis was made on the basis of surgical biopsy of lymph node and autopsy in 1 patient each. In the remaining 8 patients the diagnosis was based on radiological and endoscopic findings and the response to antituberculous treatment.

Results: Chest radiography (CXR) was abnormal in 65% patients. While the findings were non-conclusive for esophageal tuberculosis, characteristic lesions of tuberculosis in lungs or spine were suggestive of tuberculous etiology. In 15 patients, CT of the chest confirmed the corresponding CXR findings and also showed additional findings of mediastinal lymphadenopathy when CXR was normal. Fourteen patients showed mediastinal lymphadenopathy on CT of the chest. In all these patients, more than one group of lymph nodes was involved. The characteristic hypodense center of lymph nodes suggestive of tuberculosis was seen in 12 patients. Radiological abnormalities seen in barium swallow examination were extrinsic compression, traction diverticula, strictures, sinus/fistulous tracts, kinking and pseudotumor mass of esophagus in decreasing order of frequency. The middle third of the esophagus was found to be the most frequent site of involvement.

Timing of surgical intervention in patients of infected necrotizing pancreatitis not responding to percutaneous catheter drainage

BACKGROUND

The timing of surgery in patients not responding to percutaneous catheter drainage (PCD) in infected pancreatic necrosis remains challenging.

MATERIALS AND METHODS

A randomized controlled trial was designed to establish the optimal timings of surgery following PCD in patients with infected pancreatic necrosis (IPN). Patients who did not improve by day 10 after PCD insertion were included in the present study and were randomized to group A (step-up approach as a bridge to surgery) or group B (step-up approach with intention to avoid surgery). Weekly inflammatory and nutritional markers were monitored in both groups (clinical trials. gov identifier NCT-01527084).

RESULTS

From July 2011 to December 2012, 40 patients underwent treatment with PCD. The first 8 patients were randomized into two groups. The trial was stopped prematurely because of difficulty in accrual and poor progress. All subsequent patients were managed with step-up approach with the intention to avoid surgery. Of 35 patients, 24 patients were managed by PCD alone while 11 patients required surgery. In patients who did not require surgery; levels of serum high sensitivity C-reactive protein (hsCRP), interleukin-6(IL6) and prealbumin showed a falling trend. This group also had higher baseline albumin and higher albumin at 4 weeks.

CONCLUSION

During the present study, randomization into surgery at a predetermined time in step-up approach was discontinued due to poor progress. Step-up approach with the intention to avoid surgery led to a success rate of 68.5%. The present study failed to predict the optimal timing of surgery after PCD. Patients who needed surgery were sicker at the time of admission, had higher incidence of organ failure, and spent more time in the ICU compared to patients who did not need surgery. In future, inflammatory and nutritional markers may be useful to identify patients who are unlikely to respond to PCD and may help determine the timing of surgery.

Opium-related sphincter of Oddi dysfunction causing double duct sign

Double duct sign where there is a simultaneous dilatation of both the common bile duct (CBD) and pancreatic duct is usually associated with sinister causes like malignancies of pancreatic head or ampulla. Occasionally, benign causes like chronic pancreatitis or sphincter of Oddi dysfunction (SOD) may cause double duct sign. Chronic opium abuse is a rare cause of the double duct sign, and endoscopic ultrasound (EUS) findings of this rare entity have been occasionally reported. We report about a 54-year-old male with a history of chronic alcohol and opioid abuse evaluated for episodes of abdominal pain and found to have opioid-related SOD and improved with biliary sphincterotomy. EUS was done to rule out malignancy and revealed hypoechoic prominence around terminal CBD suggestive of hypertrophied muscle.

Endoscopic management of splenic pseudocysts associated with acute and chronic pancreatitis

Background

Splenic pseudocysts (SP) are a rare consequence of both acute and chronic pancreatitis. Surgery has been conventional treatment for SP and literature on role of endoscopic treatment is scant. In this study, we retrospectively evaluated SP clinical and radiological characteristics as well as the outcome following endoscopic drainage.

Methods

Retrospective analysis of SP patients seen at our unit from January 2002 to June 2015. All patients were treated with attempted endoscopic transpapillary drainage with a nasopancreatic drain or stent. Patients not responding underwent endoscopic ultrasound-guided transmural or percutaneous radiological drainage.

Results

Eleven patients with SP (all male; mean age: 40.5±8.8 years) were studied. Seven patients had chronic pancreatitis and 4 patients had SP following acute pancreatitis. The majority (10/11; 91%) had alcohol-related acute or chronic pancreatitis with one patient having coexistent pancreas divisum. Seven (64%) patients were treated successfully with transpapillary drainage only; one (9%) patient needed combined transpapillary and transmural drainage; and 3 (27%) patients needed surgery.

Conclusion

Endoscopic transpapillary drainage is an effective treatment for SP especially when it is not infected and with clear contents, and is associated with partial ductal disruption that can be bridged by an endoprosthesis.

Gastrointestinal bleeding in the tropics: Look for the hookworm

Hookworms are recognised as a cause of iron-deficiency anaemia in endemic areas. They are, however, often not considered in the differential diagnosis of overt gastrointestinal bleeding. We report the endoscopic diagnosis of hookworms as the cause of gastrointestinal bleeding in three patients, two of whom had frank haemorrhage with one presenting in hypovolemic shock. Hookworm infestation is an important treatable cause of gastrointestinal bleeding in tropical countries.

Noninvasive evaluation of active pan-ulcerative colitis with multiple strictures using Fluorine-18-Fluorodeoxyglucose positron emission tomography/computed tomography

Ulcerative colitis (UC) is an inflammatory bowel disease characterized by waxing and waning inflammation that changes in severity and extent and may progress to neoplasia, especially in the presence of strictures. When patients have nonnegotiable strictures or severe inflammation with ulcers, colonoscopy is difficult and carries the risk of perforation. The authors present a patient with pan-UC with multiple strictures, in whom fluorodeoxyglucose positron emission tomography/computed tomography was used to noninvasively evaluate the extent and severity of the disease.

Medical management of pain in chronic pancreatitis

Chronic pancreatitis is a common disorder caused by various etiological factors. It usually manifests with abdominal pain and exocrine (steatorrhea, malnutrition) or endocrine insufficiency (diabetes mellitus). Abdominal pain is the dominant symptom in these patients. Medical, endoscopic and surgical modalities are available for therapy. This review focuses on the pharmacological approaches to manage pancreatic pain. Before embarking on medical management of pain it is prudent to exclude complications like pancreatic cancer, pseudocysts, inflammatory mass, biliary or duodenal obstruction which may contribute to abdominal pain. Pharmacological measures for pain relief include central analgesics, enzyme supplements and antioxidants. Other measures include endoscopic and surgical therapy which are not discussed here. Appropriate management of exocrine and endocrine insufficiency and successful control of diabetes are also important in the management of chronic pancreatitis.

Creation of multiple transluminal gateway during endoscopic ultrasound-guided drainage of pancreatic necrosis by enlarging tract of impending rupture in duodenum

Necrotic pancreatic collections are difficult to treat endoscopically due to a concern for inadequate drainage of the necrotic debris. Multiple techniques including the use of metallic stents, endoscopic necrosectomy and use of hybrid approaches utilizing endoscopic and percutaneous approaches have been described for the management of pancreatic necrotic collections. Furthermore, multiple transluminal gateway technique has been used to create endosonography guided multiple tracts to drain a perigastric or periduodenal collection. We hereby report about a patient with walled off necrosis resulting as a complication of alcohol related acute pancreatitis that was drained using endoscopic ultrasound-guided approach. However, a spontaneous cystoduodenal fistula was used to create another tract and place transmural stents resulting in a quick resolution of symptoms.

Factors determining recurrence of fluid collections following migration of intended long term transmural stents in patients with walled off pancreatic necrosis and disconnected pancreatic duct syndrome

Background and Objectives:

Long-term indwelling transmural stents in patients with walled off pancreatic necrosis (WOPN) and disconnected pancreatic duct syndrome (DPDS) decreases risk of recurrence of pancreatic fluid collection (PFC). However, stents can spontaneously migrate causing recurrence of PFC in some patients whereas some patients may have asymptomatic migration of stents. We aim to retrospectively evaluate profile of patients with recurrent PFC following migration of transmural stents in patients with WOPN and DPDS and compare it with patients who had asymptomatic migration of stents.

Patients and Methods:

Records of consecutive patients who underwent endoscopic transmural drainage of WOPN over last 4 years were analyzed and patients with DPDS identified. Results: Thirty-five patients (29 M; mean age 37.0 ± 7.6 years) were followed-up for mean of 28.2 ± 14.0 months (range: 6–50 months). Eight patients (22.8%) had spontaneous migration of stents. It led to recurrence of PFC in three patients, whereas in five patients it was asymptomatic. The patients with recurrent PFC had early stent migration (2, 4, and 5 months respectively) whereas patients with asymptomatic migration had their stents migrating >6 months of resolution. Patients with recurrent PFC had duct disruption in pancreatic head (100% vs. 20%), and low frequency of diabetes (nil vs. 40%), steatorrhea (nil vs. 20%) as well as pancreatic atrophy (nil vs. 80%).

Conclusion:

Early migration of stents, ductal disruption in pancreatic head as well as absence of diabetes, steatorrhea, and pancreatic atrophy seem to increase risk of recurrent PFC following migration of transmural stents in patients with DPDS.

Nonfluoroscopic endoscopic ultrasound-guided transmural drainage of pseudocysts: A pictorial technical review

Pancreatic pseudocysts (PP) are one of the important local complications of pancreatitis and can be treated by surgical, laparoscopic, percutaneous, or endoscopic methods. The endoscopic methods of drainage include transpapillary or transmural drainage or a combination of these two routes. The transmural drainage can be done using conventional duodenoscope without endoscopic ultrasound (EUS) guidance or under EUS guidance. The EUS-guided transmural drainage of PP is done under EUS and fluoroscopic guidance. We have earlier reported nonfluoroscopic EUS-guided transmural drainage of walled-off pancreatic necrosis. In this pictorial technical review, we will discuss in detail this method of nonfluoroscopic EUS-guided drainage of PP.

Inguinoscrotal region as an unusual site of extra-pancreatic collections in infected pancreatic necrosis

Severe acute pancreatitis often leads to pancreatic and peripancreatic collections but, rarely, it can lead to collections at sites remote from the pancreas. Three male patients presented with abdominal pain and inguinoscrotal swelling. They were initially misdiagnosed with obstructed inguinal hernia, epididymo-orchitis and hydrocele, respectively. Later, their diagnosis of acute pancreatitis was revealed on laparotomy in one patient and on computed tomography (CT) in the remaining two patients. All these cases had extensive peripancreatic necrosis and paracolic collections tracking along the psoas muscle, downwards towards the pelvis. These collections were initially managed by percutaneous drainage and saline irrigation as a part of the ‘step-up’ approach. Two of these patients required open necrosectomy, while all required incision and drainage of inguinoscrotal collections. All the patients were discharged in satisfactory condition. Inguinoscrotal swelling is unusual as a first presentation of acute pancreatitis. A high index of suspicion, with careful study of patient's history and examination along with CT, may provide an accurate diagnosis. Local drainage may be required to control sepsis and also provide an egress route for intra-abdominal collections.

Pancreatic tuberculosis: Evaluation of therapeutic response using F-18 fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography

F-18 fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (FDG PET/CT) is a functional imaging technique that monitors glucose metabolism in tissues. Pulmonary tuberculosis (TB) has been reported to show intense uptake of FDG, with a decrease in metabolism of the tuberculous lesions after successful anti-tubercular treatment (ATT). The authors present a patient with pancreatic TB and demonstrate the usefulness of FDG PET/CT in monitoring the response to ATT.

Streptokinase may play role in expanding non-operative management of infected walled off pancreatic necrosis: preliminary results

GOALS AND BACKGROUND

We evaluated ex and in vivo effect of streptokinase on pancreatic necrosum to improve the success rate of pigtail catheter drainage and irrigation in infected walled off pancreatic necrosis using step up approach and also looked at potential risk of bleeding.

EXPERIMENT AND CLINICAL CASES

1000 IU/ml of streptokinase was added to 10 g. of intra-operatively obtained fresh tissue of peripancreatic necrosis and results compared to treatment with saline. Mixture was incubated for 12 h in thermostat at 37.5 °C and subjected to histopathology. Subsequently streptokinase (50,000 units thrice a day for 5 days through PCD) was used in two patients with walled off pancreatic necrosis (WOPN) not responding to step up approach and who were being considered for surgery. Grossly there was fragmentation of necrosum in streptokinase treated tissue. Microscopically complete loss of supportive collagenous framework was noted in streptokinase treated necrosum with clumping of necrotic tissue into structure-less mass. No such changes were discernible in saline treated tissue. In two patients with WOPN there was clearance of debris after streptokinase instillation. None of the patients was on thromboprophylaxis and bleeding was not noticed in any of the patients.

CONCLUSION

Based on ex vivo effect of streptokinase in dissolution of necrosum at periphery, we believe that in patients with walled off pancreatic necrosis (WOPN) not responding to pigtail catheter drainage and saline irrigation; streptokinase may prove to be useful adjunct.

Do the morphological features of walled off pancreatic necrosis on endoscopic ultrasound determine the outcome of endoscopic transmural drainage?

Background and Objective:

Endoscopic transmural drainage is an effective, but technically demanding treatment modality for walled off pancreatic necrosis (WOPN). The factors that determine the outcome of endoscopic treatment for WOPN have been infrequently studied. We aim to retrospectively correlate the morphological features of WOPN on endoscopic ultrasound (EUS) with the outcome of endoscopic transmural drainage.

Patients and Methods:

Over the last 3 years, 43 patients (36 males; mean age 36.04 ± 10.06 years) with symptomatic WOPN were treated by an attempted endoscopic drainage. The correlation between the morphological features of WOPN and the type of treatment offered as well as the number of endoscopic procedures undergone by the patient was assessed.

Results:

The mean size of WOPN was 9.95 ± 2.75 cm with <10%, 10-40% and >40% solid debris being present in 6, 33, and 4 patients, respectively. Patients with <10% necrotic debris needed only single session of endoscopic drainage, whereas patients with 10-40% solid debris needed two or more sessions. Patients with >40% solid debris either needed direct endoscopic debridement or surgical necrosectomy. The extent of necrosis correlated significantly (r = 0.703, P < 0.001) with the type of treatment received by the patient. With increasing size of the collection (r = 0.320, P = 0.047) and the amount of the solid debris (r = 0.800, P < 0.001), there was a significant increase in the number of endoscopic procedures required for successful outcome by the patient.

Conclusions:

The morphological features of WOPN on EUS have important therapeutic implications with collections having large size and more solid debris needing more aggressive therapeutic method for the successful outcome.

Esophageal duplication cyst in an adult masquerading as submucosal tumor

Gastrointestinal duplications usually manifest in children and may involve the esophagus in 20% cases. Esophageal duplication cysts are a rare cause of dysphagia in adults. We report the case of a 35-year-old male who presented to us with progressive dysphagia of 6 months duration. Contrast enhanced computed tomography showed a soft-tissue lesion in right lateral wall of distal thoracic esophagus. On endoscopic ultrasound, a heterogeneously echotextured lesion with anechoic component present at intramural location in the lower esophagus was noted. The patient underwent surgical excision of the lesion and histopathology confirmed the diagnosis of esophageal duplication cyst.

Intramural pseudocysts of the upper gastrointestinal tract

Background:

Intramural pseudocysts or pseudocysts occurring in the gastrointestinal tract (GIT) wall are rare and there is a paucity of data on their clinical features and management.

Patients and Methods:

We retrospectively evaluated patients with intramural pseudocysts seen at our institution over the past 6 years. Intramural location was confirmed either on surgery or endoscopic ultrasound (EUS). Depending upon the symptoms, their control with the conservative medical therapy and procedural consent, the patients underwent EUS guided single time aspiration of the pseudocyst or transmural drainage or transpapillary drainage or surgery.

Results:

A total of 9 patients with intra mural pseudocysts (male: n = 8; mean age ± SD: 39.3 ± 8.0 years; age range: 24-54 years; five patients having chronic and four patients having acute pancreatitis) were studied. The pseudocysts were located in the wall of the second part of the duodenum in five patients, in the gastric wall in three patients and in the lower esophageal wall in one patient. The size of the pseudocysts ranged from 8 mm to 8 cm and 3/9 (33%) patients had associated extra mural pancreatic pseudocysts. All patients had abdominal pain on presentation. Along with pain the patients with duodenal intramural pseduocysts also had symptoms suggestive of gastric outlet obstruction (3) or jaundice (1). The patient with esophageal intramural pseudocyst had dysphagia along with abdominal pain. Majority of these patients could be successfully treated endoscopically with no significant complications.

Conclusions:

Intramural pseudocysts of the upper GIT are very rare and EUS is a useful investigational modality for diagnosing and treating them.

Tuberculosis presenting as Dysphagia: clinical, endoscopic, radiological and endosonographic features

Objective:

Dysphagia as a presenting manifestation of tuberculosis is rare and there is paucity of data on the clinical, endoscopic and endosonographic features of these patients. We present our data related to the features over last four years.

Methods:

We analyzed retrospectively the clinical, endoscopic, radiological, endosonographic and cytological findings in 14 patients (male: 10; mean age: 37.7 ± 10.4 years) with dysphagia due to tuberculosis presenting to us over last 4 years.

Results:

Nine patients (64.3%) had Grade 1 dysphagia, 4 (28.6%) patients had Grade 2 and 1 patient (7.1%) had Grade 3. Mid esophagus was the commonest site of involvement. Endoscopic findings were extrinsic bulge (50%), linear ulcers (28.6%) and pol-ypoidal ulcerated lesion (7.1%). Endoscopic biopsies were inconclusive. Endoscopic ultrasound (EUS) demonstrated mediastinal lymph nodes being responsible for endoscopic bulge and their infiltration into esophageal wall leading on to ulcers. EUS-guided fine needle aspiration from these nodes established diagnosis in all patients.

Conclusion:

Dysphagia in tuberculosis is most commonly caused by compression by the surrounding mediastinal lymph nodes. EUS is a useful investigation for assessment of these patients.

Role of endoscopic ultrasound in the diagnosis of pancreas divisum

Objective:

The published data on the accuracy of the detection of pancreas divisum by endoscopic ultrasound (EUS) is limited. In this study, we evaluate the accuracy of detection of pancreas divisum by radial EUS in patients with chronic pancreatitis.

Methods:

We retrospectively evaluated patients with chronic pancreatitis who underwent EUS followed by endoscopic retrograde cholangiopancreatography (ERCP) in the last four years to identify patients with complete pancreas divisum.

Results:

One hundred and forty six patients with chronic pancreatitis underwent EUS examination and 20 patients (13.6%) had pancreas divisum. The overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy of absence of stack sign on EUS for the diagnosis of pancreas divisum were 50%, 97%, 73%, 93% and 91%, respectively and for the inability to trace pancreatic duct from the head to the body were 100%, 96%, 80%, 100% and 96%, respectively.

Conclusion:

EUS can diagnose pancreas divisum in a majority of patients. Pancreas divisum can be reliably excluded if pancreatic duct could be tracked backwards from the head to the body around the genu.

Clinical, endoscopic and endoscopic ultrasound features of duodenal varices: A report of 10 cases

BACKGROUND

Duodenal varices (DV) although an uncommon cause, are an important cause due to the severe nature of the bleed and associated adverse outcome.

MATERIALS AND METHODS

We retrospectively evaluated patients with DV seen at our institution over past 4 years.

RESULTS

A total of 10 patients (nine males; mean age was 35.8 ± 7.68 years) with DV were studied. Five patients had underlying cirrhosis and five had DV because of non-cirrhotic portal hypertension (four patients had extra-hepatic portal venous obstruction and one patient had non-cirrhotic portal fibrosis). Five patients presented with upper gastrointestinal (GI) bleed, whereas in the remaining five patients DV were detected on endoscopy performed for evaluation of portal hypertension. Endoscopy revealed submucosal lesion in nine patients, whereas in one patient an initial endoscopic diagnosis of Dieulafoy's lesion was made. However endoscopic ultrasound (EUS) could clearly identify DV in all patients. Of five patients presenting with upper GI bleed, three had the esophageal varices eradicated and two presented 1(st) time with bleed form DV and did not have esophagogastric varices. All patients with acute upper GI bleed were initially treated with intravenous terlipressin followed by glue (n-butyl cyanoacrylate) injection in 4/5 patients with one patient refusing further endoscopic therapy. The variceal obliteration was documented by EUS in all these four patients and there has been no recurrence of bleed in these four patients over a follow-up period of 4-46 months. The five non-bleeding DV were already on beta- blockers and the same were continued. Two of these five patients succumbed to progressive liver failure with none of these five patients having GI bleed on follow-up.

CONCLUSION

EUS is a useful investigational modality for evaluating patients with DV and endoscopic injection of glue is an effective therapy for controlling and preventing recurrence of bleed from DV.

An unusual cause of simultaneous common bile and pancreatic duct dilation

Simultaneous dilation of both the common bile duct and the pancreatic duct (double-duct sign) is usually because of ampullary or pancreatic tumours. Here we report an unusual cause of double-duct dilation; we describe the case of a 49-year-old female who developed afferent loop syndrome after pylorus-preserving pancreaticoduodenectomy: cross-sectional imaging of the abdomen revealed a double-duct sign.

Comparative evaluation of structural and functional changes in pancreas after endoscopic and surgical management of pancreatic necrosis

BACKGROUND

Patients with acute necrotizing pancreatitis may develop pancreatic insufficiency and this is commonly seen in patients who have undergone surgery for pancreatic necrosis. Owing to the paucity of relative data, we retrospectively evaluated the structural and functional changes in the pancreas after endoscopic and surgical management of pancreatic necrosis.

METHODS

The records of patients who underwent endoscopic transmural drainage of walled off pancreatic necrosis (WOPN) over the last 3 years and who completed at least 6 months of follow up were analyzed. Structural and functional changes in these patients were compared with 25 historical surgical controls (operated in 2005-2006).

RESULTS

Twenty six patients (21 M; mean age 35.4±8.1 years) who underwent endoscopic drainage for WOPN were followed up for 22.3±8.6 months. During the follow up, five (19.2%) patients developed diabetes with 3 patients requiring insulin and 1 patient with steatorrhea requiring pancreatic enzyme supplementation. The pancreatic fluid collection (PFC) recurred in 1 patient whose stents spontaneously migrated out. On follow up, in the surgery group, 2 (8%) patients developed steatorrhea and 11 (44%) developed diabetes. Five (20%) of these patients had recurrence of PFC. On comparison of follow up results of endoscopic drainage with surgery, recurrence rates as well as frequency of endocrine and exocrine insufficiency was lower in the endoscopic group but difference was not significant.

CONCLUSION

Structural and functional impairment of pancreas is seen less frequently in patients with pancreatic necrosis treated endoscopically compared to patients undergoing surgery, although the difference was insignificant. Further studies with large sample size are needed to confirm these initial results.

Consequences of long term indwelling transmural stents in patients with walled off pancreatic necrosis & disconnected pancreatic duct syndrome

INTRODUCTION

There is limited data on the long term consequences and safety profile of long term indwelling transmural stents after successful treatment of walled off pancreatic necrosis (WOPN).

AIM

To retrospectively evaluate consequences of long term indwelling transmural stents in patients with WOPN.

METHODS

The records of patients who underwent endoscopic transmural drainage of WOPN and had disconnected pancreatic duct syndrome (DPDS) were analyzed.

RESULTS

Thirty patients (26 M; mean age 37.1 ± 7.8 years) with long term indwelling transmural stents and DPDS were followed up for a mean of 20.4 ± 12.2 months (range: 3-38 months). The etiology of acute necrotizing pancreatitis was alcohol in 21, gall stones in 7 and idiopathic in 2 patients. In all patients two or three, 7 (17 patients) or 10 Fr (13 patients) 5 cm double pigtail stents were placed. ERCP revealed disconnected PD at the pancreatic head, body and tail region in 22, 7, and 1 patient respectively. Five patients (16.6%) had spontaneous migration of stents (both the stents in four patients and one stent in one patient; 7 Fr in four and 10 Fr in one patient respectively). Stent migration led to recurrence of pancreatic fluid collection (PFC) in one patient whereas in the remaining 4 patients it did not cause any symptoms. There was no recurrence of symptomatic PFC in remaining 25 patients.

CONCLUSION

Long term indwelling transmural stents in patients with WOPN and DPDS seem to be safe and also appear to decrease the risk of PFC recurrence.