7181 Endoscopic ultrasound (eus) guided fine needle injection (fni) of the pancreatic duct for the diagnosis of pancreas divisum - a new technique.

Abstract

Background: Pancreas divisum is a recognized cause of acute intermittent pancreatitis and chronic pancreatitis. EUS visualization of the stack sign for diagnosing pancreas divisum falls short of a 100% sensitivity. Traditional diagnosis has relied upon endoscopic retrograde cannulation of the minor papilla demonstrating non-union of the dorsal and ventral ducts. Utilizing recent techniques, cannulation rates for the minor papilla have improved, but are approximately 90%. Harada et al. have previously described a technique for EUS-guided injection of the pancreatic duct, however its utility in diagnosing pancreas divisum, has not been described. In this abstract, we report on two patients with pancreas divisum and consequent acute intermittent pancreatitis (AIP) or chronic pancreatitis (CP), who underwent EUS-guided FNI for the diagnosis of pancreas divisum. Methods: One patient with CP and one patient with AIP underwent EUS evaluation. The patient with AIP had undergone multiple endoscopic retrograde cholangiograms with failed attempts (including intravenous secretin) in cannulating the minor papilla. The patients underwent EUS evaluation with the Olympus GF-UM20/130 and Pentax FG-36UX or Olympus GF-UC30P. EUS findings were consistent with chronic pancreatitis, but there were no obvious EUS criteria for pancreas divisum. The pancreatic duct as it courses through the body of the pancreas was imaged with the Pentax FG-36UX or Olympus GF-UC30P linear array echoendoscope. Under EUS and fluoroscopic guidance a GIP/Mediglobe 22-gauge needle was advanced into the pancreatic duct. Injection of 60% Hypaque contrast was then used to fill the pancreatic duct. Results: EUS-guided FNI of contrast revealed pancreas divisum with a stenotic accessory papilla in both patients. In the patient with acute intermittent pancreatitis magnetic resonance cholangiopancreatography and ERCP both failed to demonstrate pancreas divisum anatomy. In the patient with chronic pancreatitis, the EUS findings lead to a repeat ERCP with successful endoscopic sphincterotomy of the minor papilla and stent placement. Neither of the patients experienced pancreatitis or other complications related to the EUS-guided FNI procedure. Conclusions: While ERCP remains the goldstandard for the diagnosis of pancreas divisum, EUS-guided FNI of the pancreatic duct may provide an alternative method for diagnosis in patients with difficult ERCP cannulation.