Chronic Calcific Pancreatitis Research Articles

Chronic Pancreatitis or Pancreatic Tumor? A Problem-solving Approach

Certain inflammatory pancreatic abnormalities may mimic pancreatic ductal adenocarcinoma at imaging, which precludes accurate preoperative diagnosis and may lead to unnecessary surgery. Inflammatory conditions that may appear masslike include mass-forming chronic pancreatitis, focal autoimmune pancreatitis, and paraduodenal pancreatitis or "groove pancreatitis." In addition, obstructive chronic pancreatitis can mimic an obstructing ampullary mass or main duct intraductal papillary mucinous neoplasm. Secondary imaging features such as the duct-penetrating sign, biliary or main pancreatic duct skip strictures, a capsulelike rim, the pancreatic duct-to-parenchyma ratio, displaced calcifications in patients with chronic calcific pancreatitis, the "double duct" sign, and vessel encasement or displacement can help to suggest the possibility of an inflammatory mass or a neoplastic process. An awareness of the secondary signs that favor a diagnosis of malignant or inflammatory lesions in the pancreas can help the radiologist to perform the differential diagnosis and determine the degree of suspicion for malignancy. Repeat biopsy or surgical resection may be necessary to achieve an accurate diagnosis and prevent unnecessary surgery for inflammatory conditions. Online supplemental material and DICOM image stacksare available for this article. ©RSNA, 2019.

ESWL vs. Pancreatoscopy-guided Lithotripsy for Painful Chronic Calcific Pancreatitis

ESWL vs. Pancreatoscopy-guided Lithotripsy for Painful Chronic Calcific Pancreatitis

2811 Outcomes of Endoscopic Ultrasonography (EUS) in Patients Referred for Biliary Dilation Without Significant Biochemical Cholestasis

INTRODUCTION: The diagnostic yield of endoscopic ultrasound (EUS) in non-jaundiced patients with unexplained biliary dilation has been reported to be 6-33%. In our experience, patients with unexplained biliary dilation who use chronic narcotic analgesics might have an even lower diagnostic yield at EUS. However, this correlation has not been well-described as yet. METHODS: We reviewed electronic medical records of patients referred to our center for EUS for the primary indication of unexplained biliary dilation between July 2007 and June 2017. Our database search yielded 767 potential subjects. Exclusion criteria included pancreaticobiliary masses, stones, or calcific chronic pancreatitis seen on prior imaging, a total serum bilirubin >3 mg/dl, or alkaline phosphatase (AP) > 1.5x the upper limit of normal. Data were also separately abstracted on patients with liver tests exceeding the above criteria, yet who had no other exclusion criteria. RESULTS: 41 patients met all inclusion and exclusion criteria. The mean age was 62.4 ± 14.5 years, 37 (90.2%) were female, the mean bile duct diameter at EUS was 12.2 ± 3.8 mm, total bilirubin was 0.6 ± 0.3 mg/dL and AP was 112 ± 62.9 U/L. Most patients (33/41, 80.5%) were symptomatic, reporting abdominal pain or weight loss. A majority (29/41, 70.7%) of patients used oral narcotics. EUS demonstrated choledocholithiasis in 3/29 patients (10.3%) using narcotics and 1/12 (8.3%) not using narcotics. No masses or other relevant pathology was observed. This patient cohort was then combined with 39 additional patients with unexplained biliary dilation who had abnormal liver biochemical tests. Multivariable logistic regression analysis revealed that patients with abnormal liver biochemical tests were 3 times more likely to have positive EUS finding (OR 2.9, CI [1.5,5.7], P = 0.002). Patients using chronic narcotic analgesics were less likely to have positive EUS finding (OR 0.3, CI [0.1, 1.1], P = 0.06). CONCLUSION: A majority of patients referred for EUS to investigate biliary dilation without biochemical cholestasis were women using chronic narcotic analgesics. The diagnostic yield of EUS in this population was low (9.8%) and no neoplasia was found. In contrast, the yield of EUS in patients with biliary dilation and elevated liver tests was strikingly higher at 85%. Use of chronic narcotic analgesics appeared to predict a reassuring EUS examination.

1253 Rare Case of Superior Mesenteric Arteriovenous Fistula as Complication of Recurrent Pancreatitis

INTRODUCTION: Superior mesenteric arteriovenous fistula (SMAVF) is a rare entity. Most common cause of SMAVF is post-traumatic, however they may be congenital, iatrogenic or secondary to connective tissue disorders. We report a case of SMAVF in setting of acute on chronic pancreatitis. CASE DESCRIPTION/METHODS: 62-year-old male with history of pancreas divisum, infrarenal abdominal aortic aneurysm, cholelithiasis and chronic calcific pancreatitis initially presented for elective Endoscopic Retrograde Cholangiopancreatography (ERCP) for obstructing pancreatic ductal stone with stent placement. After the procedure, patient had to be admitted and treated for acute post-ERCP pancreatitis. Patient underwent repeat ERCP in four weeks for stent replacement but had recurrence of pancreatitis after the second procedure. Computerized Tomography (CT) scan of the abdomen done at that time was consistent with pancreatic pseudocyst causing minimal mass effect on Superior Mesenteric Vein (SMV) without vascular thrombosis. Patient was discharged once stable but unfortunately returned to the hospital for a third time within two weeks complaining of nausea, vomiting, severe abdominal pain and diarrhea. CT Angiogram of the abdomen and pelvis was obtained this admission which showed changes consistent with colitis, increasing size of pancreatic pseudocysts with possible necrosis, new SMV thrombosis and SMAVF in region of middle colic artery. This was confirmed on mesenteric angiogram. Patient was started on anticoagulation to treat thrombosis and clinically improved after symptomatic management. The case was discussed at multidisciplinary conference and no acute intervention for SMAVF was recommended. Patient eventually underwent laparoscopic cholecystectomy few months later for cholelithiasis and SMAVF was noted to be stable on repeat CT scan at four-month interval. DISCUSSION: SMAVFs are extremely rare. As of 2005, only 40 cases of post-traumatic SMAVF and similar number of iatrogenic cases had been cited in literature. Clinical presentation can be asymptomatic or manifest as abdominal pain, anorexia, diarrhea, gastrointestinal bleed, portal hypertension and congestive heart failure. Splanchnic venous thrombosis, as seen in our patient, develops in 50 percent cases with necrotizing pancreatitis. Such thrombosis can further lead to development of SMAVF which was also noted in this case.

Outcome after Lateral Pancreaticojejunostomy for Chronic Calcific Pancreatitis: A Short Term Prospective Study

Chronic pancreatitis is a fairly common condition with pain being the major symptom and longitudinal pancreaticojejunostomy (LPJ) is performed for symptomatic relief. The aim of the study is to assess the outcome of LPJ for chronic calcific pancreatitis and to evaluate the factors influencing relief of symptoms. A prospective observational study enrolling 28 patients was conducted in the department of surgery of Shaheed Suhrawardy Medical College Hospital from January 2018 to December 2018. This study involved identification of various risk factors related to chronic pancreatitis, pancreaticojejunostomy, early post-operative outcome and postoperative assessment of pain relief at 1 and 6 months from surgery. Pain was assessed using Visual analogue scale (VAS). In chronic pancreatitis, there is a significant relief of pain in post-LPJ; the degree of relief was less in the alcoholics than non-alcoholics (p=0.09) and in smokers. There was also reduction in analgesic requirement and frequency of acute attacks of pain. In chronic pancreatitis, there is a significant relief of pain in post-LPJ, although the degree of relief is less in the alcoholics and smokers.
 J Shaheed Suhrawardy Med Coll, June 2019, Vol.11(1); 13-16

A randomized-controlled trial of early endotherapy versus wait-and-see policy for mild symptomatic pancreatic stones in chronic pancreatitis.

Although surgical or endoscopic treatment is effective for pain control in symptomatic calcified chronic pancreatitis, it is still unknown whether early intervention in mild symptomatic pancreatic stones would reduce the frequency of acute exacerbation and improve long-term outcomes. The aim of this randomized-controlled trial was to explore the efficacy of early endotherapy for mild symptomatic pancreatic stones in comparison with the wait-and-see policy. Patients with mild symptoms because of pancreatic stones were assigned randomly to the endotherapy or the wait-and-see group. The wait-and-see group received endotherapy only when they developed refractory exacerbation or intractable pain. The primary outcome was the cumulative incidence of intolerable pain attacks and acute exacerbation. The secondary outcomes were the development of pancreatic insufficiency and the progression of pancreatic atrophy. A total of 20 patients were enrolled between March 2008 and March 2011. The study was terminated prematurely because of the poor patient enrollment. Early endotherapy tended to reduce the cumulative incidence of pain attacks and exacerbation, (P=0.17) with the composite incidence of pain attacks and exacerbation of 30% in the endotherapy group and 60% in the wait-and-see group. There were no significant differences in terms of diabetic status and the presence of steatorrhea. The thickness of the pancreas decreased significantly in the wait-and-see group (9.2-6.8 mm, P=0.041), but not in the endotherapy group (8.7-9.0 mm, P=0.60). In a small group of patients, early endotherapy in mild symptomatic chronic pancreatitis was associated with a trend toward a minor number of acute attacks and atrophy progression of the pancreas.

Carcinoma in chronic calcific pancreatitis: review of literature

Carcinoma occurring the setting of chronic calcific pancreatitis (CCP) are usually multifocal, poorly differentiated, advanced on presentation and associated with poor overall survival. Hence it is imperative that these patients should be identified in the early stages of malignant progression where by curative resection can then be employed. If not, only palliative approaches are feasible in advanced stages. We wish to present our experience of pancreatic carcinoma in the setting of CCP along with a review of literature.

Pancreas Proapoptotic Proteases in Patients with Chronic Pancreatitis

Aim. To study features of localization of the DNA-ase I and endonuclease-G proapoptotic proteases in the pancreas in chronic pancreatitis (CP). Materials and methods. Histological pancreas preparations from 60 patients with various CP forms were studied: group I — 10 patients with obstructive CP; group II — 21 patients with calcific CP; group III — 13 patients with fibroparenchymal CP; group IV — 16 patients with CP complicated by pseudocyst. Pancreas biopsies were obtained during planned organ operations, as well as using a fine-needle biopsy under ultrasound control. Tissue material was fixed in Bowen medium. Microscopic tissue sections were prepared and subsequently stained with hematoxylin-eosin and by Mallory-Slinchenko. Immunohistochemical typing of proapoptotic proteases was performed according to the indirect avidin-streptavidin-peroxidase reaction (“Elite”, USA) using rabbit antibodies to DNA-I and endonuclease-G (“Chemicon”, USA, 1: 500 dilution — 1: 2000, incubation 12:00, + 4 °С).Results. Patients in all the groups demonstrated signs of chronic inflammation, with 31.7 % of cases showing signs of its exacerbation. Atrophic changes were found in most patients (96.7 %). No significant differences were observed with regard to the severity and frequency of fibrosis of various degrees in the groups: mild, moderate, severe and full fibrosis was detected in 6.7 %, 20.0 %, 16.7 % and 56.6 %, respectively. The study of the localization of proapoptotic nucleases in the structures of the pancreas showed proapoptotic nucleases of DNA-ase I to be exclusively located in the cytoplasm of pancreatic acinar cells. At all stages of CP fibrosis, single acinar cells with translocation of the nuclease from the cytoplasm into the cell nucleus were found in the lobes of the pancreas. Endonuclease-G was found in large numbers in the cytoplasm of pancreatic islets, with it lower number being detected in the cytoplasm of the epithelial cells of the ducts. Conclusions. In CP, proapoptotic proteases of DNase I and endonuclease G are expressed in the cytoplasm of cells located in different pancreas zones. Thus, DNase I is expressed in the cytoplasm of acinar cells, while endonuclease G is most typical for insular cells and those in the epithelium of the ducts. This proves the existence of various apoptosis mechanisms in the exo- and endocrine portions of the pancreas.

Laparoscopic longitudinal pancreatojejunostomy and modified Frey's operation for chronic calcific pancreatitis.

BackgroundChronic pancreatitis is a debilitating disease presenting with pain, diabetes and steatorrhoea. Surgery offers better long‐term pain relief than other interventions, but there is still uncertainty about the optimal surgical procedure and approach and a lack of long‐term follow‐up data in patients with chronic calcific pancreatitis selected for laparoscopic surgical treatment.MethodsThis was an observational cohort study of patients who underwent laparoscopic surgery for chronic calcific pancreatitis between January 2006 and April 2017, and had completed a minimum follow‐up of 1 year at a tertiary‐care teaching institute. Eligibility for the laparoscopic approach was main duct diameter greater than 7 mm, absence of extensive head calcification, size of head less than 3·5 cm, absence of local complications, and ASA grade I or II status. The primary outcome variable was a reduction in pain score by 1 year. Secondary outcomes were hospital stay, complications, pain score at 3 and 5 years, and the development or progression of exocrine and endocrine insufficiency.ResultsSome 57 patients were scheduled to undergo laparoscopic surgery for chronic pancreatitis: longitudinal pancreatojejunostomy (39), modified Frey's procedure (15) and pancreatoduodenectomy for suspicion of malignancy (3). The latter three patients were excluded from the analysis. Conversion to open surgery was needed in ten of the 57 patients (18 per cent). The mean(s.d.) age of the analysed cohort was 34·2(3·7) years and there was a predominance of men (34, 63 per cent). Adequate pain relief was achieved in 91, 89 and 88 per cent of patients at 1, 3 and 5 years of follow‐up respectively.ConclusionLaparoscopic surgical management of chronic calcific pancreatitis with longitudinal pancreatojejunostomy or modified Frey's procedure is feasible, safe and effective in selected patients for the relief of pain.

Per Oral Pancreatoscopy Identification of Main-duct Intraductal Papillary Mucinous Neoplasms and Concomitant Pancreatic Duct Stones: Not Mutually Exclusive.

Per oral pancreatoscopy (POP) assists in the evaluation and treatment of select benign and neoplastic pancreatic disorders including main-duct intraductal papillary mucinous neoplasm (MD-IPMN). Although pancreatic duct stones are classically thought of as pathognomonic for chronic pancreatitis, its co-occurrence with MD-IPMN as identified via POP may help identify an alternative etiology for presumed idiopathic chronic pancreatitis. This was a multicenter retrospective case series of patients found to have pancreatic duct stones with concomitant MD-IPMN by POP. Thirteen patients with presumed idiopathic chronic calcific pancreatitis were found on POP to have both pancreatic duct stones and MD-IPMN. All patients had a dilated pancreatic duct, and most (92.3%) were symptomatic. Per-oral pancreatoscopy may identify MD-IPMN as an etiology for patients with presumed idiopathic chronic calcific pancreatitis and associated dilated pancreatic duct. Larger prospective studies are needed to validate these findings.

Mo1018 OPTIMAL TIMING OF ENDOSCOPIC INTERVENTION AFTER EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY IN THE TREATMENT OF CHRONIC PANCREATITIS

As first-line therapy for chronic calcified pancreatitis, extracorporeal shock wave lithotripsy (ESWL) combined with endoscopic retrograde cholangiopancreatography (ERCP) can effectively clear stones in the main pancreatic duct (MPD) and relieve abdominal pain. However, given tissue damage and complications caused by ESWL, duration between ESWL and endoscopic intervention may cause difference in intubation and stone removal during ERCP. This study was to determine the optimal timing of endoscopic intervention after ESWL.

2271-PUB: Correlation of Glycaemic Control with pH and Buffering Capacity of Saliva in Patients with Fibrocalculous Pancreatic Diabetes

Fibrocalculous pancreatic diabetes (FCPD) is a form of diabetes secondary to chronic calcific pancreatitis. Microvascular and macrovascular complications of diabetes are reported in FCPD. Periodontitis is considered as the sixth complication of diabetes. Studies regarding the salivary pH, buffering capacity and periodontal health status of FCPD subjects are scarce in the literature. This Study comprised of 30 FCPD, 30 T2DM and 33 healthy controls. Study subjects were assessed for salivary pH and buffering capacity, modified gingival index, plaque index, OHI-s index, DMFT index, probing pocket depth and clinical attachment level and systemic parameters FPPG, PPPG, HbA1c, complete blood count, liver and renal function tests, FLP, ESR and CRP. The mean (±SD) salivary pH was 6.57 ± 0.63 in FCPD and 7.21±0.44 in T2DM groups (p<0.05) and buffering capacity was 4.5± 0.6 in FCPD and 5.38± 0.96 in T2DM groups(p<0.05). There was a significant negative correlation between HbA1c and salivary buffering capacity (Pearson correlation coefficient r=-0.46, p=0.012) and a weak negative correlation between HbA1c and salivary pH(r=-0.105, p=0.589) in FCPD group. The prevalence of periodontitis was 90% in FCPD and 100%T2DM groups respectively. The proportion of severe periodontitis was 56.7% in T2DM, 40% FCPD and 12.1% in control groups respectively. This study shows that the saliva is more acidic and buffering capacity is low in FCPD group compared to T2DM and control groups. As the glycaemic control worsens, salivary pH and buffering capacity decreased in FCPD subjects. The pathophysiologic mechanism responsible for the pancreatic gland destruction may also contribute to the changes in salivary pH and buffering capacity in FCPD subjects. Disclosure C. Radhakrishnan: None. R.J. Vadakkekuttical: None. S. Kozhithodi: None.

Itchy Hyperkeratotic Acral Plaque in a Patient With Chronic Calcific Pancreatitis

Itchy Hyperkeratotic Acral Plaque in a Patient With Chronic Calcific Pancreatitis

MON-139 Hyperinsulinemic Hypoglycemia In A Patient Of Chronic Calcific Pancreatitis : A Medical Oxymoron

Introduction Hypoglycemia is rare in persons without diabetes due to normal physiological defences and thus a thorough evaluation is warranted in such cases. Neurogenic symptoms occur initially followed by neuroglycopenic symptoms like cognitive impairment, behavioural changes, psychomotor abnormalities and rarely seizures and coma. Causes of hypoglycemia in non diabetic patients include hepatogenous hypoglycemia, critical illness, alcohol and multiple drugs. Major causes of hypoglycemia in a seemingly healthy individual, after excluding drug intake, include hyperinsulinemic hypoglycemia caused by Insulinomas, Nesidioblastosis, Insulin autoimmune syndrome; and IGF2 secreting tumors. Management includes removal of the tumor, if found, or medical management with Diazoxide and frequent feeds. Octreotide can be used in patients with suspected Insulinoma. Medical management is difficult and frequent feeds can lead to obesity. Chronic calcific pancreatitis, on the other hand, usually leads to hyperglycemia due to pancreatic diabetes which is generally brittle. Hypoglycemia can occur in such patients but is generally a result of antidiabetic therapy. However, it is rare to have hyperinsulinemic hypoglycemia in patients who are not on antidiabetic medication and diagnosis can be delayed. Here we present a case of hyperinsulinemic hypoglycemia in a patient of chronic calcific pancreatitis. Case A 47 year old female with history of repeated episodes of slurred speech, confusion, disorientation and abnormal limb movements for last 3 years. She had been treated as seizure disorder with antiepileptics and was incidentally found to be hypoglycemic during one of these episodes. She was subsequently referred to us for further evaluation. At presentation she was conscious, oriented and had no history suggestive of any chronic illness or drug intake other than antiepileptics. Investigations showed RBS of 85 mg/dl and HbA1c of 3.2%. During prolonged fasting test, she developed hypoglycemia within 10 hours with RBS of 26 mg/dl with concomitant serum Insulin level of 15.47 µU/ml (cutoff < 3 µU/ml with hypoglycemia) and C-peptide level of 2.07 ng/ml (cutoff < 0.2 ng/ml with hypoglycemia). These were consistent with hyperinsulinemic hypoglycemia. CT abdomen showed features of chronic calcific pancreatitis, no focal pancreatic lesion was found. 68Ga DOTATATE PET/CT scan was negative for any functional lesion. She was started on Diazoxide and advised frequent feeds. She improved symptomatically with diazoxide with recurrence of symptoms off it. She was given a trial of octreotide due to non-availability of diazoxide. She improved with octreotide and was started on long acting octreotide. Conclusion Hyperinsulinemic hypoglycemia should be excluded in all patients with unexplained seizure disorder, even if the clinical probability for the same is low, as in our patient.

Extracorporeal Shock Wave Lithotripsy for Large Common Bile Duct and Pancreatic Duct Stones: Efficacy, Safety and Analysis of Factors That Favor Stone Fragmentation

Abstract Background: Extracorporeal shockwave lithotripsy (ESWL) with subsequent endoscopic extraction of residual fragments is an established treatment option in technically challenging situations for extraction of pancreatic and common bile duct calculi. Common bile duct (CBD) stone fragmentation rates of 71 to 95% have been reported with ESWL, leading to final duct clearance rates of 70 to 90%. While complete clearance of 76% and partial clearance of 17% of pancreatic duct calculi have been documented with ESWL, our study was undertaken to investigate the efficacy and safety of ESWL in clearance of difficult bile duct and large pancreatic duct calculi. Methods: The study population consisted of 61 patients who had either large or difficult bile duct calculi or large pancreatic duct calculi documented on ultrasonography abdomen or magnetic resonance cholangiopancreatography (MRCP). All patients were subjected to ESWL sessions with endoscopic nasobiliary drainage (ENBD) placement till stones got fragmented. Results: A total of 1,284 patients underwent ERCP for either choledocholithiasis or pancreatic duct calculi during the study period (June 2015 to December 2016). Out of them 61 patients had either large or difficult CBD calculi or large pancreatic duct calculi. Forty (65.57%) had choledocholithiasis (Group-A) and 21 (34.42%) had chronic calcific pancreatitis (Group-B). CBD was cleared in 37 patients (92.5%) and 3 patients (7.5%) underwent surgical intervention. Main pancreatic duct (MPD) was cleared in all patients with clearance rate of 100%. Conclusions: ESWL is an effective and safe method for clearance of difficult CBD and pancreatic duct calculi. Combined efficacy of duct clearance is &gt;90%. Complications are minimal and managed conservatively.

Impact of calcifications on diagnostic yield of endoscopic ultrasound-guided fine-needle aspiration for pancreatic ductal adenocarcinoma.

Chronic calcific pancreatitis (CCP) is a major risk factor for pancreatic ductal adenocarcinoma (PDAC) and is common in southern India. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is useful for tissue acquisition in patients with solid pancreatic lesions. Multiple factors may affect the diagnostic yield ofFNA samples. The present study was performed to assess the impact of pancreatic calcifications on the diagnostic yield of EUS-FNA in PDAC. All patients with confirmed PDAC from January 2013 to December 2017 were included. CCP was diagnosed based on typicalimaging characteristics with or without evidence of pancreatic insufficiency along with surgical histopathology reports showing features of chronic pancreatitis. The diagnostic yield and adequacy of cellularity were assessed by a pathologist who was blinded and were compared between the two groups: group 1: PDAC patients with no evidence of CCP and, group 2: PDAC patients with CCP. A total of 122 patients were included in the study. The diagnostic yield was lower in patients in group 2 (n= 42, 25 [59.52%]) as compared to those in group 1 (n= 80, 63 [78.75%]) (p-value = 0.01). On multivariate analysis, only the presence of calcifications was found to have an independent association with diagnostic yield (odds ratio 3.83 [95% confidence interval 1.22-11.9]). CCP had a significant impact on the diagnostic yield of EUS-FNA for pancreatic adenocarcinoma. Novel techniques and newer technology that may mitigate the negative effect of calcification on diagnostic yield of EUS-FNA in patients withCCP.

Endoscopic Retrograde Cholangiopancreaticography in Children: A Single-center Experience From Northern India

To evaluate spectrum, efficacy and safety of Endoscopic retrograde cholangiopancreatography (ERCP) in pediatric population. Retrospective case record review of pediatric patients (age ≤15 y) undergoing ERCP between January 2011 to June 2015 at a tertiary care referral hospital in New Delhi, India. The Indications for ERCP, cannulation success rate, procedure success rate and complications were recorded. The mean (SD) age of the participants were 11.5 (3) years. 164 ERCP procedures were done in 126 patients (67 males). All procedures were done under conscious sedation. The common indications for ERCP were choledocholithiasis (50, 30.5%), chronic calcific pancreatitis (38,23.2%), main pancreatic duct injury with leak (21,12.8%), and bile leak (12,7.3%). The cannulation success rate was 90.4% (114 out of 126), while procedural success rate was 86% (141 out of 164). Overall 8 complications were encountered; all were successfully managed conservatively. ERCP in children can be successfully performed at centers with such expertise.

Endoscopic Retrograde Cholangiopancreatography Findings Differs From Ultrasound Results: A Study On Choledocholitihisis Patients In A Tertiary Care Hospital Of Bangladesh

Background: Endoscopic retrograde cholangio-pancreatography (ERCP) is a universally established modality in evaluation and treatment of pancreatico-biliary disorders. Choledocholothiasis is one of its common indications. In the context of Bangladesh, clinical studies on ERCP, specially, assessment of the role of pre-procedural Ultrasound as a screening tool, is relatively rare. In this work, we have analyzed the ERCP outcome of 95 patients and compared their pre-procedural ultrasound results afterwards.&#x0D; Methods: This cross-sectional observational study was conducted in the BIRDEM General Hospital during June 2013 to January2015 on 95 ERCP patients. Among 95 patients, maximum (27.7%) were diagnosed as Choledocholithiasis. The important diagnosis among the rest were, Chronic Calcific Pancreatitis (13.8%), Ca head of Pancreas (12.7%), Cholangiocarcinoma (11.7%), and peri- ampullary carcinoma (11.7%). Ultrasound could not detect common bile duct stone in 42% of choledocholithiasis patients. It detected dilated common bile duct in 30% patients and 15% patients had normal ultrasound report while they underwent ERCP due to high clinical suspicion and found to have duct stone afterwards.&#x0D; Conclusion: The role of ultrasound as a screening test for choledocholithiasis should be progressively assessed by comparing it with MRCP and ERCP results. This study will encourage further research to find correlation between the ERCP and Imaging (both ultrasound and MRCP) in choledocholithiasis patients&#x0D; Bangladesh J Medicine Jan 2019; 30(1) : 5-8

SpyGlass DS-guided lithotripsy for pancreatic duct stones in symptomatic treatment-refractory chronic calcifying pancreatitis.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) and/or extracorporeal shock wave lithotripsy are first-line therapies for draining an obstructed pancreatic duct (PD) in painful chronic calcifying pancreatitis (CCP). Pancreaticoscopy has shown promising success rates in small series. Materials and methods This study was a retrospective analysis of a clinical database. Included were all digital single-operator digital video (SOV) pancreaticoscopy-guided interventions (n = 23) on CCP patients (n = 20) between 2015 and 2017. Success and complication rates were collected from the database. Clinical success was determined by assessing pain level score (NRS) and quality of life (QoL) using standardized questionnaires. Results Overall technical success rate (successful SOV-pancreaticoscopy and PD drainage) was 95 %. Adverse events occurred in 7 of 23 procedures (30 %) and included extravasation from the PD (n = 1), self-limiting post-sphincterotomy bleeding (n = 1) and post-ERCP pancreatitis (PEP) (n = 6). At 3- to 6-month follow-up, 95 % of patients reported improvement in symptoms and reduction in intake of analgesics. Mean NRS decreased from 5.4 (±1.6) to 2.8 (± 1.8) ( P < 0.01). Clinical success was achieved in 95 % of patients. Conclusions Digital SOV-guided lithotripsy was found to be safe and effective in this highly selected population of CCP patients. PD decompression had a beneficial effect on pain reduction and QoL.

Oral Litholysis in Patients with Chronic Calcific Pancreatitis Unresponsive to or Ineligible for Extracorporeal Shock Wave Lithotripsy and Endoscopic Therapy

Background/Aims: Our study aimed to evaluate the effect of oral litholysis in patients with chronic calcific pancreatitis (CCP) unresponsive to or ineligible for extracorporeal shock wave lithotripsy (ESWL) and endoscopic therapy. Methods: Trimethadione, an antiepileptic agent, was administered orally at a dose of 0.6–0.9 g/day to 15 patients with this condition. Treatment outcome was evaluated by assessment of dissolution of the pancreatic stones on plain X-ray films and computed tomography scans of the upper abdomen. Plasma glucose, hemoglobin A1c, and body mass index (BMI) were also monitored throughout the therapy. Results: Litholysis was observed in 13 out of 15 patients (86.7%) and was definite in 10 and partial in 3. Six patients had pancreatitis attacks during the therapy; 5 of whom showed definite litholysis and had only 1 mild attack. Of the 11 patients with normal or impaired glucose tolerance at baseline, none developed diabetes mellitus and all showed litholysis. BMI significantly increased in patients whose pancreatic stones dissolved. There was no vital organ impairment by trimethadione. Conclusion: Oral litholysis using trimethadione may represent a noninvasive and effective complementary treatment in patients with CCP unresponsive to or ineligible for ESWL and endoscopic therapy.