Endoscopic Retrograde Pancreatography Research Articles

How does tolerability of double balloon enteroscopy compare to other forms of endoscopy?

Background and aimsGastrointestinal endoscopy can be difficult for patients to tolerate. Studies on endoscopic tolerability mainly focus on gastroscopy or colonoscopy with a paucity of data on double balloon enteroscopy...

Somatostatinoma of the minor papilla treated by local excision in a patient with neurofibromatosis type 1.

Somatostatinoma arising from the minor papilla in a patient with neurofibromatosis type 1 (NF1) is a known but very rare condition, which may cause non-specific symptoms and can present because of its mass effect. A fifty-year-old female presenting with ongoing non-specific abdominal pain for a few months duration was found to have a mass involving the minor papilla. She had a history of NF1 but was otherwise well. Magnetic resonance imaging showed a dilated pancreatic duct and the finding of pancreatic divisum. The lesion was (18)fluorine-fluoro-2-deoxyglucose positron emission tomography/computed tomography and (68)gallium (Ga) DOTATATE negative. Endoscopic ultrasound revealed a 1.7 cm lesion confined to the minor ampulla. Endoscopic retrograde pancreatography attempts with biopsy and endoscopic ultrasound fine needle aspiration biopsy were inconclusive and resulted in mild pancreatitis on two occasions. Open local excision of the minor papilla was undertaken without complications. Histology confirmed a completely excised grade 1 neuroendocrine tumor with intense diffuse somatostatin staining. Somatostatinoma of the minor papilla is a rare tumor that most commonly occurs in the setting of NF1 and may be amenable to local excision.

Endoscopic retrograde pancreatography: When should we do it?

Endoscopic retrograde pancreatography (ERP) is an accurate imaging modality in the diagnosis of pancreatobiliary diseases. However, its use has been substantially reduced due to the invasiveness of procedure, the risk of complications and the widespread availability of non-invasive cross-section imaging techniques (computed tomography, magnetic resonance imaging, and endoscopic ultrasound). Since the introduction of endoscopic sphincterotomy, ERP has transformed from diagnostic method to an almost exclusively therapeutic procedure. Pancreatic duct injection substantially increased the risk of post-ERP pancreatitis (1.6%-15.7%); therefore, according to international guidelines ERP is recommended only in cases where biliary intervention is required. However, the role of ERP in the management of pancreatic diseases is currently not clearly defined, but in some cases the filling of pancreatic duct may provide essential information complementing the results of non-invasive imaging techniques. The aim of this publication is to systematically summarize the literature dealing with the diagnostic yield of ERP. We would like to define the precise indications of ERP and overview a diagnostic protocol of pancreatic diseases depending on international guidelines and the opinion of Hungarian experts, because it may improve the diagnostic accuracy, minimize of burden of patients and reduce the risk of procedure related complications.

Advanced endoscopic imaging of indeterminate biliary strictures.

Endoscopic evaluation of indeterminate biliary strictures (IDBSs) has evolved considerably since the development of flexible fiberoptic endoscopes over 50 years ago. Endoscopic retrograde cholangiography pancreatography (ERCP) was introduced nearly a decade later and has since become the mainstay of therapy for relieving obstruction of the biliary tract. However, longstanding methods of ERCP-guided tissue acquisition (i.e., biliary brushings for cytology and intraductal forceps biopsy for histology) have demonstrated disappointing performance characteristics in distinguishing malignant from benign etiologies of IDBSs. The limitations of these methods have thus helped drive the search for novel techniques to enhance the evaluation of IDBSs and thereby improve diagnosis and clinical care. These modalities include, but are not limited to, endoscopic ultrasound, intraductal ultrasound, cholangioscopy, confocal endomicroscopy, and optical coherence tomography. In this review, we discuss established and emerging options in the evaluation of IDBSs.

石灰化が著明なsolid pseudopapillary neoplasmの1例

A 15-year-old boy presented with low back pain. Abdominal radiography performed by a local physician showed calcification in the left upper abdomen. Abdominal computed tomography (CT) revealed a mass, 60 mm in diameter, arising in the tail of the pancreas, and the patient was referred to our hospital. Contrast-enhanced CT, contrast-enhanced magnetic resonance imaging, and endoscopic retrograde pancreatography suggested a solid pseudopapillary neoplasm (SPN) . Laparoscopic distal pancreatectomy was performed. The tumor was a well-demarcated cystic lesion, measuring 7×7×5.5 cm. The cut surface of the tumor had a solid, hemorrhagic, and cystic appearance. Histopathological examination revealed that the tumor components were surrounded by a cystic wall showing hyaline fibrosis. The tumor cells showed funicular or nest-like structures, and the nuclei were round or oval. Calcification and cholesterin crystals were found in the stroma. Immunohistochemically, the tumor cells were positive for CD10, CD56, vimentin, and α1-antitrypsin. An SPN was thus diagnosed. We describe our experience with a boy who had an SPN with extremely marked calcification.

Pediatric Chronic Pancreatitis Is Associated with Genetic Risk Factors and Substantial Disease Burden

To determine the clinical presentation, diagnostic variables, risk factors, and disease burden in children with chronic pancreatitis. We performed a cross-sectional study of data from the International Study Group of Pediatric Pancreatitis: In Search for a Cure, a registry of children with acute recurrent pancreatitis and chronic pancreatitis. Between-group differences were compared using Wilcoxon rank-sum test. Among 170 subjects in the registry, 76 (45%) had chronic pancreatitis; 57% were female, 80% were white; median age at diagnosis was 9.9 years. Pancreatitis-predisposing genetic mutations were identified in 51 (67%) and obstructive risk factors in 25 (33%). Toxic/metabolic and autoimmune factors were uncommon. Imaging demonstrated ductal abnormalities and pancreatic atrophy more commonly than calcifications. Fifty-nine (77%) reported abdominal pain within the past year; pain was reported as constant and receiving narcotics in 28%. Children with chronic pancreatitis reported a median of 3 emergency department visits and 2 hospitalizations in the last year. Forty-seven subjects (70%) missed 1 day of school in the past month as the result of chronic pancreatitis; 26 (34%) missed 3 or more days. Children reporting constant pain were more likely to miss school (P = .002), visit the emergency department (P = .01), and experience hospitalizations (P = .03) compared with children with episodic pain. Thirty-three children (43%) underwent therapeutic endoscopic retrograde pancreatography; one or more pancreatic surgeries were performed in 30 (39%). Chronic pancreatitis occurs at a young age with distinct clinical features. Genetic and obstructive risk factors are common, and disease burden is substantial.

Diagnostic strategies for early pancreatic cancer.

Diagnosis of pancreatic cancer (PC) at an early stage with curative surgery is the approach with the potential to significantly improve long-term patient outcome. Recently, some reports showed that patients with pancreatic tumors smaller than 10 mm showed a favorable prognosis. However, the rate of tumor detection on computed tomography in patients with small pancreatic tumors is low. For the diagnoses of PC with tumors smaller than 10 mm, the rate of tumor detection was higher on endoscopic ultrasonography (EUS) than on computed tomography or other modalities, and histologic diagnosis using EUS-guided fine-needle aspiration was helpful in confirming the diagnosis. For the diagnosis of PC in situ, EUS and magnetic resonance cholangiopancreatography may play important roles in detecting the local irregular stenosis of the pancreatic duct. Endoscopic retrograde pancreatography and sequential cytodiagnosis using pancreatic juice obtained by endoscopic nasopancreatic drainage multiple times was useful in the final diagnosis of PC in situ. At present, improving survival lies in identifying those individuals with high-risk factors or precursor lesions through an effective screening method. For example, these should include ultrasonography, various biological markers, or national familial pancreatic cancer registration. Additionally, the relationship between specialists in PC from medical centers and practicing physicians plays an important role in the early diagnosis of PC.

Endoscopic ultrasound-guided pancreatic duct drainage.

Endoscopic ultrasound (EUS) has evolved from a purely diagnostic procedure to one with therapeutic capabilities. One of the most challenging therapeutic intervention for endosonographers is EUS-guided pancreatic drainage. The development of this technique has allowed access and drainage of the main pancreatic duct after failed endoscopic retrograde pancreatography and can avoid invasive procedures such as surgical and percutaneous interventions. This review discusses the indications, technique, challenges, and an algorithmic approach to EUS-guided pancreatic drainage.

Autoimmune pancreatitis with colonic stenosis: an unusual complication and atypical pancreatographic finding

BackgroundType 1 autoimmune pancreatitis (AIP) often accompanies various systematic disorders such as sclerosing cholangitis, sialoadenitis, retroperitoneal fibrosis, interstitial pneumonitis and nephritis. Although rarely reported in acute pancreatitis, colonic stenosis is an uncommon complication in cases with AIP.Case presentationA 69-year-old Japanese man complained of abdominal pain and continuous diarrhea, resistant to intake of antimuscarinic and probiotic agents. A colonoscopy demonstrated a stenosis at the splenic flexure. Computed tomography revealed a focal enlargement of the pancreatic tail with a capsule-like rim, contacting with the descending colon. Endoscopic retrograde pancreatography (ERP) was unable to visualize the main pancreatic duct (MPD) at the pancreatic tail, despite a full contrast injection. A high serum IgG4 level (1060 mg/dL) and exclusion of pancreatic cancer by endoscopic ultrasound guided-fine needle aspiration suggested AIP, but did not fulfill the diagnostic criteria, and steroid therapy was initiated. One month after starting steroid intake, pancreatic swelling was minimized and the MPD was visualized by ERP, fulfilling the international consensus diagnostic criteria (ICDC) of AIP. Colonic stenosis was relieved and the patient’s symptoms disappeared.ConclusionThe present case is the first report of AIP developing colonic stenosis by the inflammatory infiltration. In this case, steroid therapy was effective for the diagnosis and treatment of pancreatic mass involving the descending colon.

Endoscopic Ultrasound-Guided Transesophageal Drainage of a Mediastinal Pancreatic Pseudocyst

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Role of pancreatic juice cytology in the preoperative management of intraductal papillary mucinous neoplasm of the pancreas in the era of international consensus guidelines 2012.

Routine endoscopic retrograde pancreatography (ERP) for pancreatic juice cytology (PJC) during management of intraductal papillary mucinous neoplasm (IPMN) is not recommended in the international consensus guidelines 2012. The aim of the present study was to investigate the roles of PJC in relation to the new stratification of clinical findings in the consensus guidelines 2012. Medical records of 70 consecutive patients who underwent preoperative PJC, subsequent pancreatectomy, and a pathological diagnosis of IPMN were reviewed. Diagnostic ability of PJC to detect malignant lesions was calculated by the stratification of clinical findings. Forty patients had malignant lesions, including 29 with malignant IPMN, 10 with concomitant pancreatic adenocarcinoma, and one with both. Accuracies of PJC in all 70 patients and in 59 patients with IPMN alone were 77 and 80 %, respectively. The sensitivity and accuracy of PJC in patients with "worrisome features" were 100 and 94 %, respectively. Eight of 11 patients with concomitant pancreatic adenocarcinoma had non-malignant IPMN without risk factors, and 3 significant lesions could be diagnosed only by ERP/PJC. In addition, the management plan based on imaging study changed from observation to resection in two patients who had the single "worrisome feature" of branch duct IPMN and positive PJC results. As a result, PJC altered the management plan in 5 patients. Pancreatic juice cytology potentially has important roles to determine the adequate treatment choice in patients with IPMNs with "worrisome features," and to detect significant lesions that could not be detected by other imaging modalities.

The role of endoscopic retrograde pancreatography in pancreatic trauma: a critical appraisal of 48 patients treated at a tertiary institution.

Endoscopic retrograde pancreatography (ERP) is useful in the diagnosis and treatment of selected patients with pancreatic trauma. We analyzed the role of ERP in treating persistent complications of pancreatic injuries at a tertiary institution. Patients with pancreatic trauma who underwent ERP were identified from a prospective database of 426 pancreatic injuries from January 1983 to January 2011. Patient demographics, mechanism of injury, time to presentation, method of diagnosis, associated injuries, clinical management, endoscopic interventions and their timing, surgical treatment, and patient outcomes were evaluated. Forty-eight patients underwent ERP after blunt (n = 26) or penetrating (n = 22) pancreatic injury. Median time from injury to ERP was 38 days (range, 2-365 days). Diagnostic ERP was successful in 47 patients. In 11 patients, ERP demonstrated an intact main duct with minor peripheral injuries, and no further intervention was required. A pancreatic fistula was demonstrated in 24, a main pancreatic duct stricture in 12, and a pseudocyst in 10 patients. Fifteen patients had a pancreatic duct sphincterotomy, seven had a pancreatic stent inserted, and six had an endoscopic pseudocyst drainage. Ten patients ultimately required surgery, seven of whom had demonstrated a severe pancreatic duct stricture. Operations performed following ERP were distal pancreatectomy (n = 6), pancreaticojejunostomy (n = 3) and cyst-jejunostomy (n = 1). ERP allowed one quarter of the patients to be treated conservatively. Half had a successful intervention by ERP. Success was most likely in those with fistulae and pseudocysts. Surgery was ultimately avoided in more than three quarters of the patients. Therapeutic study, level V.

Pancreaticopleural Fistula Treated by Endoscopic Pancreatic Stenting in a Patient with Recurrent Pancreatitis

Pancreatic duct disruption associated with pancreatitis can lead to the development of pseudocysts, pancreatic ascites, and pleural effusion. A 50-year-old male presented with a 1-month history of postprandial epigastric pain. A chest X-ray showed right pleural effusion. Diagnostic thoracentesis revealed an amylase-rich exudate consistent with pancreatic effusion. Magnetic resonance cholangiopancreatography demonstrated a pancreaticopleural fistula tract, and endoscopic retrograde pancreatography confirmed the presence of pancreatic ductal disruption and leakage at the genu portion. The pancreaticopleural fistula was treated by transpapillary pancreatic stenting. Percutaneous drainage of the pleural effusion and octreotide injection were also performed. Follow-up endoscopic retrograde pancreatography at 8 weeks revealed no leakage of contrast media from the main pancreatic duct. Endoscopic pancreatic stenting can be an efficacious nonsurgical treatment of pancreaticopleural fistula following pancreatitis. (Korean J Med 2014;87:455-460)

Rolling in the Deep: A Quaint Sphere Rolling in the Deep Pancreatic Duct

Question: A 27-year-old woman was admitted to our hospital because of recurrent acute pancreatitis for3 years. Upper abdominal computed tomography and magnetic resonance imaging revealed a very regular sphere in the dilated pancreatic duct (Figure A, B). The computed tomographic value of the sphere was lower than that of the pancreatic parenchyma. The composition of the sphere was unclear; it may be a radiolucent pancreatic stone, polyp in the pancreatic duct, or some others. Therefore, endoscopic retrograde pancreatography (ERP) was performed.

Pancreatic Metastasis of Papillary Thyroid Carcinoma Diagnosed by Endoscopic Ultrasound and Fine-Needle Aspiration

Introduction: The National Cancer Institute estimates that in 2012 the new number of new thyroid cancer cases reported will be approximately 56,000 with 1,780 expected deaths. There are four distinct subtypes of thyroid cancer: papillary, follicular, medullary, and anaplastic, with papillary being the most common subtype. Associated metastatic disease appears in about 5% of these patients with the most common site of metastasis being the lung and bone. Metastatic disease to the pancreas is extremely rare, with only a few cases reported. Case Report: A 61-year-old female, with a history of papillary thyroid carcinoma treated by thyroidectomy and radioiodine ablation (RAI), presents for evaluation for persistent elevation of her thyroglobulin level. A positron emission tomography scan revealed a 3-cm heterogeneously enhancing lesion in the body of the pancreas. At time of presentation the patient denied any jaundice, abdominal pain, nausea, vomiting, back pain, or weight loss. On physical examination the patient was anicteric, with no abdominal tenderness or masses. Patient underwent an endoscopic ultrasound (EUS) for further evaluation revealing a round, hypoechoic well-defined mass in the pancreatic body, approximately 3.6 x 3.4 cm. The pancreatic duct, upstream from the lesion, was dilated to 5 mm. Fine needle aspiration of the mass using a trans-gastric approach was performed. Immunohistochemical staining showed the neoplastic cells to be positive for TTF-1, thyroglobulin, CK19, and CK7. CK20, monoclonal CEA, and the neuroendocrine markers were negative. CA 19-9 was focally positive. Cytology was positive for the presence of malignant cells and findings were consistent with metastatic thyroid carcinoma to the pancreas. Discussion: This case illustrates a very rare presentation of metastatic disease. For diagnosis, EUS is now recognized as the most sensitive tests for the detection of both primary and metastatic lesions of the pancreas. Also observed in our case is the utilization of EUS-FNA with sensitivity for detecting malignancy ranging from 75-90%. This technique is superior to that of CT-guided FNA as well as endoscopic retrograde pancreatography (ERP). Our case highlights the utility of EUS, EUS-FNA, and immunohistochemical staining to obtain a tissue diagnosis in suspected pancreatic metastasis.

Needle Knife Sphincterotomy and the Risk of Post-ERCP Complications: A Tertiary Center Experience

Purpose: Endoscopic retrograde cholangiographic pancreatography (ERCP) is successful in 90% of patients to achieve biliary cannulation. Needle knife sphincterotomy (NKS) has been advocated in patients which routine cannulation is not possible. Our aim was to evaluate the efficacy of cannulation and complication risk of NKS in our institution. Methods: Retrospective analysis of 706 ERCPs in which NKS was performed from 2001-2011. The cannulation was accomplished with a guide wire and NKS was used in difficult cases to gain access into the biliary duct. If the primary cannulation failed, and the wire went only into the pancreatic duct, pancreatic sphincterotomy was performed and pancreatic duct stent was placed. Results: A total of 706 patients required NKS in our cohort of which 614 (86.9%) had successful biliary cannulation. A total of 318 (45%) patients had pancreatic duct stent placed prior to NKS. In our cohort of patients who underwent NKS, post-ERCP pancreatitis (PEP) was diagnosed in 57, perforation in 6 (0.8) and bleeding in 46 (6.5%) patients. In patients with unsuccessful NKS, the risk of PEP with and without a pancreatic duct stent placement was 12.7% and 6.7% respectively. (P=0.67) In patients with successful NKS with biliary cannulation, the risk of PEP with and without a pancreatic duct stent placement was 9.6% and 6.4%, respectively. (P=0.60) Also, the risk of developing any complication in the successful NKS group did not differ in patients with and without a pancreatic duct stent placed. (14% vs. 11.1%, P=0.56) Conclusion: In patients with failed primary cannulation, NKS is successful in achieving biliary access in most patients. The use of a pancreatic duct stent prior to NKS did not appear to impact the risk of complications

A case of focal autoimmune pancreatitis (AIP) mimicking an intraductal papillary mucinous neoplasm (IPMN).

The present case involved a 76-year-old man with a cystic mass in the head of his pancreas. The cystic lesion, which measured 17.7×9.8mm, was first detected by ultrasonography (US) at the age of 72 years. Follow-up endoscopic ultrasonography (EUS) performed at 4years after the lesion had first been detected revealed a mural nodule measuring 14.0×8.4mm in the cyst. Endoscopic retrograde pancreatography (ERP) imaging revealed that the main pancreatic duct was in communication with the cyst and that there was no irregular narrowing of the main pancreatic duct. On the basis of these results, the patient was diagnosed with an intraductal papillary mucinous neoplasm (IPMN), and stomach-preserving pancreaticoduodenectomy was performed. A histopathological examination revealed that the interior of the cystic part of the lesion was lined by a pancreatic ductal epithelium. A pathological examination of the nodular lesion detected storiform fibrosis, severe lymphoplasmacytic infiltration, and hyperplasia in the pancreatic duct epithelium together with a small amount of mucus. On immunohistological staining, the infiltrating lymphoplasmacytes were found to be positive for IgG4. Accordingly, the patient was diagnosed with focal autoimmune pancreatitis (AIP). In conclusion, we reported a case of focal AIP mimicking IPMN. This case showed neither enlargement of the pancreas nor irregular narrowing of the main pancreatic duct.

Mo1536 Endoscopic Ultrasound (EUS) Guided Pancreatic Duct Intervention: Outcomes of a Single Tertiary Referral Center Experience

The role of EUS as a diagnostic and therapeutic modality is ever-expanding for the management of pancreatic disorders. There is increasing use of EUS following failed endoscopic retrograde pancreatography (ERP) to access the main pancreatic duct (MPD). We aim to describe our experience and long-term outcomes for patients undergoing EUS-guided MPD intervention.

Technologies for Imaging the Normal and Diseased Pancreas

The prognosis is poor for most patients with pancreatic cancer, chronic pancreatitis, or other pancreatic diseases. Advances in pancreatic imaging could help identify these diseases at earlier stages, when they are easier to treat. Radiographic imaging and endoscopic imaging of the pancreas have progressed from the abdominal roentogram and endoscopic retrograde pancreatography to multi-detector computed tomography, magnetic resonance cholangiopancreatography, endoscopic ultrasonography, and pancreatoscopy. These technologies have improved the diagnosis and treatment of benign disease but have not significantly increased our ability to detect early-stage disease or affect outcomes of patients with pancreatic cancer or chronic pancreatitis. Advances in endoscopic imaging and molecular-based radiographic tests could allow physicians to identify pancreatic lesions and their precursors at earlier stages. Furthermore, research studies that include these tools could improve our understanding of disease pathogenesis and identify diagnostic markers and therapeutic targets. We review endoscopic imaging modalities, focusing on new endoscopic and molecular-based radiographic imaging tests that have the potential to substantially improve diagnosis and treatment of pancreatic disease.

Sensitivity of Endoscopic Ultrasound, Multidetector Computed Tomography, and Magnetic Resonance Cholangiopancreatography in the Diagnosis of Pancreas Divisum

There are limited data comparing imaging modalities in the diagnosis of pancreas divisum. We aimed to: (1) evaluate the sensitivity of endoscopic ultrasound (EUS), magnetic resonance cholangiopancreatography (MRCP), and multidetector computed tomography (MDCT) for pancreas divisum; and (2) assess interobserver agreement (IOA) among expert radiologists for detecting pancreas divisum on MDCT and MRCP. For this retrospective cohort study, we identified 45 consecutive patients with pancreaticobiliary symptoms and pancreas divisum established by endoscopic retrograde pancreatography who underwent EUS and cross-sectional imaging. The control group was composed of patients without pancreas divisum who underwent endoscopic retrograde pancreatography and cross-sectional imaging. The sensitivity of EUS for pancreas divisum was 86.7%, significantly higher than the sensitivity reported in the medical records for MDCT (15.5%) or MRCP (60%) (P < 0.001 for each). On review by expert radiologists, the sensitivity of MDCT increased to 83.3% in cases where the pancreatic duct was visualized, with fair IOA (κ = 0.34). Expert review of MRCPs did not identify any additional cases of pancreas divisum; IOA was moderate (κ = 0.43). Endoscopic ultrasound is a sensitive test for diagnosing pancreas divisum and is superior to MDCT and MRCP. Review of MDCT studies by expert radiologists substantially raises its sensitivity for pancreas divisum.