Magnetic Retrograde Cholangiopancreatography Research Articles

S2441 Mesalamine-Induced Autoimmune Hepatitis in Patient With Ulcerative Colitis: Case Report

Introduction: Mesalamine is widely considered to be first-line therapy for patients with mild to moderate ulcerative colitis. It is generally well tolerated with usually minor side effects. Mesalamine-induced liver injury is very rarely reported, commonly in the context of multiorgan disease. Isolated mesalamine-induced autoimmune hepatitis has not been reported. Case description/methods: A 53-year-old female with one-month history of bloody diarrhea, decreased appetite, and 10-lb weight loss underwent colonoscopy that confirmed mild to moderate left-sided ulcerative colitis. Blood counts, renal function, and liver function (LFT) were normal and hepatitis B serology was negative. She was started on standard dosing of oral and rectal mesalamine and achieved clinical remission at three months. Five months later, she had abnormal LFT on routine evaluation; alanine aminotransferase (ALT) was 122 IU/L and aspartate aminotransferase (AST) was 44 IU/L, with normal total bilirubin and alkaline phosphatase. She was asymptomatic and denied personal and family history of liver disease. On repeat investigation, ALT peaked at 359 IU/L and AST at 210 IU/L (Figure 1). Serologic evaluation was notable for positive anti-nuclear antibody at 1:640 and positive anti-mitochondrial antibody of 0.5 U. Anti-smooth muscle antibody, acute viral hepatitis panel, and metabolic liver disease markers were normal. Magnetic retrograde cholangiopancreatography (MRCP) noted no abnormalities. Liver biopsy revealed inflammatory infiltrate of lymphocytes and macrophages with scattered eosinophils and plasma cells, consistent with autoimmune hepatitis. One month after discontinuation of mesalamine, liver tests normalized (AST 24 IU/L, ALT 36 IU/L). She maintained a clinical remission and normal at one year follow up after switching to adalimumab. Discussion: A recent UK audit revealed 3.2 cases of mesalamine-induced-liver-injury per million prescriptions, which included asymptomatic transaminitis, cholestatic hepatitis, and granulomatous hepatitis, mostly in the context of systemic, multiorgan disease. This is the first report, to our knowledge, of an isolated mesalamine-induced autoimmune hepatitis in a patient with ulcerative colitis. The diagnosis is strongly supported by characteristic histological findings, positive autoimmunity markers, resolution of injury with discontinuation of drug, and exclusion of other causes. It may be prudent to monitor LFT in ulcerative colitis patients treated with mesalamine.Figure 1.: Trend of transaminases following initiation and discontinuation of mesalamine.

51-Year-Old Man With Ascites and Abdominal Pain

51-Year-Old Man With Ascites and Abdominal Pain

Ultra-mini Percutaneous Hepatolithotomy in Patients With Large and Multiple Hepatolithiasis.

In this study, we applied the ultra-mini percutaneous hepatolithotomy (UM-PHL) technique on hepatolithiasis patients with multiple and large stones on which other minimally invasive methods failed, and our aim was to report its results, sharing in series for the first time. Preoperative and postoperative data, laboratory parameters, radiologic findings, and preoperative and postoperative details were recorded for a total of 14 patients for whom the UM-PHL technique was applied between April 2017 and December 2019. As all patients had multiple stones and extreme stone load and had bile duct surgery, they did not have a normal anatomy. All patients were radiologically confirmed to have had preprocedural magnetic retrograde cholangiopancreatography. Operation duration of the patients was 137.6±44.9 minutes, while intraoperative blood loss was 69.2±24.9 mL, drainage catheter removal time was 2.85±0.86 days, and the hospitalization time was 4.28±2.55 days. Intraoperative balloon dilation was applied to enlarge the stricture area in 5 patients (35.7%). On the basis of the Clavien-Dindo classification, grade 2 complication was observed in 2 patients (14.2%) due to postoperative cholangitis. Patients were followed up for an average of 15 months, and nonsymptomatic radiologic stone recurrence was detected in the 12th month control of 1 patient (7.1%). The UM-PHL technique is a successful method that facilitates stone clearance by providing minimal dilatation through percutaneous intervention and by using instruments with small diameter, and it can safely be applied with its low complication level, low recurrence ratio, and short hospitalization time.

Diseases of the Pancreas

Acute pancreatitis is characterized by an acute inflamatory process of the pancreas associated with abdominal pain and elevations in serum levels of pancreatic enzymes. The acute inflammation usually completely resolves with restoration of normal pancreatic architecture and function. By contrast, chronic pancreatitis is characterized by the presence of ongoing inflammation and irreversible damage to the gland. Recurrent attacks of acute pancreatitis may lead to chronic pancreatitis over time. This chapter discusses the epidemiology, etiology, pathogenesis, diagnosis, and treatment of acute and chronic pancreatitis. Figures illustrate findings on imaging studies in patients with pancreatic disorders. This review contains 6 figures, 25 tables, and 86 references. Keywords: Acute pancreatitis, chronic pancreatitis, pseudocyst, exocrine insufficiency, endocrine insufficiency, magnetic retrograde cholangiopancreatography, endoscopic ultrasonography

1418 A Troublesome Remnant

INTRODUCTION: Postcholecystectomy syndrome (PCS) is the persistence of symptoms of biliary colic after cholecystectomy. Although PCS is relatively common with multiple etiologies, a remnant cystic duct is a rare etiology accounting for only 2.5% of cases. Mirizzi's syndrome is a rare cause of PCS due to a remnant cystic duct stone. CASE DESCRIPTION/METHODS: A 34-year-old female with a history of choledocholithiasis status-post cholecystectomy 6 years prior presented with severe, constant, sharp right upper quadrant pain with nausea and vomiting for 1 day. She had abdominal tenderness with a negative Murphy sign. She was found to have elevated liver chemistries. Patient had two hospitalizations within the past year with similar presentations with the finding of choledocholithiasis requiring endoscopic retrograde cholangiopancreatography (ERCP) on both occasions. Magnetic retrograde cholangiopancreatography (MRCP) showed a dilated, remnant cystic duct with filling defect indicative of obstruction caused by the stone. ERCP was done with removal of one stone followed by surgical resection of the remnant cystic duct with an endoluminal stone. DISCUSSION: The cystic duct typically measures 2-4 cm in length, and formation of stone in the structure leads to symptoms of dyspepsia, nausea, vomiting, and possibly jaundice. Cholecystectomy provides symptom relief to 85% of patients. After cholecystectomy, an incomplete surgery can leave a residual duct of greater than 1 cm in length, defined as a cystic duct or gallbladder remnant. Formation of calculi in this structure can lead to PCS. PCS can present as continuation of symptoms after the operation or after an interval of 2 days to 25 years after disease free period. PCS has been reported in 5 to 40% of patients post-cholecystectomy. Most common causes are extrabiliary, however, biliary etiologies are not uncommon. The incidence of PCS due to remnant cystic duct has been reported to be less than 2.5%. Identifying and promptly treating the underlying etiology are important to minimize morbidity. Cystic duct remnant stones may predispose a patient to postcholecystectomy Mirizzi's syndrome. While difficult to diagnose with different imaging studies, this can be effectively diagnosed with MRCP and treated with ERCP. One study showed that ERCP/MRCP failed to identify 2 out of 3 patients with a remnant cystic duct. While endoscopic therapy is an effective and safe alternative to surgery for postcholecystectomy Mirizzi's syndrome, surgical intervention is a definite treatment.

1352 Doxycycline-Induced Acute Pancreatitis: A Likely Source Rarely Seen

INTRODUCTION: The diagnosis of drug-induced acute pancreatitis compared to the others causes of acute pancreatitis is estimated between 1.4 and 2%.1 Despite this association, the clinical evidence on doxycycline-induced acute pancreatitis is sparse as proving the association with a particular drug may not always be straightforward.2 In this case, we report an episode of an acute pancreatitis (AP) where well-known etiologies were ruled out and the patient was deemed to have doxycycline induced acute pancreatitis (DIAP). CASE DESCRIPTION/METHODS: A 71-year-old female with significant past medical history of cholecystectomy, hyperlipidemia and bullous pemphigoid presented to Regional Medical Center Bayonet Point with one-day history of epigastric pain with nausea and non-bilious emesis while eating. She denied prior history of AP or recent alcohol use. Review of systems was otherwise unremarkable. Patient did admit to using doxycycline twice daily starting a month prior to treat her bullous pemphigoid. Her only other home medication that has an association with drug induced acute pancreatic was simvastatin, which has not been changed or adjusted for several years. On physical examination, vital signs were within normal limits. Abdominal examination was positive for epigastric tenderness, otherwise unremarkable. Laboratory studies revealed: white blood cell count of 28,100 mm3; (neutrophils 92.9%); blood urea nitrogen 25 mg/dL; serum creatinine 1.33 mg/dL; sodium 138 meq/L; and serum lipase 6204 IU/L. Abdominal and pelvis tomography revealed peri-pancreatic fat stranding and fluid suggestive of acute pancreatitis. The patient was immediately started on intravenous normal saline. A magnetic retrograde cholangio-pancreatography was obtained to rule out choledocholithiasis, which revealed no extrahepatic biliary dilation, choledocholithiasis or choledochal filling. After an exhaustive work up, we determined the patient had DIAP. Doxycycline was immediately discontinued. The following day her symptoms improved. The patient recovered and was discharged. DISCUSSION: Tetracyclines have long been designated as causative agents in AP. Unfortunately, there have only been a few case reports of DIAP.3–5 Interestingly, several report a female patient as in this case. What makes our case unique is that doxycycline as the sole source of drug induced acute pancreatitis has rarely been reported.6–9 Further research is required to identify the mechanism of DIAP, true incidence, and additional risk factors.

31-Year-Old Woman With Jaundice and Abdominal Pain

31-Year-Old Woman With Jaundice and Abdominal Pain

Success of intraoperative imaging and management of suspected choledocholithiasis without pre-operative bile duct imaging - A case series.

BackgroundLaparoscopic common bile duct exploration (LCBDE) is gaining popularity over endoscopic retrograde cholangiopancreatography (ERCP) for the management of common bile duct stones. However, its application has been almost exclusively following preoperative stone confirmation via magnetic retrograde cholangiopancreatography (MRCP), endoscopic ultrasound (EUS) or ERCP. We present our series of LCBDE following detection of common bile duct stones with intraoperative imaging (IOI) alone, in consecutive elective and emergency patients with suspected choledocholithiasis.Materials and methodsAll patients with suspected but unconfirmed choledocholithiasis undergoing LC with intention to proceed to LCBDE between January 2015 and June 2017 were included. LCBDE was performed following the discovery of choledocholithiasis on IOI.Results371 patients with suspected choledocholithiasis underwent LC with IOI. CBD stones or obstructing sludge was identified in 107 patients (29%), with sensitivity of 96.2% and specificity of 98.5%. 100 patients, median age 59, went on to have LCBDE as indicated by intraoperative imaging. 76% were performed as emergency cases and conversion to open rate was 2%. There were no mortalities. Bile leak and retained stones occurred in 4% and 3% respectively. 7/100 patients required re-intervention, with re-look laparoscopy (n = 4) and ERCP (n = 3). Median length of stay was 1.5 and 3 days for elective and emergency cases respectively, and 30 readmission rate was 8%.Discussion and conclusionTraditionally patients presenting with suspicion of choledocholithiasis undergo preoperative MRCP/EUS and/or ERCP prior to eventual LC. We propose an alternative, more streamlined, pathway of treatment without requiring preoperative cholangiography, applicable to both elective and emergency patients.

Better non-invasive endoscopic procedure: endoscopic ultrasound or magnetic resonance cholangiopancreatography?

Aim To present our experience with a diagnostic ability of endoscopic ultrasound (EUS) and magnetic retrograde cholangiopancreatography (MRCP) in cases of choledocholithiasis verified by endoscopic retrograde cholangiopancreatography (ERCP). Methods This retrospective study was conducted after a collection of data involving 58 suspected choledocholithiasis patients who underwent ERCP from January 2013 to December 2015. Patients who were diagnosed with choledocholithiasis on the basis of clinical symptoms and radiological findings and who underwent ERCP were included in this study. The first group (29 patients) underwent EUS, and the second group (29 patients) underwent MRCP. The ERCP was performed in both groups. Sensitivity, specificity and diagnostic accuracy of EUS and MRCP were determined by comparing them with ERCP, which was considered to be a gold standard. Results Gender representation was in favour of males, 58:42%. The mean age was 55.5 years. In the group 1 (EUS) 22 patients were found to have choledocholithiasis using ERCP. The EUS stone detection rate was 88%. Endoscopic ultrasound showed sensitivity (97%), specificity (67%) and accuracy (88%), positive predictive value (PPV) of 88%, negative predictive value (NPV) of 80%. In the group 2 (MRCP) 16 patients were found to have choledocholithiasis by ERCP. MRCP sensitivity was 81%, specificity 40%, PPV of 74%, NPV of 50%. Conclusion The EUS was a superior non-invasive tool in comparison with MRCP for detecting choledocholithiasis, which was confirmed using ERCP.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases.

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals. Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2). Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2 , who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals. Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Diagnosis and treatment of pancreatic carcinoma with the first symptom of acute and chronic pancreatitis

Objective To investigate the diagnosis and treatment of pancreatic carcinoma with acute and chronic pancreatitis as the initial symptoms.Methods The clinical data of 13 patients with pancreatic carcinoma who were admitted to the First Affiliated Hospital of Dalian Medical University and the Affiliated Central Hospital of Dalian Medical University from January 2003 to June 2014 were retrospectively analyzed.The first symptoms were acute and chronic pancreatitis.Laboratory and imaging examinations were carried out on all the patients,and the treatment plan was designed according to the location and stage of the tumor as well as the patient's wishes.Surgery,radiotherapy,chemotherapy and other symptomatic treatment were selected.All the patients were followed up by telephone interview till July 2014.Results The major symptoms included abdominal pain and lumbodorsal pain (7 patients).Of the 13 patients,1 patient refused to received laboratory examination,and the levels of CA19-9 of the other 12 patients were elevated (the levels of CA19-9 of 11 patients were above 1 × 105 U/L).The levels of carcinoembryonic antigen (CEA) of 5 patients were elevated.Thirteen patients received plain or enhanced abdominal computed tomography (CT),3 received magnetic resonance imaging (MRI) and 3 received sonography.The tumors located at the head of the pancreas wcrc observed in 9 patients,tumors located at the neck of the pancreas was observed in 2 patients,and tumors located at the tail of the pancreas were observed in 2 patients.The sizes of the tumors ranged between 1.7 cm × 1.7 cm and 4.9 cm × 4.8 cm.The common bile duct,intrahepatic bile duct and pancreatic duct of 7 patients were dilated.The superior mesenteric vein of 3 patients were invaded by the tumor.The lymph nodes of 4 patients were swollen,and 3 patients had peritoneal effusion.The results of CT confirmed that 2 patients were with cholecystolithiasis,and the results of magnetic retrograde cholangiopancreatography (MRCP) confirmed that 1 patient had choledocholithiasis.The size of he pancreas of all the patients were increased using ultrasonography,and the main pancreatic ducts of 2 patients were dilated.Ten patients were diagnosed as with advanced pancreatic carcinoma.All the patients were staged by the imaging findings,5 patients belonged to stage Ⅱ and 8 belonged to stage Ⅳ.Two patients underwent pancreaticoduodenectomy,and 1 of them underwent postoperative radiotherapy and chemotherapy,and the other patient underwent palliative biliary enteric anastomosis and gastrojejunostomy.Two patients were treated by chemotherapy and 1 by radiotherapy in the 10 patients who did not received surgery.The rest 7 patients were treated with symptomatic therapy.The pathological results of the 2 patients who underwent pancreaticoduodenectomy were both moderately and poor-differentiated adenocarcinoma,and the size of the tumors were 4.0 cm × 3.0 cm × 2.5 cm and 2.5 cm × 2.0 cm × 1.0 cm.Three patients lost to follow-up among the 13 patients.The survival time of the patients with acute pancreatitis as the initial symptom ranged from 2.0 months to 6.0 months,and the median survival time was 4.5 months.The survival time of the patients with chronic pancreatitis as the initial symptom ranged from 0.5 months to 10.0 months,and the median survival time was 3.0 months.The median survival time of the 4 patients with elevated level of CEA was 3.5 months,and the median time of the 5 patients with normal level of CEA was 5.4 months.All the 10 patients who were followed up died of tumor recurrence and metastasis.Conclusion The clinical presentation of patients with acute and chronic pancreatitis as the initial symptoms is atypical,and it is difficult to achieve early diagnosis.Dynamic monitoring and combined diagnosis with laboratory and imaging examinations will improve the accuracy of diagnosis.Surgery based treatment is the preferred option. Key words: Pancreatic neoplasms; Pancreatitis; Diagnosis; Treatment

An Uncommon Cause of Recurrent Pancreatitis

Introduction: Biliary cysts are important structural anomalies of the biliary tract. While normally found in the pediatric population, 20% of these rare dilations of the biliary tree are found in adults and account for a variety of biliary and pancreatic complications. Case Presentation: A 33-year-old white male with a 3-year history of recurrent pancreatitis presented to our institution with 2 weeks of light stools, dark urine, weight loss, and fatigue. Three days prior to admission, he developed icterus and nausea. He had a cholecystectomy 3 years prior. He took no medications. He drank alcohol socially. There was no family history of gastrointestinal disease. On physical examination, he was afebrile with stable vital signs. Scleral icterus was present. He had left abdominal tenderness. No hepatosplenomegaly was appreciated. He was jaundiced. His initial laboratory evaluation was notable for a total bilirubin of 11.1, direct bilirubin of 8.4, alkaline phosphatase of 346, aspartate aminotransferase of 105, and alanine aminotransferase of 210. Lipase was 29. A serum chemistry and complete blood count were normal. A magnetic retrograde cholangiopancreatography was performed which showed a cystic dilation measuring 2.7 x 2.7 cm in the head of pancreas that was inseparable from the common bile duct and the pancreatic duct. The common bile duct was 1.7 cm dilated. Intrahepatic duct dilation was present. The pancreatic duct was not dilated. An endoscopic retrograde cholangiopancreatography confirmed bulging of the major papilla with cystic dilation of the intra-duodenal portion of the bile duct where the common bile duct and the pancreatic duct drained into the cyst consistent with a type IIIA choledococele. The pancreatic duct was irregular and tortuous in the head of the concerning for chronic pancreatitis. A biliary sphincterotomy was performed and a biliary stent was placed. A pancreatic duct stent was placed. Liver function tests did improve with this intervention and the stents were removed 1 month later. The cholangiogram was normal at that time. Discussion: Biliary cysts, while rare, do cause chronic biliary and pancreatic pathology including cholelithiasis, biliary strictures, acute and chronic pancreatitis, cholangiocarcinoma, secondary biliary cirrhosis, and cholangitis. This case illustrates that importance of keeping in mind rarely seen structural anomalies that can cause biliary and pancreatic disease and can have long term consequences such as cirrhosis, recurrent cholangitis, chronic pancreatitis, and most significantly carcinoma.

A Case of Bellʼs Palsy Heralding Leptomeningeal Carcinomatosis from Metastatic Gastric Adenocarcinoma

Purpose: Leptomeningeal carcinomatosis is a rare complication of solid tumors. We present an unusual case of a patient who presented with Bell's palsy and ocular symptoms as a result of meningeal carcinomatosis from metastatic gastric adenocarcinoma. A 27-year-old Hispanic woman presented to her primary care physician with headaches, left facial paresis, and was diagnosed with Bell's palsy. She was started on oral steroids and subsequently presented to our hospital 1 week later with intensifying headaches and blurry vision. She had no other significant comorbidities. Upon further review, she had an upper endoscopy 1 year ago in her home country for dyspepsia revealing a 1cm gastric ulcer on lesser curve, biopsy showing atypical cells and no follow-up. She had a strong family history of gastric cancer. Her physical exam findings were remarkable for left facial droop, decreased visual acuity, decreased left sided facial sensation and a palpable, 3-cm pelvic mass. Laboratory information revealed mild anemia and cholestatic liver function tests. An MRI of the brain revealed optic nerve enhancement and a few areas of dural enhancement. She underwent a lumbar puncture, CT of the chest and SPECT gallium scan revealing mediastinal, abdominal lymphadenopathy and a large pelvic mass. She was suspected to have sarcoidosis with neurologic involvement and bilateral uveitis. One week after discharge, she became icteric and had increasing abdominal pain; laboratory data showed AST 178, ALT 287, alkaline phosphatase 265, total bilirubin 1.5, and lipase of 3778. Magnetic retrograde cholangiopancreatography revealed obliteration of the pancreatic duct in the head and neck of the pancreas, extrinsic obstruction of the common bile duct from periportal lymph nodes, dilated intrahepatic bile ducts, multiple liver lesions, diffuse abdominal mediastinal lymphadenopathy and a large pelvic mass. Endoscopic retrograde cholangiopancreatography revealed a large friable mass extending from the gastro-esophageal junction to mid-body, along the lesser curvature of the stomach. The antrum and duodenum were free of tumor. A biliary plastic stent was placed and gastric biopsies revealed infiltrating high-grade adenocarcinoma, negative for Helicobacter pylori. The patient subsequently underwent pelvic mass biopsy and staging scans, which showed involvement of lungs, liver, pancreas, bone and meninges consistent with metastatic gastric adenocarcinoma. This case highlights leptomeningeal carcinomatosis presenting as Bell's palsy from a rapidly progressing gastric adenocarcinoma. Systemic symptoms in such cases should raise concern among clinicians for either direct organ involvement or paraneoplastic syndromes.

Managing injuries of hepatic duct confluence variants after major hepatobiliary surgery: An algorithmic approach

To investigate injuries of anatomy variants of hepatic duct confluence during hepatobiliary surgery and their impact on morbidity and mortality of these procedures. An algorithmic approach for the management of these injuries is proposed. During a 6-year period 234 patients who had undergone major hepatobiliary surgery were retrospectively reviewed in order to study postoperative bile leakage. Diagnostic workup included endoscopic and magnetic retrograde cholangiopancreatography (E/MRCP), scintigraphy and fistulography. Thirty (12.8%) patients who developed postoperative bile leaks were identified. Endoscopic stenting and percutaneous drainage were successful in 23 patients with bile leaks from the liver cut surface. In the rest seven patients with injuries of hepatic duct confluence, biliary variations were recognized and a stepwise therapeutic approach was considered. Conservative management was successful only in 2 patients. Volume of the liver remnant and functional liver reserve as well as local sepsis were used as criteria for either resection of the corresponding liver segment or construction of a biliary-enteric anastomosis. Two deaths occurred in this group of patients with hepatic duct confluence variants (mortality rate 28.5%). Management of major biliary fistulae that are disconnected from the mainstream of the biliary tree and related to injury of variants of the hepatic duct confluence is extremely challenging. These patients have a grave prognosis and an early surgical procedure has to be considered.

Role of endoscopic retrograde cholangiopancreatography in acute pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound (EUS) and magnetic retrograde cholangiopancreatography (MRCP), ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.

Role of Endoscopic Ultrasonography in Follow-Up of Branch Duct Type Intraductal Papillary-Mucinous Neoplasms of the Pancreas

Background/Aim: The aim of this study was to elucidate the role of endoscopic ultrasonography (EUS) in follow-up of the patients with branch duct type intraductal papillary-mucinous neoplasms of the pancreas (IPMNs). Methods: Sixty-five patients (forty-seven men and eighteen women) with branch duct type IPMNs were selected for follow-up and examined by EUS two or more times (mean, 3 times). Patients who had apparent mural nodules were excluded from follow-up study. All patients underwent initial endoscopic retrograde pancreatography (ERP), magnetic retrograde cholangiopancreatography (MRCP), and computed tomography (CT). Serial changes of the maximum cystic diameter and the presence of mural nodule were studied during the observation periods ranged from 19 to 172 months (mean, 87 months). Results: Six (9%) of 65 patients exhibited obvious progression of cystic dilatation. New apparent mural nodules were detected in 6 cases (9%) during the observation periods. These obvious changes were observed after a 19 to 114 months follow-up period (mean, 80 months). Of six patients with mural nodules, four cases underwent surgery after follow-up study, and the pathologic diagnosis was adenoma in two and non-invasive carcinoma in two. Mural nodules were accurately diagnosed in 6 cases (100%) by EUS, whereas in one (17%) by CT and in 0 (0%) by MRCP. Six patients with cystic size enlargement were followed up without surgical resection. None of the remaining 53 patients (82%) showed increases in cystic diameter and new apparent mural nodules. Conclusions: Mural nodule is an important factor affecting the follow-up, and most of branch duct type IPMNs without apparent mural nodules remained unchanged. EUS is the most sensitive method to detect mural nodules in follow-up of branch duct type IPMNs.