Moderate Pancreatitis Research Articles

Needle Knife Papillotomy in Expert Hands-Is It Safe and Effective?

Introduction: Needle knife papillotomy is a method of gaining deep biliary access when standard methods fail and is thought to be potentially unsafe. Studies have shown that when performed by an expert endoscopist, it can be a very effective way of gaining deep biliary access and relatively safe. We retrospectively analysed all needle knife papillotomies performed at our tertiary centre over a five year period. Patients and Methods: A total of 2800 ERCPs were performed between December 2000 and July 2006 and needle knife papillotomy was required in 312 patients (11.4%) with an intention to gain deep biliary access. 131 were males and 181 females. 155 of 312 were referred from other hospitals. All the reports were analysed and cross checked with notes where required. All needle knife papillotomies were performed by either of the two very experienced endoscopists in the centre. Results: Patient's age ranged from 20 to 98 years (mean age 71.9). Sedation was with Midazolam (1-25 mg) along with either Pethidine (12.5-100 mg) or Fentanyl (10-150 mg). Flumazenil was required in 7 patients for reversal. 3 patients required general anaesthetic. Indications were Jaundice (129), Dilated ducts (40), Abnormal LFTs (44), Cholangitis (22), Stones (118), Acute Pancreatitis (34), Stent review (3), Biliary leak (6), Pseudocyst (2), Pain (21), Previously failed (52), Tumour (15), PSC (1). Deep biliary cannulation was achieved in 209 patients at first (67%) and 55 out of 65 patients (84.61%) at second attempts. 2 patients had successful cannulation on 3 rd attempt, making overall successful cannulation in 266 out of 312 (85.25%). Each patient was assessed immediately after procedure, 24 hours later and then followed up at 30 th day by a specialist nurse. Complications were defined and graded according to the consensus criteria (Cotton et al, 1991). There were 52 “adverse events” reported during first attempt with needle knife papillotomy (14.4%) and 18 of these met the definition of “complication” (5.76%). One mild and one moderate bleeds reported (0.64%). There were 2 mild and 3 moderate Pancreatitis (1.6%). Two mild and one moderate perforations occurred (0.96%). Seven cases of mild Cholangitis reported (2.24%). One death occurred due to Pancreatitis (0.3%). Other events include sub mucosal injection (10), abdominal pain (14), sore eye and rhinitis at 30 days. Conclusion: Needle knife papillotomy is effective in gaining deep biliary access and can result in mild complications even in expert hands but severe/fatal complications are very rare.

Biliary Complications Following Hepatic Trauma: The Importance of ERCP

Purpose: The purpose of the study was to describe our experience with traumatic biliary complications and in particular define the efficacy, safety and outcomes of ERCP in the management of bile leaks following liver injury. Methods: A prospective analysis of liver injuries from October, 2001 to April, 2006 was performed. Information recorded included demographic, radiologic and operative interventions. A bile leak was diagnosed if there was bile noted in a surgical wound, bile leakage from an intra-abdominal drain, or a leak noted on hepatobiliary scintigraphy (HIDA). ERCPs were performed in all patients with bile leaks. Characteristics of the leak and endoscopic treatment of the injury were assessed. Clinical outcomes measured included healing of the leak, post-treatment biliary anatomy, and associated complications. Results: 225 patients experienced major hepatic trauma (145 blunt and 80 penetrating). Twenty-eight patients (12.4%; 13 blunt, 15 penetrating) underwent ERCP for biliary injury diagnosed by HIDA (26 pts.) and/or by clinical suspicion from previously noted surgical findings or percutaneous biliary drainage (10 pts.). The average AAST liver injury grade was 3.25. The mean time to diagnosis of biliary injury was hospital day 7 (range 3-18). Laparotomy was performed in 18 (64%) and surgical or CT drainage of bilomas in 10 pts. (36%). All leaks identified on nuclear scintigraphy were confirmed at ERCP. However, HIDA scanning underestimated the extent of the injury in 8 patients where the leak was characterized as contained but found to be freely extravasating on ERCP. ERCP was performed at a mean of hospital day 7.5 (range 2-28). The total number of ERCPs performed was 50. Endoscopic therapy included biliary sphincterotomy (n = 6), stent placement (n = 16) or combined therapy (n = 6). All bile leaks resolved after ERCP. Cholangiography was normal in all 16 patients who received a follow-up ERCP. The average hospital length of stay was 25.8 days (range 3-70). There was one (3.5%) ERCP-related complication which was moderate pancreatitis. There were no deaths noted. Conclusion: Bile leaks commonly occur in individuals with liver trauma (12.4%). ERCP is a safe and effective strategy for diagnosing and managing biliary complications following blunt and penetrating hepatic trauma. Although biliary scintigraphy has a high positive predictive value for diagnosing biliary leaks, ERCP better distinguishes the extent of injury and eliminates the need for more invasive surgical treatment.

The role of intraoperative cholangiogram in the management of patients recovering from acute biliary pancreatitis

Use of the standard management for gallstone-associated acute pancreatitis calls for cholecystectomy with cholangiography performed during the same hospitalization after acute symptoms has decreased. No previous studies, however, have objectively addressed the usefulness of intraoperative cholangiography (IOC) for the management of this condition. This study aimed to determine the incidence of common bile duct (CBD) stones after an acute episode of gallstone pancreatitis. The medical records of all patients who underwent a cholecystectomy and IOC after an episode of gallstone pancreatitis during the same admission between 1999 and 2004 at the University of Alberta and Royal Alexandra hospitals were examined to determine the incidence of CBD stones after resolution of gallstone pancreatitis. After a chart review for a series of 86 patients, 63 met the inclusion criteria. All except for one patient had undergone successful IOC (98%). Among the patients who had no evidence of CBD obstruction on preoperative imaging or lab work, three were found to have a filling defect on IOC and stones on their postoperative endoscopic retrograde cholangiopancreatography (ERCP) (3/63, 5%). This is not significantly different from the 4.6% incidence of CBD stones among patients with cholelithiasis who had normal preoperative imaging and blood work. In the setting of normal preoperative imaging and lab work, the incidence of CBD stones among patients recovering from acute mild to moderate gallstone pancreatitis is not significantly higher than among patients with no history of pancreatitis. Therefore, an IOC for post-gallstone pancreatitis does not alter management.

Primary precutting versus conventional over-the-wire sphincterotomy for bile duct access: a prospective randomized study

Precut is a well-known technique that is used if repeated attempts at common bile duct (CBD) cannulation fail. Opinions on the complication rate of precut are conflicting, however. The aim of the present study was to compare the efficacy and complication rate of precut used as a primary method of CBD access with the efficacy and safety of the conventional technique. During the 19-month study period, consecutive patients who were scheduled for first-time endoscopic sphincterotomy (ES) for a variety of biliary disorders were randomized into two groups: patients in group A underwent conventional wire-guided biliary cannulation followed by ES (with precut being performed only when this failed); in patients in group B precut was used as a primary technique to gain biliary access, followed by wire-guided ES. We used a specially designed, modified Erlangen type of sphincterotome for precutting. A total of 291 patients (100 men, 191 women; mean +/- SD age 65 +/- 17.5 years) were recruited: 146 patients were assigned to group A (conventional approach) and 145 to group B (primary precut approach). The indications for ES were comparable in the two groups. In group A, wire-guided cannulation of the CBD failed in 42 patients. Secondary precut was successful in 41 of these patients, leading to an overall success rate of 99.3 %. In group B, the ES success rate using primary precut was 100 % at the first attempt. The mean time to successful deep CBD cannulation was 8.3 +/- 2.1 minutes in group A and 6.9 +/- 1.8 minutes in group B ( P < 0.001). The incidence of mild to moderate pancreatitis was similar in the two groups (2.9 % in group A vs. 2.1 % in group B, P > 0.05). Mild bleeding occurred in only one patient (from group A) and this was controlled by epinephrine injection. None of the study patients developed severe pancreatitis or perforation. In experienced hands, an approach using primary precut appears to be at least as successful and safe as a conventional approach using guide-wire-based CBD cannulation followed by ES, and might also be a quicker method.

Ciclosporin Aggravates Tissue Damage in Ischemia Reperfusion-Induced Acute Pancreatitis

Ischemia reperfusion (I/R)-associated early graft pancreatitis is a major complication after pancreas transplantation. The influence of immunosuppressants on graft pancreatitis remains unclear. The aim of this study was to evaluate ciclosporin and tacrolimus in experimental pancreatic I/R. Moderate pancreatitis was induced in rats by I/R injury. Animals were assigned to 4 groups: (1) control without I/R, (2) I/R without therapy, (3) I/R + ciclosporin, or (4) I/R + tacrolimus. After 24 hours, pancreatic damage was evaluated by amylase, endothelin 1, thromboxane A2, and histology. Additionally, microcirculation was evaluated 12 hours after reperfusion by intravital microscopy. I/R significantly increased amylase compared with controls, with maximum levels after ciclosporin treatment. Histology showed comparable tissue injury in control and tacrolimus-treated animals. Ciclosporin-treated animals developed significantly (P < 0.05) more inflammation and necrosis compared with the other groups. Erythrocyte velocity evaluated by intravital microscopy was reduced in all animals after I/R. This was significantly pronounced after ciclosporin application. There was a significant increase of adherent leukocytes and platelets in ciclosporin-treated animals compared with both other groups. Tacrolimus does not negatively influence I/R-induced pancreatitis, whereas ciclosporin aggravates pancreatic tissue damage after I/R. These effects should be evaluated in the clinical setting of pancreas transplantation.

Safety advantage of endocut mode over endoscopic sphincterotomy for choledocholithiasis.

To evaluate whether an automatically controlled cut system (endocut mode) could reduce the complication rate of endoscopic sphincterotomy (EST) and serum hyperamylasemia after EST compared to the conventional blended cut mode. From January 2001 to October 2003, 134 patients with choledocholithiasis were assigned to either endocut mode group or conventional blended cut mode group at the time of sphincterotomy. The two groups were retrospectively compared for the complications after EST and serum amylase level before and 24 h after the procedure. Of the 134 patients treated, 79 were assigned to conventional blended cut mode group and 55 to endocut mode group. There was no significant difference in age, sex, and serum amylase level before EST between the two groups. Complications were found in 5 patients of the endocut mode group (9%): hyperamylasemia (5 times higher than normal) in 4 and moderate pancreatitis in 1. Complications were found in 13 patients of the conventional blended cut mode group (16%): hyperamylasemia in 12 and moderate pancreatitis in 1. Serum amylase levels were elevated in both groups 24 h after EST (P<0.02). The average serum amylase level 24 h after EST in the conventional blended cut mode group was significantly higher than that in the endocut mode group (P<0.05). Endocut mode offers a safety advantage over conventional blended cut mode for pancreatitis after EST by reducing hyperamylasemia.

Post-ERCP pancreatogastric fistula associated with an intraductal papillary-mucinous neoplasm of the pancreas – a case report and literature review

BackgroundFistula formation has been reported in intraductal papillary-mucinous neoplasms (IPMNs) with or without invasion of the adjacent organs. The presence or absence of invasion is mostly determined by postoperative histological examination rather than by preoperative work-up.Case presentationA 72 year-old Japanese woman showed remarkable dilatation of the main pancreatic duct (MPD) in the distal region of the pancreas. Subsequent ERCP also showed MPD dilatation, after which the patient suffered moderate pancreatitis. A subsequent gastroscopy revealed a small ulceration that had not been observed in a gastroscopy performed 3 months prior. Mucinous discharge from the ulceration suggested it might be the orifice of a fistula connected to the MPD. En bloc resection including the distal region of the pancreas, spleen, stomach and part of the transverse colon was performed under the pre- and intraoperative diagnosis of an invasive malignant IPMN. However, histopathology revealed the lesion to be of "borderline malignancy" without apparent invasion of the stomach. Light microscopy showed inflammatory cellular infiltrates (mainly neutrophils) around the pancreatogastric fistula, but there was no evidence of neoplastic epithelia lining the fistulous tract.ConclusionThis case highlights that a pancreatogastric fistula can develop after acute inflammation of the pancreas in the absence of cancer invasion. Further information regarding IPMN-associated fistulae is necessary to clarify the pathogenesis, diagnosis, appropriate surgical intervention and prognosis for this disorder.

Aripiprazole Causes Cholelithiasis and Hepatitis

Introduction: Aripiprazole is an effective antipsychotic with a favorable side effect profile. The purpose of this case report is to indicate that rare and potentially fatal side effects can occur on aripiprazole therapy. Case: A 54 year old male with a history of schizophrenia, cholecystectomy, on warfarin, presents with 8-day history of vomiting, diarrhea and light colored stools. He has no history of hepatitis B and C; recent travel, alcohol or acetaminophen use. Patient was started on aripiprazole for schizophrenia, two weeks prior to admission. At admission the patient was icteric with mild hepatomegaly. Aripiprazole was discontinued and coumadin held. Normal labs included ferritin, anti-smooth muscle antibody, ANA, anti-LKM1, CA 19–9 and viral hepatitis panel. In hospital after a dose of vitamin K the INR reversed to 1.7. Endoscopic ultrasound showed moderate pancreatitis without ductal dilatation or stone. CT scan showed minimal hepatomegaly with normal tissue density. The patient improved significantly after discontinuing aripiprazole and was subsequently discharged. On outpatient visit, 18 days later, the labs were: albumin 3.5 g/dl, alkaline phosphatase 95 IU/L, ALT 80 IU/L, AST 68 IU/L and INR 1.1. The patient had fully recovered. Discussion: Aripiprazole is a novel atypical antipsychotic with a favorable side effect profile. The incidence of cholelithiasis and hepatitis is less than 1%. In the absence of a biopsy, the hepatic injury could be due to an ischemic event or aripiprazole. However, the obstructive pattern of injury does not favor ischemic hepatitis. Instead the 2-week delay of adverse hepatobiliary effects is consistent with the pharmacokinetics of aripiprazole which achieves a steady state at 2 weeks. This cumulative phase is associated with a 4-fold increase in mean peak plasma concentration; which is possibly hepatotoxic, given that the metabolism of aripiprazole is hepatic. Considering the above temporal profile and pattern of hepatic injury, the likely culprit appears to be aripiprazole and not an ischemic event. Conclusion: This case report demonstrates that rare and potentially fatal side effects can occur on aripiprazole therapy, requiring close monitoring when initiating therapy.Table: Labs in Hospital

Different effects of dexamethasone and the nitric oxide synthase inhibitor L-NAME on caerulein-induced rat acute pancreatitis, depending on the severity

Effects of dexamethasone and N(G)-nitro-L-arginine methyl ester (L-NAME), the nitric oxide (NO) synthase inhibitor, on caerulein-induced acute pancreatitis were examined in rats. Acute pancreatitis was induced by caerulein (20 mug/kg, s.c.) given repeatedly 2 or 4 times every hour, and serum amylase levels, pancreas weight and myeloperoxidase (MPO) activity were measured 6 h after the first injection of caerulein. Dexamethasone (3 mg/kg) and L-NAME (30 mg/kg) were administered p.o. 30 min before the first injection of caerulein. Caerulein caused moderate or severe pancreatitis, depending on the times of injections, resulting in different degrees of increase in serum amylase levels and pancreas weight, and the marked elevation of MPO activity was observed only after injections of caerulein given 4 times per hour. Both dexamethasone and L-NAME suppressed the severity of pancreatits, yet the effect of L-NAME as compared with dexamethasone was more potent against mild pancreatitis but less potent against severe pancreatitis. These results suggest that caerulein-induced acute pancreatitis shows different responsiveness to L-NAME and dexamethasone, depending on the severity; the former is more effective against pancreatitis with less inflammation, while the latter is more effective against pancreatitis with severe inflammation. It is assumed that endogenous NO may be involved in oedema formation as the early event in the development of acute pancreatitis.

A Prospective Comparative Stent Study for Prophylaxis of Post ERCP Pancreatitis: Comparison of 5 Fr Straight Stent vs 3 FR Pigtail Stent

Pancreatitis is the most frequent ERCP complication and pancreatic stenting is an effective method to prevent this complication particularly, in high risk pts. Aim: 1. To compare frequency of post ERCP pancreatitis in high-risk pts after placement of either a modified 5Fr straight ST versus a 3Fr pigtail ST. 2. To compare ST efficacy and safety and determine the rate of spontaneous outward migration of these ST. Methods: 38 pts undergoing ERCP with high risk factors for developing post ERCP pancreatitis (SOD-12, ARP-13, abd pain-13 pts) were enrolled in this randomized, prospective, blinded study over a period of 1-yr with placement of 3Fr pigtail (15 pts) or 5Fr modified (no internal flap) (23 pts) straight ST. Pts had baseline amylase level drawn prior to as well as 6 & 24 hrs after procedure. Post ERCP pancreatitis was determined clinically & with enzyme levels >3ULN. Abd radiograph was obtained at 24-hrs & 7 days post ERCP to determine ST position. Pain scores from a scale of 1 to 10 were assessed pre ERCP at 6hrs, 24-hrs and 1 wk post ERCP. Phone contact was made at 24-hrs & 1 wk after the procedure to assess the clinical condition of the pt. 7 pts underwent repeat ERCP after ST placement & pancreatograms were compared. Results: Post ERCP pancreatitis rate with 3F & 5F ST were 33.3% (5/15) and 17.4% (4/23 pts) respectively (p=0.26). Mild post ERCP pancreatitis with 3F & 5F ST was 60% (3/5) & 75% (3/4) while that of moderate pancreatitis was 40% (2/5) & 25% (1/4 pts) (p=1.0) respectively. Spontaneous ST dislodgement at 24-hrs occurred in 7/13 pts with 3 Fr ST (53.8%) compared to 12/23 pts (52.2%) with 5Fr ST (p=0.92). There was no significant difference between the rate of pancreatitis and ST dislodgment at 24-hrs. No pt required repeat procedures for ST removal as all spontaneously passed within a wk. Among pts who underwent repeat ERCP none had duct changes or complications attributable to ST placement. Conclusions: Post ERCP pancreatitis rate seemed to be lower with modified straight 5Fr ST. However, there was no significance when compared with the pigtail 3Fr ST. None of these patients needed repeat endoscopy for ST removal nor were there any ST induced duct changes in those who had repeat pancreatogram.

Peritoneal inflammatory cells in acute pancreatitis: Relationship of infiltration dynamics and cytokine production with severity of illness

Background. The purpose of this study was to clarify the still poorly understood dynamics of peritoneal inflammatory cells (PICs) in acute pancreatitis. Methods. Acute pancreatitis of 3 different degrees of severity was induced in male Wistar rats. Peritoneal lavage was performed at 1, 6, 12, and 24 hours after the induction, and the fluids collected were analyzed for the number and subpopulation of PICs. The levels of apoptosis and necrosis, cytokines, and bacterial infection were also investigated. Results. The number of PICs was increased in mild and moderate pancreatitis, and the infiltration of inflammatory cells had occurred. In severe pancreatitis, the number of PICs increased until 6 hours after the induction, but thereafter the number decreased. Infiltration of neutrophils occurred 6 hours after the induction, but it was not sustained thereafter and infiltration of peritoneal macrophages did not occur. Cytokines in the lavage fluid increased in all 3 models during the first 6 hours after the induction. Subsequently, cytokines were reduced in mild and moderate pancreatitis but significantly increased in severe pancreatitis. The level of bacterial infection increased according to the severity. Conclusions. The relationship between the PIC dynamics and cytokine levels in severe pancreatitis is very different from that observed in mild or moderate pancreatitis. (Surgery 2002;132:86-92.)

Serum lipase, C-reactive protein, and interleukin-6 levels in ERCP-induced pancreatitis

Background: C-reactive protein (CRP) and interleukin-6 (IL-6) are elevated in acute pancreatitis. Limited studies have evaluated their role in ERCP-induced pancreatitis. The aim of this study was to assess the role of serum lipase, CRP, and IL-6 in ERCP-induced pancreatitis. Methods: Eighty-five patients (62 women, 23 men; mean age 43 years; range 16-85 years) who underwent ERCP were entered in a prospective trial. ERCP-induced pancreatitis was classified as mild, moderate, or severe. Serum levels of lipase, CRP, and IL-6 were measured before ERCP and at 12 to 24 hours and 36 to 48 hours after ERCP. Results: Mild, moderate, and severe pancreatitis occurred, respectively, in 9, 7, and 4 patients after ERCP. There were significant differences in levels of CRP and IL-6 but not lipase for patients with mild versus moderate and moderate versus severe pancreatitis. The mean CRP levels (mg/dL) at 12 to 24 hours were 0.98 ± 0.24 in mild pancreatitis, 3.89 ± 0.32 in moderate pancreatitis, and 12.0 ± 1.60 in severe pancreatitis. The levels, respectively, at 36 to 48 hours were 1.60 ± 0.31, 7.60 ± 0.74, and 25.0 ± 2.9. The mean IL-6 levels (pg/mL) at 12 to 24 hours were 16.6 ± 2.06 in mild pancreatitis, 73.0 ± 15.60 in moderate pancreatitis, and 235.5 ± 26.31 in severe pancreatitis. The levels at 36 to 48 hours were, respectively, 18.92 ± 3.28, 100.17 ± 11.56, and 438.2 ± 71.50. Conclusions: Serum CRP and IL-6 levels may be useful early markers for predicting the severity of ERCP-induced pancreatitis. (Gastrointest Endosc 2001;54:435-40.)

4625 Endoscopic ultrasound and intraductal ultrasonography are complementary for the management of ampullary tumors.

Whipple's resection is the gold standard treatment of the ampullary tumors. Nevertheless endoscopic snare resection (ESR), which is less invasive, can be applied in a curative intent when some criteria are respected : -1- no risk of metastatic lymph node e.g. benign ampullomas or early carcinomas respecting the submucosae -2- no tumoral extension inside the pancreatic and the bile ducts. While endoscopic ultrasound (EUS) stages, with a good accuracy, an ampullary tumor as respecting the muscularis propria (uT1), intraductal ultrasonography (IDUS) is very promising to appreciate the involvement of the submucosae and the existence of an intraductal extension. The combination of the two methods could then allow optimizing the therapeutic choice. AIM: to estimate the clinical impact of EUS +/- IDUS in the management of ampullary tumors PATIENTS AND METHODS: between Jan 99 and Nov 99, 10 patients with ampullary tumors had a pretherapeutic staging. A radial EUS (GFUM20, Olympus Co) was systematically performed. When the staging was uT1 an IDUS (UM-G20-29R, Olympus Co) was done. A Whipple's resection was proposed when final staging was -1- lesion infiltrating the submucosae or more ; -2- tumor extension inside the biliary or pancreatic ducts. An ESR was proposed in the other cases. RESULTS: EUS concluded to a tumor >uT1 in 4 cases. Pathology (Whipple's resection) confirmed the staging (3 pT3; 1 pT2). EUS conclude to a tumor uT1 in 6 cases and IDUS was performed. - In 4 cases tumors were considered without intraductal involvement and respecting the submucosae. ESR was always curative (severe dysplasia; resection margins free of tumor). – In 2 cases IDUS evidenced involvement of the submucosae. 1 with a tumor extension inside the ducts was operated on and diagnosed as pT2. 1 refused surgery and an ESR was performed confirming the involvement of the submucosae (positive resection margins). A moderate pancreatitis was the only ESR complication. CONCLUSION: EUS and IDUS togheter allow an accurate T staging of ampullary tumors. The clinical impact is major: endoscopic snare resection can be applied in a curative intent in early tumors, Whipple's resection in other cases or when ESR is not complete.

3464 Eus guided fine needle aspiration biopsy with a new electronic device: results on 100 consecutive patients.

We have previously demonstrated that on an intention-to-biopsy basis, EUS-FNAB in solid pancreatic tumours results in an cyto/histological diagnosis in 70 % of cases. Reasons for failure often stem from inability to penetrate lesions which are located in unfavorable areas such as the pancreatic head and uncinate process. Aim : To evaluate the feasability, efficacy and complication rate of EUS-FNAB using the new convex echo-endoscope Olympus GF UC 30 P. Methods : This device produces saggittal views of 180° has an operating channel of 2,8 mm (compared to 120° and 2 or 2.4 mm for the conventional linear scopes, respectively) and has a bridge which can alter the angle of exit of the 6 cm 22 G needle. EUS-FNAB was considered feasible by the ability to position the needle in the target, thus allowing biopsy. The biopsy was considered effective when the specimen was adequate for analysis from a cyto-histological (solid tumours) and a biochemical/cytological (pancreatic cystic lesions) point of view. Efficacy was calculated as a percentage of satisfactory specimens in relation to the number of successful biopsies and on the intention-to-biopsy i.e., of all lesions biopsied. Results : 114 EUS-FNAB were performed in 100 consecutive patients during one year. Overall feasability was 98 % with an efficacy rate of 95 % in successful biopsies and 93 % on intention-to-biopsy. The tumours included 35 pancreatic solid lesions (uncinate process 7, head 17, mean diameter : 32 mm). A single case of failed biopsy occurred : feasability = 97 %. The efficacy was 91 % on successful biopsies and 89 % on intention-to-biopsy. There were 30 cystic pancreatic lesions (head : 16, mean diameter : 23 mm) and puncture was feasible in 97 %. Cyto-histological and biochemical analyses were possible in 20 and 23 of the 29 cases respectively. A combination of biochemical and histological studies yielded an efficacy rate of 97 % in successful biopsies and 93 % on intention-to-biopsy. Other lesions types included 13 digestive wall or juxta-parietal lesions. The feasability was 100 % and the efficacy was 85 %. All 33 lymph nodes were biopsied successfully (feasability 100 %). The efficacy was 97 %. Three hepatic masses were biopsied (feasability and efficacy : 100 %). Moderate pancreatitis occurred in 2 patients. Conclusion : This new device compares favourably with the results using conventional electronic devices, particularly regarding solid pancreatic head tumours.

Acute pancreatitis associated with viral hepatitis: a report of six cases with review of literature

Association of hepatitis viruses with acute pancreatitis in the setting of nonfulminant viral hepatitis is rare. We report six cases of nonfulminant viral hepatitis complicated by acute pancreatitis, including the first documented case of hepatitis E virus (HEV) associated acute pancreatitis. The other five patients had acute viral hepatitis caused by hepatitis A infection. Besides features of viral hepatitis, the presence of typical abdominal pain, high serum amylase, and ultrasound or CT scan features suggested the diagnosis of acute pancreatitis. This complication generally developed in the initial phase of the hepatitic illness. All of the patients had mild to moderate pancreatitis that recovered uneventfully with conservative treatment.

THE EFFECT OF FR167653 ON PANCREAS ISCHEMIA-REPERFUSION INJURY IN DOGS

404 For successful pancreas transplantation, ischemia-reperfusion injury (I/RI) has been a critical problem and the role of cytokines is still unclear. In this study, we evaluated the effect of FR167653 (FR), a newly synthesized, potent suppressant of IL-1 β and TNF α on pancreas. [Methods] In adult mongrel dogs, after complete isolation of the pancreas tail, the splenic vessels were clamped for 90 minutes. During ischemia, the pancreas head was removed. The animals were divided into a control group (n=7) and a FR treatment group (n=7) that received 1 mg/kg/h of FR. We measured s-lipase, amylase, glucose and insulin before ischemia, at 0, 6, 12, 24, 48 and 72 hours after reperfusion. IVGTT was performed at sacrifice and compared to normal. RT-PCR was used for peripheral blood and then expressed as a ratio of IL-1 β/G3PDH at each time. Pancreatic tissue was obtained for histologic examination. Statistical analysis was performed by two-way ANOVA or t-test with p<0.05 for significant difference. [Results] As shown in the figure, s-lipase did not show rapid increase right after reperfusion (282±149 IU/l vs. normal 235±71), but increased markedly thereafter (1095±146 at 72 hrs) in control group. In FR group, however, lipase was significantly lower than control at all times (375±158 at 72 hrs, p=0.021). Similarly s-amylase was suppressed in FR group, but without significant difference. ΔIRI/ΔBS at 5 mins of IVGTT showed an impaired response in control (0.074±0.024) as well as FR group (0.041±0.027), compared to normal (0.147±0.023, N.S.). IL-1 β/G3PDH increased at 24 hours then gradually decreased in the control (0.342±0.047 at 24 hrs), but remained low in FR group (0.135±0.046 at 24 hrs, p=0.028). Histologic examination revealed moderate pancreatitis with edema, cell infiltration and scattered hemorrhage in the control group, and less damage in the FR group.Figure[Conclusions] There is a marked impairment of pancreas exocrine function after reperfusion. FR ameliorates I/RI of the pancreas by inhibition of proinflammatory cytokine production, which would be beneficial for pancreas preservation and transplantation.

Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals.

Increasing numbers of patients are undergoing endoscopic retrograde cholangiopancreatography (ERCP) prior to laparoscopic cholecystectomy, and more departments and doctors are performing ERCP, while new data from large prospective series have documented the risks of both diagnostic and therapeutic ERCP. The establishment in Denmark of a Patient Insurance Association, which has covered injury caused during investigation and treatment in public hospitals since July 1992, has made it possible to collect and analyze a large prospective series of ERCP complications for which compensation has been claimed. Thirty-nine consecutive claims for compensation due to complications after ERCP occurring between 1 July 1992 and 31 December 1996 were investigated. Case notes were reviewed, along with laboratory reports and radiographs. The complications were classified according to the international consensus. Claims for compensation were made in 39 cases from 25 hospitals. The indication for ERCP was appropriate in 31. Precut papillotomy for access had been performed in seven. The severity of the complications was mild in one patient, moderate in three patients, severe in 24, and fatal in nine; in two cases, the severity was not classifiable. The complications were: pancreatitis in 23 patients (seven cases fatal, one of which had involved a precut procedure), bleeding in two, perforation in nine (six had a precut procedure, one died), and other reasons in five (including one fatal case). Among the nine fatal cases, cannulation had not been achieved in two and the endoscopic retrograde cholangiogram was normal in four, one of whom underwent a sphincterotomy. One patient with a previous adenoma had an endoprosthesis removed, developed gangrenous cholecystitis afterward, and died. Thirty patients were eligible for compensation. The rejected cases included mild and moderate pancreatitis, a case of fatal hemorrhagic pancreatitis in which the patient had refused blood transfusion, and one patient who had pancreatitis prior to ERCP. ERCP, even for diagnostic purposes, may be associated with very serious and even fatal complications. The use of the precut procedure for access should still be considered dangerous. Other means of investigating the bile ducts should be developed. If endoscopic ultrasonography and magnetic resonance cholangiography prove to have the same diagnostic value as ERCP, which must be considered the gold standard for visualizing the ducts today, they might replace ERCP as the primary investigation in patients with an intermediate or low risk of bile duct stones; this would reduce the numbers of patients exposed to the risks of ERCP.

Fecal elastase 1 determination in chronic pancreatitis.

This study assessed the diagnostic accuracy of fecal elastase 1 in chronic pancreatitis. Fifty-three healthy subjects, 44 patients with chronic pancreatitis (22 severe, 13 moderate, and 9 mild), and 43 patients with nonpancreatic digestive disease were studied. Elastase 1 concentration was determined on a small sample of feces using a commercially available kit. Fecal chymotrypsin was also measured. With a cutoff level of 190 microg/g, all healthy controls except one (98.1%), and the majority of patients with nonpancreatic digestive diseases (40 of 43; 93.0%) had elastase values above this limit. Among the 44 patients with chronic pancreatitis, 34 (77.3%) had pathological values: all 22 (100%) with severe disease, 10 of 13 (76.9%) with moderate disease and 2 of 9 (22.2%) with mild disease. Chymotrypsin values were pathological in 25 of 44 (56.8%) patients with chronic pancreatitis: 17 of 22 (77.2%) with severe pancreatitis, 7 of 13 (53.8%) with moderate pancreatitis, and 1 of 9 (11.1%) with mild disease. The specificity was 95.8% for elastase 1 and 85.4% for chymotrypsin. The difference both in sensitivity and specificity of the two enzymes was statistically significant (P < 0.05). Fecal elastase 1 has a high sensitivity, superior to that of fecal chymotrypsin, in the diagnosis of chronic pancreatitis. For its simplicity and rapidity, it could represent the tubeless test of choice in chronic pancreatitis.

Endothelin-1 is a candidate mediating intestinal dysmotility in patients with acute pancreatitis.

We studied whether gastrointestinal transit was disturbed during acute pancreatitis and attempted to identify which mechanisms might be involved in acute pancreatitis. Using a noninvasive hydrogen breath test to determine the orocecal transit time, 24 patients with the clinical diagnosis of acute pancreatitis were enrolled into the intestinal motility study. Orocecal transit time was measured twice in all patients: once at the acute stage and once at recovery. Blood was obtained to study amylase, lipase, C-reactive protein, erythrocyte sedimentation rate, and endothelin-1 and nitrate/nitrite levels. Orocecal transit times measured at the acute stage were significantly delayed compared with those at recovery (mean values +/- SEM, 130.0 +/- 9.0 vs 80.8 +/- 7.4 min, P < 0.001). Plasma endothelin-1 levels exhibited a positive correlation with orocecal transit times in the acute stage (r = 0.509, P = 0.011). The percentages of altered orocecal transit times also correlated with the percentages of altered plasma endothelin-1 levels (r = 0.751, P < 0.001). Plasma nitrate/nitrite levels significantly decreased at the acute stage compared with those at recovery (5.25 +/- 0.82 vs 10.20 +/- 1.24 microM, P < 0.05). We conclude that intestinal transit is delayed in patients with mild to moderate acute pancreatitis. Elevated plasma endothelin-1 levels in the acute stage may be one mechanism mediating intestinal dysmotility.

Safety and efficacy of pancreatic sphincterotomy in chronic pancreatitis

Background: Endoscopic pancreatic sphincterotomy (EPS) is being performed with increasing frequency as a prerequisite to interventional measures in the pancreatic duct. The aim of this study was to evaluate EPS with regard to technique, success, complications, and mortality in patients with chronic pancreatitis. Methods: Between January 1989 and September 1996, the results of all consecutive EPSs in patients with chronic pancreatitis were documented in a standardized form. Patients were followed by clinical investigation and blood sample analysis at 4, 24, and 48 hours after EPS. Complications were classified according to commonly accepted criteria. Results: EPS was performed in 118 patients with chronic pancreatitis (men 75%, women 25%, 48 ± 10 years). Ninety-four patients (80%) underwent guidewire-assisted EPS, and 24 patients (20%) underwent needle-knife EPS. Seventy-seven EPS procedures (65%) were primarily successful (guidewire EPS: 60 of 94, 64%; needle-knife EPS: 17 of 24, 71%). Additional endoscopic cutting techniques (needle-knife papillotomy, biliary endoscopic sphincterotomy) were required in 41 patients (35%). In total, EPS was successful in 116 patients (98%). The complication rate was 4.2% (4 cases of moderate pancreatitis, 1 severe bleeding, no deaths). All complications were managed nonoperatively. Conclusions: In patients with chronic pancreatitis, EPS with a standard sphincterotome or with a needle-knife offers an effective and reliable approach to the pancreatic duct system. Additional cutting techniques may be necessary in approximately one third of cases before an EPS can be successfully performed. The complication rate of EPS in patients with chronic pancreatitis appears to be lower than the complication rate of biliary sphincterotomy for other indications. (Gastrointest Endosc 1998;48:244-9.)