Normal Pancreatogram Research Articles

Su1713 Endoscopic Therapy in Chronic Pancreatitis: What Are the Factors Associated With Successful Response ?

Su1713 Endoscopic Therapy in Chronic Pancreatitis: What Are the Factors Associated With Successful Response ?

Su1714 A Normal Pancreatogram At Index ERCP Is Associated With Late Minor Papillary Stenosis After Endoscopic Minor Papillotomy in the Setting of Pancreas Divisum

Pancreas divisum (PDv) is an anatomic variant found in 5-10% of the population and associated with idiopathic recurrent acute (RAP) and chronic pancreatitis (CP). Endoscopic minor papillotomy (EMP) has long term efficacy in small prospective trials, particularly in patients with RAP. Stenosis of the minor papilla/dorsal pancreatic duct near the minor papilla (MPS) is a late complication of EMP reported in 11-20% of patients. MPS is often managed by repeat EMP, though efficacy of repeat intervention remains uncertain. To our knowledge no literature exists regarding possible risks of MPS as it relates to initial presentation for index ERCP with EMP. Aims:1) Describe incidence of MPS in the setting of PDv. 2) Identify clinical, diagnostic and therapeutic risk factors prior to and accrued during index intervention for PDv that predict MPS.

The Duodenal Aspirate Volume Does Not Correlate With the PEAK Bicarbonate Concentration During Secretin Stimulated Endoscopic Pancreas Function Testing. A Note of Caution for Secretin MRCP?

Background. Abnormal exocrine function precedes most imaging changes of CP so stimulated pancreas function tests (PFT) are used as a surrogate for early diagnosis as histology is rarely obtained. Endoscopic PFT (ePFT) have shown promise as a less technically challenging PFT but may last one hour and require special equipment. Peak pancreas exocrine output takes at least 30 minutes to occur after secretagogue stimulation so we tested if a shorter endoscopic aspiration could differentiate patients with and without chronic pancreatitis. Methods. Synthetic secretin 0.2 μg/kg (ChiRhoClin,Inc.,Burtonsville,MD) was administered IV, and sedation started 30 minutes afterwards. After gastric fluid aspiration the endoscope was advanced to the major papilla and four continuous duodenal aspirations were done at 5 minute intervals, starting 35 minutes after secretin administration, collected in a sealed polyp trap on ice, and delivered to the laboratory. The first four samples were analyzed by an autoanalyzer (Corning 965, USA) calibrated to a bicarbonate of 80 mEq/L and compared to pH back titration. Variance between the methods was ±0.02 mEq/L so subsequent measurements were done with the auto-analyzer only. Peak bicarbonate concentration (PBC) >80 mEq/L during any collection is normal. ERCP and EUS were compared to ePFT and all three to a final diagnosis of CP which was established by considering history, imaging, histology and ePFT. Results. Twenty seven ePFT have been performed (16 females). Indications were suspected CP (17), abdominal pain (7), steatorrhea (2), idiopathic recurrent acute pancreatitis (1). Nine patients (pts) received a final diagnosis of CP and 18 no CP. 15 pts had ERCP (two had one, 9 pts had 2, 2 pts had 3 and 2 pts had 5). Seven pts had a normal pancreatogram. Cambridge class was I in one pt, II in 4 pts, III in 2 pts and IV in one pt. Two pts with Cambridge II and one with Cambridge III had normal PBC. 23 pts had EUS (21 had one, one pt had two, and one pt had 3). Ten pts had > 4 criteria for CP, and 6/10 pts had an abnormal ePFT. 13 pts had a normal EUS, and 11/13 had normal PBC (one pt had PBC 78.9 mEq/L). PBC was 80 mEq/ L in 17/18 pts without CP. The sensitivity and specificity of ePFT compared to ERCP and EUS and of all three compared to a final diagnosis of CP are in the tables. Conclusion. The ePFT was as good as EUS and ERCP in predicting CP. ePFT and EUS were non-statistically superior to ERCP in ruling out CP. The final diagnosis of CP was enhanced by combining numerous tests, but this proposed shorter ePFT requires less expertise, involves routine upper endoscopy, and may be more practical for regular use. More data is needed to determine how well it predicts early chronic pancreatitis, and if results decrease the ordering of other tests when CP is suspected. Comparison of ePFT to ERCP and EUS

DOES A PATENT ACCESSORY PANCREATIC DUCT PREVENT ACUTE PANCREATITIS?

The role of the accessory pancreatic duct (APD) in pancreatic pathophysiology has been unclear. We previously examined the patency of the APD in 291 control cases who had a normal pancreatogram in the head of the pancreas by dye-injection endoscopic retrograde pancreatography (ERP). APD patency was 43% and was closely related with the shape of the terminal portion of the APD. The present study aimed to clarify the clinical implications of a patent APD. Based on the underlying data, the patency rate of the APD was estimated from the terminal shape of the APD on ERP in 167 patients with acute pancreatitis. In patients with acute pancreatitis, stick-type APD, spindle-type APD, and cudgel-type APD, which showed a high patency, were rare, and branch-type APD and halfway-type or no APD, which showed quite low patency, were frequent in acute pancreatitis patients. Accordingly, the estimated patency of the APD in acute pancreatitis patients was only 21%. There was no significant relationship between the estimated APD patency and etiology or severity of acute pancreatitis. The terminal shapes of the APD with low patency were frequent in acute pancreatitis patients, and estimated APD patency was only 21% in acute pancreatitis. A patent APD may function as a second drainage system to reduce the pressure in the main pancreatic duct and prevent acute pancreatitis.

Endoscopic Appearance of the Minor Papilla Predicts Findings at Pancreatography

The minor papilla serves as a site of alternative pancreatic duct drainage via the accessory pancreatic duct. The objectives of this study were to assess the endoscopic appearance of the minor papilla for characteristics that might predict increased accessory pancreatic duct flow and hence suggest pathology of the downstream pancreatic ductal system. This was a nonrandomized, prospective analysis of consecutively enrolled patients from a tertiary care medical center (Maine Medical Center, Portland, Maine). The study cohort consisted of consecutive patients presenting for endoscopic retrograde cholangiopancreatography (ERCP) without prior pancreaticobiliary endotherapy or ductography. Sixty-four patients received a minor papilla score prior to ERCP. A normal pancreatogram was found in 37 of 64 (57.8%) patients; the remaining 27 (42.2%) patients had an abnormal pancreatogram. The median minor papilla bulge score was 0.49 (range 0-3) in the normal pancreatogram group and 2 (range 0-3) in the abnormal pancreatogram group (P < 0.0001). The median minor papilla orifice score of those with a normal pancreatogram was 0 (range 0-2) compared to 2 (range 0-3) in the abnormal pancreatogram group (P < 0.001). The median minor papilla cumulative score of 1 (range 0-5) for the normal pancreatogram group was significantly less than that for the abnormal pancreatogram group (3, range 0-6, P < 0.0001), resulting in a sensitivity of 96.3% for an abnormal pancreatogram. The minor papilla orifice was noted to be either gaping or actively dripping pancreatic juice in four out of five patients with pancreas divisum. A minor papilla without bulging or a visible orifice would suggest a normal pancreatogram at ERP. Conversely, an abnormal minor papilla, particularly a patent minor papilla orifice, should raise suspicion of pancreatic ductal pathology and can help direct pancreatic endotherapy at the major or minor papillae.

Double major papilla of Vater - a rare endoscopic finding during endoscopic retrograde cholangiopancreatography: a case report

BackgroundA double major papilla of Vater is a rare congenital anomaly with only three documented cases described in the literature.Case reportWe report the case of a 19-year-old man, with chronic ulcerative pancolitis and congenital sphrerocytosis, who underwent endoscopic retrograde cholangiopancreatography because he had persistent elevation of liver enzymes and normal MRI cholangiography. During endoscopic retrograde cholangiopancreatography, a double papilla of Vater with separate drainage for the bile duct and the pancreatic duct was observed.ConclusionEndoscopic retrograde cholangiopancreatography showed normal pancreatogram and findings compatible with sclerosing cholangitis.

Comparison of the Secretin Stimulated Endoscopic Pancreatic Function Test to Retrograde Pancreatogram

Duodenal intubation techniques with hormonal stimulation are the most accurate at diagnosing early chronic pancreatitis. Pancreatography (ERCP), the radiologic gold standard, can accurately diagnose chronic pancreatitis, but is expensive, may expose the patient to radiation, and/or induce acute pancreatitis. We have developed an endoscopic pancreatic function test (ePFT) that can assess pancreatic secretory function during upper endoscopy. We sought to determine the accuracy of the endoscopic secretin pancreatic function test using retrograde pancreatogram as the gold standard. Patients referred to The Pancreas Clinic for the evaluation and management of chronic abdominal pain and suspected chronic pancreatitis who had both endoscopic function testing and pancreatic duct imaging (ERCP) were studied. Pancreatograms were scored for duct morphologic characteristics (Cambridge classification) and compared to peak bicarbonate concentration in secretin stimulated duodenal juice. The ePFT consisted of a test dose of intravenous synthetic porcine secretin (0.2 microg), full-dose intravenous secretin (0.2 microg/kg) over 1 min, (3) upper endoscopy with moderate sedation, (4) gastric fluid aspirated and discarded, (5) duodenal fluid aspirations at 0, 15, 45, and 60 min after secretin injection, and (6) fluid analysis with lab autoanalyzer for bicarbonate concentration (historical normal cutpoint >80 mEq/L). Thirty-six patients had both the endoscopic function test and ERCP. Seventeen had chronic abdominal pain with normal pancreatograms, and nineteen had chronic abdominal pain with abnormal pancreatograms, consistent with chronic pancreatitis. The sensitivity and specificity of the endoscopic function test were 94% and 79%, respectively. The positive and negative predictive values were 80% and 94%, respectively. Overall agreement with ERCP was 86%. The ePFT with synthetic porcine secretin has excellent correlation with abnormal pancreatogram (chronic pancreatitis). Furthermore, a normal bicarbonate (negative function test, HCO(3) >80 mEq/L) essentially rules out chronic pancreatitis as a diagnostic cause of abdominal pain. Endoscopic pancreatic function testing may decrease the need for ERCP in patients with chronic abdominal pain.

ENDOSCOPIC ULTRASOUND- FINE NEEDLE ASPIRATION (EUS-FNA) DIAGNOSIS OF AN ECHINOCOCCAL PANCREATIC CYST

Case: A 49 year old female from Argentina presented with abdominal pain. This pain was located in the left upper quadrant and would radiate to her right abdomen. Her prior medical history was significant for an incidentally discovered hydatid cyst removed by partial hepatectomy five years previously. This partial hepatectomy was complicated by an ischemic common bile duct stricture which had previously required serial endoscopic dilations. Her physical examination was significant only for well healed surgical scars. No abdominal masses were palpated. CT scan of the abdomen and pelvis was performed and revealed a 4 × 2cm cystic lesion at the junction of the pancreatic neck and body. ERCP revealed a normal pancreatogram. EUS was then performed, revealing a 3.7 × 1.6 cm anechoic cystic lesion in the body of the pancreas. The cyst did not appear to contain septae or connect to the pancreatic duct, but the wall was noted to be thickened and possibly calcified. FNA of the cyst removed 6 cc of clear fluid which eventually revealed brood capsules, free scolices and scattered hooklets which are pathognomonic of Echinococcus. No post-procedure complications were noted. Albendazole therapy was subsequently initiated. The patient was subsequently referred to surgery and resection was performed of the pancreatic echinococcal cyst. Hepaticojejunostomy was also performed to correct the previous bile duct injury. The patient tolerated the operation well and is without recurrence at one-year post surgery. Discussion: The vast majority of pancreatic cysts are pseudocysts, mucinous cystadenomas, or serous cystadenomas. Echinococcus granulosus is an extremely rare cause of pancreatic cystic disease. Echinococcus can be found worldwide in areas where dogs are used to help raise livestock. Parasitic infection occurs when humans eat vegetables contaminated by dog feces containing embryonated eggs. The eggs then hatch in the small intestine and liberate oncospheres that penetrate the mucosa and migrate to distant sites, including the liver (52–77%) or the lungs (9-44%). Case reports have previously described pancreatic involvement and also described the safe aspiration of echinococcal cysts by transabdominal ultrasound FNA. A series in Kuwait described transabominal ultrasound FNA diagnosis of 11 patients with echinoccal cysts. (Med Princ Pract. 2002) We believe this to be the initial report of the diagnosis of an echinococcal cyst of the pancreas via EUS-FNA.

Long-term outcome of endoscopic dual pancreatobiliary sphincterotomy in patients with manometry-documented sphincter of Oddi dysfunction and normal pancreatogram

For patients with sphincter of Oddi dysfunction and abnormal pancreatic basal sphincter pressure, additional pancreatic sphincterotomy has been recommended. The outcome of endoscopic dual pancreatobiliary sphincterotomy in patients with manometry-documented sphincter of Oddi dysfunction was evaluated. An ERCP database was searched for data entered from January 1995 to November 2000 on patients with sphincter of Oddi dysfunction who met the following parameters: sphincter of Oddi manometry of both ducts, abnormal pressure for at least 1 sphincter (> or =40 mm Hg), no evidence of chronic pancreatitis, and endoscopic dual pancreatobiliary sphincterotomy. Patients were offered reintervention by repeat ERCP if clinical symptoms were not improved. The frequency of reintervention was analyzed according to ducts with abnormal basal sphincter pressure, previous cholecystectomy, sphincter of Oddi dysfunction type, and endoscopic dual pancreatobiliary sphincterotomy method. A total of 313 patients were followed for a mean of 43.1 months (median, 41.0 months; interquartile range: 29.8-60.0 months). Immediate postendoscopic dual pancreatobiliary sphincterotomy complications occurred in 15% of patients. Reintervention was required in 24.6% of patients at a median follow-up (interquartile range) of 8.0 (5.5-22.5) months. The frequency of reintervention was similar irrespective of ducts with abnormal basal sphincter pressure, previous cholecystectomy, or endoscopic dual pancreatobiliary sphincterotomy method. Of patients with type III sphincter of Oddi dysfunction, 28.3% underwent reintervention compared with 20.4% with combined types I and II sphincter of Oddi dysfunction (p = 0.105). When compared with endoscopic biliary sphincterotomy alone in historical control patients from our unit, endoscopic dual pancreatobiliary sphincterotomy had a lower reintervention rate in patients with pancreatic sphincter of Oddi dysfuntion alone and a comparable outcome in those with sphincter of Oddi dysfunction of both ducts. Endoscopic dual pancreatobiliary sphincterotomy is useful in patients with pancreatic sphincter of Oddi dysfunction. Prospective randomized trials of endoscopic biliary sphincterotomy alone versus endoscopic dual pancreatobiliary sphincterotomy based on sphincter of Oddi manometry findings are in progress.

Endoscopic retrograde cholangiopancreatography in the management of pancreaticobiliary disorders in children.

The role of endoscopic retrograde cholangiopancreatography (ERCP) is not yet fully established in children. The purpose of this study was to assess the use of ERCP in the diagnosis and management of various pancreaticobiliary disorders in children. Eighty-four ERCPs were performed over 5.5 years in 72 children with suspected pancreaticobiliary tract disorders with an adult-type duodenoscope. In all cases, indications, procedure time, ERCP findings, complications, patients course and therapeutic intervention (if any) were recorded. The mean (+/- SD) age of these children was 8.8 +/- 3.3 years. Successful cannulation was possible in 70 (97%) cases. Of the 44 cases with suspected biliary tract disease, 14 had a choledochal cyst, 13 had portal biliopathy, two each had CBD stones, primary sclerosing cholangitis and a bile leak, one had biliary ascariasis, eight had a normal cholangiogram, and CBD cannulation failed in two. Eight of the 28 children with suspected pancreatic disorders had chronic pancreatitis, five had pancreatic duct disruption, three had pancreas divisum and the rest had a normal pancreatogram (including all eight children with unexplained abdominal pain). Therapeutic ERCP was performed in 22 children, endoscopic nasobiliary or a nasocystic drain was placed in 16, biliary stenting was conducted in two, pancreatic duct stenting was conducted in three, and minor papilla dilation was conducted in one child. Six children had mild procedure-related complications. Endoscopic retrograde cholangiopancreatography is very useful in the treatment of cholangitis, bile leak, pseudocyst and pancreatic fistulae in children. However, its role in unexplained abdominal pain is doubtful.

Therapeutic ERCP in the management of pancreatitis in children

Background: The use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is increasing in the management of pancreatobiliary diseases in children. Methods: Over a 32-month period, we performed 34 ERCP procedures for the treatment of pancreatitis in 22 children at two university hospitals. Demographics and clinical data and ERCP findings were documented. Clinical status was assessed 6 months before the first ERCP and 6 months after the last ERCP, according to general condition, severity and frequency of pain, and health care encounters (emergency department visits, clinic visits, and hospital admissions related to the pancreatitis). Results: Mean age of the patients was 10.7 years (range 1.5 to 17 years). Abdominal pain was the main presenting symptoms with hyperamylasemia and hyperlipasemia. Clinical diagnoses included acute pancreatitis (6), recurrent pancreatitis (5), and chronic pancreatitis (11). The mean follow-up was 16.4 months. Nine patients had sphincter manometry, with abnormal results leading to biliary sphincterotomy in 4. Fifteen patients underwent a total of 23 therapeutic ERCP procedures unrelated to sphincter dysfunction. There were 2 complications of 34 procedures (6%), both being mild pancreatitis after sphincter manometry. There were no deaths. There was a significant reduction in frequency ( p < 0.01) and severity of pain ( p < 0.01) after intervention. Patients without pancreatographic changes of chronic pancreatitis had the most marked clinical improvement ( p < 0.05). In those with ductal changes of chronic pancreatitis, clinical improvement was not predicted by the extent of ductal changes. There was a significant decrease in health care encounters ( p < 0.05) and improvement in general condition ( p < 0.01) after endoscopic therapy, especially in those with a normal pancreatogram. Conclusions: Therapeutic ERCP is safe in pediatric patients with pancreatitis. Significant clinical improvement is achieved in patients with biliary or pancreatic stone disease. Prospective studies with long-term follow-up are needed to determine the impact of endoscopic therapy in patients with chronic pancreatitis and sphincter of Oddi dysfunction. (Gastrointest Endosc 2000;51:396-400.)

Endoscopic Ultrasonography in Chronic Pancreatitis

The usefulness and accuracy rate of endoscopic ultrasonography (EUS) in the diagnosis of chronic pancreatitis (CP) were prospectively evaluated in 81 patients with suspected pancreatic disease. All underwent EUS, abdominal ultrasonography (AUS), and computed tomography (CT), and endoscopic retrograde cholangiopancreatography (ERCP) was performed in 55 of the cases. The diagnosis of CP was established in 44 patients (CP group) including 24 with a calcified form. No pancreatic disease was observed in 18 patients (control group), and 19 patients had a pancreatic tumor. In the CP group AUS was less accurate than EUS in visualizing the pancreas, performances of CT scan being identical to EUS in this respect. A good correlation was observed between EUS and ERCP for visualization and measurement of the Wirsung duct. The most significant changes observed by EUS in the CP group were dilatation of the main pancreatic duct, heterogeneous echogenicity of the pancreatic parenchyma, and cysts < 20 mm in size even in noncalcified CP or with normal pancreatograms. Sensitivity of EUS for diagnosis of CP was 88% (AUS, 58%; ERCP, 74%; CT scan, 75%), the specificity being 100% for ERCP and EUS, 95% for CT scan, and 75% for AUS. The good performances of EUS allow early diagnosis of CP in symptomatic patients since heterogeneous echogenicity of the pancreatic parenchyma seems to be almost specifically associated with the disease.

Obstructive jaundice caused by pancreatic carcinoma in the setting of a normal pancreatogram

Obstructive jaundice caused by pancreatic carcinoma in the setting of a normal pancreatogram

Clinical Usefulness of Dual-Label Schilling Test for Pancreatic Exocrine Function

The usefulness of the pancreatic dual-label Schilling test as an indirect test of pancreatic exocrine function was evaluated. This dual-label Schilling test was based on the difference of absorption for [58Co]cobalamin bound to hog R protein and [57Co]cobalamin bound to intrinsic factor. In this study, the test was performed in 7 normal subjects, 5 patients with pancreatectomy, 12 patients with chronic pancreatitis, 10 patients with suspicion of chronic pancreatitis, and 13 patients without chronic pancreatitis. The normal lower limit (mean -2 SD) of excretion ratio for [58Co]/[57Co] in 24-h urine was 0.68. Of the 26 patients on whom endoscopic retrograde pancreatography was performed, none of the 9 patients with normal pancreatogram, 4 of the 9 patients with mild to moderate pancreatitic changes in pancreatogram, and 7 of the 8 patients with advanced pancreatitic changes in pancreatogram showed a positive value lower than the ratio of 0.68 in this test. In 28 patients examined with the direct test of pancreatic secretory capacity, 2 of the 13 patients with normal function, 6 of the 9 patients with mild dysfunction, and 5 of the 6 patients with definite dysfunction were positive in this test. The results of the pancreatic dual-label Schilling test significantly correlated with those of a direct test of pancreatic secretory capacity and the findings of pancreatitic changes in pancreatogram (p less than 0.01, chi 2 test). The ratio for [58Co]/[57Co] correlated (r = 0.73) with the maximal bicarbonate concentration in duodenal juice of the direct test of pancreatic secretory capacity. The impairment of bicarbonate output by the pancreas may adversely affect the transfer of cobalamin from R protein to intrinsic factor. It suggested that the pancreatic dual-label Schilling test is useful for detecting not only patients with severe pancreatic insufficiency but also the relatively early stage of chronic pancreatitis with bicarbonate secretory dysfunction of the pancreas.

The role of endoscopic retrograde cholangiopancreatography in preoperative assessment of bile duct cancer.

AbstractA total of 73 patients with carcinoma of the bile duct (59 patients) or duodenal papilla (14 patients) were reviewed with regard to the role of endoscopic retrograde cholangiopancreatography (ERCP) in preoperative assessment of these diseases. Percutaneous transhepatic cholangiography was preferred in most of the jaundiced patients and ERCP was performed after establishment of percutaneous or operative drainage above the obstruction. Pancreatography obtained in 19 patients with bile duct carcinoma revealed pancreatic invasion in 2 patients, and chronic pancreatitis in 1 patient. Other patients with normal pancreatograms included 2 patients whose initial diagnosis had been pancreatic cancer. The extent of bile duct carcinoma could be determined in 92% of 26 patients who had retrograde cholangiography, whereas it was known preoperatively in only 27% of 33 patients in whom retrograde cholangiography was not obtained. Combined use of antegrade and retrograde cholangiography performed in 13 patients was particularly useful to clearly delineate the lesion. In most of the patients with ampullary carcinoma, biopsy during ERCP confirmed the diagnosis preoperatively; 3 of these patients underwent ERCP with a different diagnosis. Biopsy after sphincterotomy revealed bile duct carcinoma in 2 patients in whom bile duct cancer was not suspected. Complications included 2 cases of cholangitis and 2 cases of mild pancreatitis. ERCP does not provide sufficient information as to the proximal bile duct anatomy and extent of the lesion, which are essential for appropriate surgical treatment. If used with precautions to prevent possible septic complications, however, it is useful in excluding pancreatic diseases by pancreatography, in specifying the distal bile duct, and in observing the duodenum and papilla. The use of several ERCP‐derived techniques such as perendoscopic biopsy, sphincterotomy, and balloon catheter cholangiography substantially increases the diagnostic utility of this procedure.

Pancreatic function and enzyme synthesis rates in mild chronic pancreatitis.

Incorporation of intravenous 75Se-methionine into duodenal juice proteins during pancreatic stimulation was measured as an index of pancreatic enzyme synthesis rates in 12 patients with a normal pancreatogram and in 6 with mild chronic pancreatitis. Isotope incorporation was significantly greater in subjects with mild chronic pancreatitis than in those with a normal pancreatogram. Thus in most patients in whom pancreatography demonstrates the characteristic radiological features of 'mild chronic pancreatitis' pancreatic acinar function is abnormal. The coexistence of morphological and functional abnormality implies that such patients do have chronic pancreatitis.

A Study of Secretory Proteins, Cytology and Tumor Site in Pancreatic Cancer

Pure pancreatic fluid was aspirated at the time of endoscopic retrograde cholangiopancreatography (ERCP), after Secretin stimulation, and was analyzed for protein in eight patients with proven adenocarcinoma of the pancreas and in 16 subjects of the same sex ratio and approximately matching ages, who had normal pancreatograms and pancreatic cytology, who served as controls. The albumin concentration, IgA, IgG, were all significantly greater in the pancreatic fluid of the cancer group, and the IgM and transferrin increase was of borderline significance. Many zymogen bands present in controls were either faintly present or absent in the cancer group at matching zymogen concentration. Cytology was positive or suspicious in eight of 11 cancer patients. The secretory protein abnormalities and cytology results in the cancer group did not depend on a particular tumor site or size, the smallest being 3 cm lesions. Hence, secretory abnormalities and gross tumor size and location are independent entities to a certain extent. It is possible that secretion changes may precede the development of gross tumor. Further study will be necessary before the actual significance of these findings for early diagnosis is known.

Accuracy and consistency of pancreatography

Pancreatography is a valuable diagnostic technic to identify structural changes in the pancreatic ductal system. Although specific diagnoses based on ductal changes are not always possible, patients with surgically normal glands and those showing changes of chronic pancreatitis were reliably identified in this series. Patients evaluated for postcholecystectomy pain usually had normal pancreatograms and grossly normal pancreatic glands at the time of surgical exploration. The overall consistency in interpretation of pancreatograms by experienced radiologists was approximately 80 per cent. Pancreatic cancer was poorly predicted due to either minimal changes in the ductal system or inability to distinguish gross changes from those seen with chronic pancreatitis.

Lundh test and ERCP in pancreatic disease.

The Lundh test and endoscopic retrograde cholangiopancreatography (ERCP) were used to investigate 40 patients with known or suspected pancreatic disease. Pancreatograms were classified as being normal or showing minimal or gross changes. There was good correlation between the two tests in assessing the degree of pancreatic disease (P less than 0.01). Gross radiographic changes were associated with a mean tryptic activity (MTA) of less than 6 IU/ml, while minimal changes were associated with an MTA between 6 and 14 IU/ml. Although some patients with normal pancreatograms had MTAs within this range, no patients with an MTA above 14 IU/ml had an abnormal pancreatogram. The Lundh meal is of great value in detecting extensive pancreatic disease and an unequivocally normal result virtually excludes significant chronic pancreatic disease. Values in the equivocal range usefully draw attention to early pancreatitis which may be confirmed by ERCP. In this paper the interpretation of pancreatograms is discussed and the clinical features of the patients with minimal change disease are reviewed.

Prospective evaluation of endoscopic retrograde cholangiopancreatography in the diagnosis of periampullary cancers.

In a prospective study of 112 patients suspected of periampullary cancer endoscopic retrograde cholangiopancreatography (ERCP) was successfully performed in 87 patients (78%). Technical failures were due to gastric outlet obstruction in four patients and inability to cannulate the ampulla of Vater in 21 patients. Successfully performed ERCP had both a high sensitivity (92%) and specificity (90%) for periampullary cancer. The few errors in pancreatogram interpretation were due to juxta-ductal cancers and difficulty in differentiating duct changes of cancer from those of chronic pancreatitis. Pancreatic cytology, performed in 21 patients, was reliable, diagnosed two pancreatic cancers when the pancreatogram failed and, if used routinely, assists interpretation of the pancreatogram. Retrograde cholangiography provided a correct diagnosis in six jaundiced patients with normal pancreatograms. Three complications of ERCP occurred in this series.