Andy S. Yu

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.

Hepatolithiasis and biliary parasites

Hepatolithiasis, or the presence of intrahepatic stones, is prevalent in East Asia and is characterized by the finding of stones within the intrahepatic bile ducts proximal to the confluence of the right and left hepatic ducts. Bile stasis and bacterial infection have been incriminated as the major aetiopathogenic factors. Clinical features include recurrent pyogenic cholangitis, multiple liver abscesses, secondary biliary cirrhosis and cholangiocarcinoma. The goals of management include accurate localization of pathologies, control of biliary sepsis and the elimination of stones and stasis. Ultrasonography, computed tomography and direct cholangiography complement each other in defining the stones, strictures and degree of liver damage. Non-operative biliary decompression by endoscopy and interventional radiology is effective in controlling the infection, but surgery remains the mainstay for the treatment of stones and strictures. Intra-operative ultrasound and flexible choledochoscopy, combined with percutaneous transhepatic cholangioscopy and intraductal lithotripsy, facilitate stone removal. Balloon dilatation and biliary stenting serve to open the bile duct strictures. The creation of a hepaticocutaneous jejunostomy after conventional surgery allows atraumatic access to the biliary system for the removal of recurrent stones. The management of biliary parasites begins with conservative measures, including analgesics and anti-helminthic therapy. In refractory cases or patients with acute cholangitis, endoscopic biliary drainage and the extraction of worms may be necessary. Improvement in sanitation plays a crucial role in the epidemiological control of these biliary diseases.

Pancreatitis caused by common bile duct stones in a 3-year-old boy with prior surgery for a choledochal cyst

Pancreatitis in children is uncommon. Compared to adults, pancreatitis in children is usually related to trauma, anatomic anomalies, infections, hereditary, and systemic disease, but not gallstones or alcohol. Most cases do not require endoscopic intervention. We report an unusual case of recurrent pancreatitis in a child related to common bile duct stones requiring endoscopic treatments after surgical treatment for choledochal cyst.

Should we rely on rapid urease test or routine staining for the accurate diagnosis of helicobacter pylori

SHOULD WE RELY ON RAPID UREASE TEST OR ROUTINE STAINING FOR THE ACCURATE DIAGNOSIS OF HELICOBACTER PYLORI RK Hsu MD M Chang MD, A Yu MD, B Yost* MD, B Ruebner* MD, JG Lee MD and JW Leung MD. Division of Gastroenterolgy and Department of Pathology*, University of California, Davis Medical Center, Sacramento CA Introduction Rapid Urease Test and histology are two common endoscopic tests for Hp detection. Discrepancies between these two tests can cause confusion in the actual diagnosis. In praetice, Genta stain is more sensitive than H&E and Giemsa stain but are not used in routine. The aim of this study is to examine the error rate of RUT and histology using routine staining as reference to the consensus results by pathologists with special interest in GI pathology. Method: Standard antral biopsy were obtained from 40 outpatients presented with ulcer and nonulcer dyspepsia using Wilson Cook Maxum biopsy forceps with cup diameter 2.5mm. The patients were not on treatment with proton pump inhibitors. The HP status was detected using Hpfast rapid urease test (RUT) and initial histology by routine H&E or Giemsa stain interpreted by general pathologists. The histology slides were then reviewed by two pathologists with special interest in GI pathology who were blinded to the initial results. Genta stain was used for the final diagnosis in doubtful cases. Using these consensus results as the gold standard, comparison of the error rate of RUT and general staining was made. The Hpfast RUT results were reevaluated independently by l0 different physicians and nurses. Results: (n = 40) Error rate with 95% Confident interval Group # error Rate SE U95 L95 RUT 16 0.4 0.l 0.9544 0.2614 H&E/Giemsa 4 0.1 0.05 0.2386 0.0307 The greatest discrepancies in the interpretation of Hpfast results were observed at the color change that were seen at the range of pH 5.8-6.5. Conclusions: 1. Inter-observational variability in the interpretation of color changes in Hpfast RUT in the marginal cases could be a factor for the discrepancies seen in routine practice. A single trained observer may avoid the problem. 2. When both tests agree with each other, the accuracy rate is 92%. 3. In doubtful cases with routine staining, Genta stain is required to confirm the diagnosis.