Moon Hee Song

Autoimmune chronic pancreatitis.

In recent years a peculiar type of chronic pancreatitis with underlying autoimmunity has been described. Lymphoplasmacytic infiltration and fibrosis on histology and elevated IgG levels or detected autoantibodies on laboratory data support the concept of autoimmune chronic pancreatitis (AIP). Pancreatic imaging reveals a rare association of diffuse enlargement of the pancreas and irregular narrowing of the main pancreatic duct, which is unique and specific to AIP. Although AIP is not a common disease, it is increasingly being recognized as knowledge of this entity builds up. Clinically it is very important to be aware of this disease because AIP can clinically disguise as pancreaticobiliary malignancies, ordinary chronic, or acute pancreatitis. Above all, AIP is a very attractive disease to clinicians in terms of its dramatic response to oral steroid therapy in contrast to ordinary chronic pancreatitis. This review discusses the clinical, laboratory, histologic, and imaging findings that are seen in patients with AIP, especially focusing on the diagnosis.

EUS in the evaluation of pancreatic cystic lesions

BACKGROUND The differential diagnosis in pancreatic cystic lesions is often difficult despite the availability of various modern imaging modalities. This study assessed the role of EUS in the following: (1) discrimination of pseudocysts from pancreatic cystic tumors, (2) differential diagnosis between serous cystadenoma and mucinous cystic tumor, and (3) prediction of accompanying malignancy in intraductal papillary mucinous tumor. METHODS EUS findings in 75 patients with pancreatic cystic lesions (58 cystic tumors, 17 pseudocysts) were evaluated. In the comparison of pseudocysts and cystic tumors, the latter included intraductal papillary mucinous tumor, mucinous cystic tumors, and serous cystadenomas, but not solid-pseudopapillary tumors. RESULTS In univariate analysis, pseudocysts exhibited echogenic debris and parenchymal changes more often than cystic tumors did (respectively, 29% vs. 6%, p < 0.05; and 65% vs. 4%, p < 0.001). In contrast, septa and mural nodules were found more frequently in cystic tumors than pseudocysts (respectively, 69% vs. 12%, p < 0.001; 56% vs. 12%, p < 0.01). Multivariate analysis revealed that parenchymal changes (odds ratio [OR] = 83.59; p < 0.01); septa (OR = 30.75; p < 0.05); and mural nodules (OR = 21.38; p < 0.05) were independent predictors of differentiation between pseudocysts and cystic tumors. Serous cystadenoma exhibited diverse EUS features, as well as a honeycomb appearance. Mural nodules were found more often in mucinous cystic tumors than in serous cystadenomas (p < 0.05). There were no factors that predicted malignancy in intraductal papillary mucinous tumor. CONCLUSIONS EUS is a useful complementary imaging method for differentiation of pancreatic cystic lesions.

Endoscopic sphincterotomy vs. endoscopic papillary balloon dilation for choledocholithiasis in patients with liver cirrhosis and coagulopathy

BACKGROUND To determine whether endoscopic papillary balloon dilation decreases the risk of hemorrhage without increasing the risk of acute pancreatitis, the results of endoscopic papillary balloon dilation were compared with those of endoscopic biliary sphincterotomy in patients with cirrhosis and coagulopathy. METHODS Twenty-one patients with liver cirrhosis with coagulopathy had endoscopic papillary balloon dilation for choledocholithiasis from January 2001 to September 2003. Twenty patients with cirrhosis and coagulopathy who underwent endoscopic biliary sphincterotomy from January 1998 to December 2000, served as a historical control group. RESULTS The rate of endoscopic biliary sphincterotomy related hemorrhage was 30% (6/20), whereas the rate for endoscopic papillary balloon dilation related hemorrhage was 0% (p=0.009). With regard to rates of hemorrhage in relation to Child-Pugh class, most (n=5) of the bleeding complications occurred in patients with Child-Pugh class C cirrhosis; bleeding occurred in only one patient with Child-Pugh B cirrhosis. There was no significant difference between the endoscopic biliary sphincterotomy and the endoscopic papillary balloon dilation groups for procedure-related pancreatitis (10% vs. 4.7%, respectively; p>0.05). CONCLUSIONS Endoscopic papillary balloon dilation may significantly reduce the risk of bleeding compared with endoscopic biliary sphincterotomy in patients with advanced cirrhosis and coagulopathy. In these patients, the substitution of endoscopic papillary balloon dilation for endoscopic biliary sphincterotomy is recommended for treatment of choledocholithiasis.

Comparison of histology and extracellular matrix between autoimmune and alcoholic chronic pancreatitis.

Objectives: In autoimmune chronic pancreatitis (AIP), the histology is known to be characteristic and histologic recovery including pancreatic fibrosis has been reported after steroid therapy. The aims of this study were to demonstrate whether these histologic findings were unique to AIP and evaluate any differences in the composition of extracellular matrix between AIP and ordinary chronic pancreatitis. Methods: Histologic findings and extracellular matrix proteins (collagen types I, III, and IV and fibronectin) were evaluated in 15 patients with clinically proven AIP and compared with those of 8 patients with surgically treated alcoholic chronic pancreatitis (ACP). Results: The pattern of fibrosis was mainly loose fibrosis with stromal edema in AIP, while it was dense fibrosis in ACP. Acinar atrophy was more diffuse and severe in AIP than ACP. While diffuse with same stage of inflammatory activity was observed in AIP, multifocal inflammation with different stage of inflammatory was seen in ACP. For extracellular matrix proteins, dense deposition (compared with normal controls) of collagen type III was observed more frequently in ACP than AIP (P < 0.05). ACP showed decreased deposition of collagen type IV more frequently than AIP (P = 0.001). Conclusion: Fibrosis and inflammation are common to both AIP and ACP, but the pattern is very different between the 2 groups, and the deposition of collagen types III and IV is substantially different between AIP and ACP.

Association between low thigh fat and non‐alcoholic fatty liver disease

Background and Aim:  Some people have a fatty liver despite having low visceral fat and a low body mass index (BMI). We investigated whether fat distribution, especially thigh subcutaneous fat and thigh intramuscular fat, is associated with non‐alcoholic fatty liver disease (NAFLD).

Endoscopic minor papilla interventions in patients without pancreas divisum

BACKGROUND Endoscopic treatment through the minor papilla is well known in patients with pancreas divisum. However, there are few data concerning endoscopic minor papilla interventions in patients without pancreas divisum when access to the main pancreatic duct via the major papilla is technically difficult. METHODS Records for 213 patients without pancreas divisum who, from April 2001 to June 2003, underwent ERCP for various pancreatic diseases were retrospectively reviewed. Patients were included if they had endoscopic interventions via the minor papilla because access through the major papilla was not possible. OBSERVATIONS Minor papilla papillotomy or fistulotomy with endoscopic interventions was successful in 10 (91%) of 11 patients. Of these 10 patients, 9 had chronic pancreatitis and one had pancreatic ductal leak from previous pancreatic surgery. The reasons for the inability to access the main pancreatic duct to the tail of the gland via the major papilla included a distorted course of the main pancreatic duct (n=5), impacted stone (n=5), and stricture (n=8). In 8 patients, there were two causes. No complication related to the minor papilla interventions was observed in any patient. CONCLUSIONS Endoscopic minor papilla interventions are technically feasible in patients with pancreatic diseases but not pancreas divisum when access to the main pancreatic duct via the major papilla is not possible.

Endoscopic Sphincterotomy Versus Endoscopic Papillary Balloon Dilatation for Choledocholithiasis in Liver Cirrhosis with Coagulopathy

Endoscopic Sphincterotomy Versus Endoscopic Papillary Balloon Dilatation for Choledocholithiasis in Liver Cirrhosis with Coagulopathy Do Hyun Park, Myung-Hwan Kim, Sung Koo Lee, Sang Soo Lee, Moon Hee Song, Jung Sik Choi, Dong Wan Seo, Young Il Min Background/Aim: To determine whether endoscopic papillary balloon dilatation (EPBD) actually decreases the risk of hemorrhage without increasing risk of acute pancreatitis, we compared the results of EPBD with those of endoscopic biliary sphincterotmy (EST) in cirrhotic patients with coagulopathy. Methods: Twentyone liver cirrhosis patients with coagulopathy were treated with EBPD for choledocholithiasis from January 2001 to September 2003. Twenty liver cirrhosis patients with coagulopathy who underwent EST from January 1998 to December 2000 served as a historical control group. Coagulopathy was defined as a prothrombin time below 50% of normal or a platelet count below 80,000 / mm3.Hemorrhagewas recorded onlywhen therewas clinical (not just endoscopic) evidence of bleeding such asmelena or hematemesis, with an associated decrease of at least 2 g per deciliter in the hemoglobin concentration, or the need for a blood transfusion. Results: Hemorrhage occurred in 6 (30%) of 20 patients in the EST group, but there was no case of hemorrhagic complications in the EPBD group (p = 0.009). With regard to the hemorrhagic rates according to Child-Pugh class in the EST group, the hemorrhagic complications mostly occurred in Child-Pugh class C patients. Moreover, three of five Child-Pugh class C cirrhotic patients with EST-related hemorrhage bled to death. In the EPBD group, however, there was not any hemorrhagic complication inChild-Pugh class C patients. Therefore, there was significant difference in the hemorrhagic complications of Child-Pugh class C patients between EST and EPBD group (5/14, 35.7% vs. 0/16, 0%; p = 0.014). On the contrary, in Child-Pugh class B, there was no significant difference in hemorrhagic complications between EST and EPBD groups (1/6, 16.6% vs. 0/4, 0%; p = NS). There was also no significant difference between EST and EPBD groups in the rate of procedure-related pancreatitis (2/20, 10 % vs. 1/21, 4.7 %; p = NS). Conclusions: EPBD may significantly reduce the risk of bleeding compared with EST in advanced cirrhotic patients with coagulopathy such as Child-Pugh class C. In these patients, EPBD should replace EST as a treatment modality for removal of choledocholithiasis. *T1476 ERCP with Sphincter of Oddi Manometry (SOM) at an Ambulatory Endoscopy Center (AEC): An Assessment of Complications Erik Springer, Yang K. Chen, Daus Mahnke, Mainor R. Antillon, Raj J. Shah BACKGROUND: Patients (pts) with suspected sphincter of Oddi dysfunction (SOD) are known to be at increased risk for post-ERCP pancreatitis. At our tertiary referral center, outpatients undergo ERCP at a multi-specialty AEC and recover in a post-anesthesia care unit.We assessed the safety of performingERCP/ SOM at an AEC. METHODS: Consecutive pts undergoing SOM over a one-yr period were identified by prospective collection and computer database. All pts had propofol administered by anesthesiology. The standard station pull-through technique was performed using the aspiration manometry catheter. Pts were transferred by ambulance to the hospital 6 miles away for 23hr observation. 30d complication rate was assessed by clinic/telephone contact and record review. Complications were defined by consensus (CONS) criteria, and by comprehensive (COMP) criteria which included unplanned ER/MDvisits,>23 hr observation, or admission for symptoms. SOD was defined by modified Milwaukee criteria. RESULTS: Between 10/02 and 10/03, 595 ERCPs were performed. 53 pts (7M, 46F, mean age 40) underwent 59 SOM procedures providing the cohort for this study. 31 SOMs were biliary, 11 were pancreatic, and 17 were biductal. SOM results: SOD Type II (29), SOD Type III (21), or normal (9). 48 pts had sphincterotomies: 32 biliary, 7 pancreatic, and 15 biductal. 31 pancreatic stents were placed prophylactically. CONS: Total 7 complications (11.9%); 6 pancreatitis, 1 bleed (mild). Pancreatitis severity: 1 mild (SOD III), 2 moderate (SOD II), and 3 severe (2 SOD II, 1 normal). COMP: Total 24 complications (41%) including 13 cases of pain requiring>23hr hospital admission, 1 abdominal pain requiring po analgesics, 1 IV site infiltration, and 2 infection. CONCLUSIONS: 1) SOM can be performed safely in an AEC provided there is on-site anesthesia support and mechanisms for hospital transfer. 2) Our pancreatitis rate is comparable to previously published series. 3) One-fifth of SOM pts without pancreatitis required >23 hr stay for pain management, thus, routine admission post-SOM is recommended. 4) Future studies reporting endoscopy-related complications should incorporate comprehensive criteria as defined for a more accurate assessment of morbidity.

Effect of Chronic Alcohol Consumption on Conscious Sedation During Colonoscopy Using Midazolam

How Safe Is Upper GI Endoscopy? David Mclernon, John Dillon, Anne Crozier, Peter Donnan, Craig Mowat With the move towards non-invasive investigation of dyspepsia, the demographics of those patients proceeding to upper GI endoscopy (OGD) have changed. The safety of OGD remains important. The National Confidential Enquiry into Perioperative Deaths recently reported on the morbidity and mortality of therapeutic procedures in England and Wales. Data collection was incomplete. The previous national audit of OGD outcomes related to practice in 1995. Aims: to assess the safety of OGD in the current era. Methods: Endoscopy records identified all patients who had OGD from 1 July 2000-30 June 2003. Patients were recordlinked to hospital records (SMR01), Carstairs deprivation scores and the death registry. Deaths within 30 days of OGD were identified and casenotes reviewed. Results: 12,925 OGDs were performed on 10,030 patients; median age 62(IQ range: 48-75), 54% female. 396 deaths occurred within 30 days of the OGD; median age 76 (IQ range: 64–83), giving a crude death rate of 3.95%. For in-patients, this rose to 9.5%, versus 0.86% for outpatients. 128 deaths followed a therapeutic OGD, giving a death rate of 1 in 5 (128/640). 48 of these had a PEG insertion, giving a death rate of 1in 6 for this indication (48/302). The death rate for diagnostic OGD was approximately 1 in 35 (268/9390). Analysis is ongoing but thus far, OGD has been judged as contributary in 43 deaths, giving a crude death rate of approximately 1 in 250. 17 of these patients had a PEG insertion, giving a death rate of 1in 18 (17/302). 22 of the OGD-related deaths followed a therapeutic procedure, giving a death rate of approximately 1 in 29 (22/640). The corresponding rate for diagnostic OGD was approximately 1 in 470 (20/9390). Logistic regression analysis was performed on the outcome of all cause mortality within 30 days of OGD, adjusting for age, sex, deprivation, co-morbidity, in/outpatient, indications, premedication type, diagnosis etc. The odds of an inpatient dying within 30 days of endoscopy compared to an outpatient is 2.29 (p ! 0.001). The odds of dying from a therapeutic procedure compared to a diagnostic procedure is 2.99 (p ! 0.001). Further results will be obtained for endoscopy-related deaths. Conclusions: The safety of OGD is determined by the pre-morbid state of the patient. This suggests that we should be more selective in our use of endoscopy, particularly when there is little likelihood of therapeutic benefit.