Peter B. Cotton

4668 Is magnetic resonance cholangio-pancreatography with cholecystokinin useful in identifying patients with sphincter of oddi dysfunction?

Sphincter of Oddi manometry (SOM) is the standard method of diagnosing SOD. SOM is invasive, can be technically difficult and associated with complications. MRCP with CCK stimulation may provide useful information relating to sphincter of Oddi function. AIM: Evaluate the sensitivity/specificity of CCK-MRCP in predicting the results of SOM in patients with clinically suspected SOD (type III). METHOD: Data from consecutive patients referred for SOM who had CCK-MRCP prior to SOM were analyzed. All MRCP studies were reported by one radiologist who was blinded to the findings of SOM. Patients with prior therapy to the papilla or known pancreaticobiliary malignancy or stricture were excluded. Equivocal/failed MRCP or SOM were excluded from analysis. SOM was performed using a standard 5 F perfused, aspirating catheter (Wilson-Cook, Winston-Salem, NC); SOD was diagnosed if the mean pressure from two leads was greater or equal to 40 mmHg. MRCP was performed with oblique coronal singleshot breath-hold, 5cm slabs (8000/150//135), FOV-24 cm. Scans were performed before and 20 mins after initiation of the CCK infusion (0.02mcg/Kg, in 6ml saline, 0.1ml/sec). CCK-MRCP was abnormal if the common bile duct increased in diameter post-CCK. RESULTS: Of 25 patients (mean age 38yrs., range7-74yrs, M/F=5/20), 18 biliary and 18 pancreatic SOM studies were analyzed; CCK-MRCP was inadequate in 2 patients. Of all 12 patients, CCK MRCP was abnormal in 4 of 6 patients with abnormal biliary SOM (sensitivity 67%) and was normal in 7 of 12 patients with normal biliary SOM (specificity 58%). Of the 5 patients with an intact gallbladder, CCK-MRCP was normal in all 3 patients with normal biliary SOM and abnormal in both patients with abnormal biliary SOM. The sensitivity and specificity of CCK-MRCP in predicting abnormal biliary SOM in post- cholecystectomy patients was 50% and 44 % respectively. There was no association between pancreatic SOM and CCK-MRCP. CONCLUSION: 1] The overall sensitivity and specificity of CCK-MRCP in predicting abnormal biliary SOM was 67% and 58% respectively. 2] The sensitivity and specificity were 100% in the small sub-group of 5 patients with the gallbladder in situ. This study is on-going to further evaluate these novel findings.

7127 Can a 3.1 mm stand-alone battery powered esophagoscope (bpe) screen the esophagus for esophagitis and barrett's ? a prospective blinded comparison with a standard videoendoscope (sve).

Intro: There exist several indications (varices, Barretts, GERD) where an esophagoscopy alone would suffice rather than a complete endoscopy. Feasibility of esophagoscopy using a prototype battery powered flexible fiberoptic esophagoscope (Olympus XEF-DP) with an outer diameter of 3.1 mm has been reported (GI Endo 1999;49: AB157). Aim: In a prospective blinded study, compare esophageal visualization between the BPE & the SVE. Methods: 95 consecutive pts. underwent sedated esophagoscopy with the BPE foll. by SVE, done by 2 endoscopists, each blinded to the findings of the other. On a visual analogue scale, the 2 endoscopists rated pt. tolerance & instrument performance. Results: 89 (M 57) pts. (mean age 56 yr.) were analyzed. Mean duration of esophagoscopy was 4.4 mins (range 2-10). Sensitivity : specificity (%) with BPE was 94 : 96 (Barretts) & 87 : 94 (all lesions). Measures of pt. tolerance were (BPE : SVE, p value): intubation ease 96 : 93, 0.06; gagging 98 : 91, 0.0012; coughing 98 : 96, 0.08; belching 89 : 92, 0.02 (higher scores indicate better rating). Measures of scope performance were (BPE : SEV, p value): visibility 90 : 98, 0.0001; air insufflation 92 : 98, 0.001; maneuverability 87 : 99, 0.001. Concl: The esophagus can be accurately visualized in under 5 min with the BPE. Inter-observer variability may account for some of the disagreements. Being a standalone instrument, not needing a light source, processor or a monitor, it could facilitate esophagoscopy outside of the conventional GI lab setting. Its tolerance unsedated, use transnasally & potential in a true screening environment are being studied.

4465 Scheduled vs. as required stent exchanges for malignant biliary obstruction. a prospective randomized study.

Background: The best strategy for stent exchange in malignant biliary obstruction is not known. Some experts advocate routine prophylactic stent exchange every 3-4 months, a strategy which might lead to many unnecessary procedures. Aim: A prospective randomized study comparing 2 commonly practiced strategies: scheduled vs. as required stent exchanges. Methods: Pts. requiring biliary stenting for malignant obstruction were randomized to either (i) scheduled exchanges every 4 months or earlier if stents occluded (SCH) or (ii) exchanges only when stents occluded (PRN). End points were either metal stenting, surgery, death or resolution of stricture not needing stenting. LFTs were monitored monthly in both gps. Occlusion was defined as a doubling of nadir alkaline phosphatase or bilirubin. Results: Of the 69 pts. recruited 5 were excluded (4- benign; 1-immediate surgery). 30 pts. (9 M) were randomized to SCH and 34 pts. (15 M) to the PRN arm. The 2 gps. were comparable in all respects (SCH : PRN) mean ages (69:72); diagnoses (%) pancreatic Ca (73 : 76), cholangioCa (10 : 14), metastases (13 : 9) and ampullary Ca (1 : 0); mean comorbidity indices (0.83 : 0.97); & stent diameters (≥10 Fr). Number of ERCPs per pt. in the 2 gps. was not different, 2.1(SCH) vs 2(PRN). Number of stents per patient [(SCH : PRN): 1 stent (15:15); 2 stents (4:10); 3 stents (5:5); 4 stents (3:2); 5 stents (3:2)] and end points [death (22:26); metal stenting (6:7); surgery (1:0); misc (1:1)] were similar. Indications for metal stenting (SCH:PRN) duodenal stenosis (3:7) and rapid reocclusion (3:1) were similar. 43% pts. (SCH) and 47% pts. (PRN) died with patent stents. The mean stent survival was 90 d (SCH) vs 97 d (PRN), (p=NS). There was no difference in the survival time of each serial stent between the two gps. There was 1 episode of stent related cholangitis leading to death in the PRN arm on day 108 (T=3.82; p>0.05). There was no difference in the number of episodes of cholangitis; 10 in SCH vs 15 in PRN (T=1.29763; p>0.25). Time to death or other endpoints was not different in the two gps. (p=0.99). Conclusion: (1) There is no difference in measured outcomes when plastic stent exchanges are performed electively every 4 months or on an as required basis for biochemical occlusion in malignant biliary obstruction. (2) Using biochemical occlusion rather than clinical occlusion may result in a lower stent related mortality than previously reported. (3) Other factors (e.g. physical proximity, personal preference) should be used when selecting a strategy.

4660 Patients with clinically suspected sphincter of oddi dysfunction are more likely to have pancreatic sphincter hypertension if pancreatic ductography is abnormal.

The incidence of pancreatic ductographic abnormalitites (PDA) in patients with normal and abnormal pancreatic orifice manometry is not known. AIM: Evaluate the incidence of (PDA) in patients with clinically suspected SOD who undergo pancreatic manometry (PSOM). METHOD: The MUSC GI Trac data base was reviewed for consecutive patients with clinically suspected SOD who had successful unequivocal PSOM between 2/94 and 11/99. Patients with pancreas divisum, prior pancreatic duct or orifice therapy, and failed/inadequate pancreatic ductography were excluded from analysis. The ductographic findings of duct dilatation, duct irregularity and irregular side branch changes, were compared individually and as a group with the findings of PSOM. PSOM was performed using a standard 5 F aspirating catheter (Wilson-Cook,Winston-Salem, NC) and PSH diagnosed if the mean pressure from two leads was >40 mmHg. RESULTS: Of 833 patients (mean age 46.3 yrs, range 16-86yrs., M/F 218/615), 429 (52%) had abnormal PSOM (ie PSH) and 431 (52%) had at least one PDA. At least one PDA was present in 248/429 (58%) of patients diagnosed with PSH, and 45% (181/402) with no PDA had PSH (p

4661 Do pancreatic features identified with endoscopic ultrasound correlate with sphincter of oddi manometry in patients with clinically suspected sphincter of oddi dysfunction? an evaluation of 462 patients.

SOM is the accepted method for diagnosing SOD. EUS can evaluate anatomical features of the pancreas. The role of EUS in the evaluation of patients with clinically suspected SOD particularly in predicting the findings of SOM, is undefined. AIM: Evaluate if EUS assessment of the pancreas correlates with SOM in patients with clinically suspected SOD. METHOD: Patients with clinically suspected SOD who underwent EUS prior to SOM between 2/94 and 11/99 at MUSC were included for analysis. Patients with pancreas divisum, prior therapy to the major papilla, or inadequate SOM or EUS were excluded. EUS features of pancreatitis ( parenchymal : foci, strands, lobularity, cysts, and ductal : hyperechoic and irregular duct margins, calcification/stones, visible side-branches and duct dilatation) were compared with the SOM diagnosis of the biliary (BSOM) and pancreatic (PSOM) orifices. All EUS examinations were blinded to the findings at SOM. SOM was performed using a standard 5 F aspirating catheter and SOD diagnosed if the mean sphincter pressure from two leads was >40 mmHg. EUS was performed using a radial echoendoscope (Olympus UM-20, UM-130) at 7.5 MHz. RESULTS: Of 462 patients (mean age 45 yrs. range16-85yrs., M/F 137/325), 372 and 370 underwent unequivocal PSOM and BSOM respectively after EUS. Of the 176 patients with abnormal PSOM, 54% (n=95) had a total >4 EUS features of pancreatitis; 46% (89/194) with normal PSOM had 3 or less features (p=1). Of patients with no EUS features, 48%(25/52) and 52% (27/52) had normal and abnormal PSOM respectively (p=0.55). Similarly there was no correlation between BSOM (148 abnormal) and the total number of EUS features. The number of parenchymal or ductal EUS features was unrelated to BSOM or PSOM. CONCLUSIONS 1] Neither the total number nor the number of parenchymal or ductal EUS features of pancreatitis predict the findings of SOM in patients with clinically suspected SOD. 2] A normal EUS examination (i.e. no features) does not exclude SOD.

6984 A dilated pancreatic duct at ercp can be associated with a lower incidence of post-ercp pancreatitis (pep).

Background: The etiology of PEP is probably multifactorial. Pancreatic stenting has been shown to reduce the incidence of PEP in selected patients. We hypothesized that normal diameter ducts are more likely to become occluded by edema and hence associated with PEP. The relationship between the findings of pancreatic ductography and PEP is not known. Aim: Evaluate if there is an association between pancreatic duct dilatation (PDIL) and PEP. Methods: The MUSC GI Trac database was reviewed for patients who had successful pancreatography. Patients with cancer, stricture, stones and prior pancreatic duct or orifice therapy were excluded. The incidence of PEP was evaluated in patients who did or did not have (PDIL). Patients were sub-grouped if they had a pancreatic stent placed and/or concomitant biliary sphincterotomy (BSx). Results: Of 3298 patients (mean age 49yrs., range 10-89yrs., M:F= 3:7), PEP occurred in 150 (5%). A dilated duct was noted in 801 patients. The incidence of PEP in all patients with PDIL was 3% (23/801) compared to 5% (127/2497) in those with no PDIL, p=0.008. The incidence of PEP in patients with and without BSx, pancreatic stenting and PDIL, is tabulated: Of all patients who had a pancreatic stent placed (n=887), there was no statistical difference in the incidence of PEP in those with PDIL (3%, 10/316) Vs no PDIL (5%, 27/571). CONCLUSIONS: 1] The overall incidence of PEP is lower if the pancreatic duct is dilated. 2] The presence of duct dilatation in patients who do not undergo BSx or PD stenting is associated with a lower incidence of PEP.

4663 Pancreatic sphincterotomy improves symptoms in patients with pancreatic sphincter hypertension persisting after biliary sphincterotomy.

BACKGROUND: PSH can persist after BSx. There is little information regarding the clinical symptom response to BSx and PSx in patients with PSH. AIM: Evaluate the effect of PSx on symptoms in patients with persistent PSH after prior BSx. METHODS: Patients with prior sphincter of Oddi dysfunction (SOD) treated initially with BSx and who had persistent PSH were analyzed. Clinical data were evaluated for the subsequent endoscopic therapy (if any). All patients were contacted by telephone to evaluate symptom response to their most recent endoscopic therapy. Manometry was performed with a standard perfused, aspirating catheter and SOD diagnosed if the mean pressure form two leads was ≥ 40 mmHg. Persistent PSH was documented by pancreatic manometry immediately after BSx and prior to PSx at a subsequent procedure. Patients who had normal pancreatic manometry were excluded from analysis. RESULTS: 42 patients (mean age 53 yrs, range 21-83 yrs , M:F=9/39) underwent isolated BSx in the setting of PSH. Of these 21 (50%) patients returned with persistent symptoms and underwent PSx. Patients were interviewed regarding symptom response at a mean of 39 months ( range 6.8-53months) after their most recent endoscopic intervention. Of the 21 patients who only had BSx as their most recent therapy (i.e. untreated PSH), 13 (62%) reported resolution of pain/symptoms, 6 (29%) reported improvement of symptoms and 2 (9%) reported no change in symptoms. Of the 21 patients who returned after BSx with persistent symptoms and who underwent PSx to treat PSH, 3 (14%) reported resolution of symptoms,11 (52%) reported improved symptoms, 6 (29%) reported no change and 1 (5%) reported worsening symptoms. After initial BSx, post-ERCP pancreatitis occurred in 4/21 (19%) patients who subsequently returned with symptoms, compared to 1/21 (5%) (NS) in patients who did not receive subsequent PSx. CONCLUSIONS: 1] Pancreatic sphincterotomy can improve symptoms in 66% of patients with prior biliary sphincterotomy but persistent PSH and symptoms. 2] However, a significant portion of patients (45%) with persistent PSH immediately after biliary sphincterotomy report symptom improvement without pancreatic sphincterotomy. This suggests that BSx alone may provide adequate symptom relief in some patients. Further study is needed to identify which patients with PSH would benefit from pancreatic sphincterotomy in addition to biliary sphincterotomy.

⁎4624 Is eus useful in predicting post-ercp pancreatitis? - an analysis of 509 patients.

BACKGROUND: EUS can provide detailed information regarding parenchymal and ductal changes in the pancreas. Other than prior history, there are no known pre-ERCP predictors of post-ERCP pancreatitis (PEP). The relationship between EUS features of pancreatitis and post- ERCP pancreatitis is unknown. AIM: Evaluate if the number or distribution (ie : ductal Vs. parenchymal ) of EUS features of pancreatitis ( parenchymal : foci, lobularity, stranding, cysts, and ductal : duct irregularity, hyperechoic margins, dilatation visible side-branches calcification/stone) are associated with the incidence of post-ERCP pancreatitis. METHOD: Consecutive patients who underwent EUS prior to ERCP at MUSC between 2/94 and 11/99 were evaluated. Patients who had an incomplete EUS, pancreatic cancer or prior pancreatic duct therapy (surgical or endoscopic), were excluded. Univariate analyses were performed to evaluate for any relationship between PEP and individual or groups of features seen on EUS. A multivariate analysis was also performed to include the influence of interventions performed during ERCP. RESULTS: Data from 509 patients (mean age 46 yrs. range 13-84 yrs., M/F: 153/356) were analyzed. PEP occurred in a total of 40 (8%) patients. The incidence of PEP in patients with >4 EUS features was 8% (22/275), and 8% (18/234) in those who had 5 EUS features compared to 7% (23/315) those with