Praveer Rai

Endoscopic Management of Portal Cavernoma Cholangiopathy: Practice, Principles and Strategy

Portal cavernoma cholangiopathy (PCC) is the presence of typical cholangiographic changes in patients with a portal cavernoma due to chronic portal vein thrombosis, in the absence of other biliary tract diseases. Probably due to biliary stasis related to the cavernoma, there is a high incidence of biliary sludge and calculi in PCC, which trigger symptoms that resolve with appropriate interventions. Persistent and troublesome symptoms are usually due to biliary stenoses or strictures, which may occur with or without biliary calculi and may be short or long, solitary or multifocal, extrahepatic or intrahepatic. Experience with endoscopic interventions in PCC over the last twenty years has shown that it is the procedure of choice for bile duct calculi. Plastic stenting with repeated, timely, stent exchanges is the first line intervention for jaundice or cholangitis due to biliary strictures. If biliary obstruction does not resolve, portosystemic shunt surgery (PSS) or transjugular intrahepatic portosystemic stent shunt (TIPS) is performed to decompress the portal cavernoma. However, for patients with non-shuntable veins or blocked shunts, repeated plastic stent exchanges are the only option though there are reports of the use of biliary self-expandable metal stents in this situation. If symptomatic biliary obstruction persists after successful PSS or TIPS, second stage biliary surgery may be necessary. Recent experience suggests that treating biliary strictures in PCC on the lines of postoperative benign biliary strictures with balloon dilatation and repeated exchanges of plastic stent bundles may be effective therapy. Endoscopic management appears to be associated with an increased frequency of hemobilia, which usually responds to standard management. Recurrent cholangitis with formation of sludge and concretions may be a problem with repeated stent exchanges, especially if patient compliance is poor. In conclusion, the current understanding is that symptomatic PCC is best managed jointly by the endoscopist and surgeon with sequential interventions designed initially to establish and maintain biliary drainage, then to decompress the portal cavernoma and, finally, if required, second stage biliary surgery or endotherapy for biliary strictures. Endoscopic therapy occupies a central role in management before, during and after surgical therapy. Paradigms of endoscopic therapy continue to evolve as knowledge of pathogenesis and natural history improves and newer approaches and techniques are applied.

Frequency of SPINK1 N34S mutation in acute and recurrent acute pancreatitis

Several studies have reported association of c.101A>G (p.N34S) mutation in SPINK1 gene with chronic pancreatitis; however, the data on its relationship with acute pancreatitis (AP) and recurrent acute pancreatitis (RAP) are limited.

Portal venous system and its tributaries: a radial endosonographic assessment.

The use of Color Doppler in endosonography has enabled detailed real-time assessment of the abdominal vasculature. Standard stations are used during the routine evaluation on endosonography. However, the imaging techniques do not describe the vascular imaging of the portal venous system and its tributaries, in detail. This article demonstrates the normal findings on the portal venous system and its tributaries using radial endosonography.

Imaging of pancreas divisum by linear-array endoscopic ultrasonography.

Pancreas divisum (PD) is the most common developmental anatomic variant of pancreatic duct. Endoscopic ultrasound (EUS) is often performed to evaluate idiopathic pancreatitis and has been shown to have high accuracy in diagnosis of PD. The different techniques to identify PD by linear EUS have been described differently by different authors. If EUS is done with a proper technique it can be a valuable tool in the diagnosis of PD. The anatomical and technical background of different signs has not been described so far. This article summarizes the different techniques of imaging of pancreatic duct in a suspected case of PD and gives a technical explanation of various signs. The common signs seen during evaluation of pancreatic duct in PD are stack sign of linear EUS, crossed duct sign on linear EUS, the dominant duct and ventral dorsal duct (VD) transition. Few other signs are described which include duct above duct, short ventral duct /absent ventral duct, separate opening of ducts with no communication, separate opening of ducts with filamentous communication, stacking of duct of Santorini and indirect signs like santorinecele. The principles of the sign have been explained on an anatomical basis and the techniques and the principles described in the review will be helpful in technical evaluation of PD during EUS.

Imaging of peritoneal ligaments by endoscopic ultrasound (with videos).

Double layered peritoneal folds or ligaments act as conduits for the passage of blood vessels in intraperitoneal organs and also provide a pathway for the spread of disease. It is difficult to identify these normal peritoneal folds at imaging. Computed tomography is the most common imaging modality used to detect diseases of the peritoneum. The ultrasound (US) has been also used for evaluation of diseases involving ligaments. Endoscopic ultrasound (EUS) is being increasingly used both for diagnostic and interventional purposes in abdomen. In this article, we have described the normal EUS anatomy of the peritoneal ligaments.

EUS-Assisted Evaluation of Rectal Varices before Banding

Rectal varices are an important cause of bleed. The bleeding can be sometimes fatal. Endoscopic management is possible and is generally done in emergency situation. Rectal variceal banding is useful. Hemodynamic evaluation has shown that the blood flow in rectal varices is from above downwards; however, the site of banding of rectal varices is unclear. This case series shows that the rectal varices should be banded at the highest point of inflow.

Safety and effectiveness of response‐guided therapy using pegylated interferon and ribavirin for chronic hepatitis C virus infection in patients on maintenance dialysis

Treatment of hepatitis C virus (HCV) infection in patients with end‐stage renal disease (ESRD) is difficult. Addition of ribavirin to pegylated‐interferon (Peg‐IFN) may help to improve the treatment response. Further, treatment duration could be shortened using a response‐guided treatment (RGT) approach.

Imaging of the pancreatic duct by linear endoscopic ultrasound

The current gold standard investigation for anatomic exploration of the pancreatic duct (PD) is endoscopic retrograde cholangiopancreatography. Magnetic resonance cholangiopancreatography is a noninvasive method for exploration of the PD. A comprehensive evaluation of the course of PD and its branches has not been described by endoscopic ultrasound (EUS). In this article, we describe the techniques of imaging of PD using linear EUS.

Techniques of imaging of the aorta and its first order branches by endoscopic ultrasound (with videos)

Endoscopic ultrasonography (EUS) is a useful modality for imaging of the blood vessels of the mediastinum and abdomen. The aorta acts as an important home base during EUS imaging. The aorta and its branches are accessible by standard angiographic methods, but endosonography also provides a unique opportunity to evaluate the aorta and its branches. This article describes the techniques of imaging of different part of the aorta by EUS.

Techniques of imaging of nodal stations of gastric cancer by endoscopic ultrasound

Nodal staging is of crucial importance in the management of gastric cancer (GC). The available modalities of nodal imaging in GC do not provide a high sensitivity and specificity of lymph node status. Comparative study of endoscopic ultrasonography (EUS) and multislice spiral computed tomography in GC has shown greater accuracy of EUS for N staging. EUS is not used routinely in patients with GC as it is not available at all centers, and its accuracy is operator dependent. Standard techniques of identification of nodal station (as suggested by Japanese Research Society for the Study of Gastric Cancer) by EUS have not been described so far. Identification of each nodal station by EUS requires adequate knowledge of anatomy as well as understanding the proper technique to perform EUS. This review presents a method to identify the regional nodal stations of GC by linear EUS and hence will help in appropriate N staging of GC.