Stephen P. Martin

Endoscopic pancreatic duct stenting to treat pancreatic ascites

BACKGROUND Management of pancreatic ascites with conservative medical therapy or surgery has met with limited success. Decompression of the pancreatic ductal system through transpapillary stent placement, an alternative strategy, has been reported in only a handful of cases of pancreatic ascites. METHODS We reviewed all cases from 1994 to 1997 in which patients with pancreatic ascites underwent an endoscopic retrograde pancreatogram documenting pancreatic duct disruption with subsequent placement of a transpapillary pancreatic duct stent. Clinical end points were resolution of ascites and need for surgery. RESULTS There were 8 cases of pancreatic ascites in which a 5F or 7F transpapillary pancreatic duct stent was placed as the initial drainage procedure. Pancreatic ascites resolved in 7 of 8 patients (88%) within 6 weeks. Ascites resolved in the eighth patient, a poor candidate for surgery, following placement of a 5 mm expandable metallic pancreatic stent. No infections, alterations in ductal morphology, or other complications related to stent placement were noted. There was no recurrence of pancreatic ascites or duct disruption at a mean follow-up of 14 months. CONCLUSIONS Our experience doubles the number of reported cases in which transpapillary pancreatic stent placement safely obviated the need for surgical intervention in the setting of pancreatic ascites. This therapeutic endoscopic intervention should be seriously considered in the initial management of patients with pancreatic ascites.

Hereditary Pancreatitis and Pancreatic Carcinoma

Abstract: Few risk factors for pancreatic cancer have emerged except for chronic pancreatitis. Recently, hereditary pancreatitis was estimated to carry a standardized incidence ratio of 53, a risk about 25 times higher than smoking. A review of the ongoing hereditary pancreatitis study of the Midwest Multi‐center Pancreatic Study Group suggests that the risk of pancreatic cancer is related to long‐standing pancreatitis rather than to the cationic trypsinogen mutations. No recommendations can be made on screening patients with hereditary pancreatitis for pancreatic cancer at this time. However, prospective data, serum, and pancreatic juice should be collected and banked on consenting patients at risk as part of prospective, multicenter trials so that evidence‐based recommendations for hereditary pancreatitis and other types of chronic pancreatitis can be made in the future.

Hereditary Pancreatitis in North America: The Pittsburgh-Midwest Multi-Center Pancreatic Study Group Study

Background: Hereditary pancreatitis (HP) was defined on a clinical basis alone until the first cationic trypsinogen gene (PRSS1) mutation was discovered through the initial phase of the current Pittsburgh Midwest Multi-Center Pancreatic Study Group (MMPSG) HP study in 1996, making genetic testing available. Aim: To evaluate the regional distribution of HP in the United States, and to compare the study’s gene mutation database with the pedigree databases to determine whether family history alone predicts the likelihood of detecting mutations in the cationic trypsinogen gene. Methods: Probands of families with HP, familial pancreatitis and idiopathic chronic pancreatitis were recruited through referrals from MMPSG collaborating centers, otehr physicians and self-referral of patients who had learned of the study through the World Wide Web (www.pancreas.org). Pedigrees were constructed, detailed questionnaires were completed and a blood sample was drawn for each proband and participating family members. The birthplace and current location of each patient was recorded, DNA was analyzed for known mutations and the pattern of phenotype inheritance was determined from analysis of each pedigree. Results: A total of 717 individuals were ascertained; 368 (51%) had clinical pancreatitis confirmed and the rest were primarily unaffected family members used for linkage studies. Forty-six clinically unaffected individuals were silent mutation carriers (11% of mutation-positive individuals). HP was most common in Minnesota, New York and the central mid-Atlantic states plus Kentucky and Ohio. One hundred and fifteen of 150 kindreds fulfilled the strict definition of an HP family, and 60 (52%) had PRSS1 mutations. Of the families with a detected mutation, 11% did not fulfill the clinical definition of an HP kindred. Conclusions: The distribution of HP within the United States shows major regional differences. The etiology of HP can be identified in a small majority of HP families through genetic testing. However, family history alone is not a good predictor of finding a mutation in the cationic trypsinogen (PRSS1) gene.

Ampullary carcinoid tumors: Rationale for an aggressive surgical approach

Two cases of ampullary carcinoid tumor are reported. These tumors are among the most rare of GI tract carcinoids and appear to have a distinct presentation and biological behavior from carcinoids arising in the duodenum. The existing literature is reviewed with attention to the implications for surgical management of this rare disease.

Prevalence and predictors of severe acute pancreatitis in patients with acquired immune deficiency syndrome (AIDS)

OBJECTIVE:Recent case control data suggested that a severe course of acute pancreatitis in HIV+ patients was 1) common (50% of cases), 2) poorly predicted by Ransons criteria (sensitivity 41%), and 3) accurately predicted by a diagnosis of AIDS (positive predictive value 67%). However, the definition of severity included length of stay in hospital and excluded commonly accepted markers (local complications, systemic complications, and need for surgery). The aim of this study was to determine 1) the prevalence of severity and 2) the value of these predictors with regard to severity, as defined by commonly accepted standardized criteria in patients with AIDS and acute pancreatitis.METHODS:A retrospective review identified 50 patients with AIDS exhibiting clinical, laboratory, and/or radiological features of acute pancreatitis.RESULTS:Only five patients followed a severe course as defined by accepted markers. Of these patients, 29 had values available for at least nine of 11 of Ransons criteria (sensitivity 80%, specificity 54%). Points were awarded most commonly for decreased serum Ca2+ (n = 14) and elevated serum LDH (n = 7).CONCLUSIONS:In patients with AIDS and acute pancreatitis at our institutions, 1) the prevalence of severity and 2) the sensitivity of Ransons criteria with regard to severity is comparable to that reported in large historical case series of immunocompetent patients. Pseudohypocalcemia and/or elevation in LDH are frequent, likely due to the catabolic infectious disease state.

Prevalence and Predictors of Severity as Defined by Atlanta Criteria Among Patients Presenting with Acute Pancreatitis

Introduction Effective triage of patients with acute pancreatitis is dependent on the ability to accurately predict a severe course. Predictors (e.g., APACHE II score of >8) have been tested against wide-ranging definitions of severity (prevalence, 15%–40%). To ensure uniformity in defining a severe course of acute pancreatitis, the Atlanta symposium of 1992 adopted all-encompassing criteria (local complications, systemic complications, need for surgery, or death). Aims To assess the prevalence of each Atlanta criteria for severe acute pancreatitis and to determine the sensitivity, specificity, and positive and negative predictive values of the APACHE II score as a predictor of these criteria for severe acute pancreatitis. Methodology We reviewed records of patients admitted to the University of Cincinnati Medical Center (Cincinnati, OH, U.S.A.) between 1994 and 1998 with acute pancreatitis. Exclusion criteria included referral from an outside hospital, immunocompromised state, and chronic pancreatitis. Results Seventy-four consecutive patients met our inclusion criteria. Ten patients (13.5%) had a severe course. Seven patients developed only local complications. Three patients had systemic complications. Pancreatic surgical intervention was required in four patients. No deaths occurred. An APACHE II score of >8 exhibited 50% sensitivity and 69% specificity (positive predictive value, 20%; negative predictive value, 89%). All patients with systemic complications and two of seven patients with only local complications had an APACHE II score of >8. Conclusions The prevalence of severity among our nonreferred patients with acute pancreatitis was less than previously reported. The APACHE II scoring system exhibited reasonable sensitivity in predicting systemic complications and/or the need for surgery, with a low positive predictive value. This most certainly is a function of the low pretest probability of severe pancreatitis. Future studies attempting to identify predictive systems that triage patients in a more cost-effective manner should restrict their analysis to Atlanta criteria other than local complications.

Use of omeprazole in the management of giant duodenal ulcer: Results of a prospective study

BACKGROUND Giant duodenal ulcer (GDU) is generally thought to require surgical intervention. Proton pump inhibitors have beneficial effects in peptic ulcer disease, but their role in GDU disease is unknown. We examined the use of omeprazole in GDU management. METHODS Twenty-eight patients were diagnosed with GDU. One patient required immediate operative intervention. The remaining 27 were placed on omeprazole (40 mg daily). When ulcer healing was documented by endoscopy, the patients were placed on oral histamine-2 receptor antagonist therapy. RESULTS Of the 28 study patients, 20 (71.4%) did not require operative intervention, and 8 (28.6%) required operation for ulcer complications. Of the 15 patients with adherent clot or a visible vessel at initial endoscopy, 7 (46.7%) required operative intervention, as compared with 1 (7.7%) of the 13 patients without a visible vessel or adherent clot. This difference was statistically significant (P < .05). Twenty-three patients underwent antral biopsy and/or enzyme-linked immunosorbent assay for Helicobacter pylori, and 9 (39.1%) had a positive result. CONCLUSIONS Omeprazole is effective in the treatment of GDU disease. An adherent clot or a visible vessel at endoscopy indicates a higher likelihood of complications requiring operation. The relatively low H pylori infection rate, as compared with other peptic ulcer disease, may indicate a different pathophysiology in GDU.

The impact of post-procedure interpretation of ERCP X-ray films by radiologists on patient care: should it be routine or selective?

BACKGROUND Review of ERCP x-ray films by radiologists is routine, but the utility of this practice is unproven. The aim of this study was to assess whether the routine post-procedural interpretation of ERCP films by radiologists alters patient management. METHODS A retrospective analysis of 212 ERCPs followed by a prospective analysis of 112 ERCPs was performed. Comparative ductogram interpretations were categorized as: I, complete agreement; II, minor findings reported only by the radiologist; III, findings reported only by the endoscopist; and IV, major findings reported only by the radiologist that altered or should have altered management. RESULTS In the retrospective analysis, 289 ductograms were identified, and interpretations were classified as: category I, 73%; category II, 16%; category III, 10.7%; and category IV, 0.3%. In the prospective study, interpretations of 167 ductograms were analyzed and classified as follows: category I, 84%; category II, 11%; category III, 5%; category IV, none. CONCLUSIONS Post-procedure interpretation of ERCP spot x-ray films by radiologists adds little to patient management. Selective consultation with radiologists would appear to be more appropriate than review by radiologists of ERCP spot x-ray films on a routine basis.

3380 Ercp interpretation by radiologists: does it have a role?

Background: Published data supporting the value of ERCP spot film interpretation by a radiologist are lacking. Aim: To determine the impact of the radiologists post-procedure interpretation of ERCP films on patient management. Methods: 212 consecutive ERCPs performed by a single endoscopist on 170 patients over a 9-month period at a tertiary referral center were identified. Endoscopy reports were retrospectively reviewed and compared to the radiologists interpretation of spot films. The findings were categorized as: I) complete agreement, II) inconsequential findings reported by the radiologist, III) findings reported and managed by the endoscopist not seen subsequently by the radiologist, and IV) discrepancies reported by the radiologist which did or should have altered patient management. Results: 11 cases were excluded because the radiology reports were unavailable. The duct of interest was cannulated in 94% of the remaining 201 cases. More than one discrepancy was noted in certain ductograms. There were 292 (99.7%) findings in category I, II and III (Table 1). Category II and III findings included filling defects, dilatation, narrowing, focal collection of contrast (stenting performed) and anatomic variants. Follow up information was available for 96% of patients with category II and III findings. Mean follow up was 5.7 months (range 1-13 months). Only one discrepancy qualified for category IV. This case involved a biloma treated with bile duct stenting and, in retrospect, surgical intervention may have been delayed. Interestingly, 12% of findings reported by the endoscopist were not seen by the radiologist, potentially due to suboptimal representation on spot films. Conclusions: Post-procedure interpretation of spot films by a radiologist almost never impacts patient management if an experienced endoscopist performs and interprets the ERCP. The routine use and cost-effectiveness of this practice warrants further study.