Is empiric cholecystectomy a reasonable treatment option for idiopathic acute pancreatitis?
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Acute Disease↗
Biomedical subjects
Peter Draganov
Publications and source records attributed to Peter Draganov.
Is the prevalence of small bowel bacterial overgrowth in patients with irritable bowel syndrome increased? The question remains unanswered.
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Adult↗
The utility and the safety of EUS-guided FNA in the evaluation of duplication cysts.
BACKGROUND: Diagnosis of a foregut duplication cyst is of great clinical impact. A definitive diagnosis of a foregut duplication cyst can avert the need for major thoracic surgery in the otherwise asymptomatic individual. This study sought to evaluate the safety and the utility of EUS and EUS-guided FNA (EUS-FNA) in the diagnosis of foregut duplication cysts. METHODS: Over a period of 4 years, 4771 patients underwent EUS for various indications at two EUS referral centers. EUS findings were consistent with a mediastinal cyst in 30 cases. EUS-FNA was performed in 22 patients. A definitive diagnosis was established based on cytology, surgical pathology, and/or clinical follow-up. FNA was done with 22-gauge needles and antibiotic prophylaxis. RESULTS: The appearance of cyst contents on EUS ranged from completely anechoic (23 cases) to hypoechoic (7 cases). Hypoechoic cystic lesions contained echogenic foci. All anechoic lesions were confirmed as benign duplication cysts based on cytology, pathology, and clinical follow-up. Hypoechoic cystic lesions were confirmed to be benign duplication cysts in 4 cases. Three cases proved to be malignant or granulomatous necrotizing lymph nodes. No periprocedural complications occurred. CONCLUSIONS: Variation exists in the EUS appearance of benign mediastinal cysts. EUS-FNA of mediastinal cysts with smaller-gauge needles, and antibiotic prophylaxis appears safe and can provide a definitive diagnosis in atypical mediastinal cystic lesions.
Adult↗
Prospective evaluation of the accuracy of the intraductal secretin stimulation test in the diagnosis of chronic pancreatitis.
BACKGROUND & AIMS: The standard secretin stimulation test (SST) is the accepted gold standard for pancreatic function testing. The intraductal secretin stimulation test (IDST) performed at the time of endoscopic retrograde cholangiopancreatography (ERCP) has been proposed as a more feasible way to evaluate pancreatic function. The accuracy of the IDST for the diagnosis of chronic pancreatitis (CP) has not been well defined. METHODS: We prospectively evaluated patients with suspected CP. The IDST, SST, and ERCP were performed in each of the 19 study patients. The SST and ERCP were used as independent diagnostic standards against which the results of the IDST were compared directly to determine the sensitivity, specificity, and accuracy of the IDST. RESULTS: When the SST was used as a diagnostic standard for CP, the sensitivity of the IDST was 80% (95% confidence interval [CI], 44%-97%), the specificity was 22% (95% CI, 2%-60%), and the overall accuracy was 52% (95% CI, 28%-75%). The positive predictive value was 53% and the negative predictive value was 50%. When the pancreatogram was used as the diagnostic standard, the sensitivity of the IDST was 100% (95% CI, 69%-100%), the specificity was 55% (95% CI, 21%-86%), and the overall accuracy was 79% (95% CI, 54%-93%). Receiver operator curves showed that there was no optimal cut-off value for peak bicarbonate concentration that led to acceptable sensitivity and specificity. CONCLUSIONS: The IDST is not accurate for the diagnosis of CP.
Adult↗
Efficacy and safety of endoscopic balloon dilation of symptomatic upper and lower gastrointestinal Crohn's disease strictures.
GOALS: To evaluate efficacy and safety of endoscopic balloon dilation with or without intralesional steroid injection, of symptomatic upper gastrointestinal (UGI) and lower gastrointestinal (LGI) Crohn's disease (CD) strictures. BACKGROUND: Patients with CD commonly develop obstructive symptoms secondary to gastrointestinal strictures. When these do not resolve with medical management, surgery is usually the only alternative. Limited data are available on the safety and efficacy of endoscopic through-the-scope (TTS) balloon dilation of CD strictures. STUDY: We performed a retrospective review of TTS balloon dilations done on CD-related UGI and LGI strictures. Postdilation intralesional steroid injections were done at the discretion of the endoscopist. Stricture was defined as luminal stenosis <10 mm in diameter, through which a scope could not be passed. Technical success was defined as the ability of the scope to traverse the stricture postdilation. Long-term success rate was claimed if a patient remained asymptomatic and did not require surgery or further endoscopic dilation. RESULTS: Over 4 years, we performed 29 stricture dilations on 17 patients (10 female, 7 male) with 20 strictures. The mean follow-up period was 18.8 months (range, 5-50 months). Stricture locations were as follows: rectal, 5; sigmoid colon, 2; colo-colonic anastomosis, 3; ileocolonic anastomosis, 4; ileum, 1; descending colon, 1; cecum, 1; and distal duodenal bulb, 3 patients. Technical success was achieved in 28 of 29 stricture dilations (96.5%). Ten strictures (34.5%) were dilated to <15 mm and 19 (65.5%) to > or = 15 mm diameter. Long-term success rate in the <15 mm group was 70%, and in > or = 15 mm group was 68.4%. Four quadrant steroid injections were done on 11 strictures. The recurrence rate in this group was 10% and that in the nonsteroid group was 31.3%. The overall long-term success rate was 76.5% by intent-to-treat analysis. Three perforations occurred (all colonic) during 29 stricture dilations, a complication rate of 10% with no mortalities. CONCLUSION: We report the first series of TTS balloon dilations with or without intralesional steroid injection, of both primary and anastomotic UGI and LGI strictures in CD patients. Long-term success was achieved in 76.5% patients with a complication rate of 10%. This mode of therapy appears safe and effective and can be considered as an alternative to surgery in selected patients with medically refractory CD-associated GI strictures. Success rates were better in patients who received four quadrant steroid injections. No difference was seen in stricture recurrence rate or complications based on diameter of TTS balloon used.
Adult↗
Zollinger-Ellison phenotype in the absence of hypergastrinemia and islet-cell tumor.
Patients with the Zollinger-Ellison syndrome are characterized by islet-cell tumors, striking gastric acid hypersecretion, and peptic ulcer disease. They often experience severe abdominal pain, diarrhea, and gastrointestinal bleeding with potentially life-threatening consequences. It is a rare syndrome caused by non-beta cell islet-cell tumors (gastrinomas) located in or in proximity to the pancreas. These tumors freely secrete gastrin, a peptide hormone that serves as a powerful stimulant of gastric acid secretion. Exuberant secretion of gastrin from the gastrinomas produces severe gastric acid hypersecretion that often leads to impressive peptic ulcer disease and the constellation of symptoms listed above. We describe a patient presenting with clinical manifestations characteristic of the ZES with strikingly elevated gastric acid secretion,multiple ulcers in the first and second portions of the duodenum and diarrhea, but in absence of islet-cell tumor and/or hypergastrinemia.
Adenoma, Islet Cell↗
Interventional endoscopic ultrasound in pancreatic disease.
The use of endoscopic ultrasound (EUS) in pancreatic disease is rapidly evolving as the field moves from a primarily diagnostic role to one of therapeutic intervention. Therapeutic EUS includes techniques such as the celiac block and transmural pseudocyst drainage. Newer techniques include EUS-guided fine-needle injection therapy in which a variety of agents are being investigated for the treatment of pancreatic cancer. Novel EUS-guided techniques are being devised to drain and alleviate pancreaticobiliary and gastroduodenal obstruction.
Anastomosis, Surgical↗
Role of osmolality of contrast media in the development of post-ERCP pancreatitis: a metanalysis.
The role of osmolality of contrast media (CM) in the development of post-ERCP pancreatitis (PEP) is debated. We therefore performed a metanalysis to determine whether osmolality affects the incidence of PEP. A literature search of English-language studies was performed using computerized databases and manual searching of abstracts and article bibliographies. Randomized controlled trials comparing the incidence of PEP associated with high- and low-osmolality contrast media (HOCM, LOCM) were considered. The outcome assessed was clinical pancreatitis as evidenced by both elevation of pancreatic enzymes and pain. Data were analyzed using logistic regression with terms for study and osmolality. Fisher's exact test was done to compare PEP rates. Homogeneity between studies was indicated by the nonsignificance of the study effect in the logistic regression model. Logistic regression also indicated no difference in PEP rates between LOCM and HOCM (P = 0.399). Comparison of PEP rates in both groups using Fisher's exact test did not indicate a difference in any individual study (all P values > 0.05). Due to the large variation of study sample sizes, we repeated the analysis by creating three study groups. The effect of osmolality was invariant to how the data were combined. The results of this metanalysis indicate that there is no significant difference between HOCM and LOCM with respect to clinical PEP.
Cholangiopancreatography, Endoscopic Retrograde↗
Is a 15-minute collection of duodenal secretions after secretin stimulation sufficient to diagnose chronic pancreatitis?
BACKGROUND: Standard hormonal stimulation tests of pancreatic function use a 60- to 90-minute collection of pancreatic secretions. A shorter 15-minute collection time has been proposed to increase the feasibility of the secretin stimulation test. The accuracy of this brief collection period for the diagnosis of chronic pancreatitis has not been well defined. METHODS: We retrospectively evaluated the accuracy of a 15-minute collection period by comparing the results of 633 complete standard secretin tests (60 minutes) to the result using only the first 15-minute collection of the same test. The gold standard used for the diagnosis of chronic pancreatitis was the final result of the complete 60-minute secretin stimulation test. RESULTS: The specificity of the first 15-minute collection was 34.6% (95% CI, 30.03%-39.21%). The positive predictive value was 44.9% (95% CI, 40.5%-49.3%). The accuracy was 57.3% (95% CI, 53.01% 59.34%). CONCLUSIONS: Using only the first 15-minute collection period in a standard 60-minute secretin test is inaccurate in the diagnosis of chronic pancreatitis.
Adult↗
Long-term outcomes for patients with post-liver transplant anastomotic biliary strictures treated by endoscopic stent placement.
BACKGROUND: Biliary stricture is one of the most common complications of liver transplantation. A number of treatment options are available, but a standard approach has not been established. METHODS: A total of 25 patients with post-liver transplantation anastomotic strictures were treated endoscopically by stent placement. Long-term outcomes (bile duct patency, morbidity, and mortality) were reviewed retrospectively. RESULTS: Placement of a stent was attempted in 25 patients with anastomotic stricture. Successful stent placement with stricture resolution at the time of stent removal was noted in 22 patients (technical success 88%). In those 22 patients, long-term success (mean follow-up after all stents removed, 54 months) was observed in 20 patients (90%) and partial success in two (10%). Long term, failure did not occur in any patient. There was no procedure- or disease-related mortally. Three mild episodes of cholangitis occurred during the period while the stents were in place, in relation to 79 endoscopic interventions for a procedure-related complication rate of 3.7%. CONCLUSIONS: The long-term outcome for patients with post-liver transplantation biliary anastomotic strictures treated with endoscopic stent placement is excellent, with no therapy- or disease-associated mortality and minimal morbidity.
Anastomosis, Surgical↗
Carcinoid of the minor papilla in incomplete pancreas divisum presenting as acute relapsing pancreatitis.
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Acute Disease↗
Long-term outcome in patients with benign biliary strictures treated endoscopically with multiple stents.
BACKGROUND: The long-term efficacy of sequential insertion of multiple plastic stents for benign biliary strictures is poorly defined. The aims of this study were to evaluate the long-term outcome (bile duct patency, complications) of this therapy and to identify predictors of a good outcome. METHODS: Retrospective review of 29 cases of benign biliary strictures treated with sequential plastic stent insertion in progressively increasing numbers and/or of increasing diameter. RESULTS: Stricture etiology was as follows: postoperative 19 (66%), chronic pancreatitis 9 (31%), and idiopathic 1 (3%). Therapy succeeded in 18 patients (62%) (mean follow-up 48.0 [11.56] months after stent removal). Therapy failed in 11 patients (38%) (mean interval to failure 11.59 [9.79] months after stent removal). The 2 groups of patients in which therapy failed had either a hilar stricture (n = 4, 25% success) or distal common bile duct stricture caused by chronic pancreatitis (n = 9, 44% success). In the remaining cases, therapy succeeded in 13 of 16 (81% success). The observed differences in success rate among subgroups were not statistically significant. There were no ERCP-related deaths. One episode of mild pancreatitis and 2 episodes of cholangitis developed during 126 ERCPs over a period of stent insertion of 36 patient years. CONCLUSIONS: In selected patients with benign biliary strictures, sequential endoscopic insertion of multiple biliary stents may lead to long-term success that could be equal to or superior to surgery with minimal morbidity. Hilar strictures and those caused by chronic pancreatitis appear to respond poorly to this therapy.
Adolescent↗
Chronic pancreatitis.
The pathogenesis of idiopathic chronic pancreatitis remains poorly understood despite the high expectations for ascribing the pancreatic damage in affected patients to genetic defects. Neither mutations in the cationic trypsinogen gene nor mutations of the cystic fibrosis conductance regulator gene account for the chronic pancreatitis noted in most patients with idiopathic chronic pancreatitis. Attempts to find an autoimmune basis for the pancreatitis in these patients have not been very successful. The diagnosis of small duct idiopathic chronic pancreatitis remains a great source of frustration for clinicians. Such patients with negative results of radiographic studies often cannot be diagnosed unless a hormone stimulation test such as a secretin test is performed. Although the porcine biologic form of secretin, which has been used to diagnose chronic pancreatitis, became unavailable because of widespread use in the treatment of children with autism, a synthetic form of porcine secretin has now been approved by the US Food and Drug Administration and is available. The true value of endoscopic ultrasonography in diagnosing small duct chronic pancreatitis remains to be fully defined. Endoscopic ultrasonography is becoming the test of choice in detecting radiographic abnormalities in both the parenchyma and ducts of the pancreas. Endoscopic ultrasonography-guided celiac plexus block can be performed relatively easily and very safely. It can provide excellent short-term pain relief in some patients, but reliable predictors of which patients will be successful with this therapy are not yet available. Because long-term follow-up data on the use of endoscopic ultrasonography in this respect are not available, and because the pain of chronic pancreatitis is, indeed, chronic, the role of endoscopic ultrasonography-guided celiac plexus block should be limited to treating those patients with chronic pancreatitis whose pain has not responded to other modalities.
Journal Article↗
A new technique to assist in difficult bile duct cannulation at the time of endoscopic retrograde cholangiopancreatography.
BACKGROUND AND OBJECTIVES: At the time of endoscopic retrograde cholangiopancreatography, deep cannulation of the bile duct is a prerequisite to be able to provide endoscopic therapy. We describe a simple technique to assist in difficult bile duct cannulation. METHODS: If the pancreatic duct is easily entered but the bile duct cannot be accessed, a guidewire is advanced into the pancreatic duct, and the cannulating catheter is removed leaving the tip of the wire in the mid pancreatic duct. Alongside the pancreatic wire, a catheter, preloaded with a second wire, is advanced via the channel of the endoscope. With the first wire in the pancreatic duct, the second wire is advanced above it in the anticipated bile duct axis. RESULTS: We have used this technique in 12 cases and succeeded in 10. No complications occurred. DISCUSSION: Inserting a pancreatic wire can assist in bile duct cannulation, by straightening and stabilizing the papilla. The use of this new technique can reduce the need for precut sphincterotomy, with its inherent increased risks of pancreatitis, bleeding, and perforation. The approach proposed by us can assist in any difficult bile duct cannulation, but it can be particularly useful when dealing with a papilla that is very prominent with a tortuous intraduodenal segment or a papilla located in a duodenal diverticulum.
Catheterization↗