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PubMed1995

[20 years of endoscopic papillotomy. Analysis of 2752 patients at Erlangen Hospital].

Following the development and introduction of endoscopic papillotomy (EPT), 2752 procedures were performed at Erlangen University Hospitals between 1973 and 1993. All papillotomies were evaluated with regard to indications, technique, results, complications and mortality. To show the development process clearly, results for the periods 1973-1980 (A), 1981-1987 (B) and 1988-1993 (C) were summarised separately. The proportion of patients with common bile duct stones was 91% in group A, 60% in group B and 41% in group C. By contrast the number of papillotomies for malignant disease rose from 1% (A) to 26% (B) and 29% (C). More recent indications such as chronic pancreatitis (11%), biliary pancreatitis (5%) and others (for example sphincter of Oddi dysfunction) (11%) were first seen in group C. While the Erlangen standard papillotomy was used in almost all cases in group A (96%), the precut technique was used (mostly with needle knife) in one-third of all papillotomies in groups B and C (32%). The success rate for EPT in all three periods was highest for common bile duct stones (from 96% for group A to 98% for groups B and C). For malignancies, the success rate was lower (89% in groups B and C). The complication rate fell significantly with time (P < 0.05) from 11% (A) to 7.6% (B) and 6.3% (C). Precut techniques did not increase the complication rate. While 71% of all complications were treated surgically in period A, the proportions fell to 28% (B) and then to 7.5% (C). Method-related mortality fell from 1.1% (A) to 0.4% (B) and 0.5% (C).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗

PubMed2002

Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy.

BACKGROUND: Biliary tract complications are a continuing source of morbidity after orthotopic liver transplantation. This is a retrospective examination of experience with ERCP in patients with biliary tract complications after orthotopic liver transplantation to determine type and frequency of complications and outcome after endoscopic therapy. METHODS: From May 1988 to August 1999, orthotopic liver transplantation was performed 408 times; 4 additional patients who underwent orthotopic liver transplantation at another hospital were also followed. The records of 367 patients who underwent choledochocholedochostomy were reviewed. Of these, 121 underwent 325 ERCPs; 226 ERCPs were performed because of acute problems (typically cholestasis with or without cholangitis), and 99 were for reevaluation of the bile duct, stent change, or stent removal. Three patients underwent ERCP because of pancreatic problems. RESULTS: A biliary complication was identified in 24.5% of patients (90 of 367) and more than 1 complication in 32%. At ERCP, 37 patients (30.5%) had biliary stones; 9 further patients (7.4%) had only sludge. Stones were completely cleared at the initial or a subsequent ERCP. Strictures were found in 55 patients (45.5%), either at the anastomosis (n = 43) or at another site(s) in the donor duct (n = 12). Balloon or bougie dilation followed by stent insertion was performed in 54 patients. Endoscopic therapy was successful in 91% of patients with biliary strictures. A biliary leak/fistulae was found in 22 patients (18.1%) and endoscopic therapy, when attempted, was successful in all. Eight patients had possible sphincter of Oddi dysfunction based on dilated recipient and donor ducts together with elevated liver enzymes. After sphincterotomy, the liver enzymes returned to normal in only one of these patients. Three patients had blood clots in the biliary tree. CONCLUSION: When biliary tract complications are suspected after orthotopic liver transplantation, ERCP identifies biliary abnormalities if present and offers multiple therapeutic options. Endoscopic therapy is usually successful but multiple procedures are often necessary, especially when treating strictures.

Adolescent↗

PubMed2002

Risk factors for complications after performance of ERCP.

BACKGROUND: ERCP has become widely available for the diagnosis and treatment of benign and malignant pancreaticobiliary diseases. In this prospective study, the overall complication rate and risk factors for diagnostic and therapeutic ERCP were identified. METHODS: Data were collected prospectively on patient characteristics and endoscopic techniques from 1223 ERCPs performed at a single referral center and entered into a database. Univariate and multivariate analyses were used to identify risk factors for ERCP-associated complications. RESULTS: Of 1223 ERCPs performed, 554 (45.3%) were diagnostic and 667 (54.7%) therapeutic. The overall complication rate was 11.2%. Post-ERCP pancreatitis was the most common (7.2%) and in 93% of cases was self-limiting, requiring only conservative treatment. Bleeding occurred in 10 patients (0.8%) and was related to a therapeutic procedure in all cases. Nine patients had cholangitis develop, most cases being secondary to incomplete drainage. There was one perforation (0.08%). All other complications totaled 1.5%. Variables derived from cannulation technique associated with an increased risk for post-ERCP pancreatitis were precut access papillotomy (20%), multiple cannulation attempts (14.9%), sphincterotome use to achieve cannulation (13.1%), pancreatic duct manipulation (13%), multiple pancreatic injections (12.3%), guidewire use to achieve cannulation (10.2%), and the extent of pancreatic duct opacification (10%). Patient characteristics associated with an increased risk of pancreatitis were sphincter of Oddi dysfunction (21.7%) documented by manometry, previous ERCP-related pancreatitis (19%), and recurrent pancreatitis (16.2%). Pain during the procedure was an important indicator of an increased risk of post-ERCP pancreatitis (27%). Independent risk factors for post-ERCP pancreatitis were identified as a history of recurrent pancreatitis, previous ERCP-related pancreatitis, multiple cannulation attempts, pancreatic brush cytology, and pain during the procedure. CONCLUSIONS: The most frequent ERCP-related complication was pancreatitis, which was mild in the majority of patients. The frequency of post-ERCP pancreatitis was similar for both diagnostic and therapeutic procedures. Bleeding was rare and mostly associated with sphincterotomy. Other complications such as cholangitis and perforation were rare. Specific patient- and technique-related characteristics that can increase the risk of post-ERCP complications were identified.

Adolescent↗

PubMed1994

Major hemorrhage from endoscopic sphincterotomy: risk factor analysis.

We carried out a retrospective cohort study on all patients undergoing sphincterotomy at our institution over a 4-year period. Major hemorrhage occurred in 10 of 189 patients (5.3%). Onset was usually delayed (mean, 3.0 days; range, 0-9 days). Six potential risk factors for postsphincterotomy hemorrhage were assessed by univariate and multivariate analysis. Three factors predicted postsphincterotomy hemorrhage: hemodialysis (relative risk, 8.4; 95% confidence interval, CI, 2.7-26.4), a prothrombin time prolonged at least 2 s above control (relative risk, 7.8; 95% CI, 2.4-25.6), and endoscopically observed bleeding at the time of sphincterotomy (relative risk, 5.9; 95% CI, 1.7-20.1). Features not independently associated with hemorrhage were sphincter of Oddi dysfunction, aspirin or nonsteroidal anti-inflammatory drug (NSAID) use within 1 week prior to sphincterotomy, and sphincterotomy length. When differentiated from endoscopically observed bleeding, clinically significant hemorrhage was usually a delayed complication, primarily in patients with hemostatic defects.

Age Distribution↗

PubMed2002

Nontraumatic pancreatitis in spinal cord injury.

STUDY DESIGN: A retrospective analysis of 10 patients with pancreatitis after traumatic spinal cord injury. OBJECTIVES: To determine the conditions leading to nontraumatic pancreatitis in spinal cord injury. SUMMARY OF BACKGROUND DATA: Little is known in the literature about pancreatitis after spinal cord injury. A few authors suggest a multifactorial pathogenesis. METHODS: Over a 4-year period the case reports of 338 patients with traumatically caused SCI were reviewed concerning p-amylase and/or lipase elevations. Acute pancreatitis was defined as an elevation of p-amylase and/or lipase of more than three times the upper normal limit. RESULTS: Ten of 338 patients had p-amylase and/or lipase elevations three times higher than the upper normal limit. All 10 were male with a mean age of 40.4 years. The average onset time of acute pancreatitis was 16 +/- 5.5 days after trauma. The usual etiologic factors of acute pancreatitis such as obstructive, toxic, or traumatic events were excluded. CONCLUSION: The clinical recognition of acute pancreatitis in paraplegic and quadriplegic patients is hampered by diminished or lost visceral sensitivity and therefore is based on laboratory investigations. The current authors therefore hypothesize that acute pancreatitis in the setting of high-level spinal cord injury may result from a combination of locally mediated sphincter of Oddi dysfunction and vagal dominant innervation of the pancreatic gland in autonomic failure.

Adolescent↗

PubMed2001

Indications and efficacy of botulinum toxin in disorders of the gastrointestinal tract.

In recent years, botulinum toxin type A (BT) has been found to be effective in the treatment of various spastic disorders of smooth muscle in the upper and lower gastrointestinal tract. The short-term efficacy of intrasphincteric injection of BT in achalasia is now well established, however, because of the chronic nature of the disease, patients will require repeated injections at regular intervals. In contrast, after a single injection into the anal sphincter, BT has impressively high healing rate with minimal side effects. BT remains a novel therapeutic approach in a range of other gastrointestinal motility disorders including diffuse oesophageal spasm, sphincter of Oddi dysfunction and anismus, and the list of its indications is increasing. BT seems to be safe but as its long-term effects remain unestablished, it should be used with caution in younger patients. In this review we discuss the mechanism of action, indications, efficacy and side-effects of BT with its use in various areas of gastrointestinal tract.

Botulinum Toxins, Type A↗

PubMed2003

The effect of transcutaneous nerve stimulation on intraductal biliary pressure in post-cholecystectomy patients with T-drainage.

OBJECTIVE: To evaluate the effects of transcutaneous electrical nerve stimulation (TENS) on intraductal biliary pressure (IDP) in basal conditions and after intravenous morphine and oral meal stimulation. DESIGN AND METHODS: Fifteen patients (5 male, 10 female) aged 31-83 years (mean 61.5 +/- 13.7 years) with prior cholecystectomy and residual in situ T-tube were examined. Final radiographs excluded any organic abnormalities. The study consisted of three sessions. On the first day (session 1), after the initial manometric intraductal pressure was measured for 15 min, TENS (using a PRO-TENS pocket stimulator) was applied for 15 min. Measurement was continued for 15 min after termination of TENS. The measurement was performed using a water-perfused manometry system (Synectics Medical, Stockholm, Sweden) by a triple-channel manometric catheter inserted into the common bile duct through a T-drain. On the following day (session 2), the protocol was similar except that, after basal IDP measurement, morphine hydrochloride 0.08 mg/kg was injected intravenously 10 min before TENS. On the third day (session 3), after basal measurements were taken, patients were given a standard test meal and the IDP was recorded continuously for 45 min. To estimate the effects of the stimuli applied, absolute intraductal pressure changes were analysed. RESULTS: In session 1, TENS reduced basal IDP in all patients by a mean of 3.95 +/- 1.6 mmHg. In 13 patients, 15 min after cessation of TENS a further decrease in IDP was observed. In two patients, termination of TENS was followed by a rebound increase in IDP; however, it did not reach the initial value (mean total decrease 5.05 +/- 2.25 mmHg). In session 2, administration of morphine produced an evident increase in IDP in all subjects by 6.9 +/- 2.7 mmHg. TENS decreased IDP in 13 patients. In two patients, TENS initially failed to lower elevated pressure, but it appeared several minutes after the end of stimulation. In 13 patients, the final IDP values were lower than the baseline pressures. In session 3, after administration of a test meal, IDP decreased within 30-40 min by a mean of 4.89 +/- 1.29 mmHg. CONCLUSIONS: TENS decreased basal as well as elevated IDP in the majority of the T-drain patients studied. The effect of TENS persisted after its termination. Elevated IDP is believed to be responsible for pain in patients with sphincter of Oddi dysfunction (SOD). Therefore, we think that TENS can be used effectively and safely as an optional therapeutic method in the treatment of biliary dyskinesia.

Adult↗

PubMed2004

Improved predictors of outcome in postcholecystectomy pain.

BACKGROUND: Endoscopic interventions have limited efficacy in sphincter of Oddi dysfunction (SOD) Type 3. Improved predictors of response to treatment are needed. METHODS: Patients with postcholecystectomy pain underwent a standardized history and physical examination and were then managed individually. Long-term outcome was determined by record review and telephone interview. Initial predictors of response to treatment were assessed. RESULTS: Mean follow-up for the 74 subjects was 36 months. Fifty were improved, and 24 had persistent pain. Patients were likely to respond to sphincterotomy if their pain was not continuous, if it was accompanied by nausea or vomiting, and if there had been a pain free interval after cholecystectomy of at least 1 year. When 2 or 3 of these predictors were present, 85% of SOD Type 2 patients and 56% of Type 3 patients had a good response. Initial history and examination features also predicted response to treatment of neuropathic pain. CONCLUSION: Among patients with postcholecystectomy pain, specific features of the initial history and examination predict response to treatment with higher accuracy than the SOD grade. These predictors identify a subset of Type 3 patients likely to respond to sphincterotomy.

Adult↗

PubMed2005

Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography in children: a large series report.

OBJECTIVES: Our goal is to evaluate the indications, findings, therapies, safety, and technical success of endoscopic retrograde cholangiopancreatography (ERCP) in children. METHODS: Our database was searched for patients 17 years of age or younger undergoing ERCP between January 1994 and March 2003. Additional information was obtained by chart review. The safety and technical success of ERCP were examined. Complications were classified by the consensus criteria. RESULTS: A total of 245 patients (95 M, 150 F; mean age 12.3 years) underwent 329 examinations. Indications included biliary pathology (n = 93), pancreatic pathology (n = 111), and chronic abdominal pain of suspected biliary or pancreatic origin (n = 41). The ERCP findings were bile duct stone(s) (n = 29), benign biliary stricture (n = 19), primary sclerosing cholangitis (n = 7), anomalous pancreaticobiliary union (n = 8), choledochal cyst (n = 5), bile duct leak (n = 6), malignant biliary stricture (n = 2), biliary atresia (n = 1), chronic pancreatitis (n = 44), pancreas divisum (n = 26), pancreatic duct stricture with (n = 6) or without (n = 9) leak, pancreatic tumor (n = 1), periampullary adenoma (n = 2), and sphincter of Oddi dysfunction (n = 65). Endoscopic therapies were performed in 71% of the procedures and included sphincterotomy, stone extraction, stricture dilation, endoprosthesis placement, snare papillectomy, and cystoduodenostomy. Thirty-two (9.7%) post-ERCP complications occurred and included cholangitis in 1 patient and pancreatitis in 31. The pancreatitis was graded mild in 24, moderate in 5, and severe in 2. No mortality related to ERCP occurred. CONCLUSIONS: Diagnostic and therapeutic ERCP results are similar in children and adults except for a lower incidence of malignant disease in children. Technical success rates are high. However, ERCP-related pancreatitis is not uncommon, and the risk and benefits should be carefully reviewed before proceeding. Outcome data are necessary and is currently being accumulated at our institution.

Adolescent↗

PubMed2005

Biliary disease after liver transplantation: the experience of the King Faisal Specialist Hospital and Research Center, Riyadh.

BACKGROUND AND AIM: The biliary tract has been referred to as the "Achilles heel" of liver transplantation. The aim of this study was to document the frequency, clinical presentation and management of biliary complications after liver transplantation in the King Faisal Specialist Hospital and Research Center (KFSH&RC), Riyadh, Saudi Arabia. METHODS: The liver transplant clinic at KFSH&RC has registered and followed 220 patients (150 male and 70 female patients; age 40.6 +/- 18.6 years; pediatric 33, adult 187) during the period from 1987 to June 2003. A total of 235 transplants were carried out on these patients. Cadaveric liver transplants had been carried out on 202 patients, non-heart beating liver transplant in three patients, live donor liver transplants in 11 and split transplant in four. Biliary reconstruction was duct-to-duct anastomosis in 147 patients and Roux-en-Y in 73. Biliary complications were suspected on clinical and biochemical parameters and confirmed using imaging techniques. RESULTS: Forty patients (18.2%) developed 53 biliary complications. These included bile leak in 16, strictures in 25, calculi in eight, and sphincter of Oddi dysfunction and possible recurrence of primary sclerosing cholangitis in the donor duct in two patients each. Bile leaks were observed in the early postoperative period (median period 30 days, range 1-150 days, 95% confidence interval [CI] 8-51). Leakage occurred at the anastomotic site in 13 patients. Patients presented with bilious drainage (n = 6), abdominal pain at T-tube removal (n = 3), fever (n = 2), sepsis (n = 1), dyspnea (n = 1) and abnormal liver tests (n = 3). Eleven patients had intra-abdominal bilious collections. Two patients were treated conservatively, eight patients had ultrasound-guided aspiration of biloma, five had biliary stenting at endoscopic retrograde cholangiopancreatography and two patients needed surgery. There were four deaths, two of which were related to bile leak, one patient was left with permanent external biliary drainage and four patients had biliary strictures in the follow-up period. Biliary strictures occurred at a median period of 360 days (range 4-2900 days; 95% CI 50-670) after the transplant. Hepatic artery thrombosis caused biliary strictures in three, while 21 strictures were localized to the anastomotic site. Biliary strictures presented with elevated liver tests in five patients, progressive cholestasis in five, cholangitis (with septicemia in five) in 11, abdominal pain in two and acute pancreatitis in three patients. Repeat sessions of endoscopic or percutaneous dilatation and stenting (mean sessions 4.4/patient, range 3-7) were attempted in 20 patients to relieve strictures, with success in only nine patients. Seven patients had surgery. Four patients with biliary strictures died. Biliary calculi developed late in the follow-up period and had the appearance of biliary casts in five and sludge in three patients. Eleven (27.5%) patients with biliary disease died compared with 35 (19.4%) patients without biliary disease. CONCLUSIONS: Biliary complications occurred in 18.2% of patients after liver transplantation and included biliary leak and biliary strictures with or without calculi. Management involved a combination of endoscopic, radiologic and operative procedures. Biliary complications caused considerable morbidity and mortality in liver transplant patients.

Adolescent↗

PubMed1989

Common duct exploration or endoscopic sphincterotomy for choledocholithiasis?

The relative indications for operative common duct exploration (CDE) and endoscopic sphincterotomy (ES) in treating common duct stones are often unclear. This prospective study compared CDE and ES in treating choledocholithiasis after excluding patients with acute cholecystitis, idiopathic pancreatitis, sphincter of Oddi dysfunction and malignant disease. One hundred and two patients had 105 CDE and a further 50 patients had 57 ES. Of the patients having CDE, 76 also had cholecystectomy for gall-bladder (GB) disease while 26 had prior cholecystectomy. With ES, in 16 the GB was present and not removed while 34 patients had had prior cholecystectomy. Hospitalization was significantly less following ES. There was one peri-operative death after CDE and none after ES. There were two late biliary-related deaths, 3 and 27 months after ES, in patients who developed acute cholecystitis. In post-cholecystectomy patients having ES, complications were fewer and less severe after ES (15%) than CDE (41%). In patients with an intact GB, peri-operative complications occurred in 30% after cholecystectomy and CDE. Following ES alone, complications occurred in 33% with the majority of these complications arising from the diseased GB. It is concluded that the optimal treatment for post-cholecystectomy patients with bile-duct stones is ES. In elderly patients with an intact GB, the bile-duct stones can be treated by ES; whether subsequent cholecystectomy is necessary should be assessed on the likelihood of future GB complications.

Adult↗

PubMed1989

Treatment of postcholedochoduodenostomy symptoms.

Upper abdominal symptoms after side-to-side choledochoduodenostomy (CDDY) may be attributed to stagnant bile, food and calculi pooling in the distal bile duct 'sump' with resultant biliary or pancreatic duct obstruction and sepsis. Endoscopic sphincterotomy (ES) provides a means of draining this sump. The aim of this study was to assess outcome following endoscopic retrograde choledochopancreatography (ERCP) and ES in patients with post-CDDY symptoms. Eight such patients (M: F = 1:7) underwent ERCP between September 1981 and March 1987. Their median age was 60 years (range: 37-72 years) and the median period since CDDY was 11 years (range: 1-28 years). The median follow-up after ERCP was 18 months (range: 14-94 months). Presenting symptoms comprised postprandial (one) or intermittent (seven) abdominal pain, cholangitis (three), pancreatitis (one) and jaundice (one). ERCP revealed bile duct abnormalities in four, consisting of filling defects alone (two), anastomotic narrowing with filling defects (one) and sclerosing cholangitis. ES was performed in seven, of whom three (all with filling defects at ERCP) remain asymptomatic and three are significantly improved. One had recurrent pancreatitis for which a sphincteroplasty and pancreatic duct septectomy was performed. ES was not performed in one because of technical difficulties (there being no subsequent improvement). It is concluded that, in patients with post-CDDY biliary symptoms, endoscopic sphincterotomy relieves the symptoms by either producing drainage of the sump at the distal bile duct, or dividing a dysfunctioning sphincter of Oddi.

Abdominal Pain↗

PubMed2002

An assessment of the learning curve for precut biliary sphincterotomy.

OBJECTIVE: Precut sphincterotomy is considered unsafe when used by inexperienced endoscopists. We sought to determine whether procedural experience with precut sphincterotomy predicted either successful cannulation or development of complications in these patients. METHODS: We describe the experience of 253 consecutive patients who underwent precut biliary sphincterotomy done by one endoscopist between September, 1993 and April, 2001. Data were prospectively collected on procedure indication and outcome. All patients were contacted by phone 30 days after the procedure to determine outcome. We also described precut utilization over time. RESULTS: All 253 precut procedures were divided chronologically into five groups of 50, with 53 in the final group. The rates of successful cannulation after precutting were 88%, 94%, 90%, 88%, and 98%, respectively (p = 0.05 for groups 1-4 vs group 5). Overall complication rates were similar in all groups (12%, 18%, 20%, 12%, and 14%), with no difference in complication severity. Female gender predicted successful cannulation (OR = 2.9 [p = 0.02]), whereas an indication of sphincter of Oddi dysfunction predicted development of complications (OR = 1.7 [p = 0.03]). The total number of ERCP procedures performed increased over time, whereas the proportion of precut sphincterotomies performed decreased. CONCLUSIONS: Although the success rate for precut sphincterotomy may increase with procedural experience, the complication rate does not seem to decrease. Precut sphincterotomy continues to carry an increased complication rate over standard sphincterotomy even when performed by an experienced biliary endoscopist. The need for precut sphincterotomy appears to decrease with increasing ERCP experience.

Clinical Competence↗

PubMed2006

Risk factors for post-ERCP pancreatitis: a prospective multicenter study.

OBJECTIVES: Pancreatitis is the most common and serious complication of diagnostic and therapeutic ERCP. The aim of this study is to examine the potential patient- and procedure-related risk factors for post-ERCP pancreatitis in a prospective multicenter study. METHODS: A 160-variable database was prospectively collected by a defined protocol on patients undergoing diagnostic or therapeutic ERCP at 15 centers in the Midwest Pancreaticobiliary Group and participating in a randomized controlled study evaluating whether prophylactic corticosteroids will reduce the incidence of post-ERCP pancreatitis. Data were collected prior to the procedure, at the time of procedure, and 24-72 h after discharge. Post-ERCP pancreatitis was diagnosed and its severity graded according to consensus criteria. RESULTS: Of the 1,115 patients enrolled, diagnostic ERCP with or without sphincter of Oddi manometry (SOM) was performed in 536 (48.1%) and therapeutic ERCP in 579 (51.9%). Suspected sphincter of Oddi dysfunction (SOD) was the indication for the ERCP in 378 patients (33.9%). Pancreatitis developed in 168 patients (15.1%) and was graded mild in 112 (10%), moderate in 45 (4%), and severe in 11(1%). There was no difference in the incidence of pancreatitis or the frequency of investigated potential pancreatitis risk factors between the corticosteroid and placebo groups. By univariate analysis, the incidence of post-ERCP pancreatitis was significantly higher in 19 of 30 investigated variables. In the multivariate risk model, significant risk factors with adjusted odds ratios (OR) were: minor papilla sphincterotomy (OR: 3.8), suspected SOD (OR: 2.6), history of post-ERCP pancreatitis (OR: 2.0), age <60 yr (OR: 1.6), > or =2 contrast injections into the pancreatic duct (OR: 1.5), and trainee involvement (OR: 1.5). Female gender, history of recurrent idiopathic pancreatitis, pancreas divisum, SOM, difficult cannulation, and major papilla sphincterotomy (either biliary or pancreatic) were not multivariate risk factors for post-ERCP pancreatitis. CONCLUSION: This study emphasizes the role of patient factors (age, SOD, prior history of post-ERCP pancreatitis) and technical factors (number of PD injections, minor papilla sphincterotomy, and operator experience) as the determining high-risk predictors for post-ERCP pancreatitis.

Adult↗

PubMed1996

Is intervention necessary after a first episode of acute idiopathic pancreatitis?

Acute idiopathic pancreatitis is a term used when no underlying cause has been identified on routine investigation. However, more specialised investigations may identify aetiological factors, biliary sludge and sphincter of Oddi dysfunction for example, in 38-72% of patients with recurrent episodes. Treatment of these abnormalities may prevent further episodes of pancreatitis. The aim of this study was to follow up and determine the outcome in patients with a first episode of idiopathic pancreatitis, and thus determine the need for further investigation and treatment in this group of patients. Thirty one patients with a single episode of idiopathic pancreatitis were studied who had no specialised investigations or specific treatment. During a median follow up of 36 months only one patient has had recurrent pancreatitis. Two patients experienced a single episode of unexplained abdominal pain; serum amylase, liver biochemistry, and abdominal ultrasound were all normal and the pain resolved within 48 hours. In conclusion, in the medium term, the prognosis is good after a first episode of idiopathic pancreatitis and specialised investigation is unnecessary.

Acute Disease↗

PubMed1990

Critical appraisal of therapeutic endoscopy in biliary tract diseases.

Endoscopic treatment (by sphincterotomy) is now the preferred method for patients with retained or recurrent bile duct stones after surgery. It is also applicable to many acutely ill or high-risk patients who have not undergone cholecystectomy. Endoscopic stenting is preferable to the percutaneous transhepatic method for palliation of malignant biliary obstruction in patients unfit or unsuitable for surgery. Balloon dilatation and stenting can be used for management of postoperative bile duct trauma and biliary fistulae, and in patients with dominant strictures in sclerosing cholangitis. Papillary stenosis and sphincter of Oddi dysfunction can be treated by sphincterotomy after careful patient selection. Endoscopy is a new and simpler form of surgery. A team approach including endoscopists, surgeons, and radiologists is essential for appropriate patient care and for objective evaluation of new methods.

Biliary Tract Diseases↗

PubMed1991

Air in the main pancreatic duct: demonstration with US.

Air in the pancreas--nearly always related to an abscess or a pancreatic fistula--is rarely demonstrated. Over a 3-year period, the authors detected air in the main pancreatic duct with ultrasonography (US) in 11 patients. The ductal caliber was normal in five patients and dilated in six. At US, air in the main pancreatic duct is characterized by strongly echogenic foci or echogenic lines in the duct, casting acoustic shadows or producing reverberation artifacts. It is likely that in patients who have biliary-enteric anastomoses or have undergone sphincterotomy, air in the duct of Wirsung is the result of biliary-pancreatic reflux. In patients who have not undergone such operations, the likely cause of pancreatic gas is duodenal-pancreatic duct reflux. Pancreatic gas may be related to causes other than a pancreatic abscess or fistula; it is therefore important for clinicians to realize that pancreatic ductal gas seen on US images may be secondary to prior surgery or due to sphincter of Oddi dysfunction.

Adult↗

PubMed2006

CCK1 antagonists: are they ready for clinical use?

Cholecystokinin (CCK) is a peptide hormone which is found both in the gastrointestinal tract throughout the human small intestine and nerves in the myenteric plexus of the enteric nervous system and in the central nervous system. This dual location constitutes the anatomical basis for this in functions as a hormone and a neurotransmitter implicated in the regulation of both systems. CCK regulates not only motor functions in the gastrointestinal tract like lower oesophageal sphincter relaxation, gastric secretion and emptying, gall bladder contractility and bile secretion into the duodenum, intestinal and colonic motility, but also sensory functions and plays a role in the regulation of food intake. These effects are mediated through selective receptors CCK1 and CCK2. Over the last few years, research has focused on understanding the role of CCK, its receptors with antagonists at the biological, pharmacological, clinical and therapeutic level. As far as the CCK1 antagonists is concerned, important inroads have been made in the potential role of these antagonists in the treatment of GERD, IBS and pancreatitis. They have also shown encouraging results in sphincter of Oddi dysfunction and some gastrointestinal cancers. This review focuses on the recent ad vances of the biological role of CCK and their CCK1 antagonists: their current basic and clinical status in gastroenterology, with particular emphasis on the potential therapeutic role of the CCK1 antagonists and future research directions.

Cholecystokinin↗