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Long Term Outcomes of Endoscopic Therapy for Idiopathic Acute Recurrent Pancreatitis (IARP)
Abstracts
M1395 Long Term Outcomes of Endoscopic Therapy for Idiopathic Acute Recurrent Pancreatitis (IARP) Ramanujan Samavedy, Suzette Schmidt, Evan L. Fogel, Lee McHenry, James L. Watkins, Stuart Sherman, Glen A. Lehman, Thomas J. Howard Background: Diagnostic ERCP plus manometry detects endoscopically treatable lesions in greater than 70% of IARP patients. We report here the long term outcomes of a series of such patients, who had endoscopic therapy (ET). Methods: We searched our ERCP database for the year 2001 and found 101 patients with preERCP diagnosis of IARP. Patients without endoscopically treatable lesions (21 pts.) including all neoplasm were excluded. Follow up done by telephone calls and chart reviews, was available on 65 of 80 patients. Mean follow up was 61 months from initial ERCP. Results: There were 37 males and 28 females; mean age of 46.2 yrs (range 5 to 92y). The ERCP findings: see Table. ET in 23 patients without CP, decreased the admissions/year of follow up from 3.5 pre ERCP to 0.9 post ERCP and chronic narcotics use from 22 to 3 patients. Eighteen of 23 are pain free, 2 have occasional pain and 3 had surgery for attempted pain control. Of the 42 patients with CP with ET, number of admissions/year pre and post ERCP went from 4.1 to 2.8. Twenty had improvement in pain, 22 continue to have pain and use narcotics daily. Thirteen had surgery for attempted pain control. Overall, fifteen patients had pancreatic surgery for pain control. Summary: In this series of IARP with treatable findings, patients without CP are usually improved with ET at long term follow up. Patients with CP only half are improved long term. Conclusions: Endotherapy for IARP is clinically warranted and often helpful for symptom relief. Surgery is often needed for ET failed patients. Outcomes to endotherapy Pain level post therapy ERCP and manometry findings
None Occasional) Daily Endotherapy
SOD, no CP SOD with CP CP (manometry normal/ not done) PDiv with CP
8 6 4
2 3 3
1 6 9
4
-
7
PDiv, no CP Long common channel Choledochocele Biliary calculi Total
4 1
1
2 2 31
9
BS - 14 DS - 12 DS - 6, PS - 8 Dilation - 6 Minor papillotomy - 17
2 25
Sphincterotomy2 BS - 2 BS - 2 BS - 19, DS - 18, PS - 6, Minor papillotomy - 17, Dilation - 6
Requiring Deceased, unrelated-U or pancreas pancreatic Ca-P surgery # U-1 U - 2, P - 1 after 3y
None 3 3
-
7
U-1 P - 1, after 8y
None
2
6
None None 15
) !2 days per month, # for persistent pain or pancreatitis after endotherapy. BS biliary sphincterotomy, DS - dual sphincterotomy, PS - pancreatic sphincterotomy, SOD - sphincter of oddi dysfunction, CP - chronic pancreatitis, PDiv - pancreas divisum
evaluation and 9/20 (45%) had pain complete or near complete resolution with jejunal tube feeds (p Z 0.008). The mean weight was 62.6 kg at baseline and 61 kg after jejunal feeding (mean decrease, 1.6 14 kg, p Z 0.27). 10/28 (36%) gained weight (mean increase, 8 7.5 kg) with jejunal feeding. 17/28 (61%) lost weight (mean decrease, 6.1 5 kg), 4 of whom had known or suspected cancer and a mean loss of 14 3.6 kg. In most cases, the weight stabilized after initial loss. Conclusions: 1) Jejunal feeding through endoscopically-placed tubes leads to clinically significant pain relief in many chronic pancreatitis patients. 2). Jejunal feeds do not impart a statistically significant effect on weight overall, but many patients gain weight while others have initial weight loss that stabilizes over time.
M1397 Prediction of Pancreatitis Following ERCP Based On the 4-H Post-Procedure Serum Amylase and Lipase Level in Japan Takayoshi Nishino, Hiroyasu Oyama, Fumitake Toki, Itaru Oi, Keiko Shiratori Background and Aim: Pancreatitis remains the most common complication of ERCP, and because it results in substantial morbidity and occasionally in death, early detection of post-ERCP pancreatitis is crucial. The aim of this study was to evaluate serum amylase and lipase level 4h post-ERCP as a predictor of pancreatitis in a prospective single-center study in Japan. Methods: We reviewed 1631 consecutive cases in which ERCP had been performed (M:F Z 974:657, age 8-97 yr, median 67 yr). Diagnostic ERCP had been performed in 910 cases, and therapeutic ERCP in 721 cases. Pancreatitis was diagnosed when abdominal pain persisted for 24 hr after ERCP and was associated with a high serum amylase level (normal range 40-125 IU/ l) and/or high serum lipase level (normal range 13-49 IU/l). The severity of the pancreatitis was diagnosed according to the scoring system proposed by the Ministry of Health, Labour and Welfare of Japan. Results: Pancreatitis developed in 69 (4.2%) of the 1631 cases, and was mild in 60 cases, moderate in 5 cases, and severe in 4 cases. There were no deaths in our series. Older age, sphincter of Oddi dysfunction, endoscopist experience less than 200 ERCPs, high contrast medium injection pressure into the pancreatic duct, brushing cytology of the pancreatic duct, and IDUS conferred increased risk independently according to a multivariate analysis. The receiver-operator characteristics (ROCs) of both the 4-h amylase level and 4-h lipase level showed good test performance with the area under the curve, which were 0.91 and 0.96 (p Z 0.007), respectively. The optimal cutoff value for amylase was 3.5-fold (443 IU/l) the normal level, and its sensitivity and specificity were 88.1% and 77.9%, respectively. The optimal cutoff value for lipase was 9.3 fold (457 IU/l) the normal value, and its sensitivity and specificity were 96.6% and 86.2%, respectively. Serum lipase was a more effective marker than amylase for predicting post-ERCP pancreatitis based on the area of the ROC curve (p Z 0.007). Conclusions:The 4-h post-ERCP amylase level and 4-h lipase level, in particular, are useful test values for predicting pancreatitis.
M1398 Proton-Pump Inhibitor for the Prevention of Pancreatic Damage Related to Endoscopic Retrograde Cholangiopancreatography Jin Kan Sai, Masafumi Suyama, Yoshihiro Kubokawa, Sumio Watanabe M1396 Jejunal Feeding in Chronic Pancreatitis Maydeen Ogara, John C. Fang, Kathryn A. Peterson, James A. Disario Current therapies are largely inadequate for pain and weight loss with chronic pancreatitis. Enteral nutrition delivered deep in the jejunum does not stimulate pancreatic secretion and holds promise as therapy. Purpose: Determine the effect of nutritional therapy via endoscopically placed jejunal feeding tubes on pain and body weight in persons with chronic pancreatitis. Methods: Retrospective case series. Results: There were 30 (23 women, 7 men) patients with a mean age of 44 (21-62) years. Pain data were available on 25 patients with a mean follow up of 7.5 (0.5-42) months. 13 (36%) had endoscopic nasoenteric tubes (ENET) initially or long term , 9 (25%) had percutaneous endoscopic gastrostomy with jejunal extension (PEG-J), 14 (39%) had direct percutaneous endoscopic jejunostomy (DPEJ) and 9 (25%) had more than one type of feeding tube. 12 (40%) complications occurred in 12 (40%) patients. Minor events were pain at the stoma in 3 (10%) with PEG-J and infections at insertion site requiring antibiotics in 3 (10%). Severe complications developed in 7 (23%) and included 5 (17%) with PEG-J tube malfunction requiring endoscopic intervention, one (3%) small bowel volvulus with obstruction following DPEJ requiring surgery, and one (3%) presumed perforation managed conservatively. The mean duration of jejunal feeding was 4.6 (0.5-26) months. 20/25 (80%) patients reported uncontrolled pain at initial
AB248 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
Background: Endoscopic retrograde cholangiopancreatography (ERCP) is associated with elevated levels of pancreatic enzymes and pancreatitis. The aim of this study was to assess the efficacy of rabeprazole sodium (RPZ), a proton-pump inhibitor (PPI), in inhibiting pancreatic secretion and thus preventing post-ERCP pancreatitis and hyperamylasemia. Methods: A total of 39 adult patients (mean age, 56.3 years), who had intraductal papillary mucinous tumor of the pancreas and were scheduled to undergo pancreatic juice cytology under ERCP, were enrolled and divided into two groups; 19 patients who had peptic ulcer or gastro-esophageal reflux disease given 10 mg/day of RPZ (PPI group), and 20 given neither PPI nor H2blocker (non-PPI group). PPI was given orally, starting 7 or more days before ERCP and continuing for 14 or more days afterward. Acute pancreatitis was considered to be present if the serum amylase level was 5-fold greater than the upper limit of normal in association with the onset of pancreatic pain. Results: After the procedure 19 non-PPI patients (95%) and 14 PPI patients (70%) had elevated serum amylase levels. The mean serum amylase value after ERCP was 631 726 IU/L in the non-PPI group, that was significantly higher than 257 238 IU/L in the PPI group throughout 24 hours of observation (p Z 0.002). One patient in the non-PPI group and none in the PPI group developed acute pancreatitis. There were no significant differences between the two groups in the duration of abnormally elevated serum amylase levels. Conclusion: Prophylactic treatment with a PPI seems to reduce pancreatic damage related to ERCP, as reflected by a reduction in the extent of increase in the serum amylase level.
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M1395 Long Term Outcomes of Endoscopic Therapy for Idiopathic Acute Recurrent Pancreatitis (IARP) Ramanujan Samavedy, Suzette Schmidt, Evan L. Fogel, Lee McHenry, James L. Watkins, Stuart Sherman, Glen A. Lehman, Thomas J. Howard Background: Diagnostic ERCP plus manometry detects endoscopically treatable lesions in greater than 70% of IARP patients. We report here the long term outcomes of a series of such patients, who had endoscopic therapy (ET). Methods: We searched our ERCP database for the year 2001 and found 101 patients with preERCP diagnosis of IARP. Patients without endoscopically treatable lesions (21 pts.) including all neoplasm were excluded. Follow up done by telephone calls and chart reviews, was available on 65 of 80 patients. Mean follow up was 61 months from initial ERCP. Results: There were 37 males and 28 females; mean age of 46.2 yrs (range 5 to 92y). The ERCP findings: see Table. ET in 23 patients without CP, decreased the admissions/year of follow up from 3.5 pre ERCP to 0.9 post ERCP and chronic narcotics use from 22 to 3 patients. Eighteen of 23 are pain free, 2 have occasional pain and 3 had surgery for attempted pain control. Of the 42 patients with CP with ET, number of admissions/year pre and post ERCP went from 4.1 to 2.8. Twenty had improvement in pain, 22 continue to have pain and use narcotics daily. Thirteen had surgery for attempted pain control. Overall, fifteen patients had pancreatic surgery for pain control. Summary: In this series of IARP with treatable findings, patients without CP are usually improved with ET at long term follow up. Patients with CP only half are improved long term. Conclusions: Endotherapy for IARP is clinically warranted and often helpful for symptom relief. Surgery is often needed for ET failed patients. Outcomes to endotherapy Pain level post therapy ERCP and manometry findings
None Occasional) Daily Endotherapy
SOD, no CP SOD with CP CP (manometry normal/ not done) PDiv with CP
8 6 4
2 3 3
1 6 9
4
-
7
PDiv, no CP Long common channel Choledochocele Biliary calculi Total
4 1
1
2 2 31
9
BS - 14 DS - 12 DS - 6, PS - 8 Dilation - 6 Minor papillotomy - 17
2 25
Sphincterotomy2 BS - 2 BS - 2 BS - 19, DS - 18, PS - 6, Minor papillotomy - 17, Dilation - 6
Requiring Deceased, unrelated-U or pancreas pancreatic Ca-P surgery # U-1 U - 2, P - 1 after 3y
None 3 3
-
7
U-1 P - 1, after 8y
None
2
6
None None 15
) !2 days per month, # for persistent pain or pancreatitis after endotherapy. BS biliary sphincterotomy, DS - dual sphincterotomy, PS - pancreatic sphincterotomy, SOD - sphincter of oddi dysfunction, CP - chronic pancreatitis, PDiv - pancreas divisum
evaluation and 9/20 (45%) had pain complete or near complete resolution with jejunal tube feeds (p Z 0.008). The mean weight was 62.6 kg at baseline and 61 kg after jejunal feeding (mean decrease, 1.6 14 kg, p Z 0.27). 10/28 (36%) gained weight (mean increase, 8 7.5 kg) with jejunal feeding. 17/28 (61%) lost weight (mean decrease, 6.1 5 kg), 4 of whom had known or suspected cancer and a mean loss of 14 3.6 kg. In most cases, the weight stabilized after initial loss. Conclusions: 1) Jejunal feeding through endoscopically-placed tubes leads to clinically significant pain relief in many chronic pancreatitis patients. 2). Jejunal feeds do not impart a statistically significant effect on weight overall, but many patients gain weight while others have initial weight loss that stabilizes over time.
M1397 Prediction of Pancreatitis Following ERCP Based On the 4-H Post-Procedure Serum Amylase and Lipase Level in Japan Takayoshi Nishino, Hiroyasu Oyama, Fumitake Toki, Itaru Oi, Keiko Shiratori Background and Aim: Pancreatitis remains the most common complication of ERCP, and because it results in substantial morbidity and occasionally in death, early detection of post-ERCP pancreatitis is crucial. The aim of this study was to evaluate serum amylase and lipase level 4h post-ERCP as a predictor of pancreatitis in a prospective single-center study in Japan. Methods: We reviewed 1631 consecutive cases in which ERCP had been performed (M:F Z 974:657, age 8-97 yr, median 67 yr). Diagnostic ERCP had been performed in 910 cases, and therapeutic ERCP in 721 cases. Pancreatitis was diagnosed when abdominal pain persisted for 24 hr after ERCP and was associated with a high serum amylase level (normal range 40-125 IU/ l) and/or high serum lipase level (normal range 13-49 IU/l). The severity of the pancreatitis was diagnosed according to the scoring system proposed by the Ministry of Health, Labour and Welfare of Japan. Results: Pancreatitis developed in 69 (4.2%) of the 1631 cases, and was mild in 60 cases, moderate in 5 cases, and severe in 4 cases. There were no deaths in our series. Older age, sphincter of Oddi dysfunction, endoscopist experience less than 200 ERCPs, high contrast medium injection pressure into the pancreatic duct, brushing cytology of the pancreatic duct, and IDUS conferred increased risk independently according to a multivariate analysis. The receiver-operator characteristics (ROCs) of both the 4-h amylase level and 4-h lipase level showed good test performance with the area under the curve, which were 0.91 and 0.96 (p Z 0.007), respectively. The optimal cutoff value for amylase was 3.5-fold (443 IU/l) the normal level, and its sensitivity and specificity were 88.1% and 77.9%, respectively. The optimal cutoff value for lipase was 9.3 fold (457 IU/l) the normal value, and its sensitivity and specificity were 96.6% and 86.2%, respectively. Serum lipase was a more effective marker than amylase for predicting post-ERCP pancreatitis based on the area of the ROC curve (p Z 0.007). Conclusions:The 4-h post-ERCP amylase level and 4-h lipase level, in particular, are useful test values for predicting pancreatitis.
M1398 Proton-Pump Inhibitor for the Prevention of Pancreatic Damage Related to Endoscopic Retrograde Cholangiopancreatography Jin Kan Sai, Masafumi Suyama, Yoshihiro Kubokawa, Sumio Watanabe M1396 Jejunal Feeding in Chronic Pancreatitis Maydeen Ogara, John C. Fang, Kathryn A. Peterson, James A. Disario Current therapies are largely inadequate for pain and weight loss with chronic pancreatitis. Enteral nutrition delivered deep in the jejunum does not stimulate pancreatic secretion and holds promise as therapy. Purpose: Determine the effect of nutritional therapy via endoscopically placed jejunal feeding tubes on pain and body weight in persons with chronic pancreatitis. Methods: Retrospective case series. Results: There were 30 (23 women, 7 men) patients with a mean age of 44 (21-62) years. Pain data were available on 25 patients with a mean follow up of 7.5 (0.5-42) months. 13 (36%) had endoscopic nasoenteric tubes (ENET) initially or long term , 9 (25%) had percutaneous endoscopic gastrostomy with jejunal extension (PEG-J), 14 (39%) had direct percutaneous endoscopic jejunostomy (DPEJ) and 9 (25%) had more than one type of feeding tube. 12 (40%) complications occurred in 12 (40%) patients. Minor events were pain at the stoma in 3 (10%) with PEG-J and infections at insertion site requiring antibiotics in 3 (10%). Severe complications developed in 7 (23%) and included 5 (17%) with PEG-J tube malfunction requiring endoscopic intervention, one (3%) small bowel volvulus with obstruction following DPEJ requiring surgery, and one (3%) presumed perforation managed conservatively. The mean duration of jejunal feeding was 4.6 (0.5-26) months. 20/25 (80%) patients reported uncontrolled pain at initial
AB248 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
Background: Endoscopic retrograde cholangiopancreatography (ERCP) is associated with elevated levels of pancreatic enzymes and pancreatitis. The aim of this study was to assess the efficacy of rabeprazole sodium (RPZ), a proton-pump inhibitor (PPI), in inhibiting pancreatic secretion and thus preventing post-ERCP pancreatitis and hyperamylasemia. Methods: A total of 39 adult patients (mean age, 56.3 years), who had intraductal papillary mucinous tumor of the pancreas and were scheduled to undergo pancreatic juice cytology under ERCP, were enrolled and divided into two groups; 19 patients who had peptic ulcer or gastro-esophageal reflux disease given 10 mg/day of RPZ (PPI group), and 20 given neither PPI nor H2blocker (non-PPI group). PPI was given orally, starting 7 or more days before ERCP and continuing for 14 or more days afterward. Acute pancreatitis was considered to be present if the serum amylase level was 5-fold greater than the upper limit of normal in association with the onset of pancreatic pain. Results: After the procedure 19 non-PPI patients (95%) and 14 PPI patients (70%) had elevated serum amylase levels. The mean serum amylase value after ERCP was 631 726 IU/L in the non-PPI group, that was significantly higher than 257 238 IU/L in the PPI group throughout 24 hours of observation (p Z 0.002). One patient in the non-PPI group and none in the PPI group developed acute pancreatitis. There were no significant differences between the two groups in the duration of abnormally elevated serum amylase levels. Conclusion: Prophylactic treatment with a PPI seems to reduce pancreatic damage related to ERCP, as reflected by a reduction in the extent of increase in the serum amylase level.
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