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Magnetic resonance cholangiography can replace endoscopic retrograde cholangiography for the diagnosis of common bile duct stones
ERCP-BILIARY
7381
383
MAGNETIC RESONANCE CHOLANGIOGRAPHY CAN REPLACE ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY FOR THE DIAGNOSIS OF COMMON BILE DUCT STONES D.WH.LEE Y.L.CHAN*, A.C.W.CHAN, W.WM.LAM*, S.C.S.CHUNG, J.Y.SUNG#, CMETREWELI*, A.K.C.LI. Departments of Surgery , Diagnostic Radiology and Organ Imaging* and Medicine#, Pdnce of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
Celiac Disease and Papillary Stenosia. M Levstik J Murray, F Johlin. Univ Of Iowa and DVA Medical center, iowa City, Iowa 52242 Introduction Celiac Disease is a genetically predetermined chronic inflammation characteristically affecting the proximal small bowel. Whilst pancreatitis has been seen in celiac disease ,no specific etiology has been identified. We have encountered three patients with celiac disease and papilla of vater stenosis. : We reviewed the records of all patients undergoing the University of Iowa who had a diagnosis o f papillary dysfunction. 170/239 patients had a fixed papillary stenosis. Of these 3/170 had a diagnosis ot celiac disease. Case one: 56 y.o. male with known celiac disease, presented with a two year history of idiopathic pancreatitis primarily on business trips. He was on a gluten free diet (GFD) with intermittent non-compliance while traveling. ERCP demonstrated normal biliary and panereatitic ducts. Biliary manometry demonstrated papillary stenosis with marked inflammation on biopsy. No further episodes on rigid GFD. Case Two: 60 y.o. female presented with acute pancreatitis. ERCP revealed papillary stenosis and was treated with papillotomy. Patient subsequently presented with T-cell small bowel lyrnphoma. Celiac disease was later confirmed with biopsy and serology. Case three: 56 y.o. female with postprandial biliary pain. She underwent ERCP which revealed duodenal ulceration, papillary stenosis and underwent a papillotomy. 18 months later, the patient presented with lactose intolerance and a diagnosis of celiac disease was made with biopsy and serology. Discussion; These 3 cases illustrate the association of papillary stenosis with celiac disease at a rate greater than chance( 1.8 %). It is likely that the mucesal inflammation seen in celiac disease involving the papilla in the duodenum is the likely etiologic factor involved in these cases. The finding of improvement following redUCtion of inflammation on a GFD, make this postulate even more likely. Whilst this retrospective survey revealed coexistence of 2% of papillary stenosis cases seen in one medical center, celiac disease should be considered as a potential etiologic factor in papillary stenosis. A prospective search may reveal further undiagnosed cases.
For patients with suspected choledocholithiasis, endoscopic retrograde cholangiography (ERC) is a standard imaging modality. Recently, magnetic resonance cholangiography (MRC) is proposed as an alternative non-invasive diagnostic method. We aim to evaluate the accuracy of MRC compared to ERC in patients with suspected choledocholithiasis in a prospective manner. Method: Patients with suspected choledocholithiasis were recruited. Non-contrast, non-breath hold, fat suppressed, respiratory-triggered, heavily T2-weighted turbo spin-echo sequence MRC were performed in these patients pdor to ERC. The results of MRC were compared with ERC. The presence of ductal dilatation and stones were then assessed by blinded observers. Results: Forty-eight patients (28 male, 20 female; age:mean=64, range=32 to 86) successfully underwent MRC evaluation with diagnostic images. Two cases were excluded from analysis because of failed ERC ( 1 previous Polya gastrectomy; 1 suboptimal cholangiogram). In the remaining 46 patients, there is a complete match of ductal dilatation (30 diated, 16 normal) between MRC and ERC.'Concerning ductal stones, MRC correctly identified 20/21 of the positive cases (sensitivity=95%) and 21/25 negative cases (specificity=84%). Conclusion: Non-centrast, non-breath holding 3 dimenional MRC has a high sensitivity and specificity in evaluation of choledocholithiasis and can therefore replace diagnostic ERC.
?384
~382 SERUM AMYLASE LEVEL MEASURED EIGHT HOURS AFTER PROCEDURES ON VATER'S pAPILLA IS A PREDICTOR PANCREATIC REACTION.
ENDOSCOPIC OF SEVERE
F. Lella, S. Caporuscio, F. Bagnolo, E. Colombo, M. euizza, U. Bonassi & P.A. Testoni. Instituee of Ineernal Medicine, University of Milan; Policlinico S. Marco, Zingonia, Italy. H y p e r a m y l a s e m i a is a c o m m o n finding after endoscopic p r o c e d u r e s on V a t e r ' s p a p i l l a (ERCP, EPTI; in most cases it has no clinical significance. However, in some cases the e n z y m a t i c raise is a s s o c l a t e d w i t h acute p a n c r e a t i t i s (1-7% of cases). Since in many i n s t i t u t i o n s these e n d o s c o p i c procedures are c u r r e n t l y p e r f o r m e d in d a y - h o s p i t a l regimen, it seems useful to identify, as early as possible, which p a t i e n t s could d e v e l o p a s e v e r e p a n c r e a t i c reaction, in order to plan a p r o l o n g e d f o l l o w - u p and a t h e r a p e u t i c app r o a c h to reduce the risk of pancreatitis. In a p r o s p e c t i v e series of 71 c o n s e c u t i v e p a t i e n t s who had u n d e r g o n e e n d o s c o p i c sphincterotomy, serum a m y l a s e activity was m e a s u r e d in bloods drawn i m m e d i a t e l y b e f o r e t h e procedure and after 2, 4, 8 and 24 hours;, tha data o b t a i n e d at 2, 4 and 8 hours w e r e t h e r e f o r e c o m p a r e d w i t h those at 24 hours, in order to detect the time in w h i c h the peak of serum amylase is p r e d i c t i v e for e i t h e r s e v e r e p a n c r e a t i c reaction or pancreatitis. Fifty out of the 71 subjects had h y p e r a m y l a s e m i a (> 220 u/l) after the p r o c e d u r e d u r i n g the follow-up period. In 11 subjects an a m y l a s e level higher t h a n five times the normal range (suggestive for severe p a n c r e a t i c reaction} still p e r s i s t e d 24 hours after the procedure; three patients showed clinical findings of acute o e d e m a t o u s p a n c r e a t i t i s (confirmed by CT scan}. O n l y the rise in serum amylase a c t i v i t y in blood drawn after 8 hours a p p e a r e d in our study s i g n i f i c a n t l y a s s o c i a t e d w i t h persistent p a n c r e a t i c reaction or p a n c r e a t i t i s (p = 0.0076). No cases with m i l d h y p e r a m y l a s e m i a (lower t h a n 5 times the n o r m a l range) at 8 hours d e v e l o p e d at 24 hours severe pancreatic reaction. On the other hand, 8/17 (47%) patients w i t h severe h y p e r a m y l a s e m i a at 8 hours had r e d u c e d level of serum enzymes at 24 hours. In conclusion, in our study on e n d o s c o p i c s p h i n c t e r o t o m y , the amylase value o b t a i n e d 8 hours after the p r o c e d u r e a v o i d s t h e r i s k of u n d e r e s t i m a t e s severe pancreatic r e a c t i o n and could be used as a k e y - p o i n t for m o n i t o r i n g and for a specific treatment.
386
~
GASTROINTESTINAL ENDOSCOPY
A PROSPECTIVE BLINDED EVALUATION OF ALL ERCP SAMPLING METHODS ON BILIARY STRICTURES. S.K. Lo, J. Cox, S. Soltani. Division of Gastroenterology, Harbor-UCLA Medical Center. Torrance, CA. UCLA School of Medicine. To date there is no data that compares all currently available ERCP tissue sampling methods in a prospective and blinded manner. METHOD: ERCP forceps biopsy and five endoscopic cytology methods were identified. To limit influence of additive manipulations, specimens were collected in the following sequence: obstructed bile fluid (BF), brushing (BR), post-brushing fluid (PB), post-dilation fluid (PD), forceps biopsy (BX), and nee,die aspiration (FNA). Each maneuver was added as it became clinically available. Interpreter and sampler biases were controlled by: 1) using a single histopathologist, r and endoscopist, 2) blinding clinical information and coding cytologic specimens, and 3) performing independent interpretations. RESULTS: Only newly presented cases were included. 36 neoplastic biliary strictures were ultimately confirmed (pancreatic-14, Cholangio-9, portal metastases-7, gallbladder-3, adenoma-2, hepatoma-]). Specificity for all methods was 100%. Stricture locations: common hepatic (CHD)-20; common bile duct (CBD)-I4, combined-2. )erior in sensitiviO )arcd TABLE 1 BF "f i r PB PD FNA -BX Positive 8/35 7/36 7/36 7/20 8/31 26/36 Sensitivity (SEN) 23% 19% 19% 35% 26% 72% P value (vs BX) 0.00005 0.00001 0.00001 0.01 0.0002 --SEN CHD/CBD (%) 47/10 2 5 / 1 8 31/14 45/27 36/22 88/64 P value (CHD vs CBD) O.O2 0.7 0.24 0.66 0.45 0.14 to all cytologic methods (table 1). In cases where all 6 methods were applied, the differences were still notable (table 2). There was a tendency to better sitivity(SEN)
I
37vo 26~
32u
37%
32%
53%
68%
I
value(vsBX) . 0.1 0.02 o.o5 0.| O.os ' 05 --yields with proximal biliary strictures for all methods. Cytology did not add to the sensitivity of biopsy. CONCLUSIONS: 1) Biopsy was highly sensitive for proxlrnal biliary strictures. 2) Modification of the basic cytologic sampling methods did not enhance the yields. 3) Contrary to published reports~ performing multiple sampling methods on the same stricture did not add to the biopsy result. Forceps biopsy is the sampling method of choice during ERCP.
VOLUME 43, NO. 4, 1996
7381
383
MAGNETIC RESONANCE CHOLANGIOGRAPHY CAN REPLACE ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY FOR THE DIAGNOSIS OF COMMON BILE DUCT STONES D.WH.LEE Y.L.CHAN*, A.C.W.CHAN, W.WM.LAM*, S.C.S.CHUNG, J.Y.SUNG#, CMETREWELI*, A.K.C.LI. Departments of Surgery , Diagnostic Radiology and Organ Imaging* and Medicine#, Pdnce of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
Celiac Disease and Papillary Stenosia. M Levstik J Murray, F Johlin. Univ Of Iowa and DVA Medical center, iowa City, Iowa 52242 Introduction Celiac Disease is a genetically predetermined chronic inflammation characteristically affecting the proximal small bowel. Whilst pancreatitis has been seen in celiac disease ,no specific etiology has been identified. We have encountered three patients with celiac disease and papilla of vater stenosis. : We reviewed the records of all patients undergoing the University of Iowa who had a diagnosis o f papillary dysfunction. 170/239 patients had a fixed papillary stenosis. Of these 3/170 had a diagnosis ot celiac disease. Case one: 56 y.o. male with known celiac disease, presented with a two year history of idiopathic pancreatitis primarily on business trips. He was on a gluten free diet (GFD) with intermittent non-compliance while traveling. ERCP demonstrated normal biliary and panereatitic ducts. Biliary manometry demonstrated papillary stenosis with marked inflammation on biopsy. No further episodes on rigid GFD. Case Two: 60 y.o. female presented with acute pancreatitis. ERCP revealed papillary stenosis and was treated with papillotomy. Patient subsequently presented with T-cell small bowel lyrnphoma. Celiac disease was later confirmed with biopsy and serology. Case three: 56 y.o. female with postprandial biliary pain. She underwent ERCP which revealed duodenal ulceration, papillary stenosis and underwent a papillotomy. 18 months later, the patient presented with lactose intolerance and a diagnosis of celiac disease was made with biopsy and serology. Discussion; These 3 cases illustrate the association of papillary stenosis with celiac disease at a rate greater than chance( 1.8 %). It is likely that the mucesal inflammation seen in celiac disease involving the papilla in the duodenum is the likely etiologic factor involved in these cases. The finding of improvement following redUCtion of inflammation on a GFD, make this postulate even more likely. Whilst this retrospective survey revealed coexistence of 2% of papillary stenosis cases seen in one medical center, celiac disease should be considered as a potential etiologic factor in papillary stenosis. A prospective search may reveal further undiagnosed cases.
For patients with suspected choledocholithiasis, endoscopic retrograde cholangiography (ERC) is a standard imaging modality. Recently, magnetic resonance cholangiography (MRC) is proposed as an alternative non-invasive diagnostic method. We aim to evaluate the accuracy of MRC compared to ERC in patients with suspected choledocholithiasis in a prospective manner. Method: Patients with suspected choledocholithiasis were recruited. Non-contrast, non-breath hold, fat suppressed, respiratory-triggered, heavily T2-weighted turbo spin-echo sequence MRC were performed in these patients pdor to ERC. The results of MRC were compared with ERC. The presence of ductal dilatation and stones were then assessed by blinded observers. Results: Forty-eight patients (28 male, 20 female; age:mean=64, range=32 to 86) successfully underwent MRC evaluation with diagnostic images. Two cases were excluded from analysis because of failed ERC ( 1 previous Polya gastrectomy; 1 suboptimal cholangiogram). In the remaining 46 patients, there is a complete match of ductal dilatation (30 diated, 16 normal) between MRC and ERC.'Concerning ductal stones, MRC correctly identified 20/21 of the positive cases (sensitivity=95%) and 21/25 negative cases (specificity=84%). Conclusion: Non-centrast, non-breath holding 3 dimenional MRC has a high sensitivity and specificity in evaluation of choledocholithiasis and can therefore replace diagnostic ERC.
?384
~382 SERUM AMYLASE LEVEL MEASURED EIGHT HOURS AFTER PROCEDURES ON VATER'S pAPILLA IS A PREDICTOR PANCREATIC REACTION.
ENDOSCOPIC OF SEVERE
F. Lella, S. Caporuscio, F. Bagnolo, E. Colombo, M. euizza, U. Bonassi & P.A. Testoni. Instituee of Ineernal Medicine, University of Milan; Policlinico S. Marco, Zingonia, Italy. H y p e r a m y l a s e m i a is a c o m m o n finding after endoscopic p r o c e d u r e s on V a t e r ' s p a p i l l a (ERCP, EPTI; in most cases it has no clinical significance. However, in some cases the e n z y m a t i c raise is a s s o c l a t e d w i t h acute p a n c r e a t i t i s (1-7% of cases). Since in many i n s t i t u t i o n s these e n d o s c o p i c procedures are c u r r e n t l y p e r f o r m e d in d a y - h o s p i t a l regimen, it seems useful to identify, as early as possible, which p a t i e n t s could d e v e l o p a s e v e r e p a n c r e a t i c reaction, in order to plan a p r o l o n g e d f o l l o w - u p and a t h e r a p e u t i c app r o a c h to reduce the risk of pancreatitis. In a p r o s p e c t i v e series of 71 c o n s e c u t i v e p a t i e n t s who had u n d e r g o n e e n d o s c o p i c sphincterotomy, serum a m y l a s e activity was m e a s u r e d in bloods drawn i m m e d i a t e l y b e f o r e t h e procedure and after 2, 4, 8 and 24 hours;, tha data o b t a i n e d at 2, 4 and 8 hours w e r e t h e r e f o r e c o m p a r e d w i t h those at 24 hours, in order to detect the time in w h i c h the peak of serum amylase is p r e d i c t i v e for e i t h e r s e v e r e p a n c r e a t i c reaction or pancreatitis. Fifty out of the 71 subjects had h y p e r a m y l a s e m i a (> 220 u/l) after the p r o c e d u r e d u r i n g the follow-up period. In 11 subjects an a m y l a s e level higher t h a n five times the normal range (suggestive for severe p a n c r e a t i c reaction} still p e r s i s t e d 24 hours after the procedure; three patients showed clinical findings of acute o e d e m a t o u s p a n c r e a t i t i s (confirmed by CT scan}. O n l y the rise in serum amylase a c t i v i t y in blood drawn after 8 hours a p p e a r e d in our study s i g n i f i c a n t l y a s s o c i a t e d w i t h persistent p a n c r e a t i c reaction or p a n c r e a t i t i s (p = 0.0076). No cases with m i l d h y p e r a m y l a s e m i a (lower t h a n 5 times the n o r m a l range) at 8 hours d e v e l o p e d at 24 hours severe pancreatic reaction. On the other hand, 8/17 (47%) patients w i t h severe h y p e r a m y l a s e m i a at 8 hours had r e d u c e d level of serum enzymes at 24 hours. In conclusion, in our study on e n d o s c o p i c s p h i n c t e r o t o m y , the amylase value o b t a i n e d 8 hours after the p r o c e d u r e a v o i d s t h e r i s k of u n d e r e s t i m a t e s severe pancreatic r e a c t i o n and could be used as a k e y - p o i n t for m o n i t o r i n g and for a specific treatment.
386
~
GASTROINTESTINAL ENDOSCOPY
A PROSPECTIVE BLINDED EVALUATION OF ALL ERCP SAMPLING METHODS ON BILIARY STRICTURES. S.K. Lo, J. Cox, S. Soltani. Division of Gastroenterology, Harbor-UCLA Medical Center. Torrance, CA. UCLA School of Medicine. To date there is no data that compares all currently available ERCP tissue sampling methods in a prospective and blinded manner. METHOD: ERCP forceps biopsy and five endoscopic cytology methods were identified. To limit influence of additive manipulations, specimens were collected in the following sequence: obstructed bile fluid (BF), brushing (BR), post-brushing fluid (PB), post-dilation fluid (PD), forceps biopsy (BX), and nee,die aspiration (FNA). Each maneuver was added as it became clinically available. Interpreter and sampler biases were controlled by: 1) using a single histopathologist, r and endoscopist, 2) blinding clinical information and coding cytologic specimens, and 3) performing independent interpretations. RESULTS: Only newly presented cases were included. 36 neoplastic biliary strictures were ultimately confirmed (pancreatic-14, Cholangio-9, portal metastases-7, gallbladder-3, adenoma-2, hepatoma-]). Specificity for all methods was 100%. Stricture locations: common hepatic (CHD)-20; common bile duct (CBD)-I4, combined-2. )erior in sensitiviO )arcd TABLE 1 BF "f i r PB PD FNA -BX Positive 8/35 7/36 7/36 7/20 8/31 26/36 Sensitivity (SEN) 23% 19% 19% 35% 26% 72% P value (vs BX) 0.00005 0.00001 0.00001 0.01 0.0002 --SEN CHD/CBD (%) 47/10 2 5 / 1 8 31/14 45/27 36/22 88/64 P value (CHD vs CBD) O.O2 0.7 0.24 0.66 0.45 0.14 to all cytologic methods (table 1). In cases where all 6 methods were applied, the differences were still notable (table 2). There was a tendency to better sitivity(SEN)
I
37vo 26~
32u
37%
32%
53%
68%
I
value(vsBX) . 0.1 0.02 o.o5 0.| O.os ' 05 --yields with proximal biliary strictures for all methods. Cytology did not add to the sensitivity of biopsy. CONCLUSIONS: 1) Biopsy was highly sensitive for proxlrnal biliary strictures. 2) Modification of the basic cytologic sampling methods did not enhance the yields. 3) Contrary to published reports~ performing multiple sampling methods on the same stricture did not add to the biopsy result. Forceps biopsy is the sampling method of choice during ERCP.
VOLUME 43, NO. 4, 1996