- Email: [email protected]
or Pancreatic Ducts Have Positive Findings on EUS?
Abstracts
evaluate if intentional early needle exchange in EUS-FNA for suspected pancreatic adenocarcinoma reduces the number of passes required for a positive preliminary and final cytology diagnosis. METHODS: Informed consent was obtained from patients presenting for anticipated EUS-FNA of suspected pancreatic solid masses. Subjects were prospectively randomized to either a control single needle group (SNG) to receive a single 22-gauge needle with 6 separate passes (unless unexpected malfunction occurred), versus an experimental multiple needle group (MNG) where the needle was intentionally replaced by a new one after 2 passes, for a total of 3 new needle uses in such cases. Preliminary onsite cytology evaluation was performed of all passes by an experienced cytopathologist who was blinded to the assigned subject group. The endoscopist was unblinded to preliminary results of either group only after the sixth pass was obtained. Final diagnosis was established in the pathology lab from review of slides and cellblock material. Only patients with a final cytology diagnosis of pancreatic adenocarcinoma underwent subgroup comparative analysis of number of needles/passes required to establish the diagnosis. Complications were also assessed. RESULTS: From Oct 2007 to Sept 2010, 50 total patients were enrolled. Out of these, 40 had final cytology diagnosis of pancreatic adenocarcinoma, and were taken through study analysis. There were 20 patients in SNG and MNG each. The mean age of the entire group was 65 years (SD 12), and 23 were males. The lesions were in the uncinate (2), head (32), neck (2) and body (4), ranging from 5-66 mm on EUS. The mean number of passes performed in the SNG was 7.8 (SD 2.9) and in the MNG was 7.1 (SD 1.5), (p ⫽ 0.67). A positive onsite diagnosis was achieved by a mean of 4.7 passes (SD 4.4) in the SNG and 3.4 (SD 2.8) in the MNG, (p ⫽ 0.38). At least one unexpected needle change (UNC) occurred in 8 SNG and 7 MNG patients, (p ⫽ 1.00). The UNC occurred within the first 6 passes (mean 3.6) in 5/8 SNG patients. A total of 3 nonfatal self-limited complications occurred, all in SNG patients. CONCLUSIONS: Early needle exchange is not associated with more optimal efficiency to establish preliminary positive onsite cytology diagnosis during EUS-FNA of pancreatic adenocarcinoma. However, the use of a single needle for the entire FNA process may result in higher needle malfunction rates, which may have cost implications.
Mo1425 Which Patients With Dilated Common Bile and/or Pancreatic Ducts Have Positive Findings on EUS? Vernon J. Carriere, Susanne Shokoohi, Jason Conway, John A. Evans, Girish Mishra Gastroenterology, Wake Forest University Baptist Medical Center, Winston-Salem, NC Background: Patients with dilated common bile duct (CBD) (⬎7mm) and/or pancreatic duct (PD) on abdominal imaging are often referred for endoscopic ultrasound (EUS) which may not delineate an obvious etiology. Prior studies addressing this issue have been limited by small sample size. Aim: Find clinical factors which may predict which patients are more likely to have positive findings on EUS and describe the etiologies for the dilated ducts found on EUS. Methods: Patients referred for EUS for dilated CBD and/or PD between 10/03 to 2/10 without an obvious etiology were included in this study. Patient demographics, clinical variables, and EUS findings were recorded. Results: A total of 140 patients were included in the study with a mean age of 64 years, 51 (36%) male and 115 (82%) white. 105 (75%) patients had a presenting symptom of abdominal pain and 12 (9%) had no complaint recorded. 28 (22%) patients reported a history of heavy alcohol use, 15 (11%) patients had a history of acute pancreatitis, 5 (4%) had a history of chronic pancreatitis and 70 (50%) had a prior cholecystectomy. The CBD was dilated in 94 (67%) with a mean diameter of 12 mm, the PD was dilated in 16 (11%) with a mean diameter of 6 mm and both ducts were dilated in 30 (21%). The imaging used to diagnosis the dilated ducts were CT in 101 (73%), MRI in 17 (12%) and abdominal US in 16 (12%). 49 (36%) had elevated LFTs, 25 (8%) had an elevated bilirubin and 13 (23%) had an elevated lipase. EUS findings explained the dilated ducts in 54 (39%) of our patients and most common diagnoses included: CBD stone in 11 (8%), noncalcific chronic pancreatitis in 9 (6%), pancreatic mass in 8 (6%), IPMN in 7 (5%), periampullary diverticulum in 4 (3%), chronic calcific pancreatitis in 4 (3%), and pancreatic cyst in 4 (3%). EUS-FNA was performed on 17 lesions, mostly (76%) in the head. The median diameter of the pancreas masses was 18 mm (range 5-35 mm). Common diagnoses included: adenocarcinoma (6 patients), mucinous cystic neoplasm (4 ), benign tissue (3), pseudocyst (2), insufficient tissue (2). The table shows the clinical factors associated with finding an etiology for the dilated ducts on EUS. Conclusion: An etiology for dilated ducts on EUS was more likely in older individuals, males, and those not having an isolated CBD dilation. Individuals with isolated PD dilation or combined PD and CBD dilation and those with elevated LFT’s or lipase were also more likely to have an underlying etiology on EUS. Approximately 10% of patients were discovered to have unsuspecting neoplasia including invasive carcinoma. EUS should be strongly considered to unmask an etiology when evaluating dilated CBD and/or PD.
www.giejournal.org
No Etiology for Dilated Ducts on EUS
Etiology for Dilated Ducts on EUS
p value
61 26% 77% 14% 5 14% 11%
68 54% 52% 33% 7 38% 41%
0.006 0.001 0.002 0.007 0.02 ⬍0.001 0.021
Age (years) Male Dilated CBD only Dilated CBD and PD Diameter of PD (mm) Any LFT elevated Elevated lipase
Mo1426 Abnormal Psychometric Profiles in Patients With Suspected Sphincter of Oddi Dysfunction Dana C. Moffatt1,2, Olga Barkay2, Gregory A. Cote2, Lee McHenry2, James L. Watkins2, Glen A. Lehman2, Evan L. Fogel2 1 ERCP/Gastroenterology, University of Manitoba, Winnipeg, MB, Canada; 2Gastroenterology, Indiana University, Indianapolis, IN Background: SOD has been associated with both irritable bowel syndrome (and other functional gastrointestinal disorders), and psychiatric illness (such as anxiety, depression or somatoform disorders). Response to treatment with endoscopic sphincterotomy (ES) in type II and type III SOD patients is suboptimal, and bears significant risk to the patient. Psychometric profiles and screening tools for somatoform disorders may be useful in screening patients who will not respond to therapy prior to undergoing ERCP. Aims: (i) To compare the psychometric profiles of patients undergoing ERCP for suspected SOD with control (non-SOD) ERCP patients; (ii) to determine whether abnormalities as detected by psychometric testing were predictive of abnormal sphincter of Oddi manometry (SOM) and/or response to ES at ERCP. Methods Subjects consisted of prospectively enrolled outpatients referred to our institution for ERCP from December 2009 to May 2010 with an indication of suspected SOD (cases) or any other standard indication for ERCP (controls). SCL-90R and the Whitely somatization index (WI) were collected prior to ERCP, and scored using normative non-psychiatric outpatient data (i.e. standard scoring protocol). A score of ⬎ 95th %ile for each psychiatric domain on the SCL90Rwas considered significantly abnormal. ERCP and SOM were performed in standard fashion. Results of the SCL-90R and WI were not disclosed to the endoscopist prior to ERCP. Patients were contacted at a median 3 months post procedure to assess response to therapy, as indicated by a 11 point likert scale and a subjective global assessment of improvement assessed by the patient. Results: Seventy two (72) SOD (18 type 2, 54 type 3) and 140 control subjects were enrolled. SOD subjects scored ⬎95%ile more frequently in 8/11 domains of the SCL-90R and had overall higher scores on the WI (p⬍0.001) (Figure 1). Abnormal manometry was identified in 44/ 72 (61%) patients, all of whom underwent biliary, pancreatic or dual ES. Neither the WI nor any domain of the SCL-90R was individually predictive of abnormal SOM. At follow up, improvement in symptoms was present in 25/44 (57%) undergoing ES. A WI ⬎3/7 was associated with a lack of response to therapy, being present in 84% of non-responders and only 16% responders (p⬍0.001). Conclusions: Patients with suspected SOD have significantly higher levels of anxiety, depression, sensitivity, somatization, compulsiveness, and hostility on the SCL-90R and tended to have higher scores on the WI when compared to individuals undergoing ERCP for standard indications. A WI score ⬎ 3/7 was associated with a lack of response to ES and may be useful as a screening tool prior to ERCP and SOM in this challenging patient population.
Mo1427 The Efficacy of High Dose Nafamostat Mesylate for the Prevention of Post-ERCP Pancreatitis Su Bum Park, Kee Tae Park, Dae Hwan Kang, Hyung Wook Kim, Cheol Woong Choi, Tae Ik Park, Dong Hyeok Cha, Min Dae Kim, Jeung Ho Heo, Eul Jo Jeong Pusan National University Yangsan Hospital, YangSan -Si, Gyeongnam, Republic of Korea Background and Aim: Pancreatitis is a major complication of endoscopic retrograde cholangiopancreatography (ERCP). Continuous infusion of nafamostat mesylate (20mg), a protease inhibitor, is effective to prevent postERCP pancreatitis in only low risk groups. This study was performed to evaluate that high dose of nafamostat mesylate (50mg) was more effective for prevention of post-ERCP pancreatitis, especially in high risk groups. Methods: From Janually 2008 to July 2010, a total of 608 patients who were performed ERCP, were analyzed. Patients were infused with 20mg (group B, 198 patients) or 50mg (group C, 197 patients) of nafamostat mesylate or control (group A, 200 patients). Serum amylase and lipase levels were checked before ERCP, 4 and 24 hours after ERCP, and when clinically indicated. After ERCP, patients were classified as high-risk if they had a history of acute pancreatitis, suspected sphincter of Oddi dysfunction, difficult cannulation,
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB341
evaluate if intentional early needle exchange in EUS-FNA for suspected pancreatic adenocarcinoma reduces the number of passes required for a positive preliminary and final cytology diagnosis. METHODS: Informed consent was obtained from patients presenting for anticipated EUS-FNA of suspected pancreatic solid masses. Subjects were prospectively randomized to either a control single needle group (SNG) to receive a single 22-gauge needle with 6 separate passes (unless unexpected malfunction occurred), versus an experimental multiple needle group (MNG) where the needle was intentionally replaced by a new one after 2 passes, for a total of 3 new needle uses in such cases. Preliminary onsite cytology evaluation was performed of all passes by an experienced cytopathologist who was blinded to the assigned subject group. The endoscopist was unblinded to preliminary results of either group only after the sixth pass was obtained. Final diagnosis was established in the pathology lab from review of slides and cellblock material. Only patients with a final cytology diagnosis of pancreatic adenocarcinoma underwent subgroup comparative analysis of number of needles/passes required to establish the diagnosis. Complications were also assessed. RESULTS: From Oct 2007 to Sept 2010, 50 total patients were enrolled. Out of these, 40 had final cytology diagnosis of pancreatic adenocarcinoma, and were taken through study analysis. There were 20 patients in SNG and MNG each. The mean age of the entire group was 65 years (SD 12), and 23 were males. The lesions were in the uncinate (2), head (32), neck (2) and body (4), ranging from 5-66 mm on EUS. The mean number of passes performed in the SNG was 7.8 (SD 2.9) and in the MNG was 7.1 (SD 1.5), (p ⫽ 0.67). A positive onsite diagnosis was achieved by a mean of 4.7 passes (SD 4.4) in the SNG and 3.4 (SD 2.8) in the MNG, (p ⫽ 0.38). At least one unexpected needle change (UNC) occurred in 8 SNG and 7 MNG patients, (p ⫽ 1.00). The UNC occurred within the first 6 passes (mean 3.6) in 5/8 SNG patients. A total of 3 nonfatal self-limited complications occurred, all in SNG patients. CONCLUSIONS: Early needle exchange is not associated with more optimal efficiency to establish preliminary positive onsite cytology diagnosis during EUS-FNA of pancreatic adenocarcinoma. However, the use of a single needle for the entire FNA process may result in higher needle malfunction rates, which may have cost implications.
Mo1425 Which Patients With Dilated Common Bile and/or Pancreatic Ducts Have Positive Findings on EUS? Vernon J. Carriere, Susanne Shokoohi, Jason Conway, John A. Evans, Girish Mishra Gastroenterology, Wake Forest University Baptist Medical Center, Winston-Salem, NC Background: Patients with dilated common bile duct (CBD) (⬎7mm) and/or pancreatic duct (PD) on abdominal imaging are often referred for endoscopic ultrasound (EUS) which may not delineate an obvious etiology. Prior studies addressing this issue have been limited by small sample size. Aim: Find clinical factors which may predict which patients are more likely to have positive findings on EUS and describe the etiologies for the dilated ducts found on EUS. Methods: Patients referred for EUS for dilated CBD and/or PD between 10/03 to 2/10 without an obvious etiology were included in this study. Patient demographics, clinical variables, and EUS findings were recorded. Results: A total of 140 patients were included in the study with a mean age of 64 years, 51 (36%) male and 115 (82%) white. 105 (75%) patients had a presenting symptom of abdominal pain and 12 (9%) had no complaint recorded. 28 (22%) patients reported a history of heavy alcohol use, 15 (11%) patients had a history of acute pancreatitis, 5 (4%) had a history of chronic pancreatitis and 70 (50%) had a prior cholecystectomy. The CBD was dilated in 94 (67%) with a mean diameter of 12 mm, the PD was dilated in 16 (11%) with a mean diameter of 6 mm and both ducts were dilated in 30 (21%). The imaging used to diagnosis the dilated ducts were CT in 101 (73%), MRI in 17 (12%) and abdominal US in 16 (12%). 49 (36%) had elevated LFTs, 25 (8%) had an elevated bilirubin and 13 (23%) had an elevated lipase. EUS findings explained the dilated ducts in 54 (39%) of our patients and most common diagnoses included: CBD stone in 11 (8%), noncalcific chronic pancreatitis in 9 (6%), pancreatic mass in 8 (6%), IPMN in 7 (5%), periampullary diverticulum in 4 (3%), chronic calcific pancreatitis in 4 (3%), and pancreatic cyst in 4 (3%). EUS-FNA was performed on 17 lesions, mostly (76%) in the head. The median diameter of the pancreas masses was 18 mm (range 5-35 mm). Common diagnoses included: adenocarcinoma (6 patients), mucinous cystic neoplasm (4 ), benign tissue (3), pseudocyst (2), insufficient tissue (2). The table shows the clinical factors associated with finding an etiology for the dilated ducts on EUS. Conclusion: An etiology for dilated ducts on EUS was more likely in older individuals, males, and those not having an isolated CBD dilation. Individuals with isolated PD dilation or combined PD and CBD dilation and those with elevated LFT’s or lipase were also more likely to have an underlying etiology on EUS. Approximately 10% of patients were discovered to have unsuspecting neoplasia including invasive carcinoma. EUS should be strongly considered to unmask an etiology when evaluating dilated CBD and/or PD.
www.giejournal.org
No Etiology for Dilated Ducts on EUS
Etiology for Dilated Ducts on EUS
p value
61 26% 77% 14% 5 14% 11%
68 54% 52% 33% 7 38% 41%
0.006 0.001 0.002 0.007 0.02 ⬍0.001 0.021
Age (years) Male Dilated CBD only Dilated CBD and PD Diameter of PD (mm) Any LFT elevated Elevated lipase
Mo1426 Abnormal Psychometric Profiles in Patients With Suspected Sphincter of Oddi Dysfunction Dana C. Moffatt1,2, Olga Barkay2, Gregory A. Cote2, Lee McHenry2, James L. Watkins2, Glen A. Lehman2, Evan L. Fogel2 1 ERCP/Gastroenterology, University of Manitoba, Winnipeg, MB, Canada; 2Gastroenterology, Indiana University, Indianapolis, IN Background: SOD has been associated with both irritable bowel syndrome (and other functional gastrointestinal disorders), and psychiatric illness (such as anxiety, depression or somatoform disorders). Response to treatment with endoscopic sphincterotomy (ES) in type II and type III SOD patients is suboptimal, and bears significant risk to the patient. Psychometric profiles and screening tools for somatoform disorders may be useful in screening patients who will not respond to therapy prior to undergoing ERCP. Aims: (i) To compare the psychometric profiles of patients undergoing ERCP for suspected SOD with control (non-SOD) ERCP patients; (ii) to determine whether abnormalities as detected by psychometric testing were predictive of abnormal sphincter of Oddi manometry (SOM) and/or response to ES at ERCP. Methods Subjects consisted of prospectively enrolled outpatients referred to our institution for ERCP from December 2009 to May 2010 with an indication of suspected SOD (cases) or any other standard indication for ERCP (controls). SCL-90R and the Whitely somatization index (WI) were collected prior to ERCP, and scored using normative non-psychiatric outpatient data (i.e. standard scoring protocol). A score of ⬎ 95th %ile for each psychiatric domain on the SCL90Rwas considered significantly abnormal. ERCP and SOM were performed in standard fashion. Results of the SCL-90R and WI were not disclosed to the endoscopist prior to ERCP. Patients were contacted at a median 3 months post procedure to assess response to therapy, as indicated by a 11 point likert scale and a subjective global assessment of improvement assessed by the patient. Results: Seventy two (72) SOD (18 type 2, 54 type 3) and 140 control subjects were enrolled. SOD subjects scored ⬎95%ile more frequently in 8/11 domains of the SCL-90R and had overall higher scores on the WI (p⬍0.001) (Figure 1). Abnormal manometry was identified in 44/ 72 (61%) patients, all of whom underwent biliary, pancreatic or dual ES. Neither the WI nor any domain of the SCL-90R was individually predictive of abnormal SOM. At follow up, improvement in symptoms was present in 25/44 (57%) undergoing ES. A WI ⬎3/7 was associated with a lack of response to therapy, being present in 84% of non-responders and only 16% responders (p⬍0.001). Conclusions: Patients with suspected SOD have significantly higher levels of anxiety, depression, sensitivity, somatization, compulsiveness, and hostility on the SCL-90R and tended to have higher scores on the WI when compared to individuals undergoing ERCP for standard indications. A WI score ⬎ 3/7 was associated with a lack of response to ES and may be useful as a screening tool prior to ERCP and SOM in this challenging patient population.
Mo1427 The Efficacy of High Dose Nafamostat Mesylate for the Prevention of Post-ERCP Pancreatitis Su Bum Park, Kee Tae Park, Dae Hwan Kang, Hyung Wook Kim, Cheol Woong Choi, Tae Ik Park, Dong Hyeok Cha, Min Dae Kim, Jeung Ho Heo, Eul Jo Jeong Pusan National University Yangsan Hospital, YangSan -Si, Gyeongnam, Republic of Korea Background and Aim: Pancreatitis is a major complication of endoscopic retrograde cholangiopancreatography (ERCP). Continuous infusion of nafamostat mesylate (20mg), a protease inhibitor, is effective to prevent postERCP pancreatitis in only low risk groups. This study was performed to evaluate that high dose of nafamostat mesylate (50mg) was more effective for prevention of post-ERCP pancreatitis, especially in high risk groups. Methods: From Janually 2008 to July 2010, a total of 608 patients who were performed ERCP, were analyzed. Patients were infused with 20mg (group B, 198 patients) or 50mg (group C, 197 patients) of nafamostat mesylate or control (group A, 200 patients). Serum amylase and lipase levels were checked before ERCP, 4 and 24 hours after ERCP, and when clinically indicated. After ERCP, patients were classified as high-risk if they had a history of acute pancreatitis, suspected sphincter of Oddi dysfunction, difficult cannulation,
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB341