- Email: [email protected]
Outcomes of endoscopic management of post liver transplant biliary strictures
S82
Abstracts
cells). while the chronic inflammatory response dominated in each case, a significant minority of PMN cells was always present. Amylase and lipase levels were similar in group A and B. Conclusions: Intraductal infusion of Gabexate Mesylate doesn’t produce any significant ductal, vascular or acinar injury. However, GM was not effective in preventing pancreatitis induction by ERCP in our dog model. We believe that the efficacy of intraductal GM should be tested in large controlled trials in human. 257 Incidence of pancreatitis in patients undergoing sphincter of Oddi manometry without endoscopic retrograde cholangiopancreatography Syed T. Bin-Sagheer, M.D., Patrick G. Brady, M.D., Jay J. Mamel, M.D., Bruce Robinson, M.D., Division of Digestive Diseases, University of South Florida, Tampa, Florida. Purpose: Acute pancreatitis is a recognized complication of sphincter of Oddi manometry (SOM). Its frequency of occurrence has been reported in the range of 4% to 31%. In an earlier retrospective study done at this institution the incidence of pancreatitis was 9.3% in patients who only had SOM when compared to 26.1% in those patients who had SOM and ERCP with or without sphincterotomy at the same session. Looking at this data as a measure of quality improvement, at two university-affiliated hospitals, SOM was done without ERCP and if ERCP was required it was done at a different session. The purpose was to see if this practice decreases the incidence of pancreatitis. Methods: A prospective patient identification, retrospective chart review, of patients who underwent SOM without ERCP between May 98 and December 2000 was performed. SOM was performed using a triple lumen catheter with water perfusion at a rate of 0.25 ml/min using an Arndorfer pneumohydraulic capillary perfusion system. The data recorded included pancreatitis after SOM, pancreatitis after ERCP and sphincterotomy, average days in the hospital after pancreatitis and time between SOM and ERCP. Results: A total of 41 patients were studied. Three (7.32%) patients had pancreatitis after SOM. Five patients subsequently underwent ERCP and sphincterotomy and one (20%) patient had pancreatitis. The overall frequency of pancreatitis after SOM and any subsequent ERCP or sphincterotomy was 4/41 (9.78%). The average days in the hospital after pancreatitis ranged from 2– 4 days, mean 2.75 days. The time between SOM and ERCP if done ranged from 6 –20 days, mean 10.4 days. Conclusions: By adopting a protocol to perform SOM only and following with ERCP when required, we were able to decrease the incidence of pancreatitis considerably at our institutions. 258 Complete Choledocal Sphincterotomy (CCS) is effective in the treatment of recurrent pain post biliary sphincterotomy Rodrigo A Castillo, MD1, Manish Dhawan, MD1, Rad Agrawal, MD FACG 1 and TJ Ravi, MD 1*. 1Gastroenterology, Allegheny, General, Hospital, United States. Purpose: To recognize intestinal pseudo-obstruction secondary to Myotonic Muscular Dystrophy. Case presentation: A 24-year old white male with past medical history significant for asthma was admitted for a fourth episode of intestinal obstruction within the last 5 years. The first two episodes resolved with medical therapy. The third episode, 2 years ago, resulted in an exploratory laparotomy without any surgical pathology. His family history was significant for myotonic muscular dystrophy in his maternal grandmother and mother. The physical examination revealed bilateral temporal wasting, ptosis, atrophy of the sternocleidomastoid muscles and distal extremity weakness. Myotonia was noted in his hands. Abdomen was soft and scaphoid with diffuse tenderness.
AJG – Vol. 96, No. 9, Suppl., 2001
Laboratory data revealed contraction metabolic alkalosis, respiratory acidosis, hyperkalemia, hypocalcemia and acute renal failure. CPK, aldolase, FSH were elevated at 1196U/L (55-170U/L), 11.6U/L (0.4U/L), and 16.2MIU/ML (1-12MIU/L) respectively. Free and total testosterone levels were decreased at 2.6ng/dL (9-30ng/dL) and 60ng/dL (300-950ng/dL) respectively. DNA analysis showed 552 CTG trinucleotide repeats on the MPK gene consistent with full mutation for myotonic dystrophy. TSH, C-reactive protein, CBC and LFTs were within the normal range. EKG showed sinus tachycardia with mild intraventricular delay in leads II, III and aVF (QRS duration: 104ms). Patient had persistent obstructive picture. An abdominal CT showed extensive dilation of small bowel loops with a cut-off point at the distal small bowel. Exploratory laparotomy revealed adhesions and a thick fibrous band. They were lysed. Post-operatively, he continued to have high NG output for a prolonged period of time. Repeated plain X-rays of the abdomen and SBFT demonstrated persistent dilation of small bowel loops. No mechanical obstruction or mucosal abnormalities were identified. Patient eventually improved on IV prokinetic agents (metoclopramide and erythromycin). He was discharged on oral metoclopramide. Conclusions: Myotonic muscular dystrophy should be considered as a possible etiology of recurrent intestinal pseudo-obstruction. It is a rare autosomal dominant disorder which is always transmitted from the affected mother to her offspring. The condition is a product of an unstable CTG trinucleotide repeat in the MKP gene on chromosome 19q13.3. It affects all types of muscle. Most patients die between the ages of 40 and 60 years from cardiac and pulmonary complications. Treatment is symptomatic.
259 Outcomes of endoscopic management of post liver transplant biliary strictures Andrew T Catanzaro MD1, Gerard A Isenberg MD1*, Robert O’Shea MD1, Amitabh Chak MD1, Anthony Post MD1 and Michael V Sivak Jr. MD1. 1Division of Gastroenterology, University Hospitals of Cleveland Case Western Reserve University School of Medicine, Cleveland, Ohio, United States. Purpose: To evaluate the outcome of patients (pts) receiving endoscopic treatment for post liver transplant (OLT) biliary strictures (BS) at our institution. Methods: From 1989 to 2000, 296 pts had an OLT. Pts who had a choledocho-choledochostomy anastomosis and BS treated endoscopically were identified. Pts received a combination of dilation with balloon or Sohendra dilators (6 or 11 Fr), 1 or 2 stents (7 or 11.5 Fr), and sphincterotomy. Stents were changed at a 3 month interval unless the clinical condition necessitated more frequent change. Decision to abandon endoscopic therapy was made by the endoscopist and transplant team. Results: 23 [19 men and 4 women; mean age 47.7 (range 26 –70)] pts underwent endoscopic therapy for BS. The table below summarizes the type and outcome of the strictures. 3 of the 4 pts with nonanastomotic strictures had evidence of of hepatic artery thrombosis after their initial OLT. 82 ERCPs were performed [mean of 2.75/pt (SD 1.0)]. Mean follow up was 3.12 years (SD 2.24, range 0.5 to 9.6 yrs). 1 pt died secondary to recurrent hepatoma. Improvement in BS was judged as an increase of diameter of the stricture lumen. Mean length of endoscopic therapy was 310 days (SD 350). 4 pts are still undergoing endoscopic treatment. There were 7 procedural complications (cholangitis ⫽ 4, pancreatitis ⫽ 2, GI bleed ⫽ 1). For all pts treated, biochemical tests improved after each ERCP by a mean of 27.5 for AST (SD 91.1), 71.1 ALT (SD 257), Alk Phos 51 (SD 149.7), and T Bili 1.44 (SD 4.31). Conclusions: Treatment of simple post OLT anastomotic strictures endoscopically is effective. However, pts with the combination of biliary leak and nonanastomotic stricture did not respond to endoscopic therapy alone.
AJG – September, Suppl., 2001
Type
Abstracts
n
Surgical Bypass re-OLT improved death
Anastomotic stricture (AS) 12 AS/Non anastomotic stricture (NAS) 1 AS/NAS/ biliary leak 3 AS/biliary Leak 7 Total 23
3 0 3 3 9
0 1 3 1 5
9 0 0 3 12
0 0 0 1 1
260 Fungal colonization may play a role in biliary stent occlusion Rick A Chadha, M.D., Jack Leya, M.D.*, John Losurdo, M.D., James Harig, M.D. and Monica Leya, M.D. 1Gastroenterology, Loyola University Medical Center, Maywood, IL, United States. Purpose: Complications of biliary stent occlusion such as late recurrent jaundice and cholangitis remain a problem, with a median stent patency of 3 months. Several trials using antibiotic prophylaxis and ursodeoxycholic acid have not significantly prolonged biliary stent patency. Based on our previously published data associating fungi as a cause of PEG failure and occlusion, we decided to study fungal growth in our biliary stents. Methods: A total of 22 biliary stents that were removed between 6/97 and 5/01 were studied. The intraluminal contents of all of the biliary stents were sent for fungal culture. The removed stents were further subdivided into occluded and non occluded based on clinical and laboratory data. Data regarding indications for initial biliary stent placement and subsequent biliary stent removal were recorded. The duration between stent placement and stent removal was also recorded. Results: Of the 22 biliary stents studied, 12 were occluded and 10 were not occluded. Fungi grew from the intraluminal contents in 16 of the stents (73%). Predominant species included Candida albicans, Candida tropicalis, and Torulopsis glabrata. Furthermore, fungl grew significantly more in 12 of the occluded stents (100%) vs. 4 of the non occluded stents (40%), (p ⫽ 0.0077). Conclusions: Fungl colonized the majority of biliary stents, and all of the occluded biliary stents in our study. Fungal colonization may play a major role in biliary stent occlusion. The clinical implications of this finding are potentially vast. Recommendation for further study protocols are provided regarding industrial microbiology and materials science.
Fungal Colonization No Fungal Colonization
Occluded Stents
Non Occluded Stents
12 0
4 6
261 Diagnostic challenge in patients with doudenal ulcerogenic islet cell tumors William Y Chey, MD, FACG RI*, Ta-min Chang, PhD RI, Lee Y Kae RI, Songy Andrew RI, Li P James RI and Goldstein Jeffrey UR. 1 Gastroenterology, Rochester Institute for Digestive & Liver Diseases, Rochester, New York, United States; and 2Medicine/Gastroenterology, University of Rochester Medical Center, Rochester, New York, United States. Purpose: Early detection of islet cell tumors associated with ulcerogenic tumor syndrome remains a diagnostic challenge for clinicians, particularly when a tumor is small and could not be found by conventional diagnostic methods. The purpose of this study was to determine diagnostic accuracy of duodenal islet cell tumors associated with peptic ulceration. Methods: Among 50 patients with ulcerogenic islet cell tumors that we studied, 5 patients (3 males and 2 females with ages ranging 55 to 73 yrs) who exhibited recurrent peptic ulceration of the stomach and/or duodenum and gastric acid hypersecretion, were found to have islet cell tumors in their duodena. No islet cell tumor was found in their pancreata by exploratory laparotomy in these patients. Their basal gastric acid output ranged from 25 to 60 mmoles/hr with the mean of 39.8 mmoles/hr. Fasting plasma gastrin level ranged from 190 to 255 pg/ml with the mean of 221 pg/ml. Four of
S83
these 5 showed a significant rise in the gastrin concentration (⬎100 pg/ml) in response to iv secretin given at 1–2 clinical units/kg (positive secretion provocative test). The 4 diagnostic approaches were made; 1) esophagogastro-duodenoscopy (EGD), 2) CAT scan of the abdomen, 3) somatostatin receptor scintigraphy, and 4) endoscopic ultrasonography (EUS). Results: In only one patient, a 1.0 cm size submucosal tumor was found preoperatively in duodenal bulb by EGD using a retroflex maneuver technique but other diagnostic tests were negative. Immunohistological examination of the biopsies from the tumor showed numerous gastrin cells. In the remaining 4 patients, by manual palpation of duodenal wall, small islet cell tumors in sizes ranging from 0.25 mm to 0.5 cm in diameter were found in duodenal bulb in one, in mid-duodenum in the remaining two. The removal of the tumors had resulted in complete cessation of acid hypersecretion, healing of ulceration and significant decreases in plasma gastrin level below 100 pg/ml. Conclusions: These observations indicate that when diagnostic tests are unrevealing while gastric acid hypersecretion and hypergastrinemia or positive secretin provative test are well established, one should consider surgical exploratory laparotomy for diagnostic and therapeutic consideration. Supported in part by Konar Foundation.
262 A screening endoscopic pancreatic function test for patients with chronic abdominal pain Darwin L. Conwell, MD1, Gregory Zuccaro, MD1*, J Brad Morrow, MD1, Frederick VanLente, PhD2, John J Vargo, MD1, John A Dumot, DO1 and Patricia Trolli, RN, CGRN1. 1The Pancreas Clinic, Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, United States; and 2Department of Laboratory Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, United States. Purpose: Patients with chronic abdominal pain(CAP) are often evaluated for the diagnosis of chronic pancreatitis(CP). Hormonal stimulation tests are the true gold standard for assessing pancreatic function when imaging studies are negative. We have developed an endoscopic pancreatic function test (TTSPFT) that reliably distinguishes patients with established CP from normal volunteers. Our study aim was to further validate this new test by evaluating a group of patients with chronic abdominal pain, but not CP. Methods: Patients referred to our pancreas clinic with CAP (⬎6 months) but no risk factors or imaging studies to suggest chronic pancreatitis underwent TTS-PFT: IV CCK octapeptide (40 ng/kg/h, Sincalide, Bracco Diagnostics Inc., Princeton, NJ)) was started in pre-procedure area. Duodenal fluid collected on ice via an upper endoscope (Olympus GIF 130) in four-10 minute aliquots at baseline, 30,40,50 and 60 minutes. Duodenal drainage fluid sent for analysis on lab autoanalyzer. Peak lipase concentrations were compared to those of normal volunteers and those with established CP. Chronic pancreatitis was determined by imaging (calcifications) and/or retrograde pancreatogram (Cambridge II-IV). Results: A total of 59 patients underwent TTS-PFT: 22 normal volunteers (NV), 18 chronic pancreatitis (CP), 19 chronic abdominal pain (CAP). All CAP pts had negative imaging studies (18-EGD, 14ERCP/MRCP, 9-EUS, 6-CT scan). Peak lipase concentrations mean(range) were as follows. NV 1,560,628 IU/L (653,400 –3,087,000),CP 380,518 IU/L (12,216 – 828,000) and CAP 1,812,667 (792,000 –3,402,000) (p ⬍ 0.001 for CAP vs. CP, and NV vs. CP, ANOVA). A cut-off of 830,000 IU/L provides maximum sens (100%) and spec (94%) for separating pts with CP from those with CAP but no risk factors for CP. There were no episodes of pancreatitis or complications associated with the procedure. Conclusions: Pancreatic function in patients with unexplained CAP is no different than NV. Endoscopic pancreatic function testing has excellent sensitivity and specificity for separating CAP pts from those with established CP. Targeted endoscopic collection of duodenal drainage fluid can be done by practicing gastroenterologist during routine upper endoscopy. Unlike other screening tests in patients with CAP (e.g. EUS), TTS-PFT reliably excludes the diagnosis of CP and can eliminate the need for more invasive/morbid procedures (ERCP, pancreatic biopsy). Patients with bor-
Abstracts
cells). while the chronic inflammatory response dominated in each case, a significant minority of PMN cells was always present. Amylase and lipase levels were similar in group A and B. Conclusions: Intraductal infusion of Gabexate Mesylate doesn’t produce any significant ductal, vascular or acinar injury. However, GM was not effective in preventing pancreatitis induction by ERCP in our dog model. We believe that the efficacy of intraductal GM should be tested in large controlled trials in human. 257 Incidence of pancreatitis in patients undergoing sphincter of Oddi manometry without endoscopic retrograde cholangiopancreatography Syed T. Bin-Sagheer, M.D., Patrick G. Brady, M.D., Jay J. Mamel, M.D., Bruce Robinson, M.D., Division of Digestive Diseases, University of South Florida, Tampa, Florida. Purpose: Acute pancreatitis is a recognized complication of sphincter of Oddi manometry (SOM). Its frequency of occurrence has been reported in the range of 4% to 31%. In an earlier retrospective study done at this institution the incidence of pancreatitis was 9.3% in patients who only had SOM when compared to 26.1% in those patients who had SOM and ERCP with or without sphincterotomy at the same session. Looking at this data as a measure of quality improvement, at two university-affiliated hospitals, SOM was done without ERCP and if ERCP was required it was done at a different session. The purpose was to see if this practice decreases the incidence of pancreatitis. Methods: A prospective patient identification, retrospective chart review, of patients who underwent SOM without ERCP between May 98 and December 2000 was performed. SOM was performed using a triple lumen catheter with water perfusion at a rate of 0.25 ml/min using an Arndorfer pneumohydraulic capillary perfusion system. The data recorded included pancreatitis after SOM, pancreatitis after ERCP and sphincterotomy, average days in the hospital after pancreatitis and time between SOM and ERCP. Results: A total of 41 patients were studied. Three (7.32%) patients had pancreatitis after SOM. Five patients subsequently underwent ERCP and sphincterotomy and one (20%) patient had pancreatitis. The overall frequency of pancreatitis after SOM and any subsequent ERCP or sphincterotomy was 4/41 (9.78%). The average days in the hospital after pancreatitis ranged from 2– 4 days, mean 2.75 days. The time between SOM and ERCP if done ranged from 6 –20 days, mean 10.4 days. Conclusions: By adopting a protocol to perform SOM only and following with ERCP when required, we were able to decrease the incidence of pancreatitis considerably at our institutions. 258 Complete Choledocal Sphincterotomy (CCS) is effective in the treatment of recurrent pain post biliary sphincterotomy Rodrigo A Castillo, MD1, Manish Dhawan, MD1, Rad Agrawal, MD FACG 1 and TJ Ravi, MD 1*. 1Gastroenterology, Allegheny, General, Hospital, United States. Purpose: To recognize intestinal pseudo-obstruction secondary to Myotonic Muscular Dystrophy. Case presentation: A 24-year old white male with past medical history significant for asthma was admitted for a fourth episode of intestinal obstruction within the last 5 years. The first two episodes resolved with medical therapy. The third episode, 2 years ago, resulted in an exploratory laparotomy without any surgical pathology. His family history was significant for myotonic muscular dystrophy in his maternal grandmother and mother. The physical examination revealed bilateral temporal wasting, ptosis, atrophy of the sternocleidomastoid muscles and distal extremity weakness. Myotonia was noted in his hands. Abdomen was soft and scaphoid with diffuse tenderness.
AJG – Vol. 96, No. 9, Suppl., 2001
Laboratory data revealed contraction metabolic alkalosis, respiratory acidosis, hyperkalemia, hypocalcemia and acute renal failure. CPK, aldolase, FSH were elevated at 1196U/L (55-170U/L), 11.6U/L (0.4U/L), and 16.2MIU/ML (1-12MIU/L) respectively. Free and total testosterone levels were decreased at 2.6ng/dL (9-30ng/dL) and 60ng/dL (300-950ng/dL) respectively. DNA analysis showed 552 CTG trinucleotide repeats on the MPK gene consistent with full mutation for myotonic dystrophy. TSH, C-reactive protein, CBC and LFTs were within the normal range. EKG showed sinus tachycardia with mild intraventricular delay in leads II, III and aVF (QRS duration: 104ms). Patient had persistent obstructive picture. An abdominal CT showed extensive dilation of small bowel loops with a cut-off point at the distal small bowel. Exploratory laparotomy revealed adhesions and a thick fibrous band. They were lysed. Post-operatively, he continued to have high NG output for a prolonged period of time. Repeated plain X-rays of the abdomen and SBFT demonstrated persistent dilation of small bowel loops. No mechanical obstruction or mucosal abnormalities were identified. Patient eventually improved on IV prokinetic agents (metoclopramide and erythromycin). He was discharged on oral metoclopramide. Conclusions: Myotonic muscular dystrophy should be considered as a possible etiology of recurrent intestinal pseudo-obstruction. It is a rare autosomal dominant disorder which is always transmitted from the affected mother to her offspring. The condition is a product of an unstable CTG trinucleotide repeat in the MKP gene on chromosome 19q13.3. It affects all types of muscle. Most patients die between the ages of 40 and 60 years from cardiac and pulmonary complications. Treatment is symptomatic.
259 Outcomes of endoscopic management of post liver transplant biliary strictures Andrew T Catanzaro MD1, Gerard A Isenberg MD1*, Robert O’Shea MD1, Amitabh Chak MD1, Anthony Post MD1 and Michael V Sivak Jr. MD1. 1Division of Gastroenterology, University Hospitals of Cleveland Case Western Reserve University School of Medicine, Cleveland, Ohio, United States. Purpose: To evaluate the outcome of patients (pts) receiving endoscopic treatment for post liver transplant (OLT) biliary strictures (BS) at our institution. Methods: From 1989 to 2000, 296 pts had an OLT. Pts who had a choledocho-choledochostomy anastomosis and BS treated endoscopically were identified. Pts received a combination of dilation with balloon or Sohendra dilators (6 or 11 Fr), 1 or 2 stents (7 or 11.5 Fr), and sphincterotomy. Stents were changed at a 3 month interval unless the clinical condition necessitated more frequent change. Decision to abandon endoscopic therapy was made by the endoscopist and transplant team. Results: 23 [19 men and 4 women; mean age 47.7 (range 26 –70)] pts underwent endoscopic therapy for BS. The table below summarizes the type and outcome of the strictures. 3 of the 4 pts with nonanastomotic strictures had evidence of of hepatic artery thrombosis after their initial OLT. 82 ERCPs were performed [mean of 2.75/pt (SD 1.0)]. Mean follow up was 3.12 years (SD 2.24, range 0.5 to 9.6 yrs). 1 pt died secondary to recurrent hepatoma. Improvement in BS was judged as an increase of diameter of the stricture lumen. Mean length of endoscopic therapy was 310 days (SD 350). 4 pts are still undergoing endoscopic treatment. There were 7 procedural complications (cholangitis ⫽ 4, pancreatitis ⫽ 2, GI bleed ⫽ 1). For all pts treated, biochemical tests improved after each ERCP by a mean of 27.5 for AST (SD 91.1), 71.1 ALT (SD 257), Alk Phos 51 (SD 149.7), and T Bili 1.44 (SD 4.31). Conclusions: Treatment of simple post OLT anastomotic strictures endoscopically is effective. However, pts with the combination of biliary leak and nonanastomotic stricture did not respond to endoscopic therapy alone.
AJG – September, Suppl., 2001
Type
Abstracts
n
Surgical Bypass re-OLT improved death
Anastomotic stricture (AS) 12 AS/Non anastomotic stricture (NAS) 1 AS/NAS/ biliary leak 3 AS/biliary Leak 7 Total 23
3 0 3 3 9
0 1 3 1 5
9 0 0 3 12
0 0 0 1 1
260 Fungal colonization may play a role in biliary stent occlusion Rick A Chadha, M.D., Jack Leya, M.D.*, John Losurdo, M.D., James Harig, M.D. and Monica Leya, M.D. 1Gastroenterology, Loyola University Medical Center, Maywood, IL, United States. Purpose: Complications of biliary stent occlusion such as late recurrent jaundice and cholangitis remain a problem, with a median stent patency of 3 months. Several trials using antibiotic prophylaxis and ursodeoxycholic acid have not significantly prolonged biliary stent patency. Based on our previously published data associating fungi as a cause of PEG failure and occlusion, we decided to study fungal growth in our biliary stents. Methods: A total of 22 biliary stents that were removed between 6/97 and 5/01 were studied. The intraluminal contents of all of the biliary stents were sent for fungal culture. The removed stents were further subdivided into occluded and non occluded based on clinical and laboratory data. Data regarding indications for initial biliary stent placement and subsequent biliary stent removal were recorded. The duration between stent placement and stent removal was also recorded. Results: Of the 22 biliary stents studied, 12 were occluded and 10 were not occluded. Fungi grew from the intraluminal contents in 16 of the stents (73%). Predominant species included Candida albicans, Candida tropicalis, and Torulopsis glabrata. Furthermore, fungl grew significantly more in 12 of the occluded stents (100%) vs. 4 of the non occluded stents (40%), (p ⫽ 0.0077). Conclusions: Fungl colonized the majority of biliary stents, and all of the occluded biliary stents in our study. Fungal colonization may play a major role in biliary stent occlusion. The clinical implications of this finding are potentially vast. Recommendation for further study protocols are provided regarding industrial microbiology and materials science.
Fungal Colonization No Fungal Colonization
Occluded Stents
Non Occluded Stents
12 0
4 6
261 Diagnostic challenge in patients with doudenal ulcerogenic islet cell tumors William Y Chey, MD, FACG RI*, Ta-min Chang, PhD RI, Lee Y Kae RI, Songy Andrew RI, Li P James RI and Goldstein Jeffrey UR. 1 Gastroenterology, Rochester Institute for Digestive & Liver Diseases, Rochester, New York, United States; and 2Medicine/Gastroenterology, University of Rochester Medical Center, Rochester, New York, United States. Purpose: Early detection of islet cell tumors associated with ulcerogenic tumor syndrome remains a diagnostic challenge for clinicians, particularly when a tumor is small and could not be found by conventional diagnostic methods. The purpose of this study was to determine diagnostic accuracy of duodenal islet cell tumors associated with peptic ulceration. Methods: Among 50 patients with ulcerogenic islet cell tumors that we studied, 5 patients (3 males and 2 females with ages ranging 55 to 73 yrs) who exhibited recurrent peptic ulceration of the stomach and/or duodenum and gastric acid hypersecretion, were found to have islet cell tumors in their duodena. No islet cell tumor was found in their pancreata by exploratory laparotomy in these patients. Their basal gastric acid output ranged from 25 to 60 mmoles/hr with the mean of 39.8 mmoles/hr. Fasting plasma gastrin level ranged from 190 to 255 pg/ml with the mean of 221 pg/ml. Four of
S83
these 5 showed a significant rise in the gastrin concentration (⬎100 pg/ml) in response to iv secretin given at 1–2 clinical units/kg (positive secretion provocative test). The 4 diagnostic approaches were made; 1) esophagogastro-duodenoscopy (EGD), 2) CAT scan of the abdomen, 3) somatostatin receptor scintigraphy, and 4) endoscopic ultrasonography (EUS). Results: In only one patient, a 1.0 cm size submucosal tumor was found preoperatively in duodenal bulb by EGD using a retroflex maneuver technique but other diagnostic tests were negative. Immunohistological examination of the biopsies from the tumor showed numerous gastrin cells. In the remaining 4 patients, by manual palpation of duodenal wall, small islet cell tumors in sizes ranging from 0.25 mm to 0.5 cm in diameter were found in duodenal bulb in one, in mid-duodenum in the remaining two. The removal of the tumors had resulted in complete cessation of acid hypersecretion, healing of ulceration and significant decreases in plasma gastrin level below 100 pg/ml. Conclusions: These observations indicate that when diagnostic tests are unrevealing while gastric acid hypersecretion and hypergastrinemia or positive secretin provative test are well established, one should consider surgical exploratory laparotomy for diagnostic and therapeutic consideration. Supported in part by Konar Foundation.
262 A screening endoscopic pancreatic function test for patients with chronic abdominal pain Darwin L. Conwell, MD1, Gregory Zuccaro, MD1*, J Brad Morrow, MD1, Frederick VanLente, PhD2, John J Vargo, MD1, John A Dumot, DO1 and Patricia Trolli, RN, CGRN1. 1The Pancreas Clinic, Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, United States; and 2Department of Laboratory Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, United States. Purpose: Patients with chronic abdominal pain(CAP) are often evaluated for the diagnosis of chronic pancreatitis(CP). Hormonal stimulation tests are the true gold standard for assessing pancreatic function when imaging studies are negative. We have developed an endoscopic pancreatic function test (TTSPFT) that reliably distinguishes patients with established CP from normal volunteers. Our study aim was to further validate this new test by evaluating a group of patients with chronic abdominal pain, but not CP. Methods: Patients referred to our pancreas clinic with CAP (⬎6 months) but no risk factors or imaging studies to suggest chronic pancreatitis underwent TTS-PFT: IV CCK octapeptide (40 ng/kg/h, Sincalide, Bracco Diagnostics Inc., Princeton, NJ)) was started in pre-procedure area. Duodenal fluid collected on ice via an upper endoscope (Olympus GIF 130) in four-10 minute aliquots at baseline, 30,40,50 and 60 minutes. Duodenal drainage fluid sent for analysis on lab autoanalyzer. Peak lipase concentrations were compared to those of normal volunteers and those with established CP. Chronic pancreatitis was determined by imaging (calcifications) and/or retrograde pancreatogram (Cambridge II-IV). Results: A total of 59 patients underwent TTS-PFT: 22 normal volunteers (NV), 18 chronic pancreatitis (CP), 19 chronic abdominal pain (CAP). All CAP pts had negative imaging studies (18-EGD, 14ERCP/MRCP, 9-EUS, 6-CT scan). Peak lipase concentrations mean(range) were as follows. NV 1,560,628 IU/L (653,400 –3,087,000),CP 380,518 IU/L (12,216 – 828,000) and CAP 1,812,667 (792,000 –3,402,000) (p ⬍ 0.001 for CAP vs. CP, and NV vs. CP, ANOVA). A cut-off of 830,000 IU/L provides maximum sens (100%) and spec (94%) for separating pts with CP from those with CAP but no risk factors for CP. There were no episodes of pancreatitis or complications associated with the procedure. Conclusions: Pancreatic function in patients with unexplained CAP is no different than NV. Endoscopic pancreatic function testing has excellent sensitivity and specificity for separating CAP pts from those with established CP. Targeted endoscopic collection of duodenal drainage fluid can be done by practicing gastroenterologist during routine upper endoscopy. Unlike other screening tests in patients with CAP (e.g. EUS), TTS-PFT reliably excludes the diagnosis of CP and can eliminate the need for more invasive/morbid procedures (ERCP, pancreatic biopsy). Patients with bor-