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Sonographically guided puncture of pancreatic masses, results and complications
A440 AGA ABSTRACTS
GASTROENTEROLOGYVol. 114, No. 4
G1788
Conclusion: 1. The prevalence of SIBO, though high in FCPD patients, is
FACTORS THAT HAVE RESULTED IN THE REDUCED MORTALITY OF ACUTE PANCREATITIS FROM 1978-1997. S. Bank, N. Pandaraboyina, B. Stark, K. Patel. Div. of Gastro. Long Island Jewish Medical Center, New Hyde Park, NY, The Long Island Campus for Albert Einstein College of Medicine.
similar to those noted in IDDM and asymptomatic controls. 2. SIBO is highly prevalent among poor and undernourished asymptomatic persons living in the tropical environment
A Prospective study of 4 time periods, i.e. 1978-82, 1983-87, 1988-92, 1993-97 showed a steady decline in the mortality of acute pancreatitis from 13.5% to 8%, to 7% and lastly, to 5% respectively. During this time, the incidence of pancreatitis has escalated so that the overall mortality has increased despite the reduction of percentage terms. The increase of acute cases in the later periods is almost totally due to an exponential rise in gallstone pancreatitis and a few miscellaneous forms such as ERCP, etc. The most impressive decrease in mortality has been in the patients with severe acute pancreatitis (SAP) from about 50% in the early period to between 12-17% over the last 4 yrs. The factors contributing to this decrease were: 1983-87 - the introduction of the common signs of severity, i.e. Ranson's and Bank's signs leading to immediate ICU therapy, improved ICU care, particularly for cardiac, pulmonary and renal complications. 1988-92 - CT scan became included in the severity score especially with regard to intrapancreatic necrosis, ICU techniques advanced and prolonged drainage of pancreatic abscess or necrotic tissue was introduced. In the middle of this period, skinny needle aspiration for the diagnosis of infection became popular. From 1992-97 the value of early antibiotics in pancreatic necrosis became established, multiple organ system failure was treated intensively with the return to use of Dextran in some centers, octreotide, somatostatin and PAF. Selective bacterial decontamination of the gut was introduced and newer antibiotics which penetrated the necrotic tissue were introduced. The place of emergency ERCP in non-alcohol induced pancreatitis became established particularly in cholangitis. Treatment of complications took great strides with both endoscopic and radiologic nonsurgical techniques taking a quantum leap for the treatment of cysts, persistent necrosis, ascites. Trials of newer agents, i.e. platelet activating factor antagonist have yet to be shown conclusively to decrease the early mortality. Conclusion: This 20 year personal prospective study has shown an impressive decline in the mortality of acute pancreatitis from 13.5-5% especially SAP. Early markers of severity and cytokine antagonists have yet to prove efficacy in reducing the mortality further. • G1789 EVALUATION OF SMALL INTESTINAL BACTERIAL OVERGROWTH IN FIBROCALCULOUS PANCREATIC DIABETES. P.K Bardhan M Kogon, Dhaka, Bangladesh, and Basel, Switzerland; A K Azad Khan, Dhaka, Bangladesh; C Beglinger, N Gyr, Basel, Switzerland. Introduction: Fibrocalculous pancreatic diabetes (FCPD) is characterized by functional and morphological damage of the pancreas, typically evident by the presence of insulin dependent diabetes mellitus (IDDM) and diffuse pancreatic calcification. Small intestinal bacterial overgrowth is present in a significant proportion of patients with chronic pancreatitis. The aim of this prospective study was to evaluate small intestinal bacterial overgrowth (SIBO) in patients with FCPD. Methods: Eight patients with FCPD (age 19-28 years) participated in the study. Pancreatic calcifications were identified by plain X-rays of the abdomen. The X-ray films were examined by an independent radiologist who was unaware of the clinical diagnoses. SIBO was diagnosed by the 14C-Xylose breath test. After oral administration of 10 laCi 14C -Xylose with lg of unlabeled xylose in 300 ml of water, breath excretion of 14CO2 was determined every 30 minutes for 3 hours. The diagnosis of SIBO was made by comparison of the 14CO2 excretion curve of each patient to the range previously determined on asymptomatic healthy controls proven SIBO negative by culture. Another 7 patients with IDDM (age 18-30 years) matched for age and nutritional status and without pancreatic calcifications or any other feature suggestive of gastrointestinal, neurological, renal or cardiovascular complication were also studied as disease controls. Eight asymptomatic persons (age 19-27 years) with normal oral glucose tolerance test and abdominal X-rays, and matched for age and nutritional status, served as asymptomatic controls. All study subjects were non-alcoholics, and did not take any antibiotic in the three months preceding the studies. Results are in mean _+SD. Results: All study subjects were undernourished (Body Mass Index 18 +_1 in FCPD, 17+-2 in IDDM, 17-+2 in asymptomatic controls), with poor socioeconomic background. 14C-Xylose test positive 14C-Xylose test negative
FCPD 6 2
IDDM 5 2
Asymptomatic controls 7 1
The differences are not statistically significant. The area under curve (AUC) calculated from the individual breath 14CO2excretion curves were 284 -+61 in SIBO positive subjects and 200 -+ 38 in SIBO negative subjects (p < 0.01). AUC of the asymptomatic controls (346 -+49) are significantly higher compared to those of FCPD (230-+36, p < .001) and IDDM patients (221 +-43, p < .001).
G1790 CHRONIC PANCREATITIS AND INFLAMMATORY BOWEL DISEASE: EVIDENCE FOR THE EXISTENCE OF SCLEROSING PANCREATITIS? M. Barthet (1), P. Hastier (2), JP. Bernard (3), G. Bordes (4), MC. Saint-Paul (3), JP. Delmont (2), JC. Grimaud (1), J. Sahel (3). (1) Hopital Nord, Department of Gastroenterology; (2) Hopital SainteMarguerite, Department of Gastroentrology, Marseille; (3) Hopital L'Archet, Department of Gastroentrology, Nice; (4) Centre Hospitalier g6nrral, Department of Gastroentrology, Digne, FRANCE Several cases of pancreatitis have been described during the course of Crohn's disease (CD) or ulcerative colitis (UC) but many of them were related to either biliary lithiasis or drug intake. We tried to evaluate and to define the clinical and morphological features of so called idiopathic pancreatitis associated with inflammatory bowel disease. We found 6 patients presenting with features of chronic idiopathic pancreatitis and ulcerative colitis and two with Crohn's disease seen between 1981 and 1996 in three hospital centers of the south of France. A review of the literature has identified 6 cases of pancreatitis associated with UC and 14 cases of pancreatitis associated with CD based on the above criteria. Hyperamylasemia was not a sensitive test as it was present in 44% and 64% of patients with UC or CD. In UC, pancreatitis was a prior manifestation in 58% of cases. In contrast, the pancreatitis appeared after the onset of CD in 58% Of the cases. In patients with UC, pancreatitis was associated with severe disease revealed by pancolitis (42%) and subsequent surgery. Bile duct involvement was more frequent in patients with UC than with CD (58% vs 12%) mostly in the absence of sclerosing cholangitis (16% vs 6%). Weightloss and pancreatic duct stenosis were also more frequent in UC than in CD (41 vs 12% and 50% vs 19% respectively). Pathological specimens were analysed in 5 cases and demonstrated the presence of inter and intralobular fibrosis with marked acinar regression in three cases and the presence of granulomas in two patients, both with CD. Pancreatitis is a rare extraintestinal manifestations of IBD. Chronic pancreatitis associated with UC differs from that observed in CD by the presence of more frequent bile duct involvement, weight loss, and pancreatic duct stenosis possibly giving a pseudo tumor pattern. G1791 SONOGRAPHICALLY GUIDED PUNCTURE OF PANCREATIC MASSES, RESULTS AND COMPLICATIONS. D. Becker, J. Wiinsche, D. Strobel, M. Wehler D. Tauschek, C. Herold, E. G. Hahn. Dept. of Medicine, Friedrich-Alexander-University of Erlangen-Nuremberg, Germany Sonographically guided puncture of pancreatic masses often appears to be difficult and dangerous due to surrounding vessels and overlying gut structures. Therefore we retrospectively analyzed the results and the complications of patients where a puncture of pancreatic masses was performed. Punctures were carded out using a 21-F- (1,1 ram) biopsy needle with a lumen inside the needle of 0,9 mm. By this we achieve tissue cylinders which can be evaluated histologically. Indications for puncture were always the attempt to verify or exclude a suspected malignoma of the pancreas. Method: All patients who underwent sonographically guided puncture of pancreatic masses within the last four years were analyzed. The results of definitive diagnosis were compared to the biopsy results. Definitive diagnosis was defined intraoperatively, by biopsy in case of a malignant histology or by clinical follow-up. When patients survived at least one year after benign biopsy, a malignoma was excluded. Furthermore, all complications reported were analyzed. Results: 47 patients with suspicion of pancreatic malignoma underwent sonographically guided puncture. Mean age was 56,8 +/- 14,7 years. 36 patients had solid masses, eleven patients had cystic masses with the suspicion of malignancy. The mean diameter of masses was 2,8 +/- 1,3 cm. Pancreatic malignoma was secured in 25 patients (23 pancreatic carcinomas, two lymphomas), 22 patients had benign diseases of the pancreas (acute or chronic inflammation, pseudocyst, abscess). Sensitivity for sonographically guided puncture was 76%, specificity was 100%. No severe complication (bleeding, pancreatitis, infection) was reported, only in one case a selflimiting arterial hypotension (RR 80/50 mm Hg) was present. Conclusion: Sonographically guided pancreatic puncture is a safe, efficient and reliable diagnostic procedure which can be carried out to determine the definitive diagnosis in cases of pancreatic masses with suspicion of malignancy. But it should only be performed when the therapeutic management will be influenced by the result obtained.
GASTROENTEROLOGYVol. 114, No. 4
G1788
Conclusion: 1. The prevalence of SIBO, though high in FCPD patients, is
FACTORS THAT HAVE RESULTED IN THE REDUCED MORTALITY OF ACUTE PANCREATITIS FROM 1978-1997. S. Bank, N. Pandaraboyina, B. Stark, K. Patel. Div. of Gastro. Long Island Jewish Medical Center, New Hyde Park, NY, The Long Island Campus for Albert Einstein College of Medicine.
similar to those noted in IDDM and asymptomatic controls. 2. SIBO is highly prevalent among poor and undernourished asymptomatic persons living in the tropical environment
A Prospective study of 4 time periods, i.e. 1978-82, 1983-87, 1988-92, 1993-97 showed a steady decline in the mortality of acute pancreatitis from 13.5% to 8%, to 7% and lastly, to 5% respectively. During this time, the incidence of pancreatitis has escalated so that the overall mortality has increased despite the reduction of percentage terms. The increase of acute cases in the later periods is almost totally due to an exponential rise in gallstone pancreatitis and a few miscellaneous forms such as ERCP, etc. The most impressive decrease in mortality has been in the patients with severe acute pancreatitis (SAP) from about 50% in the early period to between 12-17% over the last 4 yrs. The factors contributing to this decrease were: 1983-87 - the introduction of the common signs of severity, i.e. Ranson's and Bank's signs leading to immediate ICU therapy, improved ICU care, particularly for cardiac, pulmonary and renal complications. 1988-92 - CT scan became included in the severity score especially with regard to intrapancreatic necrosis, ICU techniques advanced and prolonged drainage of pancreatic abscess or necrotic tissue was introduced. In the middle of this period, skinny needle aspiration for the diagnosis of infection became popular. From 1992-97 the value of early antibiotics in pancreatic necrosis became established, multiple organ system failure was treated intensively with the return to use of Dextran in some centers, octreotide, somatostatin and PAF. Selective bacterial decontamination of the gut was introduced and newer antibiotics which penetrated the necrotic tissue were introduced. The place of emergency ERCP in non-alcohol induced pancreatitis became established particularly in cholangitis. Treatment of complications took great strides with both endoscopic and radiologic nonsurgical techniques taking a quantum leap for the treatment of cysts, persistent necrosis, ascites. Trials of newer agents, i.e. platelet activating factor antagonist have yet to be shown conclusively to decrease the early mortality. Conclusion: This 20 year personal prospective study has shown an impressive decline in the mortality of acute pancreatitis from 13.5-5% especially SAP. Early markers of severity and cytokine antagonists have yet to prove efficacy in reducing the mortality further. • G1789 EVALUATION OF SMALL INTESTINAL BACTERIAL OVERGROWTH IN FIBROCALCULOUS PANCREATIC DIABETES. P.K Bardhan M Kogon, Dhaka, Bangladesh, and Basel, Switzerland; A K Azad Khan, Dhaka, Bangladesh; C Beglinger, N Gyr, Basel, Switzerland. Introduction: Fibrocalculous pancreatic diabetes (FCPD) is characterized by functional and morphological damage of the pancreas, typically evident by the presence of insulin dependent diabetes mellitus (IDDM) and diffuse pancreatic calcification. Small intestinal bacterial overgrowth is present in a significant proportion of patients with chronic pancreatitis. The aim of this prospective study was to evaluate small intestinal bacterial overgrowth (SIBO) in patients with FCPD. Methods: Eight patients with FCPD (age 19-28 years) participated in the study. Pancreatic calcifications were identified by plain X-rays of the abdomen. The X-ray films were examined by an independent radiologist who was unaware of the clinical diagnoses. SIBO was diagnosed by the 14C-Xylose breath test. After oral administration of 10 laCi 14C -Xylose with lg of unlabeled xylose in 300 ml of water, breath excretion of 14CO2 was determined every 30 minutes for 3 hours. The diagnosis of SIBO was made by comparison of the 14CO2 excretion curve of each patient to the range previously determined on asymptomatic healthy controls proven SIBO negative by culture. Another 7 patients with IDDM (age 18-30 years) matched for age and nutritional status and without pancreatic calcifications or any other feature suggestive of gastrointestinal, neurological, renal or cardiovascular complication were also studied as disease controls. Eight asymptomatic persons (age 19-27 years) with normal oral glucose tolerance test and abdominal X-rays, and matched for age and nutritional status, served as asymptomatic controls. All study subjects were non-alcoholics, and did not take any antibiotic in the three months preceding the studies. Results are in mean _+SD. Results: All study subjects were undernourished (Body Mass Index 18 +_1 in FCPD, 17+-2 in IDDM, 17-+2 in asymptomatic controls), with poor socioeconomic background. 14C-Xylose test positive 14C-Xylose test negative
FCPD 6 2
IDDM 5 2
Asymptomatic controls 7 1
The differences are not statistically significant. The area under curve (AUC) calculated from the individual breath 14CO2excretion curves were 284 -+61 in SIBO positive subjects and 200 -+ 38 in SIBO negative subjects (p < 0.01). AUC of the asymptomatic controls (346 -+49) are significantly higher compared to those of FCPD (230-+36, p < .001) and IDDM patients (221 +-43, p < .001).
G1790 CHRONIC PANCREATITIS AND INFLAMMATORY BOWEL DISEASE: EVIDENCE FOR THE EXISTENCE OF SCLEROSING PANCREATITIS? M. Barthet (1), P. Hastier (2), JP. Bernard (3), G. Bordes (4), MC. Saint-Paul (3), JP. Delmont (2), JC. Grimaud (1), J. Sahel (3). (1) Hopital Nord, Department of Gastroenterology; (2) Hopital SainteMarguerite, Department of Gastroentrology, Marseille; (3) Hopital L'Archet, Department of Gastroentrology, Nice; (4) Centre Hospitalier g6nrral, Department of Gastroentrology, Digne, FRANCE Several cases of pancreatitis have been described during the course of Crohn's disease (CD) or ulcerative colitis (UC) but many of them were related to either biliary lithiasis or drug intake. We tried to evaluate and to define the clinical and morphological features of so called idiopathic pancreatitis associated with inflammatory bowel disease. We found 6 patients presenting with features of chronic idiopathic pancreatitis and ulcerative colitis and two with Crohn's disease seen between 1981 and 1996 in three hospital centers of the south of France. A review of the literature has identified 6 cases of pancreatitis associated with UC and 14 cases of pancreatitis associated with CD based on the above criteria. Hyperamylasemia was not a sensitive test as it was present in 44% and 64% of patients with UC or CD. In UC, pancreatitis was a prior manifestation in 58% of cases. In contrast, the pancreatitis appeared after the onset of CD in 58% Of the cases. In patients with UC, pancreatitis was associated with severe disease revealed by pancolitis (42%) and subsequent surgery. Bile duct involvement was more frequent in patients with UC than with CD (58% vs 12%) mostly in the absence of sclerosing cholangitis (16% vs 6%). Weightloss and pancreatic duct stenosis were also more frequent in UC than in CD (41 vs 12% and 50% vs 19% respectively). Pathological specimens were analysed in 5 cases and demonstrated the presence of inter and intralobular fibrosis with marked acinar regression in three cases and the presence of granulomas in two patients, both with CD. Pancreatitis is a rare extraintestinal manifestations of IBD. Chronic pancreatitis associated with UC differs from that observed in CD by the presence of more frequent bile duct involvement, weight loss, and pancreatic duct stenosis possibly giving a pseudo tumor pattern. G1791 SONOGRAPHICALLY GUIDED PUNCTURE OF PANCREATIC MASSES, RESULTS AND COMPLICATIONS. D. Becker, J. Wiinsche, D. Strobel, M. Wehler D. Tauschek, C. Herold, E. G. Hahn. Dept. of Medicine, Friedrich-Alexander-University of Erlangen-Nuremberg, Germany Sonographically guided puncture of pancreatic masses often appears to be difficult and dangerous due to surrounding vessels and overlying gut structures. Therefore we retrospectively analyzed the results and the complications of patients where a puncture of pancreatic masses was performed. Punctures were carded out using a 21-F- (1,1 ram) biopsy needle with a lumen inside the needle of 0,9 mm. By this we achieve tissue cylinders which can be evaluated histologically. Indications for puncture were always the attempt to verify or exclude a suspected malignoma of the pancreas. Method: All patients who underwent sonographically guided puncture of pancreatic masses within the last four years were analyzed. The results of definitive diagnosis were compared to the biopsy results. Definitive diagnosis was defined intraoperatively, by biopsy in case of a malignant histology or by clinical follow-up. When patients survived at least one year after benign biopsy, a malignoma was excluded. Furthermore, all complications reported were analyzed. Results: 47 patients with suspicion of pancreatic malignoma underwent sonographically guided puncture. Mean age was 56,8 +/- 14,7 years. 36 patients had solid masses, eleven patients had cystic masses with the suspicion of malignancy. The mean diameter of masses was 2,8 +/- 1,3 cm. Pancreatic malignoma was secured in 25 patients (23 pancreatic carcinomas, two lymphomas), 22 patients had benign diseases of the pancreas (acute or chronic inflammation, pseudocyst, abscess). Sensitivity for sonographically guided puncture was 76%, specificity was 100%. No severe complication (bleeding, pancreatitis, infection) was reported, only in one case a selflimiting arterial hypotension (RR 80/50 mm Hg) was present. Conclusion: Sonographically guided pancreatic puncture is a safe, efficient and reliable diagnostic procedure which can be carried out to determine the definitive diagnosis in cases of pancreatic masses with suspicion of malignancy. But it should only be performed when the therapeutic management will be influenced by the result obtained.