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Su1337 Sphincter of Oddi Manometry in Patients With Chronic Right Upper Quadrant Pain and Idiopathic Acute Pancreatitis: Role of Repeat Manometry in Patients With Recurrent or Persistent Symptoms
Abstracts
prospective cohort of patients with suspected type III SOD. The 12-mo outcomes after sphincterotomy or sham will help determine if any clinical criteria can predict sphincterotomy-responsiveness. NIDDK #U01DK074739.
Su1337 Sphincter of Oddi Manometry in Patients With Chronic Right Upper Quadrant Pain and Idiopathic Acute Pancreatitis: Role of Repeat Manometry in Patients With Recurrent or Persistent Symptoms Marc F. Catalano*1,2, Naser M. Khan1, Joseph B. Henderson1,2, Shahid Ali1,2, Joseph E. Geenen1,2, Nalini M. Guda1,2 1 GI Associates, LLC, Milwaukee, WI; 2Pancreatic Biliary Department, Aurora St. Luke’s Medical Center, Milwaukee, WI Chronic right upper quadrant (RUQ) pain affects 5% of patients following Cholecystectomy. A significant percentage of these patients will have Sphincter of Oddi dysfunction (SOD) following extensive studies. Similarly, patients with acute idiopathic pancreatitis are found to have sphincter dysfunction as an etiologic cause. Manometry of the biliary and/or pancreatic sphincter can reliably establish the diagnosis in these 2 groups of patients. A sublet of patients present with recurrent symptoms after initial response to endotherapy while others present with unresolved symptoms. Aim: To determine the value of repeat SOM in patients with acute recurrent pancreatitis (ARP), Post Cholecystectomy Syndrome (PCS) and Chronic Pain with suspected SOD in 2 subsets of patients. 1) Those with prior response to endotherapy. 2) Those with unresolved symptoms. Method: Over a 6 year period, 784 patients underwent SOM. 311 presented with PCS, 226 with ARP and 247 patients with chronic pain with intact gallbladder. 207 patients presented with recurrent or persistent symptoms for repeat SOM at 6-mos-5.4 years following initial study. This included 81 patients with ARP, 85 patients with PCS and 41 patients with chronic pain. SOM was performed in standard fashion using a perfusion manometry catheter with 3 ports. Sphincter of Oddi (SO) pressures ⱖ40 mmHg, high frequency contractions, high amplitude contractions were considered abnormal. Results: Of the 81 with ARP presenting for repeat SOM, 66 had abnormal SOM (6 biliary, 51 pancreatic, 9 dual SOD). All patients underwent Endoscopic Sphincterotomy (ES) of the appropriate sphincters with 49 (74%) having resolution of pancreatitis. In the PCS group, 85 presented for repeat SOM; 69 had abnormal SOM (59 biliary, 5 pancreatic, 5 dual); all underwent appropriate ES with 38 (55%) having resolution of symptoms. In the pain group, 41 presented for repeat SOM; 26 had abnormal SOM (25 biliary, 1 pancreatic); all underwent ES with 11 (42%) having resolution of symptoms. Follow up was 8mos-5.5years. Conclusion: Patients with ARP, PCS and chronic pain with suspected SOD may present with recurrent or unresolved symptoms following initial SOM evaluation/treatment. Repeat SOM in these patients often reveals abnormal pressures of both the CBD and PD segments of the Sphincter of Oddi. Incomplete prior manometric studies, sphincter stenosis and/or insufficient ablation are believed to be the cause of recurrent symptoms. Repeat dual SOM is recommended in these patient groups who present with recurrent/persistent symptoms. ES of intact sphincters or extension of prior ES results in substantial clinical response in all groups, although most apparent in the ARP group.
SOM Abnormal SOM Patient Resepat Category (n) NL ABN SOM CBD PD Dual ARP PCS Pain
226 311 247
67 157 108 203 95 152
81 85 41
6 59 25
51 5 1
9 5 0
Rx Response n (%)
Comp n (%)
49 (74%) 38 (55%) 11 (42%)
13 (16%) 6 (7%) 2 (5%)
Su1338 Results and Safety of ERCP With Sphincter of Oddi Manometry in Children and Adolescents Wiriyaporn Ridtitid*1,2, Evan L. Fogel1, Gregory A. Cote1, Lee Mchenry1, Glen A. Lehman1, James L. Watkins1, Stuart Sherman1 1 Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN; 2 Department of Medicine, Division of Gastroenterology, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand Background: In adults, ERCP with sphincter of Oddi manometry (SOM) is performed to evaluate patients with chronic abdominal pain or idiopathic pancreatitis. However, data on the results of ERCP with SOM in children and adolescents are scarce. Objectives: To evaluate the yield and safety of ERCP with SOM in children and adolescents. Material and Methods: Retrospective cohort study including all patients age ⱕ18 years that underwent SOM at a single ERCP referral center between January, 1994 and July, 2012. Sphincter of Oddi
www.giejournal.org
dysfunction (SOD) was defined as a basal sphincter pressure value ⱖ40mmHg in either the pancreatic or biliary sphincter segment. Post-ERCP complications were defined using consensus criteria. Results: A total of 274 patients (106 male, 262 female; mean age 15.2⫾3 years) who underwent 368 ERCPs (median number of ERCPs 1; IQR 2-1) during the study period. Clinical presentations included chronic/recurrent abdominal pain ⫾ abnormal liver enzymes (n⫽259, 70.3%), recurrent acute pancreatitis (n⫽124, 33.6%) and chronic pancreatitis (n⫽23, 6.3%). Of those, 34 patients (12.4%) had elevation of amylase or lipase ⱕ 3 times the upper limit of normal. Eighty patients (29.1%) had a prior history of cholecystectomy. Among patients age ⱖ 10 years (n⫽361), 146 (40.4%) received moderate sedation. The remainder (59.6%) underwent general anesthesia. Pancreas divisum, anomalous pancreatobiliary junction, biliary stones and choledochal cyst were found in 29 patients (7.9%), 4 patients (1.1%), 1 patient (0.3%) and 1 patient (0.3%), respectively. SOM was technically successful in 362/ 368 ERCPs (98%). SOD was identified in 221 examinations (61%): biliary alone in 9%, pancreatic alone in 30%, and both sphincters 25%. Endoscopic sphincterotomy (pancreatic and/or biliary) was performed in 62%. A protective pancreatic stent was placed in 240/286 (84%). Two were attempted and unsuccessful. Post-ERCP complications included pancreatitis 12.7% (10% mild, 2.4% moderate, 0.3% severe) and bleeding 1.7%. During the initial ERCP, three patients with post-sphincterotomy bleeding spontaneously stopped during the initial ERCP and 3 patients were successfully treated by epinephrine injection. No perforations occurred. Conclusions: In a large cohort of patients ⱕ age 18 years, ERCP with SOM has a comparable safety profile to an adult population. The incidence of congenital abnormalities, SOD and both was 9.3%, 61% and 3.5%. Prospective studies designed to measure long term outcomes in this population are needed.
Su1339 Pancreatography Adds Greater Diagnostic Value Than EUS in Detecting Chronic Pancreatitis in Patients With Sphincter of Oddi Dysfunction Types II and III: a Prospective Cohort Study Smrita Sinha*, Payal Saxena, Ali Kord Valeshabad, Vikesh K. Singh, Anthony N. Kalloo, Mouen Khashab Johns Hopkins Medical Institute, Baltimore, MD Background: Prevalence of chronic pancreatitis (CP) in patients with suspected sphincter of Oddi dysfunction (SOD) in not well-defined. In addition, there is limited data on the utility of EUS prior to ERCP in these patients. Aims: To 1) describe the prevalence of CP in patients with SOD II and III using ERCP, 2) define clinical characteristics of patients found to have CP, and 3) study performance and utility of EUS prior to ERCP. Methods: Consecutive patients with suspected SOD types II and III who underwent ERCP between 3/2011 and 10/2012 were eligible for the study. Exclusion criteria included history of acute or CP and pancreas divisum. CP was classified using Cambridge criteria (ERP) and Rosemont criteria (EUS). All pancreatograms were reviewed by a blinded expert pancreatologist. Post-ERCP pancreatitis (PEP) was defined as mild, moderate or severe as per consensus guidelines. Results: A total of 55 patients (mean age 38, female 76%, smoking history 40%, alcohol use 5%) underwent ERCP for suspected SOD (type II 17, type III 38). Mean duration of abdominal pain at first encounter was 38.5 months. Most patients (80%) underwent EUS by a single endoscopist prior to ERCP and only 6 (13.6%) met criteria for CP. No other abnormalities were found on EUS. Pancreatography revealed CP (mild 19, moderate 9, severe 1) in 53% of patients (SOD II 59% vs. SOD III 50%, p ⫽ 0.55). The sensitivity, specificity, PPV and NPV of EUS for diagnosis of CP was 33%, 88%, 82%, and 45%, respectively. Clinical characteristics were similar between patients with and without CP. Thirty-five patients underwent manometry and 77% had sphincter hypertension. CP rates were similar among patients with normal and elevated pressures (62.5% vs. 48.1% p⫽0.48). Pancreatic and/or biliary sphincterotomy was performed in 33 patients due to elevated pressures or abnormal HIDA scan score, and 88% received a prophylactic PD stent. Six total cases of PEP occurred (83.3% mild, 16.7% moderate) and rates did not differ between groups with and without CP (3.92% vs. 10.0% p⫽0.25). Additional treatments included celiac plexus block (n⫽11), pancreatic enzyme replacement (n⫽20) and/or opiates (n⫽20). At mean follow up of 203 ⫾ 177 days, the overall response rate measured in terms of sustained pain relief to collective treatment was 40.5% (17/42) and did not differ between patients with and without CP (37.4% vs. 46.7% p⫽0.54). However, patients taking opiates prior to endoscopic interventions were less likely to have pain relief (16.7% vs. 58.3%, p⫽0.007). Conclusions: There was a substantial rate of CP amongst patients with suspected SOD II and III. EUS had very low sensitivity in detecting CP when compared to pancreatography. PEP rate was low and severe cases were not encountered. Prior opiate use was associated with a decreased response to multimodal treatment.
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB289
prospective cohort of patients with suspected type III SOD. The 12-mo outcomes after sphincterotomy or sham will help determine if any clinical criteria can predict sphincterotomy-responsiveness. NIDDK #U01DK074739.
Su1337 Sphincter of Oddi Manometry in Patients With Chronic Right Upper Quadrant Pain and Idiopathic Acute Pancreatitis: Role of Repeat Manometry in Patients With Recurrent or Persistent Symptoms Marc F. Catalano*1,2, Naser M. Khan1, Joseph B. Henderson1,2, Shahid Ali1,2, Joseph E. Geenen1,2, Nalini M. Guda1,2 1 GI Associates, LLC, Milwaukee, WI; 2Pancreatic Biliary Department, Aurora St. Luke’s Medical Center, Milwaukee, WI Chronic right upper quadrant (RUQ) pain affects 5% of patients following Cholecystectomy. A significant percentage of these patients will have Sphincter of Oddi dysfunction (SOD) following extensive studies. Similarly, patients with acute idiopathic pancreatitis are found to have sphincter dysfunction as an etiologic cause. Manometry of the biliary and/or pancreatic sphincter can reliably establish the diagnosis in these 2 groups of patients. A sublet of patients present with recurrent symptoms after initial response to endotherapy while others present with unresolved symptoms. Aim: To determine the value of repeat SOM in patients with acute recurrent pancreatitis (ARP), Post Cholecystectomy Syndrome (PCS) and Chronic Pain with suspected SOD in 2 subsets of patients. 1) Those with prior response to endotherapy. 2) Those with unresolved symptoms. Method: Over a 6 year period, 784 patients underwent SOM. 311 presented with PCS, 226 with ARP and 247 patients with chronic pain with intact gallbladder. 207 patients presented with recurrent or persistent symptoms for repeat SOM at 6-mos-5.4 years following initial study. This included 81 patients with ARP, 85 patients with PCS and 41 patients with chronic pain. SOM was performed in standard fashion using a perfusion manometry catheter with 3 ports. Sphincter of Oddi (SO) pressures ⱖ40 mmHg, high frequency contractions, high amplitude contractions were considered abnormal. Results: Of the 81 with ARP presenting for repeat SOM, 66 had abnormal SOM (6 biliary, 51 pancreatic, 9 dual SOD). All patients underwent Endoscopic Sphincterotomy (ES) of the appropriate sphincters with 49 (74%) having resolution of pancreatitis. In the PCS group, 85 presented for repeat SOM; 69 had abnormal SOM (59 biliary, 5 pancreatic, 5 dual); all underwent appropriate ES with 38 (55%) having resolution of symptoms. In the pain group, 41 presented for repeat SOM; 26 had abnormal SOM (25 biliary, 1 pancreatic); all underwent ES with 11 (42%) having resolution of symptoms. Follow up was 8mos-5.5years. Conclusion: Patients with ARP, PCS and chronic pain with suspected SOD may present with recurrent or unresolved symptoms following initial SOM evaluation/treatment. Repeat SOM in these patients often reveals abnormal pressures of both the CBD and PD segments of the Sphincter of Oddi. Incomplete prior manometric studies, sphincter stenosis and/or insufficient ablation are believed to be the cause of recurrent symptoms. Repeat dual SOM is recommended in these patient groups who present with recurrent/persistent symptoms. ES of intact sphincters or extension of prior ES results in substantial clinical response in all groups, although most apparent in the ARP group.
SOM Abnormal SOM Patient Resepat Category (n) NL ABN SOM CBD PD Dual ARP PCS Pain
226 311 247
67 157 108 203 95 152
81 85 41
6 59 25
51 5 1
9 5 0
Rx Response n (%)
Comp n (%)
49 (74%) 38 (55%) 11 (42%)
13 (16%) 6 (7%) 2 (5%)
Su1338 Results and Safety of ERCP With Sphincter of Oddi Manometry in Children and Adolescents Wiriyaporn Ridtitid*1,2, Evan L. Fogel1, Gregory A. Cote1, Lee Mchenry1, Glen A. Lehman1, James L. Watkins1, Stuart Sherman1 1 Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN; 2 Department of Medicine, Division of Gastroenterology, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand Background: In adults, ERCP with sphincter of Oddi manometry (SOM) is performed to evaluate patients with chronic abdominal pain or idiopathic pancreatitis. However, data on the results of ERCP with SOM in children and adolescents are scarce. Objectives: To evaluate the yield and safety of ERCP with SOM in children and adolescents. Material and Methods: Retrospective cohort study including all patients age ⱕ18 years that underwent SOM at a single ERCP referral center between January, 1994 and July, 2012. Sphincter of Oddi
www.giejournal.org
dysfunction (SOD) was defined as a basal sphincter pressure value ⱖ40mmHg in either the pancreatic or biliary sphincter segment. Post-ERCP complications were defined using consensus criteria. Results: A total of 274 patients (106 male, 262 female; mean age 15.2⫾3 years) who underwent 368 ERCPs (median number of ERCPs 1; IQR 2-1) during the study period. Clinical presentations included chronic/recurrent abdominal pain ⫾ abnormal liver enzymes (n⫽259, 70.3%), recurrent acute pancreatitis (n⫽124, 33.6%) and chronic pancreatitis (n⫽23, 6.3%). Of those, 34 patients (12.4%) had elevation of amylase or lipase ⱕ 3 times the upper limit of normal. Eighty patients (29.1%) had a prior history of cholecystectomy. Among patients age ⱖ 10 years (n⫽361), 146 (40.4%) received moderate sedation. The remainder (59.6%) underwent general anesthesia. Pancreas divisum, anomalous pancreatobiliary junction, biliary stones and choledochal cyst were found in 29 patients (7.9%), 4 patients (1.1%), 1 patient (0.3%) and 1 patient (0.3%), respectively. SOM was technically successful in 362/ 368 ERCPs (98%). SOD was identified in 221 examinations (61%): biliary alone in 9%, pancreatic alone in 30%, and both sphincters 25%. Endoscopic sphincterotomy (pancreatic and/or biliary) was performed in 62%. A protective pancreatic stent was placed in 240/286 (84%). Two were attempted and unsuccessful. Post-ERCP complications included pancreatitis 12.7% (10% mild, 2.4% moderate, 0.3% severe) and bleeding 1.7%. During the initial ERCP, three patients with post-sphincterotomy bleeding spontaneously stopped during the initial ERCP and 3 patients were successfully treated by epinephrine injection. No perforations occurred. Conclusions: In a large cohort of patients ⱕ age 18 years, ERCP with SOM has a comparable safety profile to an adult population. The incidence of congenital abnormalities, SOD and both was 9.3%, 61% and 3.5%. Prospective studies designed to measure long term outcomes in this population are needed.
Su1339 Pancreatography Adds Greater Diagnostic Value Than EUS in Detecting Chronic Pancreatitis in Patients With Sphincter of Oddi Dysfunction Types II and III: a Prospective Cohort Study Smrita Sinha*, Payal Saxena, Ali Kord Valeshabad, Vikesh K. Singh, Anthony N. Kalloo, Mouen Khashab Johns Hopkins Medical Institute, Baltimore, MD Background: Prevalence of chronic pancreatitis (CP) in patients with suspected sphincter of Oddi dysfunction (SOD) in not well-defined. In addition, there is limited data on the utility of EUS prior to ERCP in these patients. Aims: To 1) describe the prevalence of CP in patients with SOD II and III using ERCP, 2) define clinical characteristics of patients found to have CP, and 3) study performance and utility of EUS prior to ERCP. Methods: Consecutive patients with suspected SOD types II and III who underwent ERCP between 3/2011 and 10/2012 were eligible for the study. Exclusion criteria included history of acute or CP and pancreas divisum. CP was classified using Cambridge criteria (ERP) and Rosemont criteria (EUS). All pancreatograms were reviewed by a blinded expert pancreatologist. Post-ERCP pancreatitis (PEP) was defined as mild, moderate or severe as per consensus guidelines. Results: A total of 55 patients (mean age 38, female 76%, smoking history 40%, alcohol use 5%) underwent ERCP for suspected SOD (type II 17, type III 38). Mean duration of abdominal pain at first encounter was 38.5 months. Most patients (80%) underwent EUS by a single endoscopist prior to ERCP and only 6 (13.6%) met criteria for CP. No other abnormalities were found on EUS. Pancreatography revealed CP (mild 19, moderate 9, severe 1) in 53% of patients (SOD II 59% vs. SOD III 50%, p ⫽ 0.55). The sensitivity, specificity, PPV and NPV of EUS for diagnosis of CP was 33%, 88%, 82%, and 45%, respectively. Clinical characteristics were similar between patients with and without CP. Thirty-five patients underwent manometry and 77% had sphincter hypertension. CP rates were similar among patients with normal and elevated pressures (62.5% vs. 48.1% p⫽0.48). Pancreatic and/or biliary sphincterotomy was performed in 33 patients due to elevated pressures or abnormal HIDA scan score, and 88% received a prophylactic PD stent. Six total cases of PEP occurred (83.3% mild, 16.7% moderate) and rates did not differ between groups with and without CP (3.92% vs. 10.0% p⫽0.25). Additional treatments included celiac plexus block (n⫽11), pancreatic enzyme replacement (n⫽20) and/or opiates (n⫽20). At mean follow up of 203 ⫾ 177 days, the overall response rate measured in terms of sustained pain relief to collective treatment was 40.5% (17/42) and did not differ between patients with and without CP (37.4% vs. 46.7% p⫽0.54). However, patients taking opiates prior to endoscopic interventions were less likely to have pain relief (16.7% vs. 58.3%, p⫽0.007). Conclusions: There was a substantial rate of CP amongst patients with suspected SOD II and III. EUS had very low sensitivity in detecting CP when compared to pancreatography. PEP rate was low and severe cases were not encountered. Prior opiate use was associated with a decreased response to multimodal treatment.
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB289