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Unusual ERCP appearance of obstructive jaundice caused by pancreatic cancer
5. Wyatt JI, Rathbone BJ, Sobala GM, et al. Gastric epithelium in the duodenum: its association with Helicobacterpylori and inflammation. J Clin Pathol 1990;43:635-50. 6. Wyatt JI, Rathbone BJ, Dixon MF, Heatley RV, Axon ATR. Campylobacter pylori and development of duodenal ulcer. Lancet 1988;1:118-9.
Eradication of Helicobacter pylori as the first step in the treatment of peptic stenosis To the Editor:
Rapid and simple biliary stent deployment To the Editor:
We read with great interest the paper by Lau et al.1 about surveillance of patients treated with through-the-scope balloon dilation for benign pyloric stenosis. Authors confirm that long-term stenosis recurrence is very frequent, with the need for surgery. 1 In this study, the patients were not investigated for the presence ofH. pylori. The eradication ofH. pylori could be used as first-line treatment before endoscopic dilation or surgery. In fact, our group 2 and others 3, 4 have recently shown that H. pylori eradication may resolve peptic stenosis. Particularly, in the report from de Boer and Driessen, 4 two through-the-scope balloon dilations failed in a patient, and the stenosis disappeared only after treatment for H. pylori. Especially when the obstruction is recent, H. pylori eradication should reduce inflammation and edema, with potential resolution of the stenosis. This is true both in pyloric and duodenal stenosis, as H. pylori is often present in duodenal foci of gastric metaplasia. 5, 6 However, if the stricture is caused by fibrosis (scars from recurrent ulcers), it seems likely that H. pylori eradication would provoke only reduction, but not disappearance, of stenosis. For this reason, we think that in patients affected by peptic stenosis, H. pylori should always be searched for and treated. In the H. pylori era, peptic strictures are disappearing, since it has been widely demonstrated that H. pylori eradication dramatically reduces recurrence and complications 0fpeptic disease. In light of this, H. pylori treatment constitutes more a preventive intervention than a therapy for complications of peptic ulcer disease.
Antonio Tursi, Alfredo Papa, Giovanni Cammarota, Guiseppe Fedeli, Giovanni Gasbarrini,
MD MD MD MD MD
There is a method of simplified bile duct stenting that might appeal to your readers. It has the advantage of eliminating all wire exchanges, thereby decreasing the chance of lost cannulation and reducing significantly the time necessary to perform the procedure. It is applicable for 10F size endoprostheses. The bile duct can be free cannulated using a gray stent guide catheter (Wilson-Cook, Winston-Salem, N.C.). A cholangiogram is then performed with the aid of the removable Luer lock device supplied with the catheter. A guide wire is then passed down the lumen of the introducer tube and above the stricture. The gray stent guide catheter is then advanced over the wire, above the stricture. The Luer lock is then removed, the stent is "backloaded" onto the catheter and inserted across the stricture in the conventional fashion, using a push catheter. The introducer apparatus is then removed. Variations on this theme would include preloading a wire into the gray stent guide catheter prior to cannulation and performing the cholangiogram with the aid of a side-arm adapter, similar to the Touhy-Borst variety. If one prefers the "feel" of conventional 5F tapered cannula, this may be used instead of the guide catheter. Once a chotangiogram has been performed, the fLxed Luer lock end may be clipped off the cannula using a scissors. The guide wire is then introduced and the stent is "backloaded" and deployed over the catheter, as described above. The advantages of this technique lie in its simplicity: the wire exchange (a vulnerable part of the procedure) is eliminated. Likewise, significant time (2 to 10 minutes) is also eliminated from the procedure.
William Silverman, MD University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
Catholic University Rome, Italy
REFERENCES 1. Lau JYW, Chung SCS, Sung JY, Chan ACW, Ng EKW, Suen RCY, et al. Through-the-scope balloon dilation for pyloric stenosis: long-term results. Gastrointest Endosc 1996;43:98-
Unusual ERCP appearance of obstructive jaundice caused by pancreatic cancer
!01.
2. Tursi A, Cammarota G, Papa A, Montalto M, Fedeli G, Gasbarrini G. Helicobacterpylori eradication helps resolve pyloric and duodenal stenosis. J Clin Gastreenterol 1996 (in press). 3. Annibale B, Marignani M, Luzzi I, Delle Fare GF. Peptic ulcer and duodenal stenosis: role of HeEcobacter pylori. Ital J Gastroenterol 1995;27:26-8. 4. de Boer WA, Driessen WMM. Resolution of gastric outlet obstruction after eradication ofHelicobacterpylori. J Clin Gastroenterol 1995;21:329-30.
VOLUME 44, NO. 6, 1996
To the Editor: Pancreatic cancer may result in obstructive jaundice from extrinsic compression of the bile duct, producing a characteristic ERCP finding of bile and pancreatic duct strictures, i.e., "double duct sign. "1 Rarely, ERCP may show a biliary stricture with a normal pancreatogram in patients with obstructive jaundice due to pancreatic cancer. 2 In the follow-
GASTROINTESTINAL ENDOSCOPY 757
Figure 1. The cholangiogram shows an oblong intrabiliary filling defect, separate from the bile duct wall. Extrinsic tumor projecting out of the plane of the radiograph and invaginating into the wall of the bile duct could produce this appearance under two-dimensional radiography. ing patient with pancreatic cancer, obstructive jaundice was caused by an intrabiliary malignant mass. A 68-year-old man presented with painless jaundice and 25-pound weight loss. Physical examination was unremarkable except for jaundice. An abdominal ultrasound showed dilated intrahepatic bile ducts, but the pancreas was not well visualized. The patient underwent ERCP for evaluation and treatment of obstructive jaundice. The initial cholangiogram showed a sausage-shaped filling defect occupying the midportion of the common bile duct, with intrahepatic biliary dilation, but no stricture (Fig. 1). The filling defect had smooth borders that appeared to be separate and distinct from the bile duct wall. A sphincterotomy was performed and various balloons and baskets were used in an attempt to dislodge the mass, without success. A pancreatogram showed a stricture at the head of the pancreas (Fig. 2), with its proximal margin located at the level of the intrabiliary mass. Pancreatic duct brush cytology and forceps biopsies of the intrabiliary lesion were performed for diagnosis. Finally, a 10F plastic stent was placed contiguous to the intrabiliary mass to re-establish bile flow. ACT scan obtained the following day demonstrated a lesion at the head of the pancreas suggestive of pancreatic cancer. Cytology from the pancreatic duct showed malignant cells and biopsies of the 758
GASTROINTESTINAL ENDOSCOPY
Figure 2. A representative pancreatogram shows a stricture at the head of the pancreas.
intrabiliary mass showed adenocarcinoma. The patient's jaundice was relieved with endoscopic stenting. Although the filling defect seen on the cholangiogram may have represented intrabiliary metastasis of pancreatic cancer or invasion of the tumor through the wail of the bile duct, such lesions should have an irregular border. Alternatively, the radiographic appearance in this case could have been produced by an invagination of the bile duct wall by an eccentrically growing pancreatic tumor. Positive histology and cytology excluded other types ofintrabiliary lesions. In conclusion, pancreatic cancer should be considered in the differential diagnosis of intrabiliary mass presenting concomitantly with pancreatic duct stricture; brush cytology and biopsy of the intrabiliary mass should be considered for definitive diagnosis.
John G. Lee, MD Portland VAMC Portland, Oregon
REFERENCES 1. Norton RA, Ogoshi K, Hara Y, et al. Pancreatographic abnormalities due to pancreatic cancer. Gastrointest Endosc 1973; 20:13-4. 2. Kowdley KV, Variyam EP, Sivak MV. Obstructive jaundice caused by pancreatic carcinoma in the setting of a normal pancreatogram. Gastrointest Endosc 1995;41:158-60. VOLUME 44, NO. 6, 1996
Eradication of Helicobacter pylori as the first step in the treatment of peptic stenosis To the Editor:
Rapid and simple biliary stent deployment To the Editor:
We read with great interest the paper by Lau et al.1 about surveillance of patients treated with through-the-scope balloon dilation for benign pyloric stenosis. Authors confirm that long-term stenosis recurrence is very frequent, with the need for surgery. 1 In this study, the patients were not investigated for the presence ofH. pylori. The eradication ofH. pylori could be used as first-line treatment before endoscopic dilation or surgery. In fact, our group 2 and others 3, 4 have recently shown that H. pylori eradication may resolve peptic stenosis. Particularly, in the report from de Boer and Driessen, 4 two through-the-scope balloon dilations failed in a patient, and the stenosis disappeared only after treatment for H. pylori. Especially when the obstruction is recent, H. pylori eradication should reduce inflammation and edema, with potential resolution of the stenosis. This is true both in pyloric and duodenal stenosis, as H. pylori is often present in duodenal foci of gastric metaplasia. 5, 6 However, if the stricture is caused by fibrosis (scars from recurrent ulcers), it seems likely that H. pylori eradication would provoke only reduction, but not disappearance, of stenosis. For this reason, we think that in patients affected by peptic stenosis, H. pylori should always be searched for and treated. In the H. pylori era, peptic strictures are disappearing, since it has been widely demonstrated that H. pylori eradication dramatically reduces recurrence and complications 0fpeptic disease. In light of this, H. pylori treatment constitutes more a preventive intervention than a therapy for complications of peptic ulcer disease.
Antonio Tursi, Alfredo Papa, Giovanni Cammarota, Guiseppe Fedeli, Giovanni Gasbarrini,
MD MD MD MD MD
There is a method of simplified bile duct stenting that might appeal to your readers. It has the advantage of eliminating all wire exchanges, thereby decreasing the chance of lost cannulation and reducing significantly the time necessary to perform the procedure. It is applicable for 10F size endoprostheses. The bile duct can be free cannulated using a gray stent guide catheter (Wilson-Cook, Winston-Salem, N.C.). A cholangiogram is then performed with the aid of the removable Luer lock device supplied with the catheter. A guide wire is then passed down the lumen of the introducer tube and above the stricture. The gray stent guide catheter is then advanced over the wire, above the stricture. The Luer lock is then removed, the stent is "backloaded" onto the catheter and inserted across the stricture in the conventional fashion, using a push catheter. The introducer apparatus is then removed. Variations on this theme would include preloading a wire into the gray stent guide catheter prior to cannulation and performing the cholangiogram with the aid of a side-arm adapter, similar to the Touhy-Borst variety. If one prefers the "feel" of conventional 5F tapered cannula, this may be used instead of the guide catheter. Once a chotangiogram has been performed, the fLxed Luer lock end may be clipped off the cannula using a scissors. The guide wire is then introduced and the stent is "backloaded" and deployed over the catheter, as described above. The advantages of this technique lie in its simplicity: the wire exchange (a vulnerable part of the procedure) is eliminated. Likewise, significant time (2 to 10 minutes) is also eliminated from the procedure.
William Silverman, MD University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
Catholic University Rome, Italy
REFERENCES 1. Lau JYW, Chung SCS, Sung JY, Chan ACW, Ng EKW, Suen RCY, et al. Through-the-scope balloon dilation for pyloric stenosis: long-term results. Gastrointest Endosc 1996;43:98-
Unusual ERCP appearance of obstructive jaundice caused by pancreatic cancer
!01.
2. Tursi A, Cammarota G, Papa A, Montalto M, Fedeli G, Gasbarrini G. Helicobacterpylori eradication helps resolve pyloric and duodenal stenosis. J Clin Gastreenterol 1996 (in press). 3. Annibale B, Marignani M, Luzzi I, Delle Fare GF. Peptic ulcer and duodenal stenosis: role of HeEcobacter pylori. Ital J Gastroenterol 1995;27:26-8. 4. de Boer WA, Driessen WMM. Resolution of gastric outlet obstruction after eradication ofHelicobacterpylori. J Clin Gastroenterol 1995;21:329-30.
VOLUME 44, NO. 6, 1996
To the Editor: Pancreatic cancer may result in obstructive jaundice from extrinsic compression of the bile duct, producing a characteristic ERCP finding of bile and pancreatic duct strictures, i.e., "double duct sign. "1 Rarely, ERCP may show a biliary stricture with a normal pancreatogram in patients with obstructive jaundice due to pancreatic cancer. 2 In the follow-
GASTROINTESTINAL ENDOSCOPY 757
Figure 1. The cholangiogram shows an oblong intrabiliary filling defect, separate from the bile duct wall. Extrinsic tumor projecting out of the plane of the radiograph and invaginating into the wall of the bile duct could produce this appearance under two-dimensional radiography. ing patient with pancreatic cancer, obstructive jaundice was caused by an intrabiliary malignant mass. A 68-year-old man presented with painless jaundice and 25-pound weight loss. Physical examination was unremarkable except for jaundice. An abdominal ultrasound showed dilated intrahepatic bile ducts, but the pancreas was not well visualized. The patient underwent ERCP for evaluation and treatment of obstructive jaundice. The initial cholangiogram showed a sausage-shaped filling defect occupying the midportion of the common bile duct, with intrahepatic biliary dilation, but no stricture (Fig. 1). The filling defect had smooth borders that appeared to be separate and distinct from the bile duct wall. A sphincterotomy was performed and various balloons and baskets were used in an attempt to dislodge the mass, without success. A pancreatogram showed a stricture at the head of the pancreas (Fig. 2), with its proximal margin located at the level of the intrabiliary mass. Pancreatic duct brush cytology and forceps biopsies of the intrabiliary lesion were performed for diagnosis. Finally, a 10F plastic stent was placed contiguous to the intrabiliary mass to re-establish bile flow. ACT scan obtained the following day demonstrated a lesion at the head of the pancreas suggestive of pancreatic cancer. Cytology from the pancreatic duct showed malignant cells and biopsies of the 758
GASTROINTESTINAL ENDOSCOPY
Figure 2. A representative pancreatogram shows a stricture at the head of the pancreas.
intrabiliary mass showed adenocarcinoma. The patient's jaundice was relieved with endoscopic stenting. Although the filling defect seen on the cholangiogram may have represented intrabiliary metastasis of pancreatic cancer or invasion of the tumor through the wail of the bile duct, such lesions should have an irregular border. Alternatively, the radiographic appearance in this case could have been produced by an invagination of the bile duct wall by an eccentrically growing pancreatic tumor. Positive histology and cytology excluded other types ofintrabiliary lesions. In conclusion, pancreatic cancer should be considered in the differential diagnosis of intrabiliary mass presenting concomitantly with pancreatic duct stricture; brush cytology and biopsy of the intrabiliary mass should be considered for definitive diagnosis.
John G. Lee, MD Portland VAMC Portland, Oregon
REFERENCES 1. Norton RA, Ogoshi K, Hara Y, et al. Pancreatographic abnormalities due to pancreatic cancer. Gastrointest Endosc 1973; 20:13-4. 2. Kowdley KV, Variyam EP, Sivak MV. Obstructive jaundice caused by pancreatic carcinoma in the setting of a normal pancreatogram. Gastrointest Endosc 1995;41:158-60. VOLUME 44, NO. 6, 1996