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Utility of combined ERCP and EUS in pancreaticobiliary disease
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Abstracts
chronic bacterial cholangitis, bile duct stones, cholangiocarcinoma etc. We report a case of sclerosing cholangitis in a patient with a known metastatic adenocarcinoma of the lung. Case: A 51-year old male with a 1-year history of progressive stage IV adenocarcinoma of the lung managed with various chemotherapy agents (carboplatin, taxol, navelbine) presented with jaundice and abnormal LFT’s. Patient was on a cancer experimental drug ‘iressa’ at presentation. Lab work showed Bilirubin, AST, ALT and AP at 6.5, 217, 292 and 806 respectively. Ultrasound and CT scan of the liver showed cystic changes in the liver with mild intrahepatic and extrahepatic biliary dilatation. Patient had MRCP, PTC and ERCP, which showed beaded appearance of the common bile duct, common hepatic duct and right and left hepatic ducts consistent with the appearance of sclerosing cholangitis. Patient had a stent placed into the CBD stricture and ‘Iressa’ was discontinued. LFT’s normalized on follow up. Conclusion: An extensive search of the literature does not reveal any case report citing sclerosing cholangitis as a paraneoplastic manifestation of lung cancers. There was also no reported association with cancer chemotherapeutic agents used in our patient, though the possibility of the experimental drug ‘Iressa’ as a potential etiological factor remains. In conclusion, cholangiographic changes similar to those seen on primary sclerosing cholangitis can be seen in advanced non-small cell lung cancer.
172 UTILITY OF COMBINED ERCP AND EUS IN PANCREATICOBILIARY DISEASE Kester Crosse, M.D., Oleh Haluszka, M.D., Peter Darwin, M.D.*. University of Maryland, Baltimore, MD and Fox Chase Cancer Center, Philadelphia, PA. Purpose: The diagnostic and therapeutic abilities of EUS and ERCP may be complimentary. These studies are often done separately given time constraints and operator expertise. The aim of this study is to evaluate the utility of combined EUS and ERCP in patients with pancreaticobiliary disease. Methods: Retrospective chart review of all patients scheduled for simultaneous EUS and ERCP at the University of Maryland Medical Center from 1999 to 2002 was performed. Results: 82 patients underwent both EUS and ERCP. The indications included 15 pancreatic masses, 2 recurrent pancreatitis, 36 dilated ducts without mass, 20 cystic lesions of the pancreas and 9 ampullary lesions. The EUS findings in the 15 cases with presumed pancreatic lesions included 6 (40%) with masses alone, 6 (40%) masses with vascular invasion or distant nodes , 2 (13 %) CBD stones that were extracted by ERCP, and 1(7%) cystic lesion. FNA was positive in 3/6 with masses and 5/6 masses with vascular invasion/nodes. Therapy following EUS included CBD stenting in 10/12 cases. The 5 cases with unresectable disease underwent metal stent placement and 3 had celiac blocks. The findings in the 36 cases with dilated ducts without mass included: 8 (23%) with negative EUS and ERCP, 5 (14%) with CBD stone by EUS and extraction by ERCP, 11 (31%) with pancreatic head pathology (malignant and benign) with strictures stented by ERCP, 3 (9%) with unresectable pancreatic lesions who received a celiac block and metal stent, 6 (17%) with negative EUS and pathology treated with ERCP (Klatskin tumor, papillary stenosis, CBD and PD strictures) and 2 (6%) miscellaneous (IPMT and ampullary adenoma). The 20 cystic lesions of the pancreas underwent initial ERCP. There were 5 PD disruptions, 3 communicating pseudocysts, 6 noncommunicating cystic lesions and 6 with failed pancreatograms. Therapy included 11 (55%) cystenterostomy, 5 (25%) aspiration, 2 (10%) transpapillary drainage and 2 (10%) no therapy. The 9 ampullary lesions underwent initial EUS. 5 (55%) of the ampullary lesions had no invasion by EUS and underwent ampullectomy and 4 (45%) with invasion underwent surgery or palliative sphincterotomy. Conclusions: When possible, EUS and ERCP should be done as combined procedures. Interventions may be performed based upon the information of both tests, including: stone extraction, the ability to drain a pseudocyst
AJG – Vol. 98, No. 9, Suppl., 2003
based upon the pancreatogram, ampullary adenoma management based upon depth of the lesion and palliative treatment for carcinoma. 173 EXTRA PANCREATIC MANIFESTATIONS OF ACUTE PANCREATITIS IN PATIENTS OF A MINORITY POPULATION Abbasi J. Akhtar, M.D., FACG*, Magda A. Shaheen, M.D., Ph.D. Charles R.Drew University of Medicine & Science, Los Angeles, CA. Purpose: Many studies have been published on acute pancreatitis, but few if any have focused on extra pancreatic manifestations in African American and Hispanic patients. As most of our patients belong to these two ethnic groups, we studied the frequency of extra pancreatic manifestations and their effect on mortality in these patients. Methods: Records of 760 (417 African American and 343 Hispanic) patients, ages 21-85 years, with the diagnosis of acute pancreatitis over a 15 years period were reviewed retrospectively. Data were analyzed by race/ethnicity for etiology, presence of extra pancreatic manifestations and mortality. Results: Of the 760 patients with acute pancreatitis, etiology was alcohol in 402 (53%), gall stones in 318 (42%), and miscellaneous causes including trauma, drugs and idiopathic in 40 (5%). While alcohol etiology was significantly higher among African American (63% African American, 41% Hispanic, P⬍0.05), gall stones were significantly more prevalent among Hispanics (32% African American, 54% Hispanic, P⬍0.05). One or more extra pancreatic manifestations were present in 148 patients (19.5%) and did not differ by race/ethnicity (19% African American, 20% Hispanics, P⬎0.05). The common extra pancreatic manifestations were gastrointestinal bleeding (18%), septicemia (13%), adult respiratory distress syndrome (10%), aneurysms and pseudo aneurysms (7%), and encephalopathy (5%). Of the 760 patients 109 (14%) died, however the mortality was significantly higher in patients with extra pancreatic manifestation(s) (39 patients, 26%) as compared to those without it (70 patients, 11%) (P⬍0.05). There was no difference in mortality by race/ethnicity (P⬎0.05). Conclusions: Mortality due to acute pancreatitis was high in our patient population compared to literature. Presence of extra pancreatic manifestation(s) increased the mortality significantly. 174 RADIATION EXPOSURE DURING ERCP TRAINING Lance Uradomo, M.D., Alexander Lustberg, M.D., Mark Lustberg, Ph.D., Oleh Haluszka, M.D., Peter Darwin, M.D.*. University of Maryland, Baltimore, MD and Fox Chase Cancer Hospital, Philadelphia, PA. Purpose: Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that requires substantial training and experience to perform safely and effectively. Radiation exposure to the patient and staff is a risk of this test. There has been no study that has examined radiation exposure by fluoroscopy during ERCP training. The aim of this retrospective study was to evaluate the difference in radiation exposure during ERCP between endoscopists at different levels of training. Methods: A retrospective review of 284 consecutive ERCP performed by gastroenterologists in an academic hospital during one year. All procedures were performed utilizing the same fluoroscopy equipment. Average radiation dose was estimated at 1.5 Rads per minute of fluoroscopy time based on standard settings as measured prior to the initiation of the study. Results: A total of 284 procedures were included in the analysis. Of those, 15 records omitted fluoroscopy time and were excluded from this analysis. The majority of cases, 222 (82%), were performed by fellows while 47 (18%) were performed by attending physicians alone (during fellow clinic block). The median fluoroscopy time for procedures with fellows was 389 seconds, and for attendings alone it was 322 seconds (p⫽0.23). Fluoroscopy time varied with the number of procedures performed by the fellows during that year. In a simple linear regression model, 3.5% of the variance in time is associated with the number of procedures performed by the
Abstracts
chronic bacterial cholangitis, bile duct stones, cholangiocarcinoma etc. We report a case of sclerosing cholangitis in a patient with a known metastatic adenocarcinoma of the lung. Case: A 51-year old male with a 1-year history of progressive stage IV adenocarcinoma of the lung managed with various chemotherapy agents (carboplatin, taxol, navelbine) presented with jaundice and abnormal LFT’s. Patient was on a cancer experimental drug ‘iressa’ at presentation. Lab work showed Bilirubin, AST, ALT and AP at 6.5, 217, 292 and 806 respectively. Ultrasound and CT scan of the liver showed cystic changes in the liver with mild intrahepatic and extrahepatic biliary dilatation. Patient had MRCP, PTC and ERCP, which showed beaded appearance of the common bile duct, common hepatic duct and right and left hepatic ducts consistent with the appearance of sclerosing cholangitis. Patient had a stent placed into the CBD stricture and ‘Iressa’ was discontinued. LFT’s normalized on follow up. Conclusion: An extensive search of the literature does not reveal any case report citing sclerosing cholangitis as a paraneoplastic manifestation of lung cancers. There was also no reported association with cancer chemotherapeutic agents used in our patient, though the possibility of the experimental drug ‘Iressa’ as a potential etiological factor remains. In conclusion, cholangiographic changes similar to those seen on primary sclerosing cholangitis can be seen in advanced non-small cell lung cancer.
172 UTILITY OF COMBINED ERCP AND EUS IN PANCREATICOBILIARY DISEASE Kester Crosse, M.D., Oleh Haluszka, M.D., Peter Darwin, M.D.*. University of Maryland, Baltimore, MD and Fox Chase Cancer Center, Philadelphia, PA. Purpose: The diagnostic and therapeutic abilities of EUS and ERCP may be complimentary. These studies are often done separately given time constraints and operator expertise. The aim of this study is to evaluate the utility of combined EUS and ERCP in patients with pancreaticobiliary disease. Methods: Retrospective chart review of all patients scheduled for simultaneous EUS and ERCP at the University of Maryland Medical Center from 1999 to 2002 was performed. Results: 82 patients underwent both EUS and ERCP. The indications included 15 pancreatic masses, 2 recurrent pancreatitis, 36 dilated ducts without mass, 20 cystic lesions of the pancreas and 9 ampullary lesions. The EUS findings in the 15 cases with presumed pancreatic lesions included 6 (40%) with masses alone, 6 (40%) masses with vascular invasion or distant nodes , 2 (13 %) CBD stones that were extracted by ERCP, and 1(7%) cystic lesion. FNA was positive in 3/6 with masses and 5/6 masses with vascular invasion/nodes. Therapy following EUS included CBD stenting in 10/12 cases. The 5 cases with unresectable disease underwent metal stent placement and 3 had celiac blocks. The findings in the 36 cases with dilated ducts without mass included: 8 (23%) with negative EUS and ERCP, 5 (14%) with CBD stone by EUS and extraction by ERCP, 11 (31%) with pancreatic head pathology (malignant and benign) with strictures stented by ERCP, 3 (9%) with unresectable pancreatic lesions who received a celiac block and metal stent, 6 (17%) with negative EUS and pathology treated with ERCP (Klatskin tumor, papillary stenosis, CBD and PD strictures) and 2 (6%) miscellaneous (IPMT and ampullary adenoma). The 20 cystic lesions of the pancreas underwent initial ERCP. There were 5 PD disruptions, 3 communicating pseudocysts, 6 noncommunicating cystic lesions and 6 with failed pancreatograms. Therapy included 11 (55%) cystenterostomy, 5 (25%) aspiration, 2 (10%) transpapillary drainage and 2 (10%) no therapy. The 9 ampullary lesions underwent initial EUS. 5 (55%) of the ampullary lesions had no invasion by EUS and underwent ampullectomy and 4 (45%) with invasion underwent surgery or palliative sphincterotomy. Conclusions: When possible, EUS and ERCP should be done as combined procedures. Interventions may be performed based upon the information of both tests, including: stone extraction, the ability to drain a pseudocyst
AJG – Vol. 98, No. 9, Suppl., 2003
based upon the pancreatogram, ampullary adenoma management based upon depth of the lesion and palliative treatment for carcinoma. 173 EXTRA PANCREATIC MANIFESTATIONS OF ACUTE PANCREATITIS IN PATIENTS OF A MINORITY POPULATION Abbasi J. Akhtar, M.D., FACG*, Magda A. Shaheen, M.D., Ph.D. Charles R.Drew University of Medicine & Science, Los Angeles, CA. Purpose: Many studies have been published on acute pancreatitis, but few if any have focused on extra pancreatic manifestations in African American and Hispanic patients. As most of our patients belong to these two ethnic groups, we studied the frequency of extra pancreatic manifestations and their effect on mortality in these patients. Methods: Records of 760 (417 African American and 343 Hispanic) patients, ages 21-85 years, with the diagnosis of acute pancreatitis over a 15 years period were reviewed retrospectively. Data were analyzed by race/ethnicity for etiology, presence of extra pancreatic manifestations and mortality. Results: Of the 760 patients with acute pancreatitis, etiology was alcohol in 402 (53%), gall stones in 318 (42%), and miscellaneous causes including trauma, drugs and idiopathic in 40 (5%). While alcohol etiology was significantly higher among African American (63% African American, 41% Hispanic, P⬍0.05), gall stones were significantly more prevalent among Hispanics (32% African American, 54% Hispanic, P⬍0.05). One or more extra pancreatic manifestations were present in 148 patients (19.5%) and did not differ by race/ethnicity (19% African American, 20% Hispanics, P⬎0.05). The common extra pancreatic manifestations were gastrointestinal bleeding (18%), septicemia (13%), adult respiratory distress syndrome (10%), aneurysms and pseudo aneurysms (7%), and encephalopathy (5%). Of the 760 patients 109 (14%) died, however the mortality was significantly higher in patients with extra pancreatic manifestation(s) (39 patients, 26%) as compared to those without it (70 patients, 11%) (P⬍0.05). There was no difference in mortality by race/ethnicity (P⬎0.05). Conclusions: Mortality due to acute pancreatitis was high in our patient population compared to literature. Presence of extra pancreatic manifestation(s) increased the mortality significantly. 174 RADIATION EXPOSURE DURING ERCP TRAINING Lance Uradomo, M.D., Alexander Lustberg, M.D., Mark Lustberg, Ph.D., Oleh Haluszka, M.D., Peter Darwin, M.D.*. University of Maryland, Baltimore, MD and Fox Chase Cancer Hospital, Philadelphia, PA. Purpose: Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that requires substantial training and experience to perform safely and effectively. Radiation exposure to the patient and staff is a risk of this test. There has been no study that has examined radiation exposure by fluoroscopy during ERCP training. The aim of this retrospective study was to evaluate the difference in radiation exposure during ERCP between endoscopists at different levels of training. Methods: A retrospective review of 284 consecutive ERCP performed by gastroenterologists in an academic hospital during one year. All procedures were performed utilizing the same fluoroscopy equipment. Average radiation dose was estimated at 1.5 Rads per minute of fluoroscopy time based on standard settings as measured prior to the initiation of the study. Results: A total of 284 procedures were included in the analysis. Of those, 15 records omitted fluoroscopy time and were excluded from this analysis. The majority of cases, 222 (82%), were performed by fellows while 47 (18%) were performed by attending physicians alone (during fellow clinic block). The median fluoroscopy time for procedures with fellows was 389 seconds, and for attendings alone it was 322 seconds (p⫽0.23). Fluoroscopy time varied with the number of procedures performed by the fellows during that year. In a simple linear regression model, 3.5% of the variance in time is associated with the number of procedures performed by the