• Endoscopic therapy for palliation of pain in chronic pancreatitis has variableresults.. Combinations of therapeutic modalities including endoscopic transpapillaryand transluminal drain
Trang 1• Endoscopic therapy for palliation of pain in chronic pancreatitis has variableresults Most favorable responses generally occur with extraction of obstructingdistal pancreatic duct stones Outcome is less certain when there are residualstrictures and/or advanced parenchymal disease.11 Pain relief is variable forstenting and or dilation of dominant strictures in chronic pancreatitis Stric-tures may occasionally permanently resolve with endoscopic therapy but longterm stenting is often required.10 It is unclear whether favorable short-termresponse to pancreatic stenting predicts a favorable response to surgical decom-pressive therapies such as a Peustow procedure (lateral pancreaticojejunostomy)
• Endoscopic pseudocyst drainage results in 70 to 100% resolution with rence rates of 6-20%, depending in part on whether any underlying pancreaticductal disease was simultaneously treated In general, endoscopic drainage ofpseudocysts has similar success, complication, and relapse rates to surgical drain-age Combinations of therapeutic modalities including endoscopic transpapillaryand transluminal drainage, or endoscopic and percutaneous radiological drain-age or surgical drainage are sometimes required.14
recur-• In order to reduce risk of iatrogenic pancreatitis, pancreatic stenting is ingly used in advanced endoscopy centers to aid in accessing the bile duct dur-ing precut sphincterotomy or in conjunction with biliary sphincterotomy inhigh-risk patients such as those with sphincter of Oddi dysfunction There arefew published data
- retroperitoneal from sphincterotomy
- ductal from guidewires
• Stent related
- occlusion
- migration into or out of the duct
- ulceration/obstruction by migrated stent
• General cardiopulmonary and other complications related to ERCP, sedationand analgesia
• Pancreatitis is the most common complication of ERCP and is usually defined
by a clinical picture of pancreatitis, that is new or worsened abdominal pain,associated with an amylase level at least three times normal at more that 24hours after the procedure, and requiring unplanned admission of an outpatient
or extension of a planned admission for more than one day after the procedure.Pancreatitis is graded as mild if admission is prolonged for 2-3 days, moderate if
it is prolonged for 4-10 days and severe if hospitalization of more than 10 days
or any of the following occur: pancreatic necrosis, pseudocyst, or interventionrequiring percutaneous or surgical drainage Treatment requires fasting, sup-portive care, and rarely interventional drainage procedures.6 Pancreatitis afterERCP can occasionally be severe and life-threatening with multiorgan failureand even death In general, endoscopic pancreatic therapy is relatively safer inpatients with advanced chronic pancreatitis, but riskier (10-30%) in patients
Trang 2179 Endoscopic Therapy of Benign Pancreatic Disease
• Hemorrhage occurs in under 12% of patients after sphincterotomy.2,6 tation is typical for any upper GI hemorrhage, but may present up to 10 daysafter sphincterotomy.6 Diagnosis and supportive care is typical of any upper GIhemorrhage Diagnosis and therapy are performed at endoscopy using a side-viewing duodenoscope Very rarely, angiographic embolization or surgery arerequired If patients develop melena or hematemesis after ERCP
Presen Vital signs should be checked, including orthostatic blood pressure changes
- Blood should be drawn for hgb
- IV access established
- Emergency endoscopy should be considered
- Admission to the hospital if any evidence of significant past or ongoingbleeding
• Pancreatic infection or sepsis occasionally occurs with occlusion of a
pancre-atic stent or with inadequate endoscopic drainage of an obstructed pancrepancre-atic
duct Biliary sepsis may occur with pancreatic therapy without concomitant
biliary drainage or with incompletely drained biliary obstruction Treatmentusually involves antibiotics and exchange of the occluded or malfunctioningstent If patients develop fever or chills after ERCP
- Vital signs should be checked
- Blood should be drawn for CBC, liver and pancreatic chemistries
- Abdominal flat and upright series to evaluate position of stents and possibleperforation
- Admission to hospital
• Perforation occurs in under 1% of pancreatic or biliary sphincterotomies and
is recognized by presence of abdominal pain, often with fever and/or sis, and occasionally crepitus in the neck or chest Distinctions betweenperforation and pancreatitis can be difficult, and both complications can occursimultaneously, but presence of abdominal pain despite a normal serum amy-lase or lipase should raise suspicion of perforation Radiographic confirmation
leukocyto-of perforation is made by CT scan demonstrating retroperitoneal air or fluid,and rarely manifests as free intraperitoneal air on abdominal x-rays If recog-nized early, perforations can often be managed conservatively with antibiotics,nasogastric suction, and ideally nasopancreatic and/or nasobiliary drainage, butsurgical drainage and/or diversion is sometimes required If patients developsignificant abdominal pain after ERCP with sphincterotomy
- Patient should be kept NPO
- Blood drawn for amylase, lipase, CBC
- If amylase is normal, or there is other suspicion of perforation
- Abdominal flat and upright Normal study does not rule out perforation
- Spiral CT scan obtained, including examination of “lung windows” fordetection of retroperitoneal air or fluid
Trang 3endo-be retreated with a repeat sphincterotomy; however, deeper extension of creatic sphincterotomy may result in scarring and stricturing as pancreatic tis-sue is cut.
pan-• Like any endoscopic procedure, ERCP may result in esophageal perforation,allergic medication reactions, and cardiopulmonary or other general medicalmorbidity, especially in elderly or frail patients Diagnosis and managementdepend on the type of complication
3 Sherman S, Troiano FP, Hawes RH et al Sphincter of Oddi manometry: Decreasedrisk of clinical pancreatitis with use of a modified aspirating catheter GastrointestEndosc 1990; 36:462-466
4 Soetikno RM, CarrLocke DL Endoscopic management of acute gallstone atitis Gastrointest Endosc Clin N Am 1998; 8:1-12
pancre-5 Tarnasky PR, Hawes RH Endoscopic dignosis and therapy of unexplained pathic) acute pancreatitis Gastrointest Endosc Clin N Am 1998; 8:13-38
(idio-6 Freeman ML, Nelson DB, Sherman S et al Complications of endoscopic biliarysphincterotomy N Engl J Med 1996; 335:909-918
7 Kuo WH, Pasricha PJ, Kalloo AN The role of sphincter of Oddi manometry inthe diagnosis and therapy of pancreatic disease Gastrointest Endosc Clin N Am1998; 8:79-86
8 Ng C, Huibregtse T The role of endoscopic therrapy in chronic pancreatitisinducedcommon bile duct strictures Gastrointest Endosc Clin N Am 1998; 8:181-194
9 Lehman GA, Sherman S Diagnosis and therapy of pancreas divisum GastrointestEndosc Clin N Am 1998; 8:39-54
10 Binmoeller KF, Rathod VD, Soehendra N Endoscopic therapy of pancreatic tures Gastrointest Endosc Clin N Am 1998; 8:125-142
stric-11 Deviere J, Delhaye M, Cremer M Pancreatic duct stones management GastrointestEndosc Clin N Am 1998; 8:163-180
12 Lee JG, Leung JW Tissue sampling at ERCP in suspected pancreatic cancer.Gastrointest Endosc Clin N Am 1998; 8:221-236
13 Kozarek RA Endoscopic therapy of complete and partial pancreatic duct tions Gastrointest Endosc Clin N Am 1998; 8:39-54
disrup-14 Howell DA, Elton E, Parsons WG Endoscopic management of pseuodocysts ofthe pancreas Gastrointest Endosc Clin N Am 1998; 8:143-162
Trang 4per-Anatomy of the UGI Tract
• Access to the ampulla of Vater is through the pylorus and duodenum in theintact UGI tract
• After a partial gastrectomy (Billroth II), access to the ampulla of Vater is cult and consists of retrograde passage of the duodenoscope through the effer-ent limb of the gastrojejunostomy
diffi-• After an antrectomy (Billroth I), the access is through the duodenogastrostomyand is relatively simple
• After a Whipple resection, access to the ampulla is made in a retrograde fashionthrough the afferent limb of the gastrojejunostomy
Anatomy of the Ampulla of Vater
• There is a great deal of variation in the appearance of the major ampulla ofVater The ampulla may appear as a small button of tissue, a large protuber-ance, or a thickened fold
• The ampulla can usually be located by finding a large transverse fold in thesecond part of the duodenum It is located along the medial wall of the duode-num and 24 cm distal to the duodenal bulb
• There may be a diverticulum adjacent to or encompassing the ampulla
• The ampulla may be covered by a duodenal fold and visible only after pullingthe fold off the ampulla
• Bile staining of the mucosa can be a clue to locating the ampulla
• The minor ampulla is usually 23 cm proximal to the major ampulla The minorampulla is smaller than the major ampulla and there is no bile staining Theminor ampulla is just distal the duodenal bulb, along the medial wall of theduodenum
• In the absence of pancreas divisum, the major ampulla will contain the ings to the major pancreatic duct and the bile duct In the vast majority of cases,there is one opening that houses both ducts If there are separate openings, thebile duct is usually on the superior aspect of the ampulla
Trang 5• The minor ampulla has one opening and it is very small Secretin stimulationmay help in locating the opening since pancreatic juice can be seen flowing out
of the opening
Indications and Contraindications
• Therapeutic indications for ERCP
- Obstructive jaundice The presence of dilated bile ducts on CT/US is astrong predictor of biliary obstruction and is the most common indicatorfor ERCP Cholestatic LFT’s reflect the presence of biliary obstruction andoften the first evidence of biliary disease
- Acute cholangitis usually occurs with evidence of biliary obstruction, oftenfrom a stone or stent
Occlusion of a biliary stent
- Other Indications
- Bleeding from the ampulla or tumor in the duodenal wall
- Chronic, uncomplicated obstruction of the pancreatic duct is not a quent indication for ERCP
fre Suspicion for an occult pancreatic-biliary malignancy
- Need to obtain tissue for a histologic diagnosis of a pancreatic-biliary nancy
malig Differentiation between a pancreatic, biliary, and an ampullary malignancy
- Differentiation between chronic pancreatitis and cancer
- Diagnosis, biopsy and resection of ampullary tumors
• Side viewing endoscopes are the mainstay of ERCP
- Video or fiber-optic imaging
- Diagnostic or therapeutic channel size
• Accessories for cannulation and stenting
- Papillotomes
- 1, 2, or 3 lumens
- short or long nose
- Tapered catheters
- plastic or metal tipped
- long or short taper
Table 21.1 Indications for therapeutic ERCP
Trang 6183 ERCP in Malignant Disease
- Duodenal motility is controlled with glucagon
- Catheter is placed in superior aspect of ampulla for the bile duct and orly for the pancreatic duct
inferi Catheter or guide wire is gently advanced
- Contrast is injected after cannulation is achieved
• Sphincterotomy
- Guide wire and catheter are placed in duct of choice
- Tension and cautery are applied to the cutting wire
- Needle-knife can be used in place of sphincterotome
Table 21.2 Diagnostic indications for ERCP
- Suspicion for occult pancreatic-biliary malignancy
- Need for tissue diagnosis of malignancy
- Differentiating between pancreatic, biliary, and ampullary tumors
- Differentiating between chronic pancreatitis and cancer
- Diagnosis of ampullary malignancy
Table 21.3 Contraindications for ERCP
- High risk for conscious sedation
- Severe coagulopathy
- Pyloric or duodenal obstruction
Trang 7• Stent Placement
- Stent is placed in front of “pusher” catheter
- Stent is pushed through the scope and into duct
- Correct placement is confirmed fluoroscopically
- “Pusher” catheter and wire are removed
Trang 8• During staging of esophageal, gastric, lung and rectal tumors by EUS a number
of anatomical structures are visualized in the mediastinum, upper abdomen andperirectum.2
Trang 9Table 22.1 Histologic correlates of EUS images of gastric wall
1st EUS layer (hyperechoic) Mucosa (superficial)
2nd EUS layer (hypoechoic) Mucosa (deep)
3rd EUS layer (hyperechoic) Submucosa
4th EUS layer (hypoechoic) Muscularis Propria
5th EUS layer (hyperechoic) Serosa or Adventitia
Figure 22.1 Five echo layers of the gastrointestinal wall (arrows) as seen by scopic ultrasound
endo Rectal wall
- Urinary bladder
- Prostate and seminal vesicles in men
- Vagina in women
Trang 10187 Endoscopic Ultrasound: Tumor Staging
22
Indications for EUS Tumor Staging
• Assessment of the extent of tumor invasion within the GI wall and to adjacentorgans
• T stage by the TNM classification
• Assessment of lymph nodes for invasion by malignant cells; N stage by TNMclassification
Contraindications for EUS Tumor Staging
• When the patient already has distant metastases (e.g., liver) by other imagingmethods (e.g., CT scan or transabdominal US)
• When the results from EUS staging are not going to change the therapeuticstrategy
• When the patient has comorbid factors (e.g., severe COPD, severe or unstablecardiac disease, etc.) such that he or she is at a high risk for conscious sedationand endoscopy
Equipment for Endoscopic Ultrasound
• Radial GFUM20 or GFUM30 Echoendoscope (Olympus Corp.) (Fig 22.5)
- Scan Range: 360° (at rightangle to the long axis of the scope
Figure 22.2 Mediastinal anatomy with the endoscopic ultrasound transducer (T) inthe esophagus a = Aorta, V = Azygous Vein
Trang 11- Frequency: 7.5 MegaHertz-12 MegaHertz
- Endoscopic View: 45° oblique
- A newer generation of video radial echoendoscopes is available now thatprovides a much improved video endoscopic image
• FG32UA, FG36UX, FG38UX linear array echoendoscopes (PentaxCorp.)(Fig 22.6)
- Scan range: 100° convex linear (parallel to the long axis)
- Frequency: 5 megahertz-7.5 megahertz
- Endoscopic view: 60° oblique
• GF – UM30P Mechanical Sector Scanning echoendoscope (Olympus Corp.)
- Scan range: 250° mechanical sector (parallel to the long axis
- Frequency: 7.5 megahertz
- Endoscopic view: 45° oblique
• GFUC 30P linear array echoendoscope (Olympus Corp.)
- Scan range: 180° convex linear (parallel to the long axis)
Figure 22.3 Retroperitoneal anatomy during transgastric endoscopic ultrasoundimaging p = pancreas, S = splenic vein, C = portal vein-splenic vein confluence,Arrow = main pancreatic duct
Trang 12189 Endoscopic Ultrasound: Tumor Staging
22
Figure 22.4a Prostate gland (arrow) as seen during rectal endoscopic ultrasound
Figure 22.4b Left and right seminal vesicles as seen during rectal endosonography
Trang 13- Frequency: 7.5 megahertz
- Endoscopic view: 45° oblique
• Endoscopic ultrasound guided biopsy can be performed by all four instruments
of the above but is easiest with #2 and #4, fair with #3 and the most difficultwith #1
• Endoscopic ultrasound through the scope miniprobes (Fig 22.7)
- These slender catheter type probes can be passed through the biopsy nel of standard endoscopes for performing high frequency ultrasound
chan They are applied under direct vision to the region of interest
- The probes operate at frequencies ranging from 1220 megahertz
- Ultrasound guided biopsy is not possible
- These are manufactured by Olympus Corp., Fujinon Corp., and BostonScientific /Microvasive Corp
Figure 22.5 A radial echoendoscope with a rotating transducer that scans in a360° fashion at right angles to the long axis of the instrument arrow = transducer
Figure 22.6 A linear array endoscopic ultrasound instrument that scans parallel tothe long axis of the echoendoscope allowing ultrasound guided biopsies Closedarrow = transducer, open arrow = needle for ultrasound guided biopsy