Endoscopy in the Diagnosis and Management of Acute and Chronic Pancreatitis

Contents

Foreword: Advances in Pancreatic Endoscopy ix

Charles J. Lightdale

Preface: Effective Endoscopic Management of Pancreatic Diseases xi

Martin L. Freeman

Role of Endoscopic Ultrasonography in the Diagnosis of Acute and ChronicPancreatitis 735

Tyler Stevens

Endoscopic ultrasonography (EUS) can be a useful tool for detecting theunderlying causes of acute pancreatitis and establishing the severity offibrosis in chronic pancreatitis. Ancillary techniques include fine needleaspiration and core biopsy, bile collection for crystal analysis, pancreaticfunction testing, and celiac plexus block. This review focuses on the roleof EUS in the diagnosis of acute and chronic pancreatitis.

Endoscopic Management of Acute Biliary Pancreatitis 749

Vincent C. Kuo and Paul R. Tarnasky

Videos of the needle-knife precut sphincterotomy and standardsphincterotomy techniques accompany this article

Acute pancreatitis represents numerous unique challenges to the practic-ing digestive disease specialist. Clinical presentations of acute pancreati-tis vary from trivial pain to severe acute illness with a significant risk ofdeath. Urgent endoscopic treatment of acute pancreatitis is consideredwhen there is causal evidence of biliary pancreatitis. This article focuseson the diagnosis and endoscopic treatment of acute biliary pancreatitis.

Preventing Pancreatitis after Endoscopic Retrograde Cholangiopancreatography 769

Nisa M. Kubiliun and B. Joseph Elmunzer

Post–endoscopic retrograde cholangiopancreatography (ERCP) pan-creatitis is a common and potentially devastating complication of ERCP.Advances in risk stratification, patient selection, procedure technique,and prophylactic interventions have substantially improved the endoscop-ists’ ability to prevent this complication. This article presents the evidence-based approaches to preventing post-ERCP pancreatitis and suggeststimely research questions in this important area.

Endoscopic Therapy of Necrotizing Pancreatitis and Pseudocysts 787

Jessica M. Fisher and Timothy B. Gardner

Endoscopic therapy has become an essential component in the manage-ment of post-pancreatitis complications, such as infected and/or symptom-atic pancreatic pseudocysts and walled-off necrosis. However, although

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there have been 2 recent randomized, controlled trials performed, a generallack of comparative effectiveness data regarding the timing, indications,and outcomes of these procedures has been a barrier to the developmentof practice standards for therapeutic endoscopists managing these issues.This article reviews the available data and expert consensus regardingindications for endoscopic intervention, timing of procedures, endoscopictechnique, periprocedural considerations, and complications.

Endoscopic Therapy for Acute Recurrent Pancreatitis 803

Jason R. Roberts and Joseph Romagnuolo

Endoscopy plays an important role in both the diagnosis and the initialmanagement of recurrent acute pancreatitis, as well as the investigationof refractory disease, but it has known limitations and risks. Sound selec-tive use of these therapies, complemented with other lines of investigationsuch as genetic testing, can dramatically improve frequency of attacks andassociated quality of life. Whether endoscopic therapy can reduce pro-gression to chronic pancreatitis, or reduce the risk of malignancy, is debat-able, and remains to be proven.

Endoscopic Therapy for Chronic Pancreatitis 821

Jean-Marc Dumonceau

Endoscopic therapy is recommended as the first-line therapy for painfulchronic pancreatitis with an obstacle on the main pancreatic duct (MPD).The clinical response should be evaluated at 6 to 8 weeks. Calcified stonesthat obstruct the MPD are first treated by extracorporeal shockwave litho-tripsy; dominant MPD strictures are optimally treated with a single, large,plastic stent that should be exchanged within 1 year even in asymptomaticpatients. Pancreatic pseudocysts for which therapy is indicated and arewithin endoscopic reach should be treated by endoscopy.

ERCP for Biliary Strictures Associated with Chronic Pancreatitis 833

Pietro Familiari, Ivo Bo�skoski, Vincenzo Bove, and Guido Costamagna

Chronic pancreatitis (CP)-related common bile duct (CBD) strictures aremore difficult to treat endoscopically compared with benign biliary stric-tures because of their nature, particularly in patients with calcific CP.Before any attempt at treatment, malignancy must be excluded. Singleplastic stents can be used for immediate symptom relief and as “bridgeto surgery and/or bridge to decision,” but are not suitable for definitivetreatment of CP-related CBD strictures because of long-term poor results.Temporary simultaneous placement of multiple plastic stents has a hightechnical success rate and provides good long-term results.

Endoscopic Ultrasonography–Guided Drainage of the Pancreatic Duct 847

Jessica Widmer, Reem Z. Sharaiha, and Michel Kahaleh

Over the last 2 decades there has been continuing development inendoscopic ultrasonography (EUS). EUS-guided pancreatic drainage isan evolving procedure that can be offered to patients who are high-risksurgical candidates and in whom the pancreatic duct cannot be ac-cessed by endoscopic retrograde pancreatography. Although EUS-guided

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pancreatic drainage is a minimally invasive alternative option to surgery andinterventional radiology, owing to its complexity and potential for fulminantcomplications, it is recommended that these procedures be performedby highly skilled endoscopists. Additional data are needed to define risksand long-term outcomes more accurately via a dedicated prospectiveregistry.

Endoscopic Therapy for Pancreatic Duct Leaks and Disruptions 863

Shyam Varadarajulu, Surinder S. Rana, and Deepak K. Bhasin

Pancreatitis, whether acute or chronic, can lead to a plethora of complica-tions, such as fluid collections, pseudocysts, fistulas, and necrosis, all ofwhich are secondary to leakage of secretions from the pancreatic ductalsystem. Partial and side branch duct disruptions can be managedsuccessfully by transpapillary pancreatic duct stent placement, whereaspatients with disconnected pancreatic duct syndrome require more com-plex endoscopic interventions or multidisciplinary care for optimal treat-ment outcomes. This review discusses the current status of endoscopicmanagement of pancreatic duct leaks and emerging concepts for thetreatment of disconnected pancreatic duct syndrome.

Autoimmune Pancreatitis: Role of Endoscopy in Diagnosis and Treatment 893

Sung-Hoon Moon and Myung-Hwan Kim

This review addresses the role of endoscopy in the diagnosis and treat-ment of autoimmune pancreatitis (AIP) and provides a diagnostic processfor patients with suspected AIP. When should AIP be suspected? Whencan it be diagnosed without endoscopic examination? Which endoscopicapproaches are appropriate in suspected AIP, and when? What are theroles of diagnostic endoscopic retrograde pancreatography, endoscopicbiopsies, and IgG4 immunostaining? What is the proper use of the steroidtrial in the diagnosis of AIP in patients with indeterminate computedtomography imaging? Should biliary stenting be performed in patientswith AIP with obstructive jaundice?

Palliation of Pancreatic Ductal Obstruction in Pancreatic Cancer 917

Reem Z. Sharaiha, Jessica Widmer, and Michel Kahaleh

Pancreatic stenting for patients with obstructive pain secondary to amalig-nant pancreatic duct stricture is safe and effective, and should be consid-ered a therapeutic option. Although pancreatic stenting does not seem tobe effective for patients with chronic pain, it may be beneficial in those withobstructive type pains, pancreatic duct disruption, or smoldering pancre-atitis. Fully covered metal stents may be an option, but data on their useare limited. Further studies, including prospective randomized studiescomparing plastic and metal stents in these indications, are needed tofurther validate and confirm these results.

Index 925