Miss rate of pancreas divisum by magnetic resonance cholangiopancreatography in clinical practice.

OBJECTIVES: Pancreas divisum is the most common congenital abnormality of the pancreatic anatomy. Magnetic resonance cholangiopancreatography has emerged as a noninvasive method of examining the pancreatic ductal anatomy. We aim to assess the sensitivity of MRCP for pancreas divisum. METHODS: Patients with pancreas divisum at endoscopic retrograde cholangiopancreatography (ERCP) and who had prior MRCP between January 2001 and February 2006 were identified. Sensitivities were calculated for relevant subgroups with binomial 95% confidence intervals. Fisher exact P values were calculated. RESULTS: Four hundred five patients had divisum at ERCP; of these, 111 (27%) had undergone MRCP before ERCP. Seventy-two (65%) patients had MRCP at outside centers. Twenty-three of the 72 MRCPs at referring centers correctly reported divisum. In contrast, the sensitivity was higher for the 24 MRCPs without secretin at our institution: 16 (67%). The sensitivity in the secretin-stimulated group was 67% (10/15). However, this was not different from that of MRCP without secretin. Of note, 9 (18%) of the 49 negative outside MRCPs had divisum suspected by the gastroenterologist reviewing the MRCP images before ERCP. CONCLUSIONS: Pancreas divisum seems to be often missed on MRCP, even when secretin is used. The absence of secretin, use of suboptimal magnetic resonance techniques, and inexperienced pancreatic MRCP examiners are all possible contributing factors.

Does the presence of esophagitis prior to PEG placement increase the risk for aspiration pneumonia?

The aim of this study is to determine if the endoscopic presence of esophagitis predicts aspiration pneumonia after the initiation of enteral feedings in a newly placed PEG tube. A retrospective analysis of 278 patients who received a PEG tube from November 1999 to June 2002 was performed. All PEG procedures performed by a single endoscopist were reviewed from the GI Trac database at the Medical University of South Carolina. Eleven of the procedures were aborted due to technical difficulties. Nine patients received the PEG for gastric decompression only. Seven patients died within 14 days of PEG placement from non-PEG-related complications and were excluded. The resulting 251 patients included for our analysis successfully had PEG tube placement and had at least 14 days of enteral feeding. Esophagitis was defined macroscopically by the endoscopic presence of mucosal edema, friability, or obscurity of the normal vascular pattern in the distal esophagus. Aspiration was defined as the witnessed regurgitation of or tracheal suctioning of PEG feedings. Pneumonia as a consequence of aspiration was defined by development of fever and new infiltrate on chest radiograph within 14 days of PEG placement. Two hundred fifty-one patients had PEG placement (M, 127; F, 124; average age, 62.4 year; age range, 18-95 years) performed by a single endoscopist over a 32-month period. Fourteen (5.6%) of these patients had clinically evident pulmonary aspiration, with seven of them developing pneumonia. Thirteen (93%) of these patients had normal esophageal mucosa. One of the 24 patients (4%) with esophagitis or esophageal ulceration present endoscopically had an aspiration event with subsequent pneumonia. None of the 20 patients found to have some other form of esophageal pathology had an aspiration event. The overall incidence of aspiration pneumonia after the initiation of PEG feedings was 2.7% (7/251). The odds ratio that the presence of esophagitis would predict the development of aspiration pneumonia was 1.60, with a 95% confidence interval of 0.18 to 13.89. This study argues that the presence of esophagitis alone does not increase the risk of aspiration pneumonia from PEG feedings. Other factors apart from esophagitis play an important role in the incidence of aspiration pneumonia with PEG feeding