Hydrostatic balloon catheters. A new dimension of therapeutic endoscopy.

Disorders secondary to strictures of various segments of the gastrointestinal tract, e.g. esophagus, stomach, bile ducts, pancreas and colon often produce symptoms requiring continuing medical management or aggressive intervention. Until now, surgery has been required for failures of medical treatment. Endoscopically placed balloon catheters offer an alternative method for effectively treating a variety of gastrointestinal strictures. In this report we present examples of applications of balloon catheters in clinical gastroenterology.

The role of pancreatobiliary duct anatomy in the etiology of alcoholic pancreatitis.

We determined the types of pancreatobiliary ductal anatomy in 58 chronic alcoholic patients with and without pancreatitis at ERCP. Twenty-four of 28 patients (86%) with pancreatitis had separately opening common bile ducts and pancreatic ducts, while only six of 30 patients (20%) without pancreatitis had this finding. We conclude that a separate channel configuration is an inherited predisposing factor to alcoholic pancreatitis. As both chronic alcohol ingestion and separately opening bile and pancreatic ducts have been associated with ductal epithelial hyperplasia, the pathogenesis of alcoholic pancreatitis may be by way of duct obstruction produced by cell hyperplasia.

Cholestasis: an alternative to surgery in older patients.

Until recently, benign biliary obstruction meant surgery and lengthy hospitalization--always worth avoiding in the elderly. Fortunately, new interventional endoscopy and radiologic techniques offer nonoperative choices. The authors review one of the more significant of these advances.

Biliary endoprostheses for the management of retained common bile duct stones.

Stone retention after duodenoscopic sphincterotomy may occur despite an adequate and well-performed sphincterotomy. We have identified factors contributing to stone retention in 26 patients. In 22 of these patients, the stones have been effectively managed with a biliary endoprosthesis in a manner which traps the stone proximally and maintains patency of the biliary tree. No complications were noted with this form of management for periods ranging form 3-36 months. When circumstances preclude removal of bile duct stones after duodenoscopic sphincterotomy, a biliary endoprosthesis offers a safe, effective means of stone management.

Endoscopic evaluation and therapy of periampullary adenoma.

Duodenoscopy has been helpful in the diagnosis and treatment of periampullary adenomas. Unlike colonic polyps, endoscopic appearance and histological classification is often difficult. A high incidence of carcinoma in these lesions requires their removal. Endoscopic polypectomy may be done, but only after documenting that the lesion does not contain ductal structures.

Anomalous pancreatic ducts causing "pseudomass" of the pancreas.

Computerized axial tomography (CT scan) of the abdomen is a sensitive method for examining the pancreas. Its sensitivity, however, may lead to the discovery of small mass lesions which do not represent neoplastic or inflammatory lesions. We describe our experience with 21 patients in whom mass lesions seen by CT scan were proven by endoscopic retrograde pancreatography (ERCP) to represent anomalies of the pancreatic duct. We call such lesions "pseudomasses." Our findings support the need for opacification of the pancreatic duct system to rule out lesions arising from the duct whenever lesions of the pancreas are suspected on CT scan.

Variant pancreatography.

Although variation is the rule with pancreatic duct morphology, certain anomalies occur as a result of altered embryological development. These anomalies can produce obvious clinical symptomatology or may be implicated as a cause of symptoms when noted in the evaluation of patients with gastrointestinal complaints of obscure origin. Gastroenterologists and radiologists should be familiar with these anomalies for more accurate interpretation of pancreatograms and their clinical implications.

Approach to cholestasis: an update.

New techniques have changed the approach to diagnosis and therapy in the patient with cholestasis. Screening with ultrasonography or computed tomographic scanning, followed by direct opacification of the biliary tree by percutaneous transhepatic cholangiography (PTC) or endoscopic retrograde cholangiopancreatography (ERCP) provides accurate diagnostic information. Therapeutic extensions of PTC and ERCP permit decompression of obstructed biliary systems either as an aid to preparative management or for long-term decompression in operable patients. Thus, the role of surgery in cholestasis can now be more strictly defined.