Feasibility and safety of emergency ERCP and small-caliber pancreatic stenting as a bridging procedure in patients with acute biliary pancreatitis but difficult sphincterotomy.

BACKGROUND: The aims of the present study were: (1) to assess the feasibility and safety of emergency endoscopic retrograde cholangiopancreatography (ERCP) and pancreatic duct (PD) stenting with small-caliber stents as a bridging procedure in acute biliary pancreatitis (ABP) patients in whom biliary endoscopic sphincterotomy (EST) proved difficult, failed or was contraindicated, and (2) to compare the clinical outcome of those patients having emergency ERCP with and without pancreatic stent. METHOD: Eighty-seven consecutive patients with ABP were referred for emergency ERCP. In 60 of these ABP patients, ERCP, EST, and stone extraction (if necessary) were performed without PD stenting. In the remaining 27 patients, small-caliber (3-5 F, 4 cm) pancreatic stent insertion was initially applied. All patients were hospitalized for medical therapy and were followed up. RESULTS: The mean ages, the initial symptom-to-ERCP times, the Glasgow severity scores, and the peak amylase and CRP levels at initial presentation were not significantly different in the ERCP + EST with PD stent group versus the ERCP + EST without PD stent group. More importantly, the complication rate was significantly lower in the ERCP + EST with PD stent group versus the ERCP + EST without PD stent group (7.4% vs. 25%); while the mortality rates (0% vs. 6.7%) were comparable, reasonably low, and demonstrated no statistically significant differences. CONCLUSIONS: Temporary PD stenting with small-caliber stents is a safe and effective procedure that may afford sufficient PD decompression to reverse the process of ABP and serve as a bridging procedure in severe ABP in patients with failed, complicated, or contraindicated biliary EST.

Prophylactic pancreas stenting followed by needle-knife fistulotomy in patients with sphincter of Oddi dysfunction and difficult cannulation: new method to prevent post-ERCP pancreatitis.

INTRODUCTION: The aim of the present study was to reduce post-endoscopic retrograde cholangiopancreatography (ERCP) complications with a combination of early needle-knife access fistulotomy and prophylactic pancreatic stenting in selected high-risk sphincter of Oddi dysfunction (SOD) patients with difficult cannulation. METHODS: Prophylactic pancreatic stent insertion was attempted in 22 consecutive patients with definite SOD and difficult cannulation. After 10 min of failed selective common bile duct cannulation, but repeated (>5x) pancreatic duct contrast filling, a prophylactic small calibre (3-5 Fr) pancreatic stent was inserted, followed by fistulotomy with a standard needle-knife, then a standard complete biliary sphincterotomy followed. The success and complication rates were compared retrospectively with a cohort of 35 patients, in which we persisted with the application of standard methods of cannulation without pre-cutting methods. RESULTS: Prophylactic pancreatic stenting followed by needle-knife fistulotomy was successfully carried out in all 22 consecutive patients, and selective biliary cannulation and complete endoscopic sphincterotomy were achieved in all but two cases. In this group, not a single case of post-ERCP pancreatitis was observed, in contrast with a control group of three mild, 10 moderate and two severe post-ERCP pancreatitis cases. The frequency of post-ERCP pancreatitis was significantly different: 0% versus 43%, as were the post-procedure (24 h mean) amylase levels: 206 U/L versus 1959 U/L, respectively. CONCLUSIONS: In selected, high-risk, SOD patients, early, prophylactic pancreas stent insertion followed by needle-knife fistulotomy seems a safe and effective procedure with no or only minimal risk of post-ERCP pancreatitis. However, prospective, randomized studies are awaited to lend to support to our approach.

Rescue ERCP and insertion of a small-caliber pancreatic stent to prevent the evolution of severe post-ERCP pancreatitis: a case-controlled series.

INTRODUCTION: Recently prophylactic placement of a trans-sphincteric pancreatic stent has successfully been applied to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Rescue ERCP and emergency application of small-caliber pancreatic stents during the early course of post-ERCP pancreatitis as a possible endoscopic therapy has not been reported yet. METHODS: All patients who underwent ERCP were hospitalized for at least 24 h, with routine laboratory testing of amylase levels. Out of 1,225 ERCPs, evolution of severe post-ERCP pancreatitis was anticipated in six consecutive patients, based on severe pancreatic pain attack, more than tenfold elevation of serum amylase levels at 8 and 24 h, and moderate rise of white blood cell (WBC) and C-reactive protein (CRP) levels. Rescue ERCP and emergency application of small-caliber (4-5F, 4-cm, Geenen stent) pancreatic stents were successfully performed in all patients within 8-20 h after the initial ERCP. RESULTS: Moderate to severe papillary oedema was observed in all patients during the rescue ERCP. Pancreatic pain was promptly reduced after the rescue pancreatic drainage procedure and completely diminished within 24 h after pancreatic stenting. Serum amylase levels were exponentially reduced and normalized within 72 h in all patients; no pancreatic necrosis or any other late complications were observed. Pancreatic stents could be safely removed a few days later. CONCLUSION: Rescue pancreatic stenting with small-caliber prophylactic pancreatic stents seems to be a safe and effective procedure that might be feasible to stop the evolution of severe post-ERCP pancreatitis, but prospective controlled studies are clearly demanded to support this innovative approach.

Somatosensory hypersensitivity in the referred pain area in patients with chronic biliary pain and a sphincter of Oddi dysfunction: new aspects of an almost forgotten pathogenetic mechanism.

BACKGROUND AND AIMS: Somatosensory hyperalgesia in the referred pain area (RPA) in patients with acute or chronic abdominal pain syndromes may result from the convergence of nerve fibers from visceral and somatic tissues at the spinal and supraspinal levels. Chronic biliary pain in patients with the postcholecystectomy syndrome (i.e., biliary hypersensitivity) may be explained by persistent hyperexcitability of neurons in the central nervous system (CNS). The aim of this study was to evaluate the cutaneous neural sensory perception in the RPA in patients with chronic postcholecystectomy biliary pain and a sphincter of Oddi (SO) dysfunction (SOD). METHODS: Forty-two patients with persistent biliary pain and suspected SOD, 27 age-matched healthy volunteers, and 18 age-matched asymptomatic cholecystectomized controls were prospectively investigated by quantitative sensory testing (Neurometer CPT). The biliary symptoms and the severity of pain were classified on a visual analog pain severity scale system via a previously validated and standardized questionnaire. The patients helped the doctors locate the RPA in the right upper quadrant. The sensory detection threshold was determined noninvasively (Neurometer CPT) with transcutaneous electrical stimulation at 5, 250, and 2,000 Hz, and different current intensities (range from 0.01 to 9.99 mA) applied in a single (patient) blinded method. These three frequencies selectively excite small unmyelinated (C fibers), small myelinated (A-delta), and large myelinated (A-beta) fibers, which transmit dull pain, sharp pain, and touch, respectively. The contralateral region of the abdomen left upper quadrant served as the control area. The sensory current perception threshold ratio (SCPTR) of the data measured in the contralateral area and the RPA was calculated. RESULTS: The SCPTRs in the definite SOD patients with biliary pain, healthy volunteers, the asymptomatic cholecystectomized controls, and the symptomatic cholecystectomized patients but without SOD were 2.32 +/- 1.4 versus 1.06 +/- 0.24 versus 0.97 +/- 0.16 versus 0.83 +/- 0.35 at 2,000 Hz; 2.19 +/- 1.0 versus 1.01 +/- 0.26 versus 1.02 +/- 0.25 versus 0.88 +/- 0.35 at 250 Hz; and 2.19 +/- 1.1 versus 1.12 +/- 0.26 versus 0.99 +/- 0.37 versus 0.84 +/- 0.32 at 5 Hz, respectively. Significant hypersensitivity was detected in the RPA at different stimulation frequencies in the SOD patients with biliary pain versus the cholecystectomized controls: at 5 Hz: P = 0.00001; at 250 Hz: P = 0.00001; and at 2,000 Hz: P = 0.0001, respectively. CONCLUSION: Continuous visceral pain (biliary pain) caused by local inflammatory/sensitizing processes or a CNS malfunction could lead to significant hypersensitivity of the peripheral nociceptive nerve fibers in SOD patients. Postcholecystectomy pain may be explained by persistent hyperexcitability of the nociceptive neurons in the CNS with or without objective motility disorders of the SO.

How can a pancreatic neoplasm be diagnosed by colonoscopy? A case report.

Gastrointestinal bleeding frequently manifests as a severe, life-threatening condition. The pathological conditions of the pancreas rarely associate with rectal hemorrhage. The history of a male patient with cancer of the tail of the pancreas, which invaded the large bowel and manifested clinically as a severe lower gastrointestinal bleeding, is reported. Repeated colonoscopy diagnosed a necrotising tumor mass which was communicating with the bowel through a fistula. Neoplasms of the tail of the pancreas usually do not cause early symptoms, therefore extra pancreatic extension and invasion of other organs are relatively common at the time of diagnosis. When managing patients with distal gastrointestinal bleeding, the possibility of malignancy originating from other organs other than the large bowel must always be borne in mind.

Characterization of functional biliary pain and dyspeptic symptoms in patients with sphincter of Oddi dysfunction: effect of papillotomy.

AIM: To characterize functional biliary pain and other gastrointestinal (GI) symptoms in postcholecystectomy syndrome (PCS) patients with and without sphincter of Oddi dysfunction (SOD) proved by endoscopic sphincter of Oddi manometry (ESOM), and to assess the post-endoscopic sphincterotomy (EST) outcome. METHODS: We prospectively investigated 85 cholecystectomized patients referred for ERCP because of PCS and suspected SOD. On admission, all patients completed our questionnaire. Physical examination, laboratory tests, abdominal ultrasound, quantitative hepatobiliary scintigraphy (QHBS), and ERCP were performed in all patients. Based on clinical and ERCP findings 15 patients had unexpected bile duct stone disease and 15 patients had SOD biliary type I. ESOM demonstrated an elevated basal pressure in 25 patients with SOD biliary-type III. In the remaining 30 cholecystectomized patients without SOD, the liver function tests, ERCP, QHBS and ESOM were all normal. As a control group, 30 'asymptomatic' cholecystectomized volunteers (attended to our hospital for general cardiovascular screening) completed our questionnaire, which is consisted of 50 separate questions on GI symptoms and abdominal pain characteristics. Severity of the abdominal pain (frequency and intensity) was assessed with a visual analogue scale (VAS). In 40 of 80 patients having definite SOD (i.e. patients with SOD biliary type I and those with elevated SO basal pressure on ESOM), an EST was performed just after ERCP. In these patients repeated questionnaires were filled at each follow-up visit (at 3 and 6 mo) and a second look QHBS was performed 3 mo after the EST to assess the functional response to EST. RESULTS: The analysis of characteristics of the abdominal pain demonstrated that patients with common bile duct stone and definite SOD had a significantly higher score of symptomatic agreement with previously determined biliary-like pain features than patient groups of PCS without SOD and controls. In contrary, no significant differences were found when the pain severity scores were compared in different groups of PCS patients. In patients with definite SOD, EST induced a significant acceleration of the transpapillary bile flow; and based on the comparison of VASs obtained from the pre- and post-EST questionnaires, the severity scores of abdominal pain were significantly improved, however, only 15 of 35 (43%) patients became completely pain free. Post-EST severity of abdominal pain by VASs was significantly higher in patients with predominant dyspepsia at initial presentation as compared to those without dyspeptic symptoms. CONCLUSION: Persistent GI symptoms and general patient dissatisfaction is a rather common finding after EST in patients with SOD, and correlated with the presence of predominant dyspeptic symptoms at the initial presentation, but does not depend on the technical and functional success of EST.