Bone mineral metabolism and bone mineral density in alcohol related and idiopathic chronic pancreatitis.

BACKGROUND: There is limited information on the bone mineral metabolism in patients with chronic pancreatitis (CP). METHODS: 103 patients with CP (all males: mean age 38.6 ± 20.64 yrs) and 40 age matched control males (mean age: 36.7 ± 20.70 yrs) were prospectively studied. Serum levels of 25 (OH) Vitamin D3, alkaline phosphatase (ALP), and parathyroid hormone (PTH) were measured. Bone mineral density (BMD) was measured using adual-energy X-ray absorptiometry (DEXA) scanner. RESULTS: Seventy two (70%) patients had alcohol related chronic pancreatitis (ACP), 30 (29.1%) patients had idiopathic chronic pancreatitis (ICP) and one patient had post-traumatic chronic pancreatitis. Fifty nine (59.8%) patients had chronic calcific pancreatitis (CCP) and 39 (37.8%) patients were diabetic. Steatorrhea was noted in 21 (20.4%) patients. On comparison with controls, patients with chronic pancreatitis had significantly lower 25 (OH) Vitamin D3 levels (p = 0.01). On evaluation of bone mineral density (BMD) at lumbar spine, 46% patients were osteopenic and 12% patients were osteoporotic. On evaluation of BMD of femur, 30.1% patients were osteoporotic and 39.8% patients were osteopenic. No significant difference was found in the frequency of metabolic osteopathy between alcoholic and idiopathic groups (p = 0.108), calcific and non-calcific groups (p = 0.410), diabetic and non-diabetic groups (p = 0.126). smokers and non-smokers (p = 0.198), and patients with and without history of steatorrhea (p = 0.265) and indifferent severity groups ofupancreatitis (p = 0.910) CONCLUSIONS: Majority of patients with both ACP and ICP had low BMD and similar frequency of bone changes between various groups suggests that systemic inflammation may play an important role in its pathogenesis. Further detailed metabolic studies are necssary to define the pathogenic mechanism of metabolic osteopathy associated with chronic pancreatitis.

Morphological features of fluid collections on endoscopic ultrasound in acute necrotizing pancreatitis: do they change over time?

BACKGROUND: There have been attempts to develop universally applicable nomenclature for pancreatic fluid collections (PFCs) in acute pancreatitis. But PFCs following acute necrotizing pancreatitis (ANP) has not been studied by sensitive imaging techniques like endoscopic ultrasound (EUS). The aim of the study was to prospectively study morphological structure of pancreatic fluid collections occurring after ANP by serial EUS. METHODS: Patients with ANP having PFC at ≥4 weeks of onset of symptoms seen at our center from October 2011 to November 2012 were prospectively followed up with EUS at 6 weeks, 3 months and 6 months respectively and the amount of solid content in the collection was quantified as percentage amount of echogenic material. The symptomatic patients undergoing EUS/percutaneous drainage also underwent EUS prior to drainage for assessment of solid content. RESULTS: Of the 54 patients enrolled, 7 patients were lost to follow up or refused EUS. Forty seven patients (34 males; mean age 36.7±11.6 years) were studied. Etiology of acute pancreatitis was alcohol (n=22), gallstones (n=10), idiopathic (10), gallstones+alcohol (n=3) and drug induced (n=2). Contrast enhanced computed tomography done after 3 days of onset of ANP had shown less than 30%, 30-50% and more than 50% necrosis in 6 (13%), 14 (30%) and 27 (57%) patients respectively. On EUS at 6 weeks, 41/47 (87%) patients had fluid collection with solid debris. Follow up EUS at 3 and 6 months revealed progressively decreasing solid content in PFCs. CONCLUSIONS: All PFCs following ANP may not have solid necrotic content and over a period of time necrotic content tends to liquefy. This may have therapeutic implications.

Comparative evaluation of structural and functional changes in pancreas after endoscopic and surgical management of pancreatic necrosis.

BACKGROUND: Patients with acute necrotizing pancreatitis may develop pancreatic insufficiency and this is commonly seen in patients who have undergone surgery for pancreatic necrosis. Owing to the paucity of relative data, we retrospectively evaluated the structural and functional changes in the pancreas after endoscopic and surgical management of pancreatic necrosis. METHODS: The records of patients who underwent endoscopic transmural drainage of walled off pancreatic necrosis (WOPN) over the last 3 years and who completed at least 6 months of follow up were analyzed. Structural and functional changes in these patients were compared with 25 historical surgical controls (operated in 2005-2006). RESULTS: Twenty six patients (21 M; mean age 35.4±8.1 years) who underwent endoscopic drainage for WOPN were followed up for 22.3±8.6 months. During the follow up, five (19.2%) patients developed diabetes with 3 patients requiring insulin and 1 patient with steatorrhea requiring pancreatic enzyme supplementation. The pancreatic fluid collection (PFC) recurred in 1 patient whose stents spontaneously migrated out. On follow up, in the surgery group, 2 (8%) patients developed steatorrhea and 11 (44%) developed diabetes. Five (20%) of these patients had recurrence of PFC. On comparison of follow up results of endoscopic drainage with surgery, recurrence rates as well as frequency of endocrine and exocrine insufficiency was lower in the endoscopic group but difference was not significant. CONCLUSION: Structural and functional impairment of pancreas is seen less frequently in patients with pancreatic necrosis treated endoscopically compared to patients undergoing surgery, although the difference was insignificant. Further studies with large sample size are needed to confirm these initial results.

Consequences of long term indwelling transmural stents in patients with walled off pancreatic necrosis & disconnected pancreatic duct syndrome.

INTRODUCTION: There is limited data on the long term consequences and safety profile of long term indwelling transmural stents after successful treatment of walled off pancreatic necrosis (WOPN). AIM: To retrospectively evaluate consequences of long term indwelling transmural stents in patients with WOPN. METHODS: The records of patients who underwent endoscopic transmural drainage of WOPN and had disconnected pancreatic duct syndrome (DPDS) were analyzed. RESULTS: Thirty patients (26 M; mean age 37.1 ± 7.8 years) with long term indwelling transmural stents and DPDS were followed up for a mean of 20.4 ± 12.2 months (range: 3-38 months). The etiology of acute necrotizing pancreatitis was alcohol in 21, gall stones in 7 and idiopathic in 2 patients. In all patients two or three, 7 (17 patients) or 10 Fr (13 patients) 5 cm double pigtail stents were placed. ERCP revealed disconnected PD at the pancreatic head, body and tail region in 22, 7, and 1 patient respectively. Five patients (16.6%) had spontaneous migration of stents (both the stents in four patients and one stent in one patient; 7 Fr in four and 10 Fr in one patient respectively). Stent migration led to recurrence of pancreatic fluid collection (PFC) in one patient whereas in the remaining 4 patients it did not cause any symptoms. There was no recurrence of symptomatic PFC in remaining 25 patients. CONCLUSION: Long term indwelling transmural stents in patients with WOPN and DPDS seem to be safe and also appear to decrease the risk of PFC recurrence.

Duodenal tuberculosis--a rare case report and review of literature.

Extrapulmonary tuberculosis is rare and often difficult to diagnose infection. We report a case of duodenal tuberculosis, who presented with upper gastrointestinal symptoms. There was evidence of obstruction in the third part of duodenum (D3) on oesophagogastro endoscopy, barium meal follow through and CT scan of abdomen. On exploration there was thickening of D3 and D4 causing luminal obstruction. Resection of stricturous segment with end-to-side duodenojejunostomy was done. Biopsy of the diseased segment was tubercular. Antitubercular treatment was given to the patient for 6 months and he is doing well on follow up (1 year after surgery). Duodenal tuberculosis being the rarest form of intestinal tuberculosis poses great difficulty in diagnosis. High index of suspicion supported by radiological investigation, exploratory laparotomy and histopathological examination of the tissue can only lead to a definitive diagnosis of this rare condition. Treatment is both surgical which involves resection or by-pass for an obstructive lesion and medical which includes antitubercular therapy.

Non-surgical management of pancreatic pseudocysts associated with arterial pseudoaneurysm.

BACKGROUND: Pseudoaneurysms associated with pancreatic pseudocysts are different from simple, isolated pancreatic pseudoaneurysms and there is paucity of published data on their non surgical treatment. AIM: To retrospectively analyze results of combination of angioembolisation or thrombin injection followed by endoscopic transpapillary drainage for management of pseudoaneurysms associated with pancreatic pseudocysts. METHODS: Eight patients (all males; mean age ± SD: 31.2 ± 6.1 years; age range: 21-38 years) underwent radiological management of the pseudoaneurysm followed by endoscopic drainage of the pseudocysts. RESULTS: All patients had pseudocysts (median size 4 cm) with underlying chronic pancreatitis. All patients had abdominal pain on presentation and 7/8 (87.5%) patients had presented with overt gastrointestinal bleeding. The size of the pseudoaneurysms varied from 1 to 4 cm. Two patients were treated with percutaneous thrombin injection whereas six patients underwent digital subtraction angiography and angioembolisation. All patients underwent successful endoscopic transpapillary drainage through the major (5) or minor papilla (3) and resolution of pseudocysts was noted within 6 weeks (median 4 weeks). No significant complication of the procedure was noted in any of the patients. CONCLUSIONS: Pseudoaneurysms associated with pancreatic pseudocysts can be successfully and safely treated with a combination of radiological obliteration of the pseudoaneurysm followed by endoscopic transpapillary drainage.

Implications of culture positivity in acute pancreatitis: does the source matter?

BACKGROUND AND AIMS: Sepsis is an important complication and cause of morbidity and mortality in acute pancreatitis (AP). The source of sepsis may be infected pancreatic and peripancreatic collections and/or necrosis or extrapancreatic including infections in the bloodstream or respiratory and urinary tracts. We studied the implications of the source of sepsis on various outcome parameters in AP like persistent organ failure (POF), length of hospital (LOH) stay, and mortality. METHODS: A retrospective analysis of culture reports of AP patients was done, and the outcome parameters were recorded. RESULTS: Three hundred fifty-seven patients (229 M; age: 40.3 ± 14.04 years) of AP who had detailed culture reports were included. Eighty-four (23.5%) patients had pancreatic (or peripancreatic) source (group 1), 52 (14.6%) patients had other (extrapancreatic) sources (group 2), 20 (5.6%) patients were noted to have positive cultures from sources, which were both pancreatic and extrapancreatic (combined) sources (group 3), while 201 patients had sterile cultures. POF was seen in 147 (48%) patients (group 1: 67.8%; group 2: 65%; group 3: 90%; group 4: 34% [P < 0.001]). The mean LOH stay was 22.1 ± 20.26 days (group 1: 30.2 ± 20.64 days; group 2: 26.4 ± 26.82 days; group 3: 47.3 ± 32.60 days; group 4: 15.2 ± 11.34 days [P < 0.001]). Seventy (19.7%) patients succumbed to their illness (group 1 [22.9%]; group 2 [36.5%]; group 3 [40%]; group 4 [12%] [P < 0.001]). CONCLUSIONS: POF and LOH stay were more common in patients with combined pancreatic and extrapancreatic sources of sepsis. Mortality was significantly higher in patients with sepsis (groups 1, 2, 3) compared with sterile groups.

Non-fluoroscopic endoscopic ultrasound-guided transmural drainage of symptomatic non-bulging walled-off pancreatic necrosis.

BACKGROUND AND AIM: Endoscopic treatment of pancreatic necrosis is less invasive than surgery but is a technically demanding procedure. The aim of the present study was to retrospectively evaluate the safety and efficacy of endoscopic ultrasound (EUS)-guided transmural drainage of symptomatic non-bulging walled-off pancreatic necrosis (WOPN) without the use of fluoroscopy. METHODS: Over the last 24 months, 20 patients (16 men) with symptomatic non-bulging WOPN were treated endoscopically at Department of Gastroenterology, PGIMER, Chandigarh, India.The WOPN was transmurally approached using a linear echoendoscope and the tract dilated over the wire and multiple stents and a nasocystic drain were placed. RESULTS: All 20 patients had acute severe pancreatitis and the etiology of pancreatitis was alcohol in 12, gallstones in six and idiopathic in two patients. All patients were symptomatic with pain and six patients had fever and presented 5 to 16 weeks after an acute episode.The size of WOPN ranged from 5 to 16 cm.All 20 patients had marked improvement with radiological resolution noted in 19 patients and only one patient required direct endoscopic necrosectomy. One patient with multiple WOPN had a large peripherally located WOPN that did not resolve after transmural drainage and required an additional percutaneous drainage. One to seven endoscopic sessions were required and all these patients had complete resolution within 6 weeks.There were no complications of the procedure.There has been no recurrence of symptoms in these patients over a median follow up of 14 months. CONCLUSION: EUS-guided transmural drainage of non-bulging WOPN without the use of fluoroscopy appears to be safe and effective.

Achalasia cardia associated with esophageal varices: a therapeutic dilemma.

A 63-year-old male, chronic alcohol consumer, presented with progressively increasing dysphagia of 6 months duration. Upper gastrointestinal endoscopy revealed dilated esophagus with residue along with esophageal varices. Esophageal manometry revealed findings suggestive of classic achalasia cardia. Endoscopic ultrasound (EUS) examination revealed peri-esophageal collaterals as well as prominent perforators at lower end of esophagus. The co-existence of varices with achalasia is very rare and this case posed a difficult therapeutic dilemma as risk of bleeding from the varices limited the treatment options available. This case was successfully treated with EUS-guided botulinum toxin injection.

Tubercular versus Crohn's ileal strictures: role of endoscopic balloon dilatation without fluoroscopy.

BACKGROUND: Benign ileal strictures can cause considerable morbidity and they have been conventionally treated with surgery. The aim of this study was to report our experience of endoscopic balloon dilatation (EBD) in patients with terminal ileal strictures because of Crohn's disease and tuberculosis. METHODS: Over the last 8 years, 9 patients (6 males; mean age 39.7±13.2 years) with benign terminal ileal strictures were treated by EBD using a colonoscope and through-the-scope controlled radial expansion balloon dilators. RESULTS: The etiology of benign ileal stricture was Crohn's disease in 5 and tuberculosis in 4 patients. All the patients with Crohn's disease had no or partial response to 4 weeks of steroid therapy and there were no mucosal ulcerations on ileoscopy. Three patients with ileal strictures due to tuberculosis underwent dilatation after completion of the antitubercular therapy (ATT) while one patient required dilatation 3 months after starting ATT. All patients had single ileal stricture with length of stricture ranging from 0.6-1.8 cm. EBD was successful in all 9 patients with a median number of dilating sessions required of 2 (range: 1-5 sessions). Patients with Crohn's disease required more endoscopic sessions as compared to patients with tuberculosis but this difference was not statistically significant (mean number of session being 3.0±1.58 vs. 1.75±0.5 sessions respectively; P=0.1). One patient with ileal tuberculosis had enterolith proximal to the stricture that could be removed with dormia. There were no complications of the endoscopic procedure. CONCLUSIONS: EBD is an effective, safe, and minimally invasive treatment modality for benign ileal strictures.

Role of endoscopic ultrasound in evaluation of unexplained common bile duct dilatation on magnetic resonance cholangiopancreatography.

BACKGROUND: Dilated common bile duct (CBD) without obvious cause is a not uncommon finding on magnetic resonance cholangiopancreatography (MRCP). The aim of this study was to evaluate the diagnostic performance of endoscopic ultrasound (EUS) in patients with unexplained dilated CBD on MRCP. METHODS: Patients referred for EUS evaluation of a dilated CBD were retrospectively analyzed with respect to serum alkaline phosphatase prior to EUS and subsequent outcome after EUS. RESULTS: Over a 3-year period, 40 patients (24 males; mean age 38.9±9.9 years) with dilated CBD were retrospectively identified. Ten patients had elevated serum alkaline phosphatase. The diagnosis reached after EUS examination was: CBD stones in 15 (37.5%) with largest size of CBD stone being 9 mm, mass in CBD in 2 (5%), benign biliary stricture in 2 (5%), biliary stricture with underlying chronic pancreatitis in 1 (2.5%) patient respectively. EUS examination revealed normal CBD in 20 (50%) patients and two of these patients had periampullary diverticulum. All the patients with abnormal liver function tests had a detectable CBD pathology whereas 20/30 (66.6%) patients with normal liver biochemistry had normal EUS findings. There was no significant difference in the mean CBD diameter between the groups with demonstrable pathology compared with those without (P=0.64). CONCLUSION: EUS is a useful investigational modality for patients with unexplained dilated CBD on MRCP. The mean CBD diameter and the presence of normal liver function tests are not predictive of underlying pathology.

Role of endoscopic ultrasound in the diagnosis of pancreas divisum.

OBJECTIVE: The published data on the accuracy of the detection of pancreas divisum by endoscopic ultrasound (EUS) is limited. In this study, we evaluate the accuracy of detection of pancreas divisum by radial EUS in patients with chronic pancreatitis. METHODS: We retrospectively evaluated patients with chronic pancreatitis who underwent EUS followed by endoscopic retrograde cholangiopancreatography (ERCP) in the last four years to identify patients with complete pancreas divisum. RESULTS: One hundred and forty six patients with chronic pancreatitis underwent EUS examination and 20 patients (13.6%) had pancreas divisum. The overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy of absence of stack sign on EUS for the diagnosis of pancreas divisum were 50%, 97%, 73%, 93% and 91%, respectively and for the inability to trace pancreatic duct from the head to the body were 100%, 96%, 80%, 100% and 96%, respectively. CONCLUSION: EUS can diagnose pancreas divisum in a majority of patients. Pancreas divisum can be reliably excluded if pancreatic duct could be tracked backwards from the head to the body around the genu.

Tuberculosis presenting as Dysphagia: clinical, endoscopic, radiological and endosonographic features.

OBJECTIVE: Dysphagia as a presenting manifestation of tuberculosis is rare and there is paucity of data on the clinical, endoscopic and endosonographic features of these patients. We present our data related to the features over last four years. METHODS: We analyzed retrospectively the clinical, endoscopic, radiological, endosonographic and cytological findings in 14 patients (male: 10; mean age: 37.7 ± 10.4 years) with dysphagia due to tuberculosis presenting to us over last 4 years. RESULTS: Nine patients (64.3%) had Grade 1 dysphagia, 4 (28.6%) patients had Grade 2 and 1 patient (7.1%) had Grade 3. Mid esophagus was the commonest site of involvement. Endoscopic findings were extrinsic bulge (50%), linear ulcers (28.6%) and pol-ypoidal ulcerated lesion (7.1%). Endoscopic biopsies were inconclusive. Endoscopic ultrasound (EUS) demonstrated mediastinal lymph nodes being responsible for endoscopic bulge and their infiltration into esophageal wall leading on to ulcers. EUS-guided fine needle aspiration from these nodes established diagnosis in all patients. CONCLUSION: Dysphagia in tuberculosis is most commonly caused by compression by the surrounding mediastinal lymph nodes. EUS is a useful investigation for assessment of these patients.