G A Lehman

Twenty asymptomatic paid volunteers (13 females, 7 males, mean age 34 years, range 21-52 years), underwent endoscopic ultrasonography (EUS) to assess variation in the appearance of ductular and parenchymal features of the pancreas. Following this investigation, 69 patients with chronic abdominal pain of suspected pancreaticobiliary origin were evaluated with EUS followed by endoscopic retrograde cholangiopancreatography (ERCP) and in 16 patients secretin stimulated intraductal pure pancreatic juice (PPJ) collection. Thirty patients were found to have chronic pancreatitis based on clinical, ERCP and/or PPJ data, and EUS was abnormal in 24 of these individuals. All of the 19 patients with abnormal pancreatograms also had an abnormal EUS. Twenty-two of the 30 patients with chronic pancreatitis had early disease (no or minimal changes on ERCP). In this subgroup of patients, the sensitivity of EUS was 86% versus 50% for ERCP (p = 0.01). For all patients, the sensitivity, specificity and accuracy of EUS in diagnosing chronic pancreatitis was 80%, 86% and 84% respectively. Using logistic regression analysis eight EUS features were found to be indicative of chronic pancreatitis including echogenic foci within the gland, focal regions of reduced echogenicity within the gland, increased thickness/echogenicity of the main pancreatic duct (MPD) wall, accentuation of the gland's lobular pattern, cysts, an irregular contour or dilation of the MPD and side branch dilation (p < or = 0.05). Generation of a receiver operating characteristic curve to assess the sensitivity and specificity of EUS in diagnosing chronic pancreatitis based on the number of abnormal findings demonstrated that sensitivity and specificity were optimal when three or more abnormal parenchymal and/or ductular features were found. These results suggest that EUS can play an adjunctive role to ERCP and PPJ in the diagnosis of early chronic pancreatitis.

Acute pancreatitis may occur after the performance of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy. During ERCP and endoscopic sphincterotomy, the pancreas is subjected to many types of potential injury--mechanical, chemical, hydrostatic, enzymatic, microbiological, allergic, and thermal. These factors may act independently or in concert to induce postprocedure pancreatitis. The potential role of each etiologic factor in the development of ERCP- and endoscopic sphincterotomy-induced pancreatitis is detailed. The management of this complication is reviewed. Patient factors that increase the risk for pancreatitis and techniques to prevent or limit this complication are described. A variety of agents have been shown to prevent or treat pancreatitis in animal models, but extrapolation to humans has been almost uniformly unsuccessful. Although postprocedure pancreatitis is unlikely to be completely eliminated, careful patient selection and attention to detail may reduce the incidence of this untoward event.

BACKGROUND: Pancreaticobiliary disease in pregnancy is relatively uncommon. The frequency of choledocholithiasis in pregnancy requiring intervention has been reported to be as low as one in 1200 deliveries. Traditionally, intervention in these patients has been surgical. Although surgery has an overall low morbidity and mortality for the expectant mother, it carries with it a 4- to 6-wk recovery period and a possibly increased risk of fetal wastage. Published information regarding the role and safety of ERCP in pregnancy is limited. This series of 23 pregnant patients undergoing ERCP was collected from six different medical centers. METHODS: Twenty-three pregnant patients with symptomatic pancreaticobiliary disease underwent a total of 29 ERCPs (three patients had diagnostic ERCP, and 20 had therapeutic ERCP). Fifteen, eight, and six procedures were performed in the first, second, and third trimesters, respectively. The only ERCP complication was pancreatitis in one patient. There was one spontaneous abortion (3 months after ERCP) and one neonatal death; however, casual relationship to ERCP was not apparent. CONCLUSION: Diagnostic and therapeutic ERCP appears reasonably safe and effective in pregnancy. Cautious and selective use of this procedure offers a viable alternative to surgery or observation in patients with emergent pancreaticobiliary problems.

PURPOSE: To determine whether helical computed tomography (CT) performed during intravenous cholangiography can provide useful images of the biliary tree and to compare this technique with endoscopic retrograde cholangiography (ERC). MATERIALS AND METHODS: Eighteen adult patients with clinically suspected biliary disease who were referred for ERC were first examined with helical CT cholangiography performed 75 minutes after intravenous infusion of 100 mL of 10.3% iodipamide meglumine. RESULTS: Helical CT cholangiography revealed good opacification of the biliary tree in 13 of 14 patients with serum bilirubin levels less than 2 mg/dL (34 mumol/L) and poor opacification in three of four patients with levels greater than 2 mg/dL. In six of seven patients with choledocholithiasis, the diagnosis was made by means of helical CT cholangiography. CONCLUSION: Helical CT cholangiography may be a clinically useful method for visualization of the biliary tree in some patients with suspected biliary disease with normal bilirubin levels and in patients in whom attempts at ERC fail.