Chronic Pancreatitis: When to Scope? Gregory A. Cote, MD, MS Assistant Professor of Medicine Indiana University School of Medicine

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1 Chronic Pancreatitis: When to Scope? Gregory A. Cote, MD, MS Assistant Professor of Medicine Indiana University School of Medicine Endoscopy & Chronic Pancreatitis Diagnosis EUS ERCP Exocrine Function Therapy EUS - celiac block Obstructive CP 1

2 The Challenge Pain + Calcific Chronic Pancreatitis C ompressed 11:1 P age: 5 0 of I M : 5 0 SE : 3 c m C ompres s ed P age: of I M : 4 0 SE : c m Pain (pancreatic-type) C ompressed 11:1 C ompressed 11:1 Diagnosis: Ductal and Parenchymal 2

3 Diagnostic criteria for chronic pancreatitis: Cambridge classification ERP Side branches Irregularity, beading, dilation > 3 mild disease Main pancreatic duct Dilation, irregularity, beading Moderate disease Intraductal stones, communicating pseudocysts Marked disease Computed tomography ERP features plus: Parenchymal calcifications Gland atrophy What is the role for diagnostic ERP? Very small! MRCP with secretin EUS Common clinical questions Early chronic pancreatitis Pancreas divisum Recurrent acute pancreatitis 3

4 Alternative tests for early CP Endoscopic ultrasound High sensitivity (80%) Low interobserver reliability Pancreatic function testing CCK (acinar cell function) or Secretin (ductal cell) High sensitivity Time consuming Normal pancreas (salt+pepper) normal histology Stranding/lobularity perilobular fibrosis Mild dilation/hyperechoic duct wall periductal fibrosis Intraductal stone stone material by histology Siwar Albashir, et al. Amer J Gastro,

5 Exocrine function Intraductal vs. duodenal sampling of pancreatic juice Secretin ductal cell stimulation volume and bicarbonate concentration CCK acinar cell stimulation enzyme output Stool Fecal fat Fecal elastase EUS and pancreatic function testing 25 patients with EUS, epft and pancreas histology (within 12 months) EUS ( 4 criteria) Sensitivity 84% (95% CI=69, 100) Specificity of 100% (95% CI=40, 100) epft Sensitivity of 86% (95% CI=67, 100) Specificity of 67% (95% CI=13, 100) EUS or epft Sensitivity 100% (95% CI=63, 100) Albashir S, Bronner MP, Parsi MA, et al. Endoscopic ultrasound, secretin endoscopic pancreatic function test, and histology: correlation in chronic pancreatitis. Am J Gastro

6 Suspected chronic pancreatitis MRI/MRCP EUS Positive Indeterminate S-MRCP epft ERP + IDST (?) Endoscopic therapy 6

7 Adapted from AGA slide deck, Chronic Pancreatitis Causes of pain in chronic pancreatitis PD obstruction increased PD pressure Ischemia Pseudocyst Duodenal and common bile duct obstruction Inflammation Neural inflammation EUS-guided celiac plexus block Injection of bupivicaine ( %) and triamcinolone Review of 6 studies (221 patients) 51% response rate Can be reapplied every 3-6 months if effective Kaufman M, Singh G, Das S, et al. J Clin Gastroenterology,

8 EUS-guided celiac block Optimal technique and agent? LeBlanc J, et al., GIE % in 10-pt pain scale Stevens T, et al., CGH pt Pain Disability Index (0-70) CP (n=50) CP (n=40) 2-site (n=27) 1-site (n=23) Bupivicaine (n=19) Bupivicaine + Triamcinolone (n=21) Response (n=16) Response (n=15) Response (n=3) Response (n=3) Median duration of response = 28 days 8

9 Dumonceau JM, et al. Gut 2007 THERAPEUTIC ERCP IN CHRONIC PANCREATITIS: A TAIL OF TWO HEADS Case 1: Ventral duct obstruction 9

10 CT: Obstructing stone with upstream dilation Extracorporeal shock wave lithotripsy (ESWL) Repeat ERCP Fragmentation Stone Extraction & Stent 10

11 Symptom resolution Balloon dilation Completion pancreatogram Case 2: Ventral duct stricture 11

12 Interval improvement in head stricture, but persistent symptoms Persistent pain Stent Dense calcifications in the head 12

13 Goals of ERP-based therapies Alleviate outflow obstruction PD stones, strictures Evacuate fluid collections Organized fluid collections, organized necrosis (formerly known as pseudocysts ) Divert flow away from a fistula/leak Leaks, fistulas Endoscopic techniques Sphincterotomy Stenting Stricture dilation Stone removal 13

14 Pancreatic sphincterotomy BES Complications Pancreatitis (7%) Bleeding (.5%) Perforation Sphincter stenosis PES Pancreatic Stricture Biliary Stricture Traversing the stricture is sometimes the greatest challenge Beware of dilated side branches Guidewires have memories (nightmares) Avoid over-injection and acinarization Risk of PEP Interferes with further visualization 14

15 Traverse the stricture Acinarization Traverse Dilation Graduated passage dilation Balloon dilation 15

16 Therapeutic pancreatic stents Dilation alone is rarely adequate Stent diameter is usually limited by the unaffected downstream (closer to the head) duct Multiple stents in parallel (5 10 Fr) Progressive stenting 3Fr 7Fr 16

17 Upsize 7Fr + 5Fr Now Endoscopic Rx: international cohorts Author, year N f/u, mos Surgery Ongoing Endoscopic Rx No further Rx Binmoeller, % 13% 61% Rosch, % 16% 60% Delhaye, % 18% 61% Tadenuma, % 20% 79% Inui, % - - Farnbacher, % 18% 59% Dumonceau JM, et al. ESGE Clinical Guidelines, Endoscopy

18 Indicators of Endoscopic Success Patient Short disease duration Low frequency of pain attacks prior to Rx Discontinuation of smoking and alcohol Structural Obstructive calcifications in the head Complete stone clearance Absence of stricture Stone disease only Success defined as pain relief for > 2 years after endoscopic Rx Dumonceau JM, et al. ESGE Clinical Guidelines, Endoscopy 2012 Options for challenging PD stones Mechanical lithotripsy Intracorporeal lithotripsy Requires pancreatoscopy Laser and Electrohydraulic Extracorporeal shockwave lithotripsy (ESWL) Stones > 5-10mm Surgery 18

19 Baskets Basket extraction Mechanical lithotripsy ESWL vs. ESWL + ERCP RCT comparing ESWL alone (n=26) with ESWL + ERCP (n=29), 2-year follow-up Predominant pancreatic head stones with PD dilation Pain relapse rates similar in ESWL (10/26) and ESWL + ERP (13/29) Average decrease in number of pain episodes during the first year after Rx similar: ESWL alone (3.8) Combination (3.7) Addition of secretin to ESWL increases the likelihood of complete stone clearance after one ERCP Choi K, et al. Pancreatology 2012 Dumonceau JM, et al. Gut

20 Obstructive CP: Surgery vs. Endoscopy Obstructive CP (n=39) Izbicki Pain Score p < Endo (n=19) Surgery (n=20) Death (n=1) Lost to FU (n=1) Convert to surgery (n=4) PJ (n=18) Whipple/Frey (1/1) 0 Baseline 2-year follow-up Surgery Endoscopy Cahen, et al. New England J Med, Endoscopic Story 1/19 patients died 5 days post-eswl from a perforated duodenal ulcer 16/19 patients with stone complete stone removal 16/18 required ESWL 16 patients with PD stricture Stenting for a median of 27 weeks 9/16 required parallel stenting 7/16 had recurrent stenosis during follow-up Resolved stricture in 8/16 Conversion to surgery in 4/19 1 of 4 with relief following surgery 20

21 Long-term outcomes Variable Endoscopy (n=16) Surgery (n=15) P value Pain relief 6 (38%) 12 (80%) Complete 4 (25%) 8 (53%) Partial 2 (13%) 4 (27%) No 10 (62%) 3 (20%) Izbicki pain score (mean) Exocrine insufficiency persist/develop Endocrine insufficiency persist/develop / / /6 (100%) 11/2 (86%) /11 (69%) 4/3 (47%) 0.32 Pain relief classified as complete = Izbicki score 10; partial = score > 10 but > 50% reduction from baseline Cahen DL, et al. Gastro 2011 Summary EUS, MRI and endoscopic pancreatic function tests have largely replaced diagnostic ERCP Endoscopic Rx EUS celiac block: predictors of success unclear PD strictures: focal head strictures respond the best Beware of extensive parenchymal disease PD stones: ESWL for stones > 5-10mm Head >>> Body/Tail Most cases require collaboration with radiology, surgery 21

22 Thank You 22

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