Acute Pancreatitis. Case: NG. Idiopathic Pancreatitis is Common. Investigation and Management of Idiopathic Acute Recurrent Pancreatitis (IARP)

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1 BRIGHAM AND WOMENS HOSPITAL Investigation and Management of (IARP) Acute Pancreatitis j Darwin L. Conwell MD, MS Associate Professor of Medicine Harvard Medical School Boston, MA Case: NG 54 year old female Hospitalized for 4 episodes of acute recurrent pancreatitis Labs: nml LFTs, lipase > 3x ULN Radiology acute interstitial pancreatitis CT Negative for etiology / mass What do I do now? Why Do We Care? C A D B Aoun E, JOP 2007; 8: Whitcomb D, Best Prac and Res in Clin Gastro 2002; 16:347 SAPE Hypothesis Step A: Acinar cell stimulation Alcohol, gallstone, TG, oxidative stress Step B: Sentinel Event Early: pro-inflammatory respone Late: Stellate cells, profibrotic response Step C: Removal of stimulus Abstinence, cholecystectomy, lipid lowering agents Step D: Recurrent stimulation Stellate cell mediated periacinar fibrosis Outline Pathophysiology of recurrent pancreatitis SAPE Hypothesis Definition / Nomenclature Etiologies Imaging Specific diseases Pearls Algorithm What I do Idiopathic Pancreatitis is Common No obvious etiology is identifiable history (alcohol, family history) laboratory tests (hyperlipidemia, hypercalcemia) gallbladder ultrasound 30 percent of patients with acute pancreatitis Nomenclature Unexplained pancreatitis Recurrent pancreatitis Idiopathic pancreatitis no cause found even after an exhaustive search for an etiology Vila, JJ, et al. Scan J Gastro 2010; 45: Fischer M, et al., Pancreatology 2010;10:

2 Interchangeable Nomenclature Unexplained Recurrent Idiopathic Radiologic Imaging CT Scan (DIAGNOSTIC) Chronic pancreatitis Pancreatic neoplasm Pancreatic cyst IPMN MRI and MRCP (DIAGNOSTIC) Pancreatic duct abnormalities, tumors IPMN Biliary tract abnormalities When to Evaluate? Retrospective study (n=31) first episode of unexplained acute pancreatitis 1/31 ( 3 %) recurrent attack median follow-up of 36 months This finding suggests that extensive investigation for unusual causes of pancreatitis is not required after the first episode of unexplained pancreatitis. Endoscopic Imaging EUS (DIAGNOSTIC) Ampullary tumor, chronic pancreatitis Gallbladder disease IPMN, Pancreas neoplasm Chronic pancreatitis Further evaluation of CT findings ERCP (DIAGNOSTIC AND THERAPEUTIC) Sphincter of Oddi manometry Sphincterotomy Ballinger AB, Gut 1996; 38:293. How to Evaluate? Various strategies have been proposed in a multitude of case series different groups variable follow-up Diagnostic evaluation MRI, MRCP, endoscopic ultrasound, ERCP, bile analysis for microlithiasis and sphincter of Oddi manometry Sajith KG, et al., Dig Dis Sci 2010 Where to Look for Answers? Occult gallstones (microlithiasis) Hypertriglyceridemia Anatomical ampulla, bile duct, pancreatic duct Tumors ampulla, pancreas cancer, IPMN Sphincter of Oddi dysfunction Autoimmune pancreatitis Inflammatory / Alcohol Genetic Idiopathic 2

3 Microlithiasis is the Most Common Cause of Idiopathic Acute Recurrent Pancreatitis Cystic Neoplasms / Tumors Viscous suspension small stones (<5 mm in diameter) Biliary Sludge Modification of bile by gallbladder mucosa IPMN (Intraductal Papillary Mucinous Neoplasms) Males, 7 th decade ACUTE RECURRENT PANCREATITIS Main duct (75%), branch duct, OR mixed FISH EYE, MUCIN LAKES, Associated with invasive adenocarcinoma 1/3 have Peutz-Jeghers gene (STK11/LKB1) Surgery before development of carcinoma Nature Clinical Practice Gastroenterology & Hepatology (2005) 2, Microlithiasis 75 patients Cholesterol monohydrate crystals or calcium bilirubinate granules Commonly observed in ARP Intervention / treatment Cholecystectomy UDCA Sphincterotomy Lee SP, NEJM 1992; 326(9): Ros E, Gastroenterology 1991; 101(6): Mean age 32 years 80% male Number of attacks 5 8 year follow-up Garg PK, Clin Gastro Hep (1):75-9 Hypertriglyceridemic Pancreatitis (HTG) Pathogenesis: Hydolysis of TG by pancreatic lipase cause FFA and radical damage Clinical Presentations Primary genetic Poorly DM Hypothyroidism Obesity Drug / diet induced Chronic Pancreatitis was the Most Common finding in 47% of Patients! 1-4% admissions for AP 50% gestational pancreatitis Diabetes mellitus (72%) Lipemia (lactescence) (45%) Volume displacement False low serology (amylase) 1/3 Normal serology Serum TG level > 1,000 ml/dl Tsuang W., et al., Am J Gastroenterol. 2009; 104(4): Fortson MR, Am J Gastroenterol 1995;90(12): Garg PK, Clin Gastro Hep (1):75-9 3

4 CP Diagnosis is Elusive Pancreas Funtion Test epft Duodenal View Summary of (HISORT) Criteria (H) Histology (I) Pancreatic Imaging (S) Serology (1gG4 > 140 mg%) (O) Other Organ Involvement Biliary strictures, Parotid/Lacrimal gland Mediastinal lymphadenopathy Retroperitoneal fibrosis Pancreas Fluid [HC03] 80 meq/l (RT) Response to steroid therapy Wu B et al., Am J Gastro 2009;104(10): Stevens T et al., Am J Gastro 2006;101(2): Chari ST, et al., Pancreas. 2010;39(5): (Honolulu Consensus Document) Chari ST, et al., Clin Gastroenterol Hepatol Aug;4(8): Yang DH, et al., Abdom Imaging Jan-Feb;31(1): EUS Chronic Pancreatitis Diagnostic Criteria PARENCHYMAL Hyperechoic foci Hyperechoic strands Lobularity of gland Cysts DUCTAL Main duct dilation Duct irregularity Hyperechoic margins Stones Dilated side branches Anatomical / Obstructive Pre-Secretin Post-Secretin Pancreas divisum IPMN Biliary anomalies Pancreas anomalies Total EUS score > = 5 is abnormal and suggestive of chronic pancreatitis Trauma Autoimmune Pancreatitis Clinical, histologic, and morphologic findings Extrapancreatic manifestations sclerosing cholangitis primary biliary cirrhosis retroperitoneal fibrosis rheumatoid arthritis Sarcoidosis Sjögren's Syndrome Systemic autoimmune disorder IgG4 positive plasma cells AJR Am J Roentgenol 1998 May;170(5): Eur Radiol 2001;11(8): Radiology 2004 Nov;233(2): Sphincter Of Oddi Three component muscular structure Fasting: MMC controlled Fed: nutrient driven myoactivity Confluence of distal bile duct and pancreas duct Mechanical STENOSIS Functional abnormalities DYSKINESIA Pancreas: Outflow defect COPYRIGHT 2007 THE JOHNS HOPKINS UNIVERSITY. ALL RIGHTS RESERVED. 4

5 Sphincter of Oddi Manometry Biliary Scintigraphy (non-invasive, alternative to SOM) Criteria Score Peak Time 0,1 Time of Gallbladder visualization 0,1 Prominence of biliary tree 0, 1, 2 Bowel visualization 0, 1, 2 CBD Emptying 0, 1, 2, 3 CBD to Liver Ratio 0, 1, 2, 3 A score of 5 or greater has a 100% sensitivity / specificity for SOD COPYRIGHT 2007 THE JOHNS HOPKINS UNIVERSITY. ALL RIGHTS RESERVED. Sostre S, J Nucl Med 1992;33:1216 Persson B, Eur J Nucl Med 1993;20:770 Craig AG, Gut 2003;52:352 Sphincter of Oddi Dysfunction(SOD) Elevated basal pressure > 40 mm Hg Genetic Defects: CF Three Types (% accuracy predicting SOD): Type I (92%) Elevation of pancreas enzymes (> 1.5 times normal) Dilated pancreatic duct (> 6mm head, >5 mm body) Delayed drainage of contrast (> 9 minutes) Type II (58%) 1 or 2 of the above Type III (35%) None of the above Hogan WJ, Endoscopy 1988; Suppl 1:179 Sherman S, Am J Gastroenterol 1991;86:586 Geenan JE, NEJM 1989;320:82 Pathological Processes Associated with Pancreatology. 2010;10(4): Levy M, Am J Gastro 2001; 96:

6 Case NG: ERCP Report smrcp epft SOM THERAPY: Without a prior sphincterotomy, an attempt to place 5 Fr 3 cm long stent in the dorsal pancreas was made over a 0.025" wire. The procedure was successful. At completion of placement the stent position was ideal. The proximal end lay within the head of the pancreas. A generous pancreatic sphincterotomy was successful with a needle-knife sphincterotome using endocut settings over the pancreatic stent. COMPLICATIONS: There were no complications associated with the procedure Vege S, UpToDate May 2010 Case: NG 54 year old female 4 episodes of IARP; GB in situ Lab evaluation - serology negative MRI c/w Acute Interstitial Pancreatitis Endoscopic Ultrasound (Linda Lee) hypodense area; c/w resolving AP or Neoplasm; FNA NEG 5th episode of pancreatitis; LFTS NL ERCP selective, safe, step-wise Case NG: ERCP Report IMPRESSION: 1. Normal cholangiogram. Bile aspirate sent for crystal analysis. 2. Pancreas divisum. Likely the etiology of her recurrent pancreatitis. 3. Minimal change in duct caliber in the body of the pancreas. 4. Successful minor sphincterotomy and pancreatic stent placement. RECOMMENDATION: Repeat endoscopic retrograde cholangiopancreatography (ERCP) and stent removal in 1 week. FOLLOW-UP: Stent removed 1 week. No crystals in bile. No pancreatitis x 4 years. Case NG: ERCP Report John Saltzman MAJOR PAPILLA: The major papilla appeared normal. ERC: The common bile duct, common hepatic duct, right and left hepatic ducts, intrahepatic ducts, cystic duct and gallbladder were normal. There were no stones or strictures noted. Aspirated samples were obtained from the common bile duct and sent for crystal analysis. ERP: The pancreatic duct was successfully cannulated. The ventral duct ended in the head of the pancreas suggestive of pancreas divisum. ERP DORSAL: The dorsal pancreatic duct was successfully opacified with a catheter and contrast. Pancreas divisum was confirmed. The dorsal duct was minimally dilated and had one slightly prominent uncinate branch. There was also an area of minimal change in duct caliber in the body of the pancreas without upstream dilation. Where Do We Look for Answers? Microlithiasis - EARLY Hypertriglyceridemia Anatomical ampulla, bile duct, pancreas divisum Tumors ampulla, pancreas cancer, IPMN Sphincter of Oddi Dysfunction (SOD) Autoimmune Pancreatitis Inflammatory Chronic Pancreatitis - LATE Genetic Idiopathic 6

7 Acute Idiopathic Recurrent Pancreatitis What do I do? Is this a Chronic Pain Syndrome? Confirm Diagnosis Review biochemistry, medications Review CT scan Serology during attacks Repeat Ultrasound Secretin MRCP Pancreatic function test / EUS for chronic pancreatitis (primary or secondary) Biliary Scintigraphy (Type II SOD) Acute Idiopathic Recurrent Pancreatitis What do I do? Consider: Celiac sprue, HIV Genetic testing (family history, asthma, sterile) Cholecystectomy / UDCA ERCP: Choose MD wisely; selective, meticulous Art of Medicine: discontinue all smoking / alcohol, anti-oxidants, low fat diet, pancreatic enzymes, SL NTG, calcium blockers Repeat imaging in 3-6 months Sick days Avoidanc of Emergency Room Idiopathic watchful waiting, PRAYER Acknowlegements God Family Cleveland Clinic Foundation Mentors / Teachers / Colleagues (Zuccaro, Achkar, Richter, Carey, Vargo, Dumot et al..) Brigham and Womens Hospital Mentor / Teachers / Colleagues (Banks, Wu, Saltzman, Carr-Locke, Thompson, Lee et al..) 7