Disclosures General GI + Advanced Endoscopy: NAFLD/Stones/Pancreatitis 123 Blank Blank, LLC Aldo Maspons, MD Assistant Professor Director of Endoscopy Department of Pediatrics Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine Overview Case 1 Anatomy Stones in infants Cholecystectomy Choledocholithiasis Gallstones Pancreatitis Fatty Liver Disease Pancreatic Trauma EUS/ERCP 2 month old female Fever + Urinary tract infection Ultrasound 1.5mm Gallstones Common Bile Duct Sizes Left Hepatic Duct Common Hepatic Duct Portal Vein < 1 year old < 8 years old Adolescent & Adult 2/3 size of Portal Vein < 1.6 mm < 3.3 mm 5mm Gall Bladder Common Bile Duct Major Pancreatic Duct 1
Cholelithiasis Choledocholithiasis G a llstones AGA Bogue CO et al JPGN 2010 Diseases Leading to Cholecystectomy Stones < 2 cm Asymptomatic stones Stones > 2 cm Symptomatic stones Bogue CO et al JPGN 2010 F F F Fat Female Fourteen 2
Case 2 14 year old obese Hispanic Female Intermittent abdominal pain RUQP x 1 year Now worse epigastric and right upper quadrant abdominal pain vomiting jaundice Case 2 ROS: afebrile, jaundice PMHx: none Past surgical hx: none FMHx: mom, sister: cholecystectomy Medications: none PE: Afebrile, HR 105, rr:18, 110/80 BMI > 95% Abd: tender mid epigastric, RUQP Case 2 Ultrasound Cholelithiasis CBD: 5.5mm Hepatic Steatosis Edematous pancreas MRCP Dilated biliary tree No CBD stones Labs CMP + GGT + Direct Bilirubin + INR + Lipase Triglycerides + ionized Ca + S u r g e r y >7,50 0 AGA 3
MRCP AND STONES 90% demonstration 4mm Likelihood of Choledocholithiasis VERY STRONG STRONG MODERATE CBD stone on transabdominal US Clinical ascending cholangitis T. Bilirubin >4 mg/dl Dilated CBD on US (>6 mm with gallbladder in situ) T. Bilirubin level 1.8 4 mg/dl Abnormal liver biochemical test other than bilirubin Age older than 55 y Clinical gallstone pancreatitis Presence of any very strong predictor Presence of both strong predictors No predictors present Mandelia A. J Clin Diagn Res 2013 Reid J. The Surgeon. 2015 HIGH (>50%) HIGH (>50%) LOW (<10%) GIE Volume 71, No. 1 : 2010 Likelihood of Choledocholithiasis VERY STRONG STRONG MODERATE CBD stone on transabdominal US Clinical ascending cholangitis T. Bilirubin >4 mg/dl Dilated CBD on US (>6 mm with gallbladder in situ) T. Bilirubin level 1.8 4 mg/dl Abnormal liver biochemical test other than bilirubin Age older than 55 y Clinical gallstone pancreatitis Likelihood of Choledocholithiasis VERY STRONG STRONG MODERATE CBD stone on transabdominal US Clinical ascending cholangitis T. Bilirubin >4 mg/dl Dilated CBD on US (>6 mm with gallbladder in situ) T. Bilirubin level 1.8 4 mg/dl Abnormal liver biochemical test other than bilirubin Age older than 55 y Clinical gallstone pancreatitis Presence of any very strong predictor Presence of both strong predictors No predictors present Presence of any very strong predictor Presence of both strong predictors No predictors present HIGH (>50%) HIGH (>50%) LOW (<10%) GIE Volume 71, No. 1 : 2010 HIGH (>50%) HIGH (>50%) LOW (<10%) GIE Volume 71, No. 1 : 2010 Likelihood of Choledocholithiasis VERY STRONG STRONG MODERATE CBD stone on transabdominal US Clinical ascending cholangitis T. Bilirubin >4 mg/dl Dilated CBD on US (>6 mm with gallbladder in situ) T. Bilirubin level 1.8 4 mg/dl Abnormal liver biochemical test other than bilirubin Older than 55 years Clinical gallstone pancreatitis Kids and Adult Criteria VERY STRONG STRONG MODERATE Sensitivity of Ultrasound for CBDS: 43% pts Very Strong criteria: sensitivity 59%, specificity 100% Using Very Strong or Strong criteria: Sensitivity 78%, specificity 43% Presence of any very strong predictor Presence of both strong predictors No predictors present HIGH (>50%) HIGH (>50%) LOW (<10%) Mehta S, Fishman DS. Texas Children s Hospital GIE Volume 71, No. 1 : 2010 4
Pediatric Criteria and CBD Stones Cholesterol stones> Hemolytic stones Conjugated Bilirubin > 0.5mg/dL ALT 350 AST GGT 400 CBD > 6 ERCP: 84% of Cases Biliary Indications for ERCP Therapeutic Fishman DS et al. WJGNET. June 2016 Fox et al, JPGN 2000; 30:335-8. S T R I C T U R E Non-Alcoholic Fatty Liver Disease 6, 000, 000 + 5
Obese + Mexican American 56% ALT> 25 for boys ALT >22 for girls 96 cal ETOH = 120 calories 24 cal Fructose 6
Fructose 60 calories High Blood Pressure High Blood Pressure Feig, D. Jama 2008 Fructose 200 g/day x 2 weeks 24-hour ambulatory blood pressure High Triglycerides High Cholesterol Allopurinol Perez Pozo, et al. Int J Obesity, 2010 7
6 months % Increase Cholesterol 6 months % Increase Triglycerides 12 40 10 8 6 30 20 4 10 2 0 2 soda milk water 0 10 20 soda milk water Maersk M. et al. Am J Clin Nutr 2012;95:283 9 Maersk M. et al. Am J Clin Nutr 2012;95:283 9 Fructose Evaluation Liver Labs Repeat in 2 3months If no improvement Refer/consult with gastroenterology expand differential diagnosis TREATMENT Lifestyle modifications No sugar sweetened beverages Exercise Frequent contact GOAL of Treatment Decrease in ALT If fibrosis: resolution NASPGHAN GUIDELINES: NAFLD 2016 8
Pancreatitis Atlanta Classification 2 of 3 1. Clinical 2. Lipase: 3 x Upper Limits of Normal 3. Imaging: Characteristic Pancreatitis management https://youtu.be/tmpgj7p_xsw Pain management Fluids Feeds Sooner is better (decreased LOS) Regular vs Low fat Abu El Haija. JPGN vol. 6. Number 3. 2016 9
Injury Grade NO DUCT INJURY DUCT INJURY 1, 2 3,4,5 American Association for the Surgery of Trauma Wood et al. Journal of Pediatric Surgery (2010) 45, 401 406 Acute vs Recurrent vs Chronic Hauben et al.journal of Pediatric Surgery (2007) 10
Chronic Pancreatitis Hyperechoic strands lobulation Hyperechoic foci Dilated irregular main pancreatic duct visible side branches Hyperechoic irregular main duct wall Ductal stones R o s e m o Pancreatic Pseudocyst https://www.youtube.com/watch?v=2hadl0m 6Ls0 Celiac Plexus Block Pancreatic Divisum 11
Overview Anatomy Stones in infants Cholecystectomy Choledocholithiasis Gallstones Pancreatits Fatty Liver Disease Pancreatic Trauma EUS/ERCP General GI + Advanced Endoscopy: NAFLD/Stones/Pancreatitis Aldo Maspons, MD Assistant Professor Director of Endoscopy Department of Pediatrics Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine CHOLECYSTECTOMY 1980-1996 2005-2008 p value Total # of patients 128 406 Females 69 (54%) 293 (73%) Mean age 10 13 Hispanics 28 (22%) 144 (35%) 0.005 Over Weight or Obese with Non-Hemolytic Gallstones 69% Hemolytic disease 52 (41%) 74 (18%) <0.0001 Biliary dyskinesia 0 61 (15%) 0.0001 12
NASH Brunt's criteria. Histological features were scored: steatosis (0 3) lobular inflammation (0 3) ballooning (0 2) Portal Inflammation (0 2) 13