watson endoscopy pancreatitis - gi nurseginurse.com/library/coursematerial/watson_the role of...
TRANSCRIPT
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The Role of Endoscopy in Pancreatitis
Rabindra R Watson, MDAssistant Clinical Professor of MedicineDirector, Faculty Career Development in
Advanced EndoscopyGeffen School of Medicine at UCLA
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Disclosures
§ Boston Scientific – Consultant
§ Medtronic – Consultant
§ Apollo Endosurgery – Consultant
§ Off-label uses that are discussed will be identified accordingly
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Objectives
§ Discuss the role of Endoscopy in diagnosis
§ Discuss the role of Endoscopy in therapy
§ To scope or not to scope
§ Endoscopic management of complications
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Case 1
§ A 43yo Hispanic female with obesity, DM2 presents with acute epigastric abdominal pain
§ WBC 16k, Alt 225, Lipase >4000
§ No EtOH, lipids WNL, Ca WNL, no significant family Hx
§ Trans-abdominal U/S: 7 mm CBD without stone
§ MRCP normal
§ What is your diagnosis? What Next?
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Case 1
§ A 43yo Hispanic female with obesity, DM2 presents with acute epigastric abdominal pain
§ WBC 16k, Alt 225, Lipase >4000
§ No EtOH, lipids WNL, Ca WNL, no significant family Hx
§ Trans-abdominal U/S: 7 mm CBD without stone
§ MRCP normal
§ What is your diagnosis? What Next?
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Biliary Pancreatitis: Gallstone Migration
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gallstones
fluid
pancreas
GallstonePancreatitis
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Diagnosis of Biliary Pancreatitis§ Biochemical
§ bilirubin, alkaline phosphatase, ALT, AST, amylase
§ x3 fold elevation of ALT has 95% PPV
§ Imaging
§ US - gallbladder not seen in up to 20%
§ ~20% sensitive for CBD stones
§ CT - useful for prognosis
§ ERCP - ‘gold standard’
§ What about Endoscopic Ultrasound?
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Chak et al, Gastrointest Endosc, 1999
Diagnosis of choledocholithiasis
Ultrasound EUS ERCP
Sensitivity 50% 91% 92%
Specificity 100% 100% 87%
Accuracy 83% 97% 89%
PPV 100% 100% 79%
NPV 74% 95% 94%
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EUS Detection of Occult Cholelithiasis
US (18), CT (6), repeat US (6), ERCP (13)
gallstone (14), CBD stone (3)
EUS
Idiopathic pancreatitis (n=4)
'Idiopathic pancreatitis' (n=18)
Acute pancreatitis (n=89)Biliary cause = 64
Liuetal,Gastrointest Endosc,2000
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Sludge!
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Diagnosis of Biliary Pancreatitis§ EUS or MRCP?
§ Systematic Review: 301 pts
§ No significant difference:
§ Aggregated sensitivity 93 vs 85%
§ Aggregated specificity 96 vs 93%
§ EUS may have higher sensitivity for small stones (<6mm)
§ EUS can detect biliary sludge, MRCP generally cannot
Verma D, et al. GIE 2006
EUS is highly accurate for evaluation of suspected biliary pancreatitis
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Case 1
§ EUS performed:
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Case 2
§ 54yow o/w healthy presents with dx of acute
pancreatitis 02/14
§ c/o intermittent RUQ abd pain for past year
§ Single episode of elevation in lipase to 288 09/13
§ Lipids, Ca2+ normal, no sig EtOH, no meds/suppl
§ Transabdominal U/S wnl
§ What Next?
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Case 2
What Next?
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Case 2
15 x 15 mm hypoechoic area in neck with upstream duct dilation and atrophy
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Case 2PANCREAS (FINE NEEDLE ASPIRATION):- Scant atypical ductal cells (see comment)
COMMENT: The cytomorphological features are suspicious foradenocarcinoma. Material however is somewhat scant and thepatient's history of pancreatitis has been noted. Recommendclinical and imaging correlation with further work-up asindicated.
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Case 2
• Treated with 5-FU, abraxane, oxaliplatin, avastin
x 6 months
• Underwent distal pancreatectomy at Hopkins, R0
resection, 3/23 LN+
• Recommended further chemo
• Disease progression, death 01/15
Anyone age > 40 with unexplained pancreatitis à EUS
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Case 3
§ 54 y/o Asian male is admitted with vague abdominal pain and pancreatitis
§ Reports history of 30 pound weight loss
§ Managed conservatively and discharged
§ Pain is improved but now returns jaundiced
§ No ETOH, HL, or stones (prior U/S)
§ MRI ordered
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MR Pancreas is performed
23 mm mass of head of pancreas with biliary stricture and upstream dilation
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What is your next step?
1. Pancreaticoduodenectomy (Whipple)
2. ERCP w stent placement
3. Check IgG4 and also perform EUS/ERCP
4. EUS
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Case 3
§ Serum IgG4: 307
§ EUS
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Case 3
§ FNA
Benign pancreatic tissue with partial acinaratrophy, areas of fibrosis, and mild to moderate mixed inflammatory cell infiltrates consisting of lymphocytes, plasma cells, neutrophils and occasional eosinophils.
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Autoimmune Pancreatitis
§ AIP: systemic inflammatory disease that affects the pancreas
§ Type I: lymphoplasmacytic infiltrate (IgG4 +)
§ Type II: Idiopathic duct centric (IgG4 (-)
§ Type I more likely to present as mass lesion, systemic disease
§ Elevated IgG4 only present in ~20% in Type II
§ May result in pancreatic duct strictures, biliary strictures (autoimmune cholangiopathy)
Sugumar A., Curr Opin Gastroenterol 2010
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Autoimmune Pancreatitis
§ HISORt criteria: § Histology, § Imaging – Sausage pancreas, peripancreatic halo,
§ Serology – IgG4,
§ Other organs, § Response to therapy
§ Ampullary bx: near 100% specificity
§ Treatment: Prednisone 6-8 weeks. Recurrent 20-25% may require immunomodulators
Sugumar A., Curr Opin Gastroenterol 2010
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Case 4
§ 75yo male presents at 6PM with abdominal pain, fever to 38.9, hypotension, tachycardia, altered mental status
§ bilirubin 8.1, lipase 2500
§ 1st year GI fellow is called for ERCP who states “We should let the patient cool off”
§ Now what?
§ Call attending/fire fellow?
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Biliary Stone Extraction in Acute Pancreatitis
• Severe vs Mild pancreatitis
• Cholangitis/jaundice
• Persistent obstruction
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Urgent ERCP in Acute Biliary Pancreatitis
Meta-analysis of 5 RCTs 702 pts: early ERCP decreased complications but NOT mortality in predicted severe pancreatitis,
mild - no difference
Author Patients Morbidity Mortality Comments
Neoptolemos 121 Yes NoBenefit only in
predicted severe disease
Fan 195 Yes No Reduced biliary sepsis
Folsch 229 No No Excluded jaundiced pts
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Indications for ERCP in Biliary Pancreatitis§ Jaundice (bilirubin > 5mg/dl)
§ Cholangitis
§ Severe pancreatitis (within 24 hrs)
§ Smoldering or worsening clinical course
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Case 4
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Case 4 Returns…
§ Patient returns 2 months later with recurring post-prandial abdominal pain, early satiety, occasional vomiting
§ CT scan ordered
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§ Pseudocyst
§ What Next?
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Pseudocysts
§ History of Pancreatitis!
§ No true epithelium
§ Caution: peripancreatic fluid collection in acute pancreatitis
§ A late complication > 4 weeks
§ Treat for symptoms only
§ Endoscopic EUS-guided Cystogastrostomy
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Day 1 Day 7 Day 28
Evolution of Necrosis into a Pseudocyst
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Drain
SymptomaticRapidlyenlargingComplication
*Largecystscanbesafelyfollowed,butaremorelikelytorequiredrainage
Pseudocyst
Drain
Persists6- 12months
Follow
*Observe
Asymptomatic
Management of Pseudocysts
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Case 4
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Lumen-Apposing Metal Stent
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Lumen-Apposing Metal Stent(LAMS)
Shah RJ, et al. Clin Gastro Hep 2015Walter D, et al Endoscopy 2015
§ Decreased procedure time§ 90+% technical and clinical
success
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• Indications for intervention on pancreatic necrosis: • pain requiring narcotics• suspicion of infected necrosis• inability to eat• failure to thrive• gastric/duodenal/biliary obstruction
• Up to 40% of patients with unsuspected infected necrosis
Rodriguez JR, et al. Ann Surg 2008;247:294-299
Walled-off Necrosis
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Surgical
PercutaneousEndoscopic*
Management of Walled-off Necrosis
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Necrosectomy
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Minimally invasive step-up approach versus maximal necrosectomy in patients with acute
necrotizing pancreatitis (PANTER)
N Engl J Med 2010;362:1491-502
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• Multicenter prospective randomized trial
• 88 patients (45 open necrosectomy, 43 step-up)
• Randomized to:
• open necrosectomy
• step up - percutaneous or endoscopic drainage
• + 72 hours – second procedure
• + 72 hours – VARD - Video-assisted retroperitoneal debridement
• Intervention deferred for 4 weeks when possible
N Engl J Med 2010;362:1491-502
Walled-off Necrosis
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• Primary endpoint:
69% of open necrosectomy
40% of step up - risk ratio 0.57, p=0.006
• Step-up with less multi-organ failure 12% v 40%, p=0.002
• Step-up with less new-onset DM 16% v 38%, p=0.02
• Rate of death similar: 16% v 19%, p= 0.70
N Engl J Med 2010;362:1491-502
Walled-off Necrosis
“Step-up”approach is standard of care, endoscopic therapy first line
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• 2 U.S. Centers – 313 pts
• 106 DPS – double pigtail stents
• 101 FCSEMS – fully covered self-expanding metal stents
• 86 LAMS – lumen-apposing metal stents
• No difference in technical success 99%
• Overall clinical success 89.6%
§ Early AE lower in the FCSEMS group c/w DP and LAMS group (1.6%, 7.5%, and 9.3%, p<0.01)
Siddiqui AA, et al. GIE 2016
Walled-off Necrosis – Which Stent(s)?
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• At 6mo f/u, resolution lowest with DPS
• (81% vs 95% FCSEMS vs 90% LAMS; p=0.001)
• Less procedures with LAMS
• (2.2 vs 3 FCSEMS vs 3.6 DPS, p=0.04)
• On multivariate analysis, DPS sole predictor of treatment failure
• Likelihood of success: FCSEMS = LAMS, but LAMS with more early AEs (bleeding)
Siddiqui AA, et al. GIE 2016
Walled-off Necrosis – Which Stent(s)?
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Case 5
§ 17yo female with a history of chronic pancreatitis
§ Complained of recurrent pain episodes resulting in missed school days
§ Requiring narcotic pain medications
§ Referred for possible endoscopic therapy
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Case 5
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Case 5
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Cholangioscopy
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Pancreaticocholangiography
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Case 5
§ A month later, patient with improvement in pain
§ However patient continues on narcotics
§ Mother asks, “Is there anything we can do to control the pain without the drugs?”
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Celiac Plexus Block
§ Useful in the management of chronic pain
§ Pancreatic cancer – neurolysis (98% EtOH)
§ Chronic pancreatitis – block (TAC)
§ Celiac plexus
§ Dense network of gangliaand nerve fibers
§ Transmits pain sensationfor the pancreas
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Celiac Plexus Block
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Percutaneous Endoscopic Ultrasound
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Celiac Plexus Block
§ Efficacy
§ Decreased pain based on mean visual analog score
§ Decreased opioid use
§ Reduction in constipation
§ Safety
§ No increased adverse events
53Yan BM, Myers RP. Am J Gastroenterol. 2007.
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Celiac Ganglia Neurolysis§ Ganglia CAN be visualized on
EUS§ Ovoid, irregular, “raisins”§ 200 consecutive pts: Ganglia seen
in 81%§ Access/Injection of ganglia may
lead to pain, hemodynamic response
§ RCT 68 pts – VAS decrease of 3 pts§ Response 74 vs 46%§ Complete response 50 vs 18%
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Gleeson FC, et al. Endoscopy 2007Doi S, et al. Endoscopy 2013
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Conclusions
§ EUS is critical in the diagnostic evaluation of acute pancreatitis
§ ERCP is indicated for decompression in the setting of severe pancreatitis/cholangitis
§ Endoscopic management of pseudocysts and WON is first line
§ Endoscopic therapy is a useful adjunct in the management of chronic pancreatitis
Sugumar A., Curr Opin Gastroenterol 2010
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Thank you!
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Rabindra Watson, MD
Contact Information
§ E-mail: [email protected]
§ Location: UCLA Division of Digestive Diseases
200 UCLA Med Plaza, Suite 365-A
Los Angeles, CA 90095
§ Referral Line: 310-267-3636
§ Referral Fax: 310-206-0007
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