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ERCP) and Pure Pancreatic Juice Cytology in Patients with Pancreatic Disease

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ERCP) and Pure Pancreatic Juice Cytology in Patients with Pancreatic Disease Gut: first published as 10.1136/gut.17.1.14 on 1 January 1976. Downloaded from Gut, 1976, 17, 14.21 Assessment of endoscopic retrograde cholangio- pancreatography (ERCP) and pure pancreatic juice cytology in patients with pancreatic disease A. R. W. HATFIELDI, A. SMITHIES, R. WILKINS, AND A. J. LEVI From Northwick Park Hospital and Clinical Research Centre, Middlesex SUMMARY Pure pancreatic juice has been collected from 61 patients at the time of endoscopic retrograde cholangio-pancreatography (ERCP) for the purpose of cytodiagnosis. The ERCP and cytological findings are discussed. Pure pancreatic juice cytology may help in the interpretation of the pancreatogram in both pancreatitis and pancreatic carcinoma. In patients with pancreatic carcinoma, ERCP alone was diagnostic in 65%, cytology alone in 54 %. By combining these two approaches, a diagnostic result was obtained in 92 % of patients. The introduction of ERCP to Great Britain in the trast medium. In two-thirds of the patients studied, last four years has been a major advance in the pancreatic juice was collected before the injection investigation of pancreatic and biliary disease of contrast medium. (Cotton, 1972). This investigation is both practical Pancreatic juice was collected in all but two and safe, but there can be considerable difficulties patients using the following two methods. in the interpretation of the pancreatogram. Although the exfoliative cytology of duodenal Method I The cannula was inserted through the http://gut.bmj.com/ aspirates for the diagnosis of pancreatic disease has papilla of Vater into the pancreatic duct to a depth been practised since 1949 (Lemon and Byrnes, 1949), of 2-3 cm. it has not become a routine investigation. Duodenal intubation and drainage are time consuming and Method 2 In patients where the cannula failed to there are major difficulties in the interpretation of enter the pancreatic duct, juice was collected from the cytological findings. the orifice of the papilla of Vater. Using the technique of endoscopic cannulation of In two patients where neoplastic involvement of on September 25, 2021 by guest. Protected copyright. the papilla of Vater, it has been possible to collect the duodenum made location of the papilla of Vater pure juice directly from the pancreatic duct for the impossible, pancreatic juice was collected from the purpose of cytodiagnosis. lumen of the duodenum. In this study, pure pancreatic juice was collected A stimulus for pancreatic secretion was found to at the time of ERCP and the value of this combined be necessary before juice could be collected from diagnostic approach is assessed in patients with and within the pancreatic duct. In this study, a single without pancreatic disease. intravenous injection of Boots secretin was given at a dose of 1 unit/kg body weight. In most patients a Methods flow of juice through the cannula was obtained. If this flow were poor, gentle aspiration with a syringe TECHNIQUE was needed. Five 1 ml samples of pancreatic juice ERCP was performed in the usual way, using an were collected for cytological examination at 0, 5, Olympus JF-B duodenoscope on patients lightly 10, 15, and 20 minutes after secretin stimulation. sedated with intravenous diazepam. The procedure At the end of the pancreatic juice collection, the was undertaken in the x-ray department under samples were taken immediately to the cytology fluoroscopic control, using 65% Angiograffin con- department where each was spun at 1 500 r.p.m. using a cytocentrifuge. In this way, the cells are 'Present address and for correspondence: Academic Unit of Gastro- deposited in a discrete circle on the slide, presenting enterology, The London Hospital, Whitechapel, London, El 1BB. a compact area, facilitating cytological screening. Received for publication 23 October 1975 The slides were stained with Papanicolaou stain. 14 Gut: first published as 10.1136/gut.17.1.14 on 1 January 1976. Downloaded from Assessment ofendoscopic retrograde cholangio-pancreatography (ERCP) andpurepancreaticjuice cytology 15 PATIENTS Results A total of 61 patients were included in this study. These patients were all undergoing investigations for ERCP FINDINGS suspected pancreatic and biliary disease. Twenty- six of these patients were finally judged to have no Normal group detectable pancreatic disease, as evidenced by a A pancreatogram was obtained in 25 out of 26 normal Lundh test, normal serum amylase levels, no patients in this group. In all these 25 patients the radiological evidence of abdominal calcification, and radiological findings were considered to be within clinical follow-up of between four and 18 months. normal limits (Fig. 1). In some of these patients Nine patients had pancreatitis, five with relapsing minor side duct irregularities and small cysts of less pancreatitis, and four with chronic pancreatitis. The than 2 mm in diameter were seen (Fig. 2); these were five patients with relapsing pancreatitis had all considered to be the results of the normal ageing experienced at least two attacks of acute pancrea- process. The biliary system was outlined in 17 of the titis diagnosed clinically, with serum amylase values 26 patients. on each occasion rising above 1 000 Somogyi units; in two the diagnosis was confirmed at laparotomy Pancreatitis group and radiological evidence of pancreatic calcification In this group of nine patients a pancreatogram was was seen in a further one patient. The four patients obtained in eight. Changes compatible with pancrea- with chronic pancreatitis had abnormal Lundh titis were seen in six of these patients (Fig. 3). In tests, with mean trypsin levels of below 2 1U/I, seven patients the biliary system was demonstrated. and radiological evidence of pancreatic calcification was seen in two patients. Pancreatic carcinoma group Twenty-six patients had pancreatic carcinoma; in A pancreatogram was obtained in 20 of the 26 22 of these the diagnosis was confirmed at laparo- patients in this group. In 18 of these the radiological tomy, and in the remaining four at necropsy. In no changes seen were considered diagnostic of carci- patient was the tumour considered resectable at the noma (Fig. 4), and in two patients the changes were time of laparotomy. only suggestive of carcinoma. A normal pancreato- The ERCP findings were in no way taken into gram was never obtained in any of the patients in http://gut.bmj.com/ account when considering the final diagnosis in any this group. Endoscopic evidence of neoplastic in- of these patients. volvement of the duodenum was obtained in only on September 25, 2021 by guest. Protected copyright. Fig. 1 The normal pancreatogram. Gut: first published as 10.1136/gut.17.1.14 on 1 January 1976. Downloaded from Fig. 2 A pancreatogram in a woman aged 76 years with no detectable pancreatic disease. There are some small cysts and minor side duct irregularities (arrowed) compatible with her age. Fig. 3 A pancreato- gram in a man 68 http://gut.bmj.com/ years with relapsing pancreatitis. There is irregularity in the main pancreatic duct (large arrow) together with cysts and side duct irregularities (small arrows). Coarse on September 25, 2021 by guest. Protected copyright. acinarfilling occurred at an early stage of contrast injection. Gut: first published as 10.1136/gut.17.1.14 on 1 January 1976. Downloaded from Assessment ofendoscopic retrograde cholangio-pancreatography (ERCP) andpurepancreaticjuice cytology 17 Fig. 4 A pancreatogram in a wonman aged 55 years with pancreatic carcinoma. There is an irregular stenosis of the main pancreatic duct in the head of the pancreas (arrow) with dilatation ofthe main duct in the body. Fine acinar filling of the head ofthepancreas has been produced by continued contrast injection. three of the patients. In 15 of the 26 patients the Pancreatic group biliary system was outlined and neoplastic involve- Normal duct cells were seen in all nine patients in ment of the biliary system was demonstrated in 12 this group. In eight patients numerous degenerate patients. cells were seen, but in one patient these cells were scanty. http://gut.bmj.com/ CYTOLOGY FINDINGS Pancreatic carcinoma Several types of morphologically distinct cells were Malignant cells were seen in 14 of the 26 patients seen in the pure pancreatic juice. Low columnar in this group, in a further three patients the cyto- cells often arranged in clusters were present in all logical findings were suspicious, and in the remain- specimens. These were considered to be derived from ing nine patients no malignant cells were seen. In all the pancreatic duct (Fig. 5). In some patients there the 26 patients in this group numerous degenerate were cells with fragmented karryorhectic nuclei, the cells were seen. on September 25, 2021 by guest. Protected copyright. fragments arranged peripherally in a rather dense, usually eosinophilic cytoplasm; they appeared to be COMBINED ERCP AND CYTOLOGY RESULTS degenerate cells (Fig. 6). These cells were usually The combined results in the 26 patients with pan- separate but occasionally lay in sheets. creatic carcinoma are shown in Fig. 8. ERCP and Occasionally, goblet cells with a granular cyto- cytology were both diagnostic in eight patients, plasm were present. Polymorphs and macrophages ERCP was diagnostic in 10 patients when cytology were occasionally seen but rarely in any great was negative. There were six patients where the number. cannula could not be passed through the papilla of Malignant cells either separate or in clusters Vater and ERCP failed. Malignant cells were found were found in some cases (Fig. 7). In patients where in the pancreatic fluid aspirated from the papilla in pure juice had been collected from the orifice of the all these six patients. At necropsy all these patients papilla of Vater, cells from the duodenal epithelium were found to have a pancreatic tumour obstructing were seen and cells described as bile duct cells were the main pancreatic duct close to the papilla of also present.
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