658 T. Scratcherd Gut: first published as 10.1136/gut.16.8.658 on 1 August 1975. Downloaded from minutes that gave the maximal result. The secretin (1967). Measurement of tryptic activity in intestinal juice as a diagnostic test of pancreatic disease. Gut, 8, 408-414. test was considered abnormal if any one of these Levin, G. E., Youngs, G. R., and Bouchier, I. A. D. (1972). Evaluation variables fell below the lower limits for control of the Lundh test in the diagnosis of pancreatic disease. J. clin. Path., 25, 129-132. subjects. Lundh, G. (1962). Pancreatic exocrine function in neoplastic and There was little difference between the two tests inflammatory disease; a simple and reliable new test. Gastro- test enterology, 42, 275-280. (table I) and neither was better than the other in Lurie, B., Brom, B., Bank, S., Novis, B., and Marks, I. N. (1973). the separation of chronic pancreatitis from pan- Comparative response of exocrine pancreatic secretion creatic carcinoma (table II). following a test meal and secretin-pancreozymin stimulation. Scand. J. Gastroent., 8, 27-32. The results suggest that the Lundh test is likely Mottalob, A., Kapp, F., Noguera, E. C. A., Kellock, T. D., Wiggins, to be more useful in clinical practice because of its H. S., and Waller, S. L. (1973). The Lundh test in the diagnosis of pancreatic disease: A review of five years' experience. Gut, practical advantages. The secretin test could be 14, 835-841. reserved for more complicated cases, eg, for some Waller, Sheila L., Kapp, F., Mottaleb, A., Noguera, E. C. A., with coeliac disease. Kellock, T. D., and Wiggins, H. S. (1972). A preliminary patients comparison of the Lundh and secretin pancreozymin tests in the diagnosis of pancreatic disease. (Abstr.) Arch. Mal. Appar. dig., 61, 227C. References Zeitlin, I. J., and Sircus, W. (1974). Factors influencing duodenal trypsin levels following a standard test meal as a test of Cook, H. B., Lennard-Jones, J. E., Sherif, S. M., and Wiggins, H. S. pancreatic function. Gut, 15, 173-179.
Endoscopic retrograde choledochopancreatography in the diagnosis of pancreatic disease
P. R. SALMON From Bristol Royal Infirmary http://gut.bmj.com/ The diagnosis of pancreatic disease remains difficult taneous information from both the biliary tract and in spite of the recent advances afforded by fibre- the pancreas and therefore detect primary biliary optic endoscopy. The introduction of fibre-optic tract disease and biliary complications of pancreatic endoscopy (Hirschowitz, Curtiss, Peters, and Pollard disease. In addition, a more precise definition of 1958) and the subsequent development of a cannu- pancreatic pathology is possible leading to the lating endoscope (Takagi, Go, Sugiura, Futagawa, detection of complications such as pancreatic duct and Hioki, 1969; Oi, Ichioka, and Takemoto, 1969; strictures, cysts, and calculi. Finally, additional on September 30, 2021 by guest. Protected copyright. Oi, 1970; Takagi, Ikeda, Nakayama et al, 1970) procedures may be provided (the collection of have led to the widespread use of endoscopic pancreatic juice and cytology) or be indicated (eg, retrograde choledochopancreatography (ERCP) in percutaneous transhepatic cholangiography, selective the diagnosis and management of pancreatic and pancreatic angiography). These indications are set biliary tract disease (Qi, 1970; Oi, Takemoto, and out in table I. Nakayama, 1970; Oi, Kobayashi, and Kono, 1970; Takagi et al, 1970; Ogoshi, Tobita, and Hara, 1970; Fujita, Soma, and Kidokoro, 1970; Demling and SuspectedPancreatic Disease Pancreatitis Classen, 1970; Kasugai, Kuno, Aoki et al, 1971; Cancer Kobayashi, Tanaka, and Tsuneoka, 1971; Salmon, Primary biliary tract pathology Brown, Htut, Burwood, and Read, 1971a; Cotton, Known Pancreatic Disease Complications Salmon, Blumgart, Burwood, Davies, Lawrie, Pierce, Pancreatic (strictures, cysts, calculi) and Read, 1972; Blumgart, Salmon, Cotton, Davies, Biliary (strictures) Indications for surgery Burwood, Beales, Lawrie, Skirving, and Read, 1972; Postoperative assessment Kasugai, Kuno, Kobayashi, and Hattori, 1972; SpecialProcedures Burwood, Davies, Lawrie, Blumgart, and Salmon, Cytology 1973; Blumgart, Salmon, and Cotton, 1974). Pure juice collection Clinically ERCP is of value both in suspected and in Manometry known pancreatic disease. It can provide simul- Table I Indications for ERCP in pancreatic disease Gut: first published as 10.1136/gut.16.8.658 on 1 August 1975. Downloaded from Symposium on diagnosis ofpancreatic disease 659 The main problems involved in ERCP are (1) parenchymal filling, duct anatomy and congenital patient selection; (2) endoscopy' technique and abnormalities. Selective catheterizatio'n'of the bile radiological management; and (3) interpretation of duct after pancreatography can usually be achieved results. by withdrawing the catheter (whose tip is calibrated) The techniques required for choledocho-pan- until the tip is almost removed from the papillary creatography are both endoscopic and radiographic orifice then angling the catheter tip upwards towards so that close cooperation with an interested radi- the patient's head before re-insertion. Selective ologist employing equipment of high quality invar- catheterization, although usually possible by this iably produces better results. The technical details means, may be difficult when there are either two of endoscopy are now widely agreed (Cotton and orifices without a common channel or where there colleagues, 1972; Salmon and colleagues, 1972; is a very short common channel. Blumgart and Salmon, 1973; Salmon, 1974). Although successful cannulation of the relevant The examination is most often performed with a duct system can now be achieved in between 80 and specialized duodenoscope (Olympus JFB-2, Machida 90 % of cases, failures occur. These may be seen in FDS) but may also be performed with a suitable patient intolerance (refusal, failed intubation), gastroduodenoscope, eg, the ACMI F5-A. Of parti- gastroduodenal disease (gastric volvulus, pyloric cular value is the ability to examine the second part stenosis), Billroth II (Polya) gastrectomy, distorted of the duodenum before cannulation. By this means second part of duodenum, periampullary diverti- distortion of the second part and periampullary culum, Vaterian stenosis, ampullary carcinoma, and cancer may be diagnosed and in the latter case papillitis. In cases where the patient cannot tolerate confirmed by biopsy and brush cytology. The intra- the procedure it may be worthwhile making another mural bile duct may also be studied and lower bile attempt at a later date after discussion with the duct obstruction may often be apparent when the patient and perhaps using heavier sedation. In the duct is clearly distended. case of Billroth II partial gastrectomy the afferent It is essential to obtain a medical duodenal ileus loop must be intubated, and a forward-viewing for cannulation and this can be achieved by em- duodenoscope may be more suitable for these ploying a suitable anticholinergic agent, namely, patients (Safrany, 1972). The problems of the hyoscine-N-butyl bromide (Buscopan), or glucagon accurate diagnosis and pathogenesis of papillitis and (0 5-1 mg intravenously). Foaming can be eliminated Vaterian stenosis have not yet been accurately by a suitable silicone preparation (Salmon, 1974). worked out. http://gut.bmj.com/ The prone position is usually employed for Whereas endoscopic cholangiography can now be injections of contrast medium so that antero- considered to be the investigation of choice in the posterior views are obtained with an under-couch jaundiced patient where infusion cholangiography tube. is either impracticable or has failed, the value of Good radiological management provides the key endoscopic pancreatography is more difficult to for success in obtaining high quality choledocho- assess. There are a number of reasons for this, the
pancreatograms. An experienced radiographer and most important being the relative difficulty in inter- on September 30, 2021 by guest. Protected copyright. radiologist are essential and high quality image preting the pancreatogram. intensification facilities allow of the early detection The European Endoscopy Study Group has of pancreatic duct filling and detail of the branch collected data from a number of European centres ducts (Bauerle, Grassman, Classen, and Demling, and shown the most common form of the normal 1972) and parenchymal opacification. Parenchym- pancreatogram (Cotton, 1973). The normal pancreas ography is generally to be avoided as the risk of usually lies on the posterior abdominal wall crossing precipitating acute pancreatitis is increased. A video the first and second lumbar vertebrae obliquely, tape recorder and/or a 100 mm camera may give with the tail of the gland situated at a higher level additional information on the dynamics of duct than the head. There are as many as nine commonly filling and emptying whilst an overcouch tube should recognized patterns in the overall shape of the gland be available for delayed films (Burwood et al, 1973). although most take a pistol-shaped course (ascend- Good radiological management will include the ing-horizontal-horizontal form). These normal choice of optimum contrast, eg, methylglucamine variations make it very difficult to diagnose patho- and sodium diatriazoate 60 % (Urografin) or methyl- logical displacement of the duct. Duct lengths are glucamine diatriazoate 65 % (Angiografin) for difficult to measure accurately and are therefore pancreatography and sodium diatriazoate 25 % probably of little value in diagnosis but duct diam- (Hypaque) for choledochography (Burwood, 1974), meters may be of more value. Available data on the recognition of injected air bubbles, the correct maximum duct diameters in normal subjects are positioning of the patient and early recognition of shown in figure 1. There is general agreement that Gut: first published as 10.1136/gut.16.8.658 on 1 August 1975. Downloaded from 660 P. R. Salmon Kreel, Sandin, and Slavin, 1973), probably due to a PANCREATIC DUCT WIDTH (mm) combination of age, postmortem artefact, and possibly radiographic magnification. Age alone did 0 1 2 3 4 5 6 7 not appear to be a significant factor in the European study group (fig 2). An additional difficulty may be presented by local anatomical structures such as the I~~~~~~~~~~~~~ICLASSEN splenic vessels, superior mesenteric artery, osteo- phytes, and lymph nodes which can alter the pan- creatogram. Subtraction films may sometimes help SEIFERT to evaluate these difficult cases. Pancreatitis eT CREMER The value of ERCP in pancreatitis lies in the demon- stration of structural changes in the ducts, the presence of complications (strictures, cysts, stones) COTTON and the demonstration of accompanying biliary SALMON )I disease-gallstones and common duct obstruction (fig 3). Although the value of surgical drainage OGOSHI T BH procedures in chronic pancreatitis is controversial, a preoperative demonstration of duct anatomy may KASUGAI T B H be of value to the surgeon (Trapnell, 1974), and 01 T B H follow up of cases subjected to pancreatic surgery may establish whether drainage has been successful or not. Nakajima, Tada, Sugawara, Kato, and KREEL
PANCREATIC DUCT WIDTH
7 HEAD BODY Fig 2 Comparison of age and pancreatic duct width in subjects 6 with normalpancreas measured from the headand body of the 5 ~~--"*0*-:* gland: r = 0176, P > 00S, 4 head; r = 0144, P > 0 05, body. mm " - - t~~~-, -" . . (From Cotton, 1973) 3 2 * '*-* *- 1
20 40 60 80 20 40 60 80 age Gut: first published as 10.1136/gut.16.8.658 on 1 August 1975. Downloaded from Symposium on diagnosis ofpancreatic disease 661
Pancreatitis Minimal Moderate Marked Chanve Pancreas Main pancreatic duct Rigidity + Tortuosity + .+ Irregular calibre + Obstruction +
Cyst formation + ,+ Calculi ,+ Branch ducts Rigidity + ++ + Irregular distribution + ++ + ++ Dilatation + ++ +. + + Irregular calibre + ++ + ++ Cystic dilata.tion + + Calculi _- + Parenchyma Coarse opacification _- + Size ofpancreas
Diminished _- + Biliary System Lower common bile duct Rigidity + ++ Dilatation + ++ Stenosis ++ Irregularity + Table II Criteria for ERCP in the diagnosis of chronic pancreatitis' 'After Kasugai, Kuno, and Kizu (1974) Fig 3 Chronic pancreatitis with stricture of lower common bile duct. Note proximal dilatation ofbiliary 1974). In our own series in Bristol (Salmon, 1975b) system and gross disorganization ofpancreatic duct ('chain of lakes' 40 cases of pancreatic cancer were diagnosed out of http://gut.bmj.com/ appearance) a total of 450 examinations. There are insufficient data at present to show that 'early' diagnosis of extreme to differentiate cancer from pancreatitis. pancreatic cancer can be effected by ERCP but the Both in fact may coexist. Cotton and Beales (1974) results of increased experience in the interpretation demonstrated a surgical lesion(stricture, obstruction, of pancreatograms coupled with pancreatic cytology or cyst) in nearly half of a group of 31 cases of (Shida, 1973; Hatfield, Whittaker, and Gibbs, 1974) recurrent pancreatitis. may produce better results. What is already clear, A comparison of pancreatography with exocrine however, is that the clinical management of the on September 30, 2021 by guest. Protected copyright. function studies (Salmon, 1975a) has shown that patient may be influenced by ERCP. The decision minimal change pancreatitis may be associated with to perform pancreaticoduodenectomy or a palliative a normal maximum bicarbonate but a decreased choledochoenterostomy may be based on the results trypsin output. A further feature of minimal change of ERCP. Several authors, such as Ogoshi and Hara lesions is an elevated fasting serum cholecystokinin (1972) and Stadelman, Safrainy, Loffler, Barna, level as measured by radioimmunoassay (Harvey, Miederer, Papp, Kaufer, and Sobbe (1974), divide 1975). the duct changes in pancreatic cancer into several types, depending on whether there is a main duct Pancreatic Cancer stricture with proximal dilatation (fig 4), an interrup- tion of contrast material (fig 5), complete obstruction Most series show between 5 and 10% of their total (fig 6), tapering obstruction due to an acinar cell ERCP cases to have pancreatic carcinoma but carcinoma, or cavernous filling of the gland paren- comparison is difficult due to varying methods of chyma with obstruction. Although it is useful to case selection. Kasugai et al (1972b) demonstrated recognize the various forms pancreatic cancer can carcinoma in 14 of 380 cases (5%) and a similar take, there is no evidence at present that classifying figure was obtained from 54 of 1082 examinations pancreatic cancer in this manner has altered the published from Budapest and Bonn (Stadelmann, prognosis of this disease. Safrany, Barna, Miederer, Papp, Kaufer, and Sobbe, Endoscopic retrograde choledochopancreato- '662 P. R. Salmon Gut: first published as 10.1136/gut.16.8.658 on 1 August 1975. Downloaded from mg.. P... ~~~~~graphy should not be used alone to exclude pan- creatic cancer but should be related to other in- vestigations such as scintigraphy, pancreatic cytol- . ogy,thexoddcrine function studies, and more recently ~~~;~~;, echotomography employing a grey-scale video system (Bekaert, Afschrift, Colardyn, and Eleivaut,
...... ,,,,,, cholangitis and septicaemia, transmission of hepa- Catos o ations op edo- ofteadditional medicationsuceasanichdoinrgi dRugs.
f ..cationsoccurindaabeouth2eoof ERCP maypatientsoinclude thosewithrjaundcreattsubattributed to [email protected]; jnectedtoseRdcPybts only whenathereni preexisting - (ie1Cholangitis and septicaemiarmaay
tE obstructivesbiliar disese. nh ufiseophylanico Fig 4 Carcinoma of head ofpancreas. Note long whether administered parenterally or directly into stricture in head ofgland with gross proximal dilatation the bile duct at endoscopic choledochography. http://gut.bmj.com/ on September 30, 2021 by guest. Protected copyright.
Fig 5 Carcinoma of body ofpancreas. Interruption of may i t contrast material, spotty parenchymalafilling, and h a a pancreatic drregucaritCwith att of yF
Fig 6 Carcinoma ofpancreas. Complete obstruction of pancreatic duct atjunction ofhead and body ofgland Fig 6 Gut: first published as 10.1136/gut.16.8.658 on 1 August 1975. Downloaded from Symposium on diagnosis ofpancreatic disease 663 The transmission of hepatitis has not been collection ofpancreatic fluid for cytodiagnosis using a duodeno- scope. Gut, 15, 305-307. recorded but it is a wise precaution to demand a Hirschowitz, B. I., Curtiss, L. E., Peters, C. W., and Pollard, H. M. negative hepatitis antigen (HbAg) report in patients (1958). Demonstration of a new gastroscope, the 'Fiberscope'. Gastroenterology, 35, 50. with chronic hepatobiliary disease. Pancreatitis is Kasugai, T., Kuno, N., Aoki, I. (1971). 'Fiber duodenoscopy rare following endoscopic pancreatography (less analysis of 353 examinations.' Gastrointestinal Endoscopy, 18, 9, Kasugai, T., Kuno, N., Kobayashi, S., and Hattori, K. (1972a.) than 2 %), though transient hyperamylassaemia Endoscopic pancreatocholangiography. 1. The normal occurs in 40 to 45 % of patients. One case of fatal endoscopic pancreatocholangiogram. Gastroenterology, 63. 227-234. necrotizing pancreatitis was reported by Ammann, Kasugai, T., Kuno, N., Kizu, M., Kobayashi, S., and Hattori, K. Deyhle, and Butikofer (1973) following ERCP in a (1972b). Endoscopic pancreatocholangiography. 2. The patient with relapsing acute pancreatitis. Pancreatic pathological endoscopic pancreatocholangiogram. Gastro- enterology, 63, 227. cysts should not be filled with contrast material Kasugai, T., Kuno, N., and Kizu, M. (1974). Endoscopic cholangio- unless surgery is planned within 24 to 28 hours since pancreatography. Stomach and Intestine (Tokyo), 8, 3-8. Kobayashi, M., Tanaka, N., and Tsuneoka, K. (1971). Retrograde cysts which do not drain freely rapidly become cholangiography with duodenoscope. Baika, 27, 629. infected following pancreatography. Kreel, L., Sandin, B., and Slavin, H. (1973). Pancreatic morphology: a combined radiological and pathological study. Clin. Radiol., X-irradiation during ERCP is low (about 10% 24, 154. of that employed for infusion cholangiography). Millbourn, E. (1960) Calibre and appzarance of the pancreatic ducts However, cumulative x-ray damage to the fibre and relevant clinical problems. Acta chir. scand., 118, 286. Nakajima Tada, Sugawara, Kato, and Kawai (1973). Endoscopic bundles eventually occurs. Replacing these bundles pancreatography. Stomach and Intestine (Tokyo), 8, 3. is expensive and may cost as much as 30% of the Ogoshi, K., and Hara, Y. (1972). Retrograde pancreato-choledocho- graphy. Jap. J. clin. Radiol., 17, 455. price of a new instrument. Ogoshi, K., Tobita, Y., and Hara, Y. (1970). Endoscopic observation of the duodenum and pancreato-choledochography using duodenal fiberscope under direct vision. Gastroent. Endoscopy References (Tokyo), 12, 83. Oi, I. (1970). Endoscopic pancreato-cholangiography. Saishin Igaku, Ammann, R. W., Deyhle, P., and Butikofer, E. (1973). Fatal necrotizing 25, 2292. pancreatitis after per-oral cholangiopancreatography. Gastro- Oi, I., Ichioka, S., and Takemoto, T. (1969). Intestinal endoscopy: enterology, 64, 320. chiefly on the present status of endoscopic examination of the Bauerle, H., Grassman, P. H., Classen, M., and Demling, L. (1972). duodenum. Stomach and Intestine (Tokyo), 4, 469. The use of radiographic techniques in gastroenterological Oi, I., Kobayashi, S., and Kondo, T. (1970a). Endoscopic pancreato- endoscopy. Electromedia, 4, 109. cholangiography. Endoscopy, 2, 103. Bekaert, S., Afschrift, M., Colardyn, F., and Eleivaut, A. (1975) Oi, I., Takemoto, T., and Nakayama, K. (1970b). Fiberduodeno- Tomoechography of the pancreas". Proceedings of the 2nd scopy-early diagnosis of cancer of the papilla of Vater. InternationalSymposium ofDigestive Endoscopy(Belgian Society Surgery, 67, 561. of Digestive Endoscopy), Brussels. (Abstr.) Safrany, L. (1972). Endoscopy and retrograde cholangio-pancreato- http://gut.bmj.com/ Blumgart, L., and Salmon, P. (1973). Fiber duodenoscopyand transpa- graphy after Billroth It operation. Endoscopy, 4, 198. pillary cholangiopancreatography. In Recent Advances in Salmon, P. R. (1975a). Pancreatic function and its relation to pan- Surgery. Churchill, Livingstone, London. creatography. In 2nd International Symposium of Digestive Blumgart, L. H., Salmon, P. R., and Cotton, P. B. (1974). Endoscopy Endoscopy (Belgian Society of Digestive Endoscopy), Brussels. and retrograde choledochopancreatography in the diagnosis (Abstrs.) of the patient with jaundice. Surg. Gynec. Obstet., 138, 565- Salmon P. R. (1975b). Early diagnosis of pancreatic cancer. Pro- 570. ceedings of the 11th Symposium on Advanced Medicine. Pitman, Blumgart, L. H., Salmon, P., Cotton, P. B., Davies, G.T., Burwood, London. R., Beales, J. S. M., Lawrie, B., Skirving, A., and Read, A. E. Salmon, P. R. (1974). Fibre-optic Endoscopy. Pitman Medical, London.
(1972). Endoscopy and retrograde choledochopancreatography Salmon, P. R., Brown, P., Htut, T., Burwood, R., and Read, A. E. on September 30, 2021 by guest. Protected copyright. in the diagnosis of the jaundiced patient. Lancet, 2, 1269. Duodenoscopy. 1971 (Letter) Lancet, 1, 1298-1299. Burwood, R. J. (1974). The role of radiology in fibre-optic endoscopy. Salmon, P. R., Brown, P., Thein-Htut, and Read, A. E. (1972). Ia Fibre-optic Endoscopy, by P. R. Salmon p. 183. Pitman, Endoscopic examination of the duodenal bulb: clinical London. evaluation of forward and side viewing fibreoptic systems in Burwood, R. J., Davies, G. T., Lawrie, B. W., Blumgart, L. H., and 200 cases. Gut, 13, 170-175. Salmon, P. R. (1973). Endoscopic retrograde choledocho- Salmon, P. R., Blumgart, L., Burwood, R., Davies, G., and Read, pancreatography: a review with a report of a collaborative A. E. (1973). Endoscopy in the diagnosis of obstructive series. Clin. Radiol., 24, 397-415. jaundice. In Endoscopy of the Small Intestine with Retrograde Cotton, P. B. (1973). The normal endoscopic pancreatogram. Pancreato-cholangiography, edited by L. Demling and M. Endoscopy, 6, 65-70. Classen, p. 98. Thieme, Stuttgart. Cotton, P. B., and Beales, J. S. (1974). Endoscopic pancreatography Schiller, K. F. R., Cotton, P. B., and Salmon, P. R. (1972). Hazards in management of relapsing acute pancreatitis. Brit. med. J. of routine upper gastro-intestinal endoscopy: a review of 608-611. British experience. In Proceedings ofthe 2nd European Congress Cotton, P. B., Salmon, P. R., Blumgart, L. H., Burwood, R. J., of Digestive Endoscopy, Paris. Davies, G. T., Lawrie, B. W., Pierce, J. W., and Read, A. E. Shida, M. (1973). Personal communication. (1972). Cannulation of papilla of Vater via fiber-duodeno- Stadelmann, O., Safrany, L., Loffler, A., Barna, L., Miederer, S. E., scope: assessment of retrograde cholangiopancreatography in Papp, J., Kaufer, C., and Sobbe, A. (1974). Endoscopic 60 patients. Lancet, 1, 53. retrograde cholangiopancreatography in the diagnosis of Demling, L., and Classen, M. (1970). Duodenojejunoskopie. Dtsch. pancreatic cancer. Endoscopy, 6, 84-93. med. Wschr., 95, 1427. Takagi, T., Go, T., Sugiura, M., Futagawa, S., and Hioki, R. (1969). Fujita, R., Soma, S., and Kidokoro, f. (1970). Endoscopy of the Fiberoptic duodenoscopy. Surgery, 65, 597. duodenum (experience using Olympus Jf-2). Gastroent. Takagi, K., Ikeda, S., Nakagawa, Y. et al (1970). Retrograde pan. Endosc., 12,97. creatography and cholangiography by fiberduodenoscope- Harvey, R. F. (1975). Personal communication. Gastroenterology, 59, 445. Hatfield, A. R. W., Whittaker, R., and Gibbs, D. D. (1974). The Trapnell, J. (1974). Personal communication.