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Endoscopic Management of Pancreatitis 2001 년 도 대한쉐당도연구회 학술대회 口특 강口 Endoscopic Management of Pancreatitis Joseph W. Leung, M.D., FRCP., FACP., FACG C.W. Law Professor of Medicine, Chief, Division of Gastroenterology, University of California, Davis Health System and VA Northem Califomia Health Care System Leaming objectives: distal common duct. Characteristic EUS appearance 1. Understand the role of ERCP in the diagnosis has also been described in the diagnosis of pancreas and treatment of pancreatic diseases divisum. In addition, EUS guided fine needle aspi­ 2. Discuss the pathophysiology of acute and chro­ ration cyto10gy or biopsy is an effective too1 for the mc pancreatltls diagnosis of underlying pancreatic malignancy. Des­ 3. Discuss the management of pain associated with pite the advances in pancreaticobili앙y imaging, thera­ pancreatic diseases peutic ERCP continues to play an important role in 4. Endoscopic management of acute biliary pancre­ the treatment of pancreatic diseases. Endoscopy is atitis, idiopathic pancreatitis and pancreas divisum useful to rule out the presence of an ampullary 5. Endoscopic management of chronic pancreatitis tumor as a cause of pancreatitis. Endoscopic brush in c1uding strictures, stones and pseudocysts cytology, aspiration bile cytology and needle biopsy 6. Discuss parasitic infestation of the pancreatic also aid in the diagnosis of under1ying pancreatic system malignancies. INTRODUCTION DEFINITIONS Diagnostic and therapeutic ERCP play an im­ Acute pancreatitis is defined as inflammation of portant role in the management of patients with pan­ the pancreas with no residual damage upon reco­ creaticobiliaη problems. Diagnostic pancreatogram veη ， except in cases complicated by strictures or compliments ultrasound scan and CT scan in the pseudocyst formation. Overall, biliaη stone is the imaging of the pancreas. Magnetic resonance cholan­ most common cause of acute pancreatitis (Table 1). gio-pancreatography (MRCP) produces good images Chronic pancreatitis - recurrent inflammation of of the biliary and pancreatic ductal systems and has the pancreas with residual parenchymal damage, a potential in replacing diagnostic ERCP exami­ morphological changes and functiona1 loss. Long­ nations in the future. Similarly, endoscopic ultra­ term complications inc1uded ducta1 strictures and sonography (EUS) is usefu1 in the imaging of the dilation, and intraductal stone formation. Clinically, pancreas and the distal bile duct. It is more sensitive patients develop symptoms of pancreatic insuffici­ than abdominal u1trasound scan in defining pan­ ency inc1uding ma1absorption and steatorrhea, ob­ creatic pathologies and in detecting stones in the structive jaundice and diabetes. Alcoho1 is the most 13 14 2001 년도 대한쉐담도연구회 학술대회 Table 1. Causes of acute pancreatitis the epigastrium and often radiates to the back and the right and left upper abdomen. It may be due to Bi1 iary stones Alcohol tissue inflammation but more common as a result of Metabolic (e.g. hypercalcemia and hyperlipidemia) pancreatic ductal hypertension due to obstruction Medications (e.g. antibiotics and immunosuppressives) Trau ma (recent or prior) (stones or strictures). Pain can occur as a result of Iatrogenic (surgical or 히en띠doscopiκc이) nerve entrapment due to chronic inflammation and Po잉s toperattve Transpapillary foreign bodies fibrosis or a malignant tumor with nerve infiltration. (e.g. T-tubes, stents or parasites) Indeed, an underlying primary or metastatic tumor in Cystic fibrosis Collagen vascular disease the pancreas must be excluded if an elderly patient Infections without any risk factors presents with the first attack Familial of acute pancreatitis Pain management involves resting the pancreas by common cause of chronic pancreatitis. following a low fat diet, and taking pancreatic en­ zyme supplements with each meal and abstinence CLlNICAL COMPLlCATIONS OF from alcohol. Pain management is often difficult in CHRONIC PANCREATITIS such patients and may require high dose of potent analgesics, which may include narcotic pain medi­ Pancreatic steatorrhea - the pancreas has good cine, lInd many patients may eventually become de­ functional reserve and needs to lose 90% of its pendent on narcotic medicine. Alternative use of functioning tissue secondaη to inflammation or cutaneous fentanyl patch is useful for pain control. destruction before malabsorption occurs. Pancreatic In severe cases, celiac plexus block performed by steatorrhea therefore occurs more commonly as a the 띠 ection of absolute alcohol or phenol under result of a blocked pancreatic duct secondary to fluoroscopic or EUS guidance have been described stone or stricture (benign or malignant) at the head to block the sympathetic and parasympathetic nerve of the pancreas. Obstructive jaundice may occur in plexus, in order to control the pain. However, the 10 - 15 % of patients with chronic calcific pan­ effect of celiac plexus blocked is short lived and creatitis, as a result of involvement of the distal thus is more usef비 for pain associated with pan­ common bile duct by pancreatic inflammation and creatic cancer rather than chronic pancreatitis. fibrosis. It is significantly related to severity of the Pancreatic stenting for ductal obstruction has been underlying pancreatitis which is reflected by the described to relief pain associated with stricture due degree of calcification in the head of the pancreas. to chronic pancreatitis or a head of pancreas tumor. It is important to rule out an underlying or asso­ Stenting is only a temporary measure for benign ciated pancreatic malignancy as a cause of obstruc- obstruction and in cases with good response to stent­ tive jaundice. ing, definitive drainage proced따es including a distal pancreatectomy, Puestow operation with pancreatico­ PAIN MANAGEMENT IN PANCREATIC j 텅 unostomy and the Fry’s procedure including par­ DISEASES tial resection of the head of pancreas and pancre­ atic이에 unostomy may be considered to provide adequ- Pain associated with pancreatitis is localized to ate drainage of the pancreatic system and pain relief. Joseph W. Leung : Endoscopic Management of Pancreatitis 15 Table 2. Modified Glasgow criteria Age > 55 yrs Wbite blood count > 15 ， αXJ/mm3 Blood urea nitrogen > 45 mg/dL Glucose > 180 mg/dL Albumin < 3.2 g/dL Ca\cium <8 mg/dL Pa02 < 60 mm Hg Lactate dehydrogenase > 500 IU/L ASSESSMENT OF SEVERITY OF ACUTE BILlARY SPHINCTEROTOMY FOR PANCREATITIS ACUTE BILlARY PANCREATITIS The Ranson's criteria or rnodified Glasgow cri­ Irnpacted stone at the arnpulla causes obstruction teria are used to gauge the severity of the pancre­ to the flow of pancreatic juice and raised intra-pan­ atitis especially in patients presented with acute creatic pressure with resultant pancreatitis. Endo­ biliaη pancreatitis. The presence of three or rnore scopic intervention inc1udes biliary sphincterotorny factors predicts severe pancreatitis and a poor and rernoval of the obstructing stone. The likelihood c1 inical outcorne (Table 2). of finding an irnpacted arnpullary stone at the tirne of ERCP drops significantly after 72 hours because ACUTE BILlARY PANCREATITIS the irnpacted stone often passes spontaneously. In patients with severe biliary pancreatitis ( > 3 risk The rnost cornrnon cause of acute pancreatitis is factors on the Ranson's or rnodified Glasgow cri­ biliary pancreatitis. Obstruction at the arnpullary teria), urgent ERCP and sphincterotorny has been orifice or the cornrnon channel level rnost cornrnonly shown to irnprove the c1 inical outcorne of these result frorn an irnpacted stone. Papi1lary stenosis patients as dernonstrated by Neoptolernos et al. This inc1 uding sphincter of Oddi dysfunction and parasitic benefit however, was not observed in patients with infestation e.g. ascariasis are uncornrnon causes of rnild pancreatitis. Lai et al in a subsequent con­ biliary pancreatitis. Although cornrnon duct stones trolled study dernonstrated a sirnilar benefit for ur­ can forrn de novo, they are rnore likely to have gent ERCP in patients with acute cholangitis assoc­ originated frorn the gall bladder. In rare cases, CBD iated with biliary pancreatitis. In the pediaπic pa­ stones can arise frorn the intrahepatic bile ducts as tients with acute biliary pancreatitis, biliary sphinc­ in patients with oriental cholangitis or hepatoli­ terotorny is also useful in rernoving cornrnon duct thiasis. In young patients with congential choledo­ stones associated with congenital choledochal cyst chal cysts, bile duct stones rnay forrn as a result of (CCC). Despite succ강 ssful stone extraction, patients stasis and bacterial infections. Stones can forrn as a with CCC are sti1l at risk of recurrent stone for­ result of reflux of pancreatic juice into. the cystic rnation, even after cyst resection. This is due to the dilation of the cornrnon bile duct, and these are continued reflux of pancreatic juice into the distal typically calciurn carbonate stones. CBD sturnp because of the long cornrnon channel 16 200! 년도 대한쉐담도연구회 학술대회 method is to perforrn a needle knife papillotomy IDIOPATHIC PANCREATITIS over an indwelling stent inserted in the main pan­ creatic duct. With the improvement in pancreaticobi\iary imagc ing, most patients with acute pancreatitis have an PANCREATIC STONE EXTRACTION IN identifiable cause. Bile collection and analysis for CHRONIC PANCREATITIS cholester이 or bilirubin microcηstals have suggested that biliary sludge or microlithiasis may be an Chronic pancreatitis is complicated by the for­ important cause of acute biliary pancreatitis. The mation of
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