2001 년 도 대한쉐당도연구회 학술대회 口특 강口

Endoscopic Management of

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 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. 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 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 . 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 , 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 ductal stones in the main duct as well as treatment is similar to patients with stone disease the side branches. Stone extraction can be perforrned and sphincterotomy and may pre­ following pancreatic sphincterotomy using a Dorrnia vent recurrent attacks of pancreatitis. Apart from basket or balloon catheter. πle non-radiopaque stones microlithiasis, sphincter of Oddi dysfunction and un­ are often soft and consist mainly of protein plugs derlying pancreas divisum account for a significant and calcium carbonate. πlese sludgy stones can be number of patients diagnosed with idiopathic pan­ easily removed using a balloon catheter or a basket. creatltls However, the calcified stones are irregular in shape

and usually veη hard in consistency and difficult to PANCREATIC SPHINCTEROTOMY IN be removed. Even when the stones are located in RECURRENT ACUTE PANCREATITIS the main pancreatic duct, they tend to forrn spicules ASSOCIATED WITH SOD and get stuck to the side branches. Capturing these stones with a basket may be difficult. The rough Pancreatic sphincterotomy improves drainage from surface of the stones can easily burst the balloon the pancreas in patients with recurrent pancreatitis when attempted stone extraction is perforrned with secondary to sphincter of Oddi dysfunction or pa­ the balloon catheter. In difficult cases with large pillary stenosis. Sphincterotomy of the main pan­ pancreatic stones, extracorporeal shockwave litho­ creatic orifice can be perforrned similar to that of a tripsy (ESWL) may be required to fragment the bi1iary sphincterotomy. A standard papillotome is stones before endoscopic removal. inserted over a previously placed guide wire into the pancreatic duct and positioned at the level of the ENDOSCOPIC MANAGEMENT OF ampulla. It is suggested that a pure cut current PANCREATIC STRICTURES should be used to reduce the risk of coagulation injury and subsequent risk of edema around the St디 ctures and dilation of the main pancreatic duct pancreatic orifice and pancreatitis. A cut of 5 - 8 is pathognomonic of chronic pancreatitis. It can mm is made in the 1- 20’cJock direction. However, occur as a result of inflammation or trauma to the it is sometimes difficult to gauge the size or extent pancreatic duct. Stones occurring above a stricture of the sphincterotomy. Excess cutting carries a risk are difficult to remove as the strictures are tight and

。 f bleeding and perforation. The size of the papil­ sometimes multiple. Dilation of the strictures is lotomy and adequacy of drainage also depends on required before stone extraction. It can be perforrned the diameter of the pancreatic duct. An altemative by initially negotiating the stricture with a guide Joseph W. Leung : Endoscopic Management of Pancreatitis 17 wire. Over the wire, graded dilators can be inserted inward migration. Altemative1y, a single pigtail is to open up the stricture. Altematively, a dilation formed at the distal end of the stent to prevent balloon (4 - 6 mm diameter) can be passed over the inward migration. In addition, multiple side holes gllide wire and positioned through the stricture with are fashioned to allow better drainage from the side the help of the radiopaque markers. The balloon is branches. The conventional pancreatic stents are then inflated using the pressure insufflator with either straight or have a slight curve. As such, the dilute contrast. Fluoroscopy is used to monitor the longer stents do not conform to the contour of the correct positioning of the balloon, observing the pancreatic duct and may result in the proximal tip initial waist formation and subsequent full expansion pushing against the wall of the pancreas causing of the balloon for effective dilation. For veη tight subsequent stricture formation. A modification has strictures, smaller .028 or .018 guide wires may be been be made by changing its configuration to an S used to initially to traverse the stricture. Smaller shape so that the stent aligns properly with the balloon with a slimmer catheter may be reqllired in curvature of the pancreatic duct. This helps to keep veη difficult cases. The Soehendra stent retriever (7 the stent in position, although downward rnigration or 10 Fr) has been used for dilation of veη tight is still possible. It is unclear as to how long a pancreatic strictures. This device has a flexible metal pancreatic stent will rernain patent in vivo. The shaft and a screw design at the tip that can be used general consensus is to rernove the stent after 1 to 4 to drill through a tight stricture prior to stent place­ weeks to avoid any cornplications from stent block­ ment. Subsequent balloon dilation and stenting may age. Because spontaneously downward rnigration and be required to open up a tight pancreatic stricture. dislodgement of the stent have been reported, a plain X-ray of the abdornen should be taken to STENTING FOR BENIGN OBSTRUCTION check for the presence and position of the stent AND PANCREATIC STRICTURE prior to sedating the patient for a planned stent removal. Altematively, a 5 or 6.5 Fr nasopancreatic Stent placement is indicated to insure adequate drain can be placed to provide drainage of the drainage of the pancreatic systern following stricture pancreatic systern and this can be rernoved after 1 dilation, stone extraction or after pancreatic sphinc- to 3 days without a repeat procedure. terotorny. Different types of stents are available. The configurations of the pancreatic stents are sornewhat STENTING FOR MALIGNANT different to the biliary stents although sorne biliary PANCREATIC STRICTURE stents have been used or rnodified for this purpose.

까1e stents are usually 5 to 7 French in diarneter, Although painless obstructive jaundice is a classi- with lengths varying between 3 to 12 crn. Usually cal presentation of an underlying head of pancreas straight stents with flaps are used instead of pig- cancer, sorne patients suffered considerable pain as a tailed stents. The upstrearn anchoring flap is re- result of rnain pancreatic duct obstruction and pan- rnoved because of concems that this flap that pre- creatic ductal hypertension. These patients respond vents downward rnigration may actually encourage well to endoscopic stenting and drainage. In such inward rnigration of the stent into the pancreas. The situations, rnanipulation of the guide wire through downstrearn flap provides the rnain resistance to the obstructed area rnay sometirnes be difficult as 18 2001 년도 대한혜답도연구회 학술대회 the upstream pancreatic duct may be completely CBD obstruction associated with chronic pancreatitis blocked. It is useful to consider the hydrophilic or are less responsive to endoscopic therapy. slippeη wires to negotiate the difficult strictures. ENDOSCOPIC MANAGEMENT OF ENDOSCOPIC MANAGEMENT OF PANCREATIC DUCT LEAKS OBSTRUCTIVE JAUNDlCE ASSOCIATED WITH PANCREATIC DlSEASES Leakage from the pancreatic duct may resu1t from trauma to the pancreas; a common example is fall­ Obstructive jaundice can complicate chronic pan­ ing off the bicycle with crushing injury and trans­ creatitis but it is an uncommon complication of sim­ ection of the pancreas. Free leakage may lead to ple acute pancreatitis. However, transient abnonna­ pancreatic ascites or cyst fonnation. Complete trans­ lities in function tests can result from com­ ection of the pancreas may require distal pancreatec­ pression of the distal bile duct due to edema in the tomy. In patients with a communicating cyst, stent­ head of the pancreas. In patients with pancreatitis ing at the papilla level reduces the intra pancreatic complicated by pseudocyst in the head of the pan­ pressure and directs the flow of pancreatic juice creas, compression of the bile duct may result in back into the duodenum and decreases the leakage. obstructive jaundice. Temporary stenting can be used For cyst communicating with a side branch of the to provide biliary drainage but the treatment should pancreatic duct, we prefer to place a stent across the be directed to the treatment of underlying fluid area of leakage, diverting the pancreatic juice and to collection promote healing of the duct injury. In patients with ca1cific pancreatitis, obstruction of the distal bile duct can occur in 10 to 15% of ENDOSCOPIC DRAINAGE PANCREATIC patients, and is more common in those with sig­ PSEUDOCYSTS nificant ca1cification in the head of the pancreas. Although a radiological stricture may be present, Most pancreatic cyst or pseudocysts fonn as a jaundice may not occur and liver function abnor­ complication of acute pancreatitis. Small fluid col­ malities may only be a slight elevation in the alka­ lection may resolve spontaneously with conservative line phosphatase level. In such cases, we recommend treatment. Repeated imaging with u1trasound or CT conservative management because stenting will result scans is used to monitor the fluid collection. If the in contamination of the biliary system and sepsis. cyst is large ( > 6 cm) and does not resolve after 6

HOYlever, patients with jaundice and significant ob­ weeks, endoscopic drainage can be attempted if the struction may benefit from temporary stenting. It is cyst is in close proximity to the or duo­ important to perfonn brushing cytology and/or bio­ denum. Usually cystic fluid collection may cause an psy to rule out an underlying malignancy before external bulge pushing on the stomach. If the stenting. Long-tenn management of these patients separation between the cyst and stomach wall is less may require surgical resection and bilioenteric anas­ than 1 cm on CT scan, transgastric cystic drainage tomosis for drainage. Although success with end­ can be perfonned. Some recommend an initial oscopic balloon dilation and stenting has been re­ endoscopic ultrasound examination to rule out any ported for post -op benign bile duct strictures, distal large blood vessel between the cyst and the stomach Joseph W. Leung : Endoscopic Management of Pancreatitis 19 wal1 as uncontrol1ed bleeding has been reported as a 5 to 7% of the population but not al1 patients fatal complication of cystgastrostomy. develop c1 inical symptoms. It is however a signi­ ficant cause of idiopathicpancreatitis. The most

CYSTGASTROSTOMY common presentatlOn IS pancreat1c pam or recurrent

idiopathic pancreatitis. 까1Í s is due to a relative ob­ It is important to localize the apex or the most struction of the flow of pancreatic juice through the prominent bulging of the cyst in the stomach. A 25 smal1 minor papil1ary orifice. In the early stages, gauge sclerotherapy needle can be used to puncture there are no significant changes in the pancreatic the cyst and inject contrast to define the position of duct. However, with chronic obstruction, di1ation of the cyst. A needle knife is then positioned over the the main pancreatic duct and the side branches with bulging part of the cyst and cauteη applied to the changes of chronic pancreatitis can occur in the needle knife to drill a hole into the cyst. Once the dorsal pancreas. Initial treatment of pain or recurrent cyst is entered, the needle is removed and a guide pancreatitis is usually conservative with abstinence wire is inserted into the cyst to secure the track. from alcohol and a low fat diet. Oral pancreatic The sheath of the needle is removed and a 6 - 8 enzyme supplements are used to rest the pancreas. mm di1ation balloon is inserted over the guide wire and the communication between the cyst and the ENDOSCOPIC MANAGEMENT OF stomach wall is di1ated. Bal1 00n dilation minimizes PANCREAS DIVISUM the risk of bleeding compared to extension of the communication with a papi1lotome. After balloon The current recommended endoscopic therapy for dilation, one or more 10 French straight or double pancreas divisum is minor papi1lotomy. It is usually pigtai1 stents are inserted to decompress the cyst performed with a needle knife cutting on an in­ into the stomach. The procedure should be covered dwelling stent in the dorsal pancreatic duct. Tem­ with antibiotics to reduce the risk of infection. porary stenting is performed to insure drainage from Transgastric or transduodenal drainage is effective in the pancreas and the stent is usually removed after treating a non-complicating cyst. If there is evidence one week. Minor papi1lotomy and stenting has been of necrotic pancreatic tissue or a phlegmon, endo shown to be effective in reducing the attacks of scopic drainage is more difficult and carries a sig­ pancreatitis in patients with pancreas divisum, more nificant risk of infection. so than patients with changes of chronic pancreatitis. Repeat endoscopic therapy may be necessary be­ PANCREAS DIVISUM cause of recurrent stenosis of the minor orifice A different c1 inical situation may occur in patients Pancreas divisum is a congenital developmental with absent Santorini’s duct where the main pan­ anomaly in which the two parts of the pancreas did creatic system does not drain through the minor not fuse together in utero. As a result, these patients papi1la. As a result, the drainage of the pancreas is have a small ventral pancreas that empties at the mainly through the main papi1la. Because of the main papil1a with the common bile duct but the lack of an overflow valve at the minor papi1la, main bulk of the pancreas drains through the dorsal relative obstruction at the main papi1la secondary to duct at the minor papi1la. Pancreas divisum occur in SOD may result in recurrent pancreatitis. 20 2001 년도 대한쉐담도연구회 학술대회

treatment of pancreatic diseases inc1 uding manage­ PARASITIC INFESTATIONS OF THE ment of complications of pancreatitis. Successful PANCREATIC SYSTEM endoscopic drainage may provide temporary or de­ finitive treatment for obstruction of the pancreatic In endemic areas, parasitic infestation may cause system and helps in the management of pain com- pancreatitis due to migration of the adult parasites plicating acute and chronic pancreatitis. However, into the pancreatic duct. This has been reported in endoscopic pancreatic therapy should be performed patients with clonorchis sinesis and ascariasis. The by experienced endoscopists as these procedures presence of the ascaris worm causes obstruction of may caπy significant complications which inc1ude the main pancreatic duct and pancreatitis. A typical pancreatitis, sepsis, bleeding and perforation. finding on abdominal ultrasound examination is the four lines sign due to the presence of the worm in SUGGESTED FURTHER READING the pancreatic duct. Endoscopic removal of the worm using grasping forceps is effective in treating Endoscopic therapy of pancreatic disease. Gastroin- the pancreatitis. It is important to give these patients testinal Endoscopy Clinics of North America. Edited a course of anthelminthic therapy to eradicate the by Sherman., 1998 gut infestations following endoscopic treatment to prevent recurrence.

CONCLUSION

Endoscopic therapy plays an important role in the