EUS
Pancreatite Acuta
Paolo G. Arcidiacono
Endoscopic Ultrasonography Unit
Gastroenterology and Gastrointestinal Endoscopy Unit
IRCCS San Raffaele Hospital
Vita Salute San Raffaele University
Milan, Italy
Endosonography Unit
San Raffaele Scientific Institute
Diagnostic EUS
Hisinaga K, Hisinaga A, et al.
High speed rotating scanner for transgastric sonography AJT 1980
Endosonography Unit
San Raffaele Scientific Institute
Operative EUS
Vilmann P. Jacobsen GK, Hnriksen FW et al
Endoscopic Ultrasonography with guided fine needle aspiration
biopsy in pancreatic disease. Gastrointest Endosc
1992;38:172-3
Endosonography Unit
San Raffaele Scientific Institute
Therapeutic EUS
Wiersema MJ, Sandusky D, Carr R et al
Endosonography-guided cholangiopancreatography.
Gastrointest Endosc. 1996 Feb;43:102-6.
Endosonography Unit
San Raffaele Scientific Institute
The Normal Pancreas
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Physiological Changes
• Age related
• Congenital duct abnormalities
– p. divisum
– P. alfa
Endosonography Unit
San Raffaele Scientific Institute
Indications
Benign
Acute pancreatitis
Chronic pancreatitis
Malignant
Exocrine
Endocrine
Endosonography Unit
San Raffaele Scientific Institute
Acute
Pancreatitis
Results from gallstone disease
in almost 40% of cases
EUS Detection Rates of CBD stones
Pts.
Freq %
Sens %
Spec %
Acc %
1470
21 – 66
84 – 100
90 – 100
92 - 99
Denis 93, Amouyal 94, Napoleon 94, Salmeron 94, Shim 95,
Palazzo 95, Prat 96, Sugyiama 97, Norton 97, Canto 98, Buscarini 98
Endosonography Unit
San Raffaele Scientific Institute
EUS detection of Choledocolithiasis
ERCP
EUS
Sensitivity
79 – 95
84 – 94
Specificity
89 – 100
96 – 98
Accuracy
95 – 97
94 - 95
Endosonography Unit
San Raffaele Scientific Institute
Risk of presence of common bile duct (CBD) stones in patients with
suspected choledocholithiasis according to clinical, biologic, and
morphologic criteria
Risk
Clinical Parameters
Biologic
Parameters
CBD
Diameter
Low
No associated clinical
history
Normal
≤ 7 mm
Intermediate
Acute ascending cholangitis
pancreatitis
↑ALP ≤ twice
↑ GGT
8-10 mm
High
Acute ascending cholangitis
jaundice
↑ ALP > twice
> 10 mm
Abbreviations: ALP, alkaline phosphatase; ALT, alanine transaminase; AST,
aspartate transaminase; GGT, gamma glutamyltransferase
Endosonography Unit
San Raffaele Scientific Institute
Prediction of common bile duct stones in the earliest
stages of acute biliary pancreatitis
H. C. van and the Dutch Pancreatitis Study Group;Endoscopy 2011;43:8-13
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Acute pancreatitis and CBD stones
Decision Analysis Models
CBD Stone Probability
(%)
7 - 45
> 45
ERCP
MRCP + ERCP
EUS + ERCP
IOC
Arguedas ’01, Am J Gastroenterol 2001 Oct;96(10):2892-9
Endosonography Unit
San Raffaele Scientific Institute
Acute pancreatitis and CBD stones
In high risk patients CBD stone prevalence
ranges from 30 – 51%
Prat F, Edery J, Meduri B et al.
Early Eus of the bile duct before endoscopic sphincterotomy for acute biliay
pancreatitis Gastrointest Endosc 2001;54;724-29
Buscarini E. Tansini P, Vallisa D et al.
EUS for suspected choledocolithiasis: do benefits outweigh costs? A prospective
controlled study. Gastrointest Endosc 2003;57;510-8
Endosonography Unit
San Raffaele Scientific Institute
Acute Pancreatitis of biliary origin
decision tree analysis
ERCP vs MRCP or EUS + ERCP
•
EUS + ERCP (when needed) is dominant in severe ABP
as compared to ERCP alone (742 $CDN)
• EUS + ERCP is slightly dominant in nonsevere ABP (58$
CDN) but with a significant decrease in ERCP related
complications (0.9% fewer cases of pancreatitis ERCP
related or recurrent)
• MRCP is more expensive as compared to EUS in both
groups
Romagnuolo J, Currie G, et al. GIE 2005;61;86-97
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
EUS-guided ERCP
• When performed in single session reduction of
– 3 days hospital stay
– 30 min anaesthesia
• Can detect causes other then cbd stones that might
cause biliary obstruction
Endosonography Unit
San Raffaele Scientific Institute
EURCP diagnosis and treatment of
common bile duct stones
19 pts 4 stones + 12 sludge 16 EURCP
1 failure 94.7% success rate
Overall time 27 min average EUS diagnosis 7 min + ERCP 20 min
R.Rocca et al. GIE 2006;63;479-483
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Primary and Recurrent Idiopathic Acute Pancreatitis
EUS reveals the cause in more 70% of unexplained acute pancreatitis
• Microlithiasis
– CBD
12 – 16%
– Gallbladder
5 – 77%
• Chronic pancreatitis 32 – 45%
• Pancreas Divisum
6.5 – 15%
• Pancreatic Cancer
3.5% - 10%
Liu CL, Lo CM, Chan JK et al.GIE 2000;51;28-32
Tandon M, Topazian M; Am J Gastroenterol 2001;96;705-9
Yusoff I, Raymond G, Sahai A; GIE 2004;60;673-8
Mariani A, Arcidiacono PG, Testoni PA;
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Autoimmune Pancreatitis
• Rare disease increasing incidence due to increasing
ability in diagnosis
• Increase IgG4 serum levels
• IgG4 precence in immunostaining
• DD : pancreatic cancer
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Pseudocyst Drainage
P.G. Arcidiacono
Endosonography Unit
Gastroenterology and Gastrointestinal Endoscopy Unit
Vita Salute San Raffaele University
IRCCS San Raffaele Scientific Institute
Milan
Endosonography Unit
San Raffaele Scientific Institute
Pancreatic Pseudocyst
• the most common cystic lesion of the pancreas
• arise as a consequence of pancreatic injury
• disruption of pancreatic duct or side branches
Endosonography Unit
San Raffaele Scientific Institute
Ductal disruption
• Acute pancreatic injury
–
–
–
–
Acute pancreatitis
Trauma
Surgical resection
Pancreatic injury abdominal surgery
• Chronic injury
– Chronic pancreatitis
– Autoimmune pancreatitis
Endosonography Unit
San Raffaele Scientific Institute
Background
Incidence as a complication of
• Acute pancreatitis
• Chronic pancreatitis
Spontaneous Resolution
• Acute pancreatitis
• Chronic pancreatitis
7 – 15%
20 – 25%
85%
< 10%
Endosonography Unit
San Raffaele Scientific Institute
Acute pseudocysts
•
•
•
•
Require at least 4 weeks to form
Significant amount of debris
Limited pancreatic necrosis ductal leak
Pancreatic or peripancreatic fat necrosis liquefying over time
• DD pancreatic necrosis
– Necrotic tissue
– No defined borders
– drainage infection due to stent occlusion
Endosonography Unit
San Raffaele Scientific Institute
Psuedocyst Drainage
Indication
Endosonography Unit
San Raffaele Scientific Institute
When (old
definition)
6 cm – 6 week criteria
• low rate of spontaneous resolution
• higher rate of complications
• enlarging cyst or duct obstruction this timing is not
mandatory
Patient could remain asymptomatic with
pseudocyst > 6cm with little risk of rupture,
infection or bleeding
Endoscopic treatment is associated with a finite
and presumably higher risk of complications
Endosonography Unit
San Raffaele Scientific Institute
Actual Accepted
Indications
To treat symptoms
–
–
–
–
–
abdominal pain (eating)
weight loss
gastric outlet obstruction
obstructive jaundice
pancreatic duct leakage
Infections absolute indication for drainage
Endosonography Unit
San Raffaele Scientific Institute
Predrainage Evaluation
DD “masquerader” of pseudocyst
–
–
–
–
–
–
–
cystic pancreatic neoplasm
duplication cysts
true pancreatic cysts
pseudoaneurism
solid necrotic neoplasm
lymphocele
gallbladder
Endosonography Unit
San Raffaele Scientific Institute
Predrainage Evaluation
Aspect and shape of the collection
– wall
– fluid (clear or debris)
– relationship to surrounding structures
• parenchima
• lumenal
• vessels (surrounding or inside)
Endosonography Unit
San Raffaele Scientific Institute
Which
Method
Surgical Drainage
Percutaneous Catheter Drainage
Endoscopic Drainage
Echoendoscopic Drainage
Endosonography Unit
San Raffaele Scientific Institute
Endoscopic
Drainage
• CT scan right before the drainage
• Transpapillary
– cyst communication with the pancreatic duct (60%)
• Transenteric
– Cyst not communicating with the duct
– Need for:
• Luminal bulge
• No more than 10 mm distance
Endosonography Unit
San Raffaele Scientific Institute
Endoscopic
Drainage
Clinical Experience
Study
No.
Patients
Technical
Success %
Bleeding
Perforation
Other
Complications
Recurrence
Rate %
Mortality
Cremer et al
33
97
1 (3%)
0
2 (6%), infec
12
0
Howell et al
9
89
1(11%)
0
0
0
0
Barthet et al
71
100
4 (5.6%)
2 (3%)
6 (8.4%), infec
18
0
Funnell et al
5
100
0
0
0
20
0
Binmoeller et al
24
83
2 (8%)
0
2 (8%), infec
25
0
Deviere et al
9
100
0
0
0
0
0
Smits et al
17
82
2 (12%)
2 (12%)
0
18
0
Fockens et al
19
84
2 (10%)
1(5%)
0
NA
0
Bohnacker et al
27
89
4 (15%)
0
13 (48%), infec
6
0
Monkemuller et al
94
94
6 (6%)
5 (5%)
0
NA
0
Vitale et al
27
85
0
0
7
0
Beckingham et al
34
71
1 (3%)
1 (3%)
1(4%),
pancreatitis
0
7
0
Dohmoto et al
13
100
0
0
0
15
0
Bejanin et al
26
85
1(4%)
2(8%)
1(4%), infec
15
0
Total
408
90
24 (6%)
13 (3%)
25 (6%)
12.00%
0
Endosonography Unit
San Raffaele Scientific Institute
EUS
Guided
Drainage
• Eus diagnostic role:
–
–
–
–
–
Cyst diagnosys
Definition of echographic pattern
Wall aspects
Vascular pattern
Duct communication
Endosonography Unit
San Raffaele Scientific Institute
Pentax EG3830UT
CST10 Wilson
Cook
Endosonography Unit
San Raffaele Scientific Institute
Rottura Wirsung
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute
Clinical Experience
EUS Drainage
Study
No of
Patients
Average
Cyst size
(cm)
Drainage
Site
Average
F/U in
Months
Recurrence
Rate
Success
Rate (%)
Mortality
Complication
Rate (%)
Comments
Chan et al
1
8.5
G
2.5
None
100
0
0
Wiersema
1
16
D
12
None
100
0
0
Gerolami et al
3
6
2G/ 1D
31.7
None
100
0
0
Pfaffenbach et al
11
10.5
6G
4.2
18%
91
0
0
Ardengh et al
2
7
2G
2
None
100
0
0
Giovannini et al
6
4.5
6G
8
16%
100
0
0
Fuchs et al
3
12
3G
13
None
100
0
0
Seifert et al
6
5
4G/2D
5.5
None
100
0
0
Inui et al
3
8
1G/2D
3.6
33%
67
0
0
Giovannini et al
35
7.8
33G/2D
27
9%
88.5
Norton et al
14
8
11G/3D
6
21%
93
0
7
1sepsis--> surg
1 stent impa into gastric
wall-->stent replaced
Vosoghi et al
14
11
11G/3D
16.4
7%
93
0
7
1 bleeding-->surg
Total
99
8.7
80G/14D
11
9%
94
0
1.4
2.9
1repeat EUS, 1 surg
1repeat EUS Drainage
1 ERCP W/PS
1 Pneumoperitoneum
managed medically
20 pancreatic abscess
4 needed surg
Endosonography Unit
San Raffaele Scientific Institute
Comparison
•
99 pts treated Kahaleh M. Endoscopy 2006;38;355-9
EUD
EGD
N° tot
46
53
Short term
93
94
Long term
84
91
Complication
19
18
Endosonography Unit
San Raffaele Scientific Institute
EUD after Failed EGD
Varadarajulu S. GIE 2007; 22
53 pts with PSC first EGD attempt 23 failures (43%)
most due to lack of bulging
EUD 100% success
No complications
90% long term success
Endosonography Unit
San Raffaele Scientific Institute
Prospective RCT comparing EUS and EGD
for transmural drainage of PPC
Varadaraiulu S.; GIE 2008;68;6;1102-11
• Endoscopists with > 400 ERCP/year
• Endosonographer with > 600 EUS/year
• > 100 EGD and > 100 EUS drainage
EUS
Tech Succ
EGD
P-value
N°
%
N°
%
14/14
100
5/15
33
<.001
Technical success was significantly greater for EUS than EGD even after
Endosonography Unit
adjusting for luminal compression
San Raffaele Scientific Institute
Conclusions
EUS has a primary role in the
diagnosis, and treatment of acute
pancrreatitis and related
complications
Endosonography Unit
San Raffaele Scientific Institute
Conclusions
There are more than one way to skin a cat
BUT
In 2011 it should be better, when available, to
choose the best and safest one!
Endosonography Unit
San Raffaele Scientific Institute
Endosonography Unit
San Raffaele Scientific Institute