Pancreatic fluid collections are a frequent complication of acute pancreatitis. The revised Atlanta criterion classifies chronic fluid collections into pseudocysts and walled-off pancreatic necrosis (WON). Symptomatic PFCs require drainage options that include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, minimally invasive endoscopic drainage has now become the preferred approach. An endoscopic ultrasonography (EUS)-guided approach for pancreatic fluid collection drainage is now the preferred endoscopic approach. Both plastic stents and metal stents are efficacious and safe; however, metal stents may offer an advantage, especially in infected pseudocysts and in WON. Direct endoscopic necrosectomy is often required in WON. Lumen apposing metal stents allow for direct endoscopic necrosectomy and debridement through the stent lumen and are now preferred in these patients. Endoscopic retrograde cholangiopancreatography with pancreatic duct exploration should be performed concurrent to PFC drainage in patients with suspected PD disruption. PD disruption is associated with an increased severity of pancreatitis, an increased risk of recurrent attacks of pancreatitis and long-term complications, and a decreased rate of PFC resolution after drainage. Ideally, pancreatic ductal disruption should be bridged with endoscopic stenting.
Background and Objectives: Endoscopic drainage/debridement of symptomatic walled off necrosis (WON) using lumen-apposing metal stents (LAMS) is both safe and effective. While endoscopic management of WON is the standard approach to treatment, the ideal concomitant medical therapy remains unclear. The purpose of this study was to further elucidate the effect of proton pump inhibitor (PPIs) therapy on the technical and clinical success of endoscopic treatment of WON. Methods: Two hundred and seventy-two patients in 8 centers with WON managed by endoscopic drainage using LAMS were evaluated. Patients were followed for at least 6 months following treatment. The patients were divided into two groups: Those that used PPIs continuously during the therapy and those not on PPIs continuously during the interval of therapy. Outcomes included but were not limited to technical success, clinical success, number of procedures performed, and adverse events. Results: From 2013 to 2016, 272 patients underwent WON drainage with successful transmural LAMS placement. The two groups were split evenly into PPI users and non-PPI users, and matched in regards to demographics, etiology of pancreatitis, WON size, and location. There was no difference in the technical success between the two groups (100% vs. 98.8%, P = 1), or in clinical success rates (78.7% vs. 77.9%). There was a significant difference in the required number of direct endoscopic necrosectomies to achieve clinical success in the PPI vs. non-PPI group (3.2 vs. 4.6 respectively, P < 0.01). There were significantly more cases of stent occlusion in the non-PPI group vs. PPI group (9.5% vs. 20.1% P = 0.012), but all other documented adverse events were not significantly different. Conclusion: Discontinuing PPIs during endoscopic drainage and necrosectomy of symptomatic WON appears to reduce the number of endoscopic procedures required to achieve resolution. Continuous PPI results in higher rates of early stent occlusion.
INTRODUCTION: PEG tube has become the modality of choice for providing access for long term enteral nutrition. Despite a good safety record, complications due to PEG dislodgment do occur. We present a case of PEG tube causing Choledo-duodenal fistula, presenting with Ascending Cholangitis. To the best of our knowledge, this unusual complication of PEG tube hasn't been described before. CASE DESCRIPTION/METHODS: 38 y.o.male with anoxic brain injury, PEG tube placed 6 months ago, presented for evaluation of Jaundice. Vitals were BP 145/108 | Pulse 135 | Temp 101.5 °F. On exam, patient had jaundice, abdomen was soft, Non tender, PEG tube was in the LUQ and Murphy’s sign was negative. Labs showed WBC 12 10X3 U/L, AST 46 U/L, ALT 131 U/L, TB 2.2 mg/dL, DB 1.1 mg/dL. CT abdomen and Pelvis revealed intrahepatic, extrahepatic and CBD dilatation to 1.2 cm, normal Pancreas. PEG tube with fluid-filled balloon was at the level of the pylorus or proximal duodenum. Small and large bowel were nondilated. The diagnosis of ascending cholangitis was made and ERCP was performed. ERCP showed the PEG tube balloon in the duodenum. It was repositioned into the stomach and the scope was advanced to the 2nd portion of the duodenum. There was a large white base ulcer at the duodenal sweep extending into the 2nd portion of the duodenum. Occlusion cholangiogram showed extravasation of the contrast from the distal CBD into the duodenal ulcer. There was a fistulous tract between the CBD and the ulcer. Sphincterotomy was made and a biliary stent was placed to heal the fistula. Biospy of the ulcer showed small intestinal mucosa with ulceration, fibrinoid exudates and no malignancy. Repeat ERCP 8 weeks later for stent removal, showed a chronic entero-biliary fistula. DISCUSSION: Our case is unique in that, this is the first CD fistula described in the literature as a complication of PEG tube presenting with ascending cholangitis. We hypothesize that the inflated balloon migrated into the duodenum due to gastric peristalsis and got incarcerated into the duodenum. 90% cases of CD fistula are due to impacted stone in the distal CBD. Other causes are Ampullary carcinoma or Cholangiocarcinoma. Based on our literature review, this is the only reported case of CD Fistula resulting from dislodged PEG tube causing direct pressure necrosis of the duodenal mucosa leading to erosion and fistulation with the distal CBD. Our case brings to light a new and potentially avoidable complication of PEG tubes.
INTRODUCTION: We present a rare case of Ectopic Liver (EL) tissue along the pancreatic tail, that developed into HCC. Based on our research, there are only 4 reported cases of primary HCC in EL tissue around the pancreas. Our case originates in the retroperitoneum near the pancreas. CASE DESCRIPTION/METHODS: 70 y.o Female with Tuberous Sclerosis was referred for an incidental finding of an abdominal mass. She was seen by her PCP for back pain and difficulty ambulating. Physical exam showed chronic facial rash. Abdominal exam was negative for a palpable mass, tenderness, guarding or rebound. Labs revealed normal LFTs and normocytic anemia. Viral hepatitis panel was negative. MRI abdomen showed a 6.8 × 7 cm mass in the LUQ with a central cystic cavity and a surrounding solid component.The mass abuted the pancreatic tail and loops of bowel and was of unclear origin. EUS showed a normal appearing pancreas. A hypoechoic mass with cystic and solid components was noted next to the pancreas. FNA was performed. Immunohistochemical staining was positive for Hepatocyte specific antigen (HSA), supporting hepatic origin and CK7 highlighting the presence of a bile ductules. This supported the diagnosis of hepatic tissue. Surgical resection was recommended. A 8 cm mass involving the splenic vein and pancreatic tail was noted and distal pancreatectomy and splenectomy was performed. Surgical pathology showed carcinoma with hepatic differentiation, most consistent with primary HCC, adherent to the pancreas, but not involving the pancreatic parenchyma. No benign liver tissue was identified. A diagnosis of HCC arising within and replacing a rest of ectopic liver was made. AFP post-op was normal. Post-op course was uneventful. DISCUSSION: EL is defined as liver tissue found outside and not in communication with the normal liver. It is susceptible to same diseases as normal liver and especially prone to malignancy, despite the lack of risk factors. Given the difference in arteriovenous and bile system, EL tissue may have longer exposure to carcinogens. MRI shows "post contrast peripheral solid enhancement" - suggestive of HCC with ectopic tissue enhancement in arterial phase, however is less highlighted compared to HCC in normal liver. AFP is > 20ng/mL in 60% cases. Surgical resection is the primary treatment with no reported tumor recurrence. Our case highlights the importance that any EL is at high risk for HCC development, despite the lack of risk factors and negative FNA biopsies and surgical therapy needs to be offered.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.