Radiological appearance of pancreatic calculi in tropical versus alcoholic chronic pancreatitis

Endoscopic Retrograde Cholangiopancreatography for Management of Chronic Pancreatitis

Management of symptomatic chronic pancreatitis (CP) has shifted its approach from surgical procedures to minimally invasive endoscopic procedures. Increased experience and advanced technology have led to the use of endoscopic retrograde cholangiopancreatography (ERCP) as a therapeutic tool to provide pain relief and treat CP complications including pancreatic stones, strictures, and distal biliary strictures, pseudocysts, and pancreatic duct fistulas. In this article the authors will discuss the use of ERCP for the management of CP, its complications, recent advancements, and techniques from the most up to date literature available.

Imaging of Tropical Chronic Pancreatitis—A Unique Clinico-Radiological Entity

Tropical chronic pancreatitis (TCP) is a unique juvenile nonalcoholic form of chronic pancreatitis prevalent in tropical developing countries. TCP is characterized by the younger age of onset, rapid progression, higher prevalence of diabetes and pancreatic calculi, and greater propensity to develop pancreatic malignancy. Identifying the distinct imaging features is critical for the diagnosis of TCP. Awareness of this condition will not only enable the radiologist to recognize it early but also help in better management. In this article, we review the etiopathogenesis, distinct imaging features, and complications of TCP.

ESWL for large pancreatic calculi: Report of over 5000 patients

INTRODUCTION

The primary aim of this study was to evaluate efficacy, safety and short-term pain relief after ESWL for large pancreatic calculi in over 5000 patients at a single center.

METHODS

This is a retrospective analysis of prospectively collected data. Patients with painful calculi >5 mm, located in the head, neck and body region in the MPD, who were not amenable for extraction by the standard procedure of endoscopic pancreatic sphincterotomy were subjected to ESWL using a third generation dual focus lithotripter. Patients were followed up at 6 months for outcome evaluation.

RESULTS

A total of 5124 patients (66% males) were subjected to ESWL. Majority of stones (79.2%) were radiopaque. Single calculi were seen in 3851 (75.1%).The majority of stones were located in head region of MPD in 2824 (55.1%) patients. 4386 (85.5%) patients required 3 or less sessions for fragmentation and complete stone clearance was achieved in 3722 (72.6%). EPS was performed in 5022 (98%) while PD stenting was required in 3536 (69%) patients. Of the 4280 patients followed up for 6 months, 3529 (82.6%) patients were pain free. Another 512 (11.9%) patients had significant reduction in VAS score. In 229 (5.3%) there was no decrease in pain intensity. Minor and self-limiting complications were reported in 1153 (22.5%).

DISCUSSION

Our study confirms the safety and efficacy and short-term pain relief of ESWL for large calculi in the MPD. In properly selected patients, this should be offered as the first line of therapy for all large MPD calculi not amenable to the standard techniques of stone extraction.

mutTCPdb: a comprehensive database for genomic variants of a tropical country neglected disease-tropical calcific pancreatitis

Tropical calcific pancreatitis (TCP) is a juvenile, non-alcoholic form of chronic pancreatitis with its exclusive presence in tropical regions associated with the low economic status. TCP initiates in the childhood itself and then proliferates silently. mutTCPdb is a manually curated and comprehensive disease specific single nucleotide variant (SNV) database. Extensive search strategies were employed to create a repository while SNV information was collected from published articles. Several existing databases such as the dbSNP, Uniprot, miRTarBase2.0, HGNC, PFAM, KEGG, PROSITE, MINT, BIOGRID 3.4 and Ensemble Genome Browser 87 were queried to collect information specific to the gene. mutTCPdb is running on the XAMPP web server with MYSQL database in the backend for data storage and management. Currently, the mutTCPdb enlists 100 variants of all 11 genes identified in TCP, out of which 45 are non-synonymous (missense, nonsense, deletions and insertions), 46 are present in non-coding regions (UTRs, promoter region and introns) and 9 are synonymous variants. The database is highly curated for disease-specific gene variants and provides complete information on function, transcript information, pathways, interactions, miRNAs and PubMed references along with remarks. It is an informative portal for clinicians and researchers for a better understanding of the disease, as it may help in identifying novel targets and diagnostic markers, hence, can be a source to improve the strategies for TCP management.

Database URL: http://lms.snu.edu.in/mutTCPDB/index.php

Management of Pancreatic Calculi: An Update

Pancreatolithiasis, or pancreatic calculi (PC), is a sequel of chronic pancreatitis (CP) and may occur in the main ducts, side branches or parenchyma. Calculi are the end result, irrespective of the etiology of CP. PC contains an inner nidus surrounded by successive layers of calcium carbonate. These calculi obstruct the pancreatic ducts and produce ductal hypertension, which leads to pain, the cardinal feature of CP. Both endoscopic therapy and surgery aim to clear these calculi and decrease ductal hypertension. In small PC, endoscopic retrograde cholangiopancreatography (ERCP) followed by sphincterotomy and extraction is the treatment of choice. Large calculi require fragmentation by extracorporeal shock wave lithotripsy (ESWL) prior to their extraction or spontaneous expulsion. In properly selected cases, ESWL followed by ERCP is the standard of care for the management of large PC. Long-term outcomes following ESWL have demonstrated good pain relief in approximately 60% of patients. However, ESWL has limitations. Per oral pancreatoscopy and intraductal lithotripsy represent techniques in evolution, and in current practice their use is limited to centers with considerable expertise. Surgery should be offered to all patients with extensive PC, associated multiple ductal strictures or following failed endotherapy.

Pancreatic Calculus Causing Biliary Obstruction: Endoscopic Therapy for a Rare Initial Presentation of Chronic Pancreatitis

INTRODUCTION

Biliary obstruction in chronic calcific pancreatitis (CCP) is often caused by inflammatory or fibrotic strictures of the bile duct, carcinoma of head of pancreas or less commonly by compression from pseudocysts. Pancreatic calculi causing ampullary obstruction and leading to obstructive jaundice is extremely rare.

METHODS

The medical records of all patients with CCP or biliary obstruction who underwent endoscopic retrograde cholangiopancreatography (ERCP) over 4 years between 2010-2014 at Kasturba Medical College, Manipal were analyzed.

RESULTS

Five patients of CCP with impacted pancreatic calculi at the ampulla demonstrated during ERCP were identified. All 5 presented with biliary obstruction and were incidentally detected to have CCP when evaluated for the same; 3 patients had features of cholangitis. All the patients were managed successfully by endoscopic papillotomy and extraction of pancreatic calculi from the ampulla with resolution of biliary obstruction.

CONCLUSION

Pancreatic calculus causing ampullary obstruction, though very rare, should be considered as a possibility in patients with CCP complicated by biliary obstruction. Endoscopic therapy is affective in the resolution of biliary obstruction in such patients.

Fibrocalculous pancreatic diabetes (FCPD)

Fibrocalculous pancreatic diabetes (FCPD) is an uncommon form of diabetes that occurs as a result of chronic calcific pancreatitis, in the absence of alcohol abuse. The disease is restricted to tropical regions of the world, and southern India has the highest known prevalence of FCPD. The typical patient with FCPD is a lean adolescent or young adult of either sex, presenting with history of recurrent bouts of abdominal pain and steatorrhea. Demonstration of large, discrete pancreatic calculi by plain radiographs or ultrasonography of the abdomen is diagnostic. While the exact etiology of FCPD is unknown, genetic, nutritional and inflammatory factors have been hypothesized to play a role. Diabetes in FCPD is often brittle and difficult to control; most patients require multiple doses of insulin for control of glycemia. However, in spite of high blood glucose levels, patients rarely develop ketosis. Malabsorption responds to pancreatic enzyme supplementation. Surgical removal of stones is indicated for symptomatic relief of intractable pain. While patients with FCPD develop microvascular complications as frequently as those with type 2 diabetes, macrovascular disease is uncommon. Development of pancreatic malignancy is the most dreaded complication and should be suspected in any patient who complains of weight loss, back pain or jaundice.

Long-term clinical outcomes of extracorporeal shockwave lithotripsy in painful chronic calcific pancreatitis

BACKGROUND

Long-term results of extracorporeal shockwave lithotripsy (ESWL) for large pancreatic duct (PD) stones in patients with idiopathic calcific pancreatitis (CP) are scanty.

OBJECTIVE

To evaluate intermediate and long-term results of ESWL in a large cohort of patients with idiopathic CP.

DESIGN

Cross-sectional study; retrospective chart review.

SETTING

A high-volume, tertiary-care center for endoscopy and GI diseases.

PATIENTS

A total of 636 patients with idiopathic CP who underwent ESWL and ERCP were followed-up. Patients were divided into intermediate (24-60 months) and long-term (>60 months) follow-up groups.

INTERVENTION

ESWL and ERCP.

MAIN OUTCOME MEASUREMENTS

Improvement in pain, analgesic use, hospitalization for pain, recurrence of calculi, need for additional intervention, and quality of life.

RESULTS

A total of 636 of 1006 patients who underwent ESWL between 2004 and 2009 were followed for a maximum of 96 months. There were 364 patients in the intermediate follow-up group and 272 in the long-term follow-up group. After ESWL and ERCP, absence of pain was seen in 250 patients (68.7%), mild-to-moderate pain in 94 patients (25.4%), and severe pain in 20 patients (5.5%) of the intermediate group. In the long-term group, 164 patients (60.3%) had no pain, 97 patients (35.7%) had mild or moderate episodes of pain, whereas 11 patients (4.04%) had episodic severe pain. Recurrence of calculi was seen in 51 patients (14.01%) in the intermediate follow-up group and in 62 patients (22.8%) in the long-term group. Quality of life improved in a significant number of patients in both groups.

LIMITATIONS

Retrospective study, single center, recall bias, and subjective pain and quality-of-life measurement scale.

CONCLUSION

ESWL for large PD calculi offers good results in patients of idiopathic CP on intermediate and long-term follow-up.

Endotherapy in chronic pancreatitis

Chronic pancreatitis (CP) is a progressive disease with irreversible changes in the pancreas. Patients commonly present with pain and with exocrine or endocrine insufficiency. All therapeutic efforts in CP are directed towards relief of pain as well as the management of associated complications. Endoscopic therapy offers many advantages in patients with CP who present with ductal calculi, strictures, ductal leaks, pseudocyst or associated biliary strictures. Endotherapy offers a high rate of success with low morbidity in properly selected patients. The procedure can be repeated and failed endotherapy is not a hindrance to subsequent surgery. Endoscopic pancreatic sphincterotomy is helpful in patients with CP with minimal ductal changes while minor papilla sphincterotomy provides relief in patients with pancreas divisum and chronic pancreatitis. Extracorporeal shock wave lithotripsy is the standard of care in patients with large pancreatic ductal calculi. Long term follow up has shown pain relief in over 60% of patients. A transpapillary stent placed across the disruption provides relief in over 90% of patients with ductal leaks. Pancreatic ductal strictures are managed by single large bore stents. Multiple stents are placed for refractory strictures. CP associated benign biliary strictures (BBS) are best treated with multiple plastic stents, as the response to a single plastic stent is poor. Covered self expanding metal stents are increasingly being used in the management of BBS though further long term studies are needed. Pseudocysts are best drained endoscopically with a success rate of 80%-95% at most centers. Endosonography (EUS) has added to the therapeutic armamentarium in the management of patients with CP. Drainage of pseudcysts, cannulation of inaccessible pancreatic ducts and celiac ganglion block in patients with intractable pain are all performed using EUS. Endotherapy should be offered as the first line of therapy in properly selected patients with CP who have failed to respond to medical therapy and require intervention.

Nonalcoholic, nonbiliary pancreatitis: cross-sectional imaging spectrum

OBJECTIVE

The purpose of this review is to describe the epidemiologic, etiopathogenetic, clinical, and imaging characteristics of various nonalcoholic, nonbiliary pancreatitis syndromes.

CONCLUSION

The spectrum of nonalcoholic, nonbiliary pancreatitis includes autoimmune pancreatitis, groove pancreatitis, hereditary pancreatitis, tropical pancreatitis, tuberculous pancreatitis, and metabolic pancreatitis. Advances in genetics and molecular pathology have shed new light on the etiopathogenesis and course of these syndromes. Accurate diagnosis aided by imaging findings allows optimal management.

Extracorporeal shock wave lithotripsy and endotherapy for pancreatic calculi-a large single center experience

AIM

Large pancreatic ductal calculi and pain are a feature of chronic calcific pancreatitis (CCP) in the tropics. This large single center study evaluates the role of extracorporeal shock wave lithotripsy (ESWL) in fragmentation of large pancreatic stones and relief of pain in patients with CCP.

METHODS

Patients with CCP presenting with pain and large pancreatic duct (PD) calculi (>5 mm diameter) not amenable to extraction at routine endoscopic retrograde cholangio pancreatography (ERCP) were taken up for ESWL using a 3rd generation lithotripter. Stones in the head and body of pancreas were targeted at ESWL; 5,000 shocks were given per session. The calculi were fragmented to <3 mm size and then cleared by endotherapy. Pancreatic duct stents were deployed when indicated. A total of 1,006 patients underwent ESWL. Complete clearance was achieved in 762 (76%), partial clearance in 173 (17%) and unsuccessful in the rest. More than 962 (90%) of patients needed less than three sessions of ESWL. At 6 months, 711 (84%) of 846 patients who returned for follow up had significant relief of pain with a decrease in analgesic use. Complications were mild and minimal.

CONCLUSION

ESWL is an effective and safe modality for fragmentation of large PD calculi in patients with CCP.

Endoscopic pancreatic-stent placement and sphincterotomy for relief of pain in tropical pancreatitis: results of a 1-year follow-up

BACKGROUND

Tropical chronic pancreatitis frequently presents with intractable abdominal pain. Surgical treatment has its own morbidity and mortality, and long-term results may not be satisfactory.

OBJECTIVE

To analyze the results of endoscopic pancreatic-stent placement and sphincterotomy for the pain of tropical pancreatitis.

DESIGN

Retrospective review.

SETTING

Tertiary-referral hospital.

PATIENTS

Twenty-four patients with tropical pancreatitis with severe, persistent pain not responding to standard medical therapy over a period of 30 months beginning January 1998.

INTERVENTIONS

Stent placement of the pancreatic duct, along with sphincterotomy.

MAIN OUTCOME MEASUREMENTS

At least 80% global improvement in pain as reported by the patient during follow-up after the procedure.

RESULTS

In the 19 evaluable patients, the intended procedure, pancreatic stent placement along with sphincterotomy, was successful in 14 (73.7%); 3 others had sphincterotomy alone. Over a follow-up period of 6 to 38 months, 12 of the 14 patients (85.7%) who underwent stent placement plus sphincterotomy and 2 of the 3 patients who had sphincterotomy alone responded. Twelve of these were completely free of pain, and the remaining 2 patients had mild infrequent pain that occurred once in 2 to 4 months, lasting a few hours at a time and never needing hospitalization. The only major complication was the development of pancreatic sepsis, which required stent removal in 1 patient. Eight patients were stent free at the end of 6 months, and, over a further follow-up of 6 to 20 months, the pattern of pain relief persisted in them.

LIMITATIONS

The retrospective nature of the study, the limited numbers studied, and the lack of assessment of pain on a standard visual analog scale.

CONCLUSIONS

Stent placement of the pancreatic duct with pancreatic sphincterotomy constitutes an important nonsurgical therapeutic option for the intractable pain of tropical pancreatitis.

Multiple main pancreatic duct stones in tropical pancreatitis: safe clearance with extracorporeal shockwave lithotripsy

BACKGROUND AND AIM

Extracorporeal shockwave lithotripsy (ESWL) has an established role in the management of pancreatic ductal stones. Its efficacy in management of multiple stones in tropical pancreatitis is unknown. The aim of this study was to prospectively evaluate: (i) the efficacy of main pancreatic duct stone clearance; and (ii) associated complications with ESWL therapy in tropical pancreatitis.

METHODS

Consecutively recruited patients with tropical pancreatitis underwent fragmentation of main pancreatic duct stones using ESWL. Endoscopic retrograde cholangiopancreatography (ERCP) using standard techniques was performed to manage residual stones. Complete, partial and unsatisfactory clearance was defined as >90%, 50-90% and <50% of stone clearance, respectively. Clinical and technical data were collected on a pre-formatted data sheet. Statistical analysis was performed on an intention-to-treat basis.

RESULTS

A total of 250 patients (mean+/-SD age 35.2+/-11.9 years; 66% men), 86.8% with multiple radio-opaque stones, underwent ESWL between February 2004 and May 2005. Of the 250 patients, 149 (59.6%) achieved complete clearance and 59 (23.6%) achieved partial clearance of pancreatic calculi. Main pancreatic ductal decompression was achieved in 70.0% (175/250) of patients. Complications occurred in 5.6% (14/250) during ESWL and in 1.2% (3/250) during ERCP. A mean of 1.3 sessions, with mean+/-SD 5.5+/-0.7 intensity setting, 85.8+/-13.5 pulses per minute and 3862+/-1426 shocks per session were required.

CONCLUSION

Clearance of multiple main pancreatic duct stones in patients with tropical pancreatitis is safely performed via ESWL followed by ERCP ductal drainage.

Tropical chronic pancreatitis

Tropical chronic pancreatitis (TCP) is a juvenile form of chronic calcific non-alcoholic pancreatitis, seen almost exclusively in the developing countries of the tropical world. The classical triad of TCP consists of abdominal pain, steatorrhoea, and diabetes. When diabetes is present, the condition is called fibrocalculous pancreatic diabetes (FCPD) which is thus a later stage of TCP. Some of the distinctive features of TCP are younger age at onset, presence of large intraductal calculi, more aggressive course of the disease, and a high susceptibility to pancreatic cancer. Pancreatic calculi are the hallmark for the diagnosis of TCP and in non-calcific cases ductal dilation on endoscopic retrograde cholangiopancreatography, computed tomography, or ultrasound helps to identify the disease. Diabetes is usually quite severe and of the insulin requiring type, but ketosis is rare. Microvascular complications of diabetes occur as frequently as in type 2 diabetes but macrovascular complications are uncommon. Pancreatic enzyme supplements are used for relief of abdominal pain and reducing the symptoms related to steatorrhoea. Early diagnosis and better control of the endocrine and exocrine dysfunction could help to ensure better survival and improve the prognosis and quality of life of TCP patients.

Tropical pancreatitis

Tropical pancreatitis is an uncommon cause of acute, and often chronic, relapsing pancreatitis. Patients present with abdominal pain, weight loss, pancreatic calcifications, and glucose intolerance or diabetes mellitus. Etiologies include a protein-calorie malnourished state, a variety of exogenous food toxins, pancreatic duct anomalies, and a possible genetic predisposition. Chronic cyanide exposure from the diet may contribute to this disease, seen often in India, Asia, and Africa. The pancreatic duct of these patients often is markedly dilated, and may contain stones, with or without strictures. The risk of ductal carcinoma with this disease is accentuated. Treatment may be frustrating, and may include pancreatic enzymes, duct manipulations at endoscopic retrograde cholangiopancreatography, octreotide, celiac axis blocks for pain control, or surgery via drainage and/or resection.

[Tropical chronic pancreatitis in a young patient]

Tropical chronic pancreatitis is a form of idiopathic chronic pancreatitis that has not previously been described in Spain. Typically it is related to dietary factors and malnutrition, although genetic factors may also play a significant role in the development of the disease. We report a case of chronic tropical pancreatitis in a 27-year-old woman from the Dominican Republic domiciled in Spain since 1992. The patient was admitted to our hospital for acute pancreatitis that fulfilled the diagnostic criteria (clinical and radiological) for chronic tropical pancreatitis. This case has led us to review this uncommon entity. Because of the increasing number of immigrants from tropical countries, chronic tropical pancreatitis will probably need to be taken into account in the differential diagnosis of chronic pancreatitis in our patients.

The problem of classification and staging of chronic pancreatitis. Proposals based on current knowledge of its natural history

BACKGROUND

Even though the four international meetings held so far on classification of pancreatitis have helped considerably to further our understanding of the disease, all have serious drawbacks that limit their clinical utility. The main problem with the Marseille classifications is the need for histologic proof, and the Cambridge classification relies on imaging modalities that are not sensitive or specific enough.

RESULTS

Chronic pancreatic inflammation (CP) has been observed in association with several systemic diseases (such as autoimmune diseases), and since the natural history of the pancreatic affliction in these conditions is clearly distinct from that seen in other forms of CP, these need to be classified separately. Furthermore, many clinical/aetiologic forms of chronic calcifying pancreatitis (CCP) exist which differ sufficiently in their clinical features and management to deserve individual recognition.

PROPOSAL

A subclassification of CCP into alcoholic, tropical, hereditary, hypercalcaemic, hyperlipoproteinaemic, drug-induced, and idiopathic is proposed. The staging of chronic alcoholic pancreatitis has been a controversial issue, mainly because of the apparent unpredictability of the course of pain. However, several large follow-up studies in the past decade suggest that recurrent acute exacerbations dominate the clinical picture in the first few years after onset of symptoms, and progressive pancreatic insufficiency is the predominant feature in the late stages of the disease. On the basis of the results of these studies it is proposed that alcoholic chronic pancreatitis be divided into four stages: I) latent or subclinical, II) early, or stage of inflammatory complications, III) late, or stage of severe pancreatic insufficiency, and IV) advanced, or stage of secondary painless pancreatitis.