ERCP: Pancreatic Disease

Great, um, so moving on, uh, one of the topics that we wanted to, to cover, um, to some degree was, um, ERCP management in, in the setting of acute slash acute recurrent pancreatitis. And so as we know, there's been a trend towards when ERCP was first introduced, um, back in the 1970s that it was purely a diagnostic modality, and as time has gone by, it's evolved from a diagnostic, um, to a more therapeutic, uh, modality and Because of the advances that we've had with our radiology colleagues and their, their, uh, their capabilities of, of, um, identifying abnormalities just from a radiologic non-invasive standpoint and so I, I wanted to go over to one case first that'll somewhat demonstrate, uh, one of the, the patients that we had. And so this is a 15 year old male with cerebral palsy. He has a history of encephalopathy with epilepsy. Um, he's also G tube feeding dependent, um, because of his, uh, his disability, um, and so one month prior he had, when he presented to us, one month prior he had a spinal fusion surgery for his scoliosis. Um, his presenting symptoms to us were G tubilius drainage, abdominal distention, and some, uh, component of abdominal pain, abdominal discomfort. Um, his initial imaging because of his presentation and because of his, uh, some limitation due to his disability, um, he did have a CT scan, um, as well as a an ultrasound early on in the course of his presentation, and there were abnormalities that, that we, um, that were identified that we'll get, um, over to the next slide, um, from a biochemical standpoint, um, he was found to have elevations in his serum lipase and amylase, um, with normal liver function tests. So just quickly, here are two images from this patient's CT, and this case shows the value that CT gives in these very complex cases and in these complex patients. What you have on the left there is an axial image and on the right, a coronal image in this patient, so you can see there's spinal hardware in place. There's a severe scoliotic curvature. All of these elements make it difficult to get a good ultrasound. Yellow arrows indicate the pancreas, which because the patient's anatomy is shifted off to the left side there and what you can see is right in the midbody of the pancreas there's a fluid collection that's replacing a large chunk of the pancreas. There's essentially normal pancreas or not normal, but preserved pancreatic tissue on either side of that collection. But nothing around that collection that looks like preserved pancreatic tissue, so that looks like an area of necrosis or walled off necrosis at this point. The asterisk in both of the images demonstrate the extensive ascites and fluid that has accumulated due to the inflammatory process in the pancreas. So, um, his, his, his recovery was rather prolonged, and, and during his, uh, extended hospitalization, his lipase peaked, um, even higher than it was at the time of presentation, um, and he was, um, also, it was difficult to advance his enroll fees despite the fact that he already had ro access via his gastrostomy, um, so, um, I believe it was, uh, one or perhaps even 2 weeks into his hospitalization with his slow recovery that we repeated his ultrasound. And I just said this is a complex case and ultrasound can be a little bit difficult in these cases, but once you've got a lay of the land with CT and you know what you're looking for, you can use ultrasound in these patients to sort of target and look at those areas of interest and again though, if you see something that has changed dramatically or if you're just not getting a good sense of things, you may need to go back. To cross sectional imaging, CT or MRI, depending on the patient and the exact situation, but ultrasound can be a good modality to follow patients serially over time. It's easier on the patients. There's the lack of ionizing radiation, and what the ultrasound showed in this patient was that that fluid collection, the peripancreatic or intrapancreatic fluid collection, was increasing in size on the follow-up ultrasound. So moving to our next poll question, uh, what would be the next best course of action that, uh, individuals, if they were confronted with this patient and his, his, uh, clinical progression or lack of progression, how would you, uh, decide on approaching him next? So number 1 would be either watchful waiting with supportive medical management, um, and continuing what we're attempting to do. Uh, number 2, endoscopic intervention with endoscopic ultrasound. 3, ERCP, or 4, surgical intervention. So we'll come back to this poll question. Uh, so what we opted to do based on his, his, um, his findings and increased, uh, fluid collection, um, we opted to actually go forward with an ERCP. And so here's his first fluoroscopic imaging image, uh, that is a, uh, a scalp film before we do anything. And, and as I had mentioned, um, he had a recent one month prior, uh, spinal fusion surgery and so it was a little bit challenging to actually, um, identify and, and visualize, um, the normal ductal structures that we typically want to see. From the ERCP standpoint with those rods in place, but it, uh, we were able to accomplish what we needed to. And so here's his next fluoroscopic image, as you can see on the, on the image on the left, he does have contrast filling in his gallbladder and a cystic duct. Um, there was no apparent abnormality, um, uh, or any type of pathology from his biliary tree standpoint, but, um, secondary contrast injection and, and, uh, opacification of his pancreatic duct, we see with the two yellow arrows there's a blush of contrast extravasation. Uh, in the midbody, um, almost at the mid and at the body tail junction and further down towards the tail there's also an, uh, an additional extravasation with the yellow arrow, uh, to the far right, um, uh, documenting his, uh, his pancreatic duct leak. So, um. I don't have an image here, but, uh, what we opted to do at that time in terms of therapeutic endoscopic therapy was, um, perform a pancreatic sphincterotomy as well as a pancreatic duct stent placement, um, to really allow the flow of his pancreatic juices to the path of least resistance with hopes that it would resolve the, the, um, the defect that he has in his duct. So this is his repeat ERCP 4 or 5 weeks later and the removal of his pancreatic duct stent and, and, um. Fortunately for him, he had a very positive successful outcome from his endoscopic ERCP intervention and so we see that his duct is a little bit tortuous like it had been before, but more importantly, his extravasation towards the tail as well as that blush of contrast that was in the body is no longer present. So again, the part of the decision to go forward with the ERCP was based on his clinical suspicion. Um, for a pancreatic duct league as well as, uh, more importantly, um, whether or not you have, uh, such, uh, the, the type of expertise that you have at your your particular institution, and so, um, if you're at a pediatric institution. Um, there is a growing number of pediatric gastroenterologists, um, uh, becoming skilled in, uh, performing ERCP, um, and so if you, if there is, uh, that readily availability, perhaps that would be one of the options that someone would choose to go on, um, to early, earlier rather than later with the understanding that, um, again the goal is to hopefully be therapeutic and given the, uh, invasive nature of, um, ERCP and the, the potential that it might exacerbate someone's pancreatitis. I think the poll question is ready to be shown, the responses. Mark, a nice way to wrap up our first session. Actually a good mix. It is a good mix. Yeah, it is a good mix. if I see correctly, it's a watchful waiting and supportive, um, measures is 44% and then 33% endoscopic intervention with ERCP, um, so people are a little more shy to do the ERCP and then, um, endoscopic with an EUS actually at 22% and none chose surgery. Good, sounds good. Yeah, don't you think we can wrap up our first one and this way we could just introduce the next session for the chronic pancreatitis? Yeah, my question is though, the reason people would shy away from ERCP, I'm assuming is that their fear of worsening the pancreatitis or. Uh, likely that that's the scenario. And so it's a balance of high, uh, what's your clinical suspicion suspicion and what do you anticipate that you're gonna encounter at the time of ERCP with the hopes that you would be capable of resolving that. And so it wasn't 100% clear in this particular case that the ERCP was the best option. Um, the watchful waiting, um, that, that the pollers, um. Several pollers actually chose, um, we chose not to do that because it was more of an extension of what we already had attempted to do in terms of a conservative approach and also there was that particular option of continuing that wasn't necessarily acceptable for the family as well. Got it. OK. And in the setting of a patient with an enlarging collection, I mean, he's already showing himself to some degree potentially be failing watchful waiting, right? Correct. That is correct. OK, sounds good. Well, thank you guys for um allowing us to introduce this very interesting discussions on acute and acute recurrent pancreatitis. I think we will take 5 or 10 minutes break. How much are we allowed? 55 minutes break and then we'll start the chronic pancreatitis. Sounds great. All right, thank you. See you in 5.