Role of endoscopy in acute pancreatitis

1. Role of endoscopy in acute
Pancreatitis
Dr Amol S Dahale
Assistant Professor
Dept of Gastroenterology
GIPMER

2. Natural History Acute Pancreatitis
Acute
pancreatitis
N-1396
Interstitial
992(71%)
Necrotizing
286(21%)
Abscess
36(3%)
Pseudocyst
82(6%)
Beger et al World J Surg 1997

3. Local GI Complications of Severe Acute
Pancreatitis n-163
0
10
20
30
40
50
60
70
Infection(42%) GI Fistula(15%) Pancreatic
Leak(13%)
Pseudocyst(18%)
61/103
25 21
30
8/33
Ho HS Arch Surg 1995

4. Acute Pancreatitis-Role of Endoscopy
Role of
Endoscopy
Therapeutic
< 4 week
Biliary Stone /Obstruction
Cholangitis
Feeding
Infected collection (APFC/ANC)
>4week
Pseudocyst /WOPN
(Sterile/infected)
Diagnosis
CBD Stone
G B Microlithiasis
P Divisum

5. Novel uses of endoscopy in Acute pancreatitis
Gastrointestinal Fistula OTSC + External /endoscopic
drainage
Pseudo aneurysm EUS guided Thrombin +Coil
placement
PD leak not tackled by routine
ERCP
EUS guided PD drainage

6. Role of endoscopy in <4
weeks duration

7. Acute biliary pancreatitis
Anderloni A W J Gastroenterol 2015
Biliary
Pancreatitis
20% biliary
complications
30-50 %
Recurrence
50%
Spontaneous
stone passage

8. Early ERCP in biliary pancreatitis
Lancet 1988, NEJM 1993
Shorter Hospital Stay (9 days vs. 17 days)
Decreased local complications (17% vs. 34%)
Mortality trends and systemic complications trends
favors early ERCP (12% vs. 22%)

9. Indications for ERCP
Suspected bile duct stone with cholangitis
Persistent biliary obstruction, Bilirubin >5 mg/dl
Clinical deterioration (unstable vitals, increasing WBCs, pain)
Stone detected in the common bile duct on imaging
NEJM 2014

10. Timing of ERCP
Urgent ERCP
<24 Hours
• Cholangitis
Early ERCP
<72 hours
• Persistent bile duct stone
AGA Guidelines 2015

11. NEJM 2014
Graphical Depiction
ERCP

12. Endoscopic placement of Naso-jejunal Tube
Zhu et al Gastroenteral Res Pract 2016
>50% patients with severe disease intolerant to
oral feed
Force feeding required
NG Vs NJ--??
Naso-jejunal feeding –NJ Tube

13. Role of endoscopy in >4
week duration

14. Local Complications –setting and Duration..
• WON• ANC
• Pseudocyst• APFC
<4wks >4wks
>4wks<4wks
InterstitialpancreatitisNecrotisingpancreatitis
Revised Atlanta classification 2012

15. APFC PSEUDOCYST
ANC WALLED OF NECROSIS

16. Paradigm shift
SURGERY
BEFORE 1990
PERCUTANEOUS
DRAINAGE
AFTER 1990
ENDOSCOPIC
DRAINAGE
SINCE 2007

17. Management of fluid collection
• Most radical treatment
• Increased morbidity or mortality
• Long term complications
• Now salvage approach
Traditional
management
(Surgical)
• Single or multiple catheters
• Persistent external fistulas
(27%)
• Limited ability to remove debris
• Frequent upsizing
• Frequent imaging
• Meticulous catheter care
Percutanoues
drainage (PCD)
• Multiple plastic catheters
placed to drain
• No external catheter
• Cannot be done if collection
is not apposed to lumen
• Technical expertise needed
• Suboptimal drainage of
debris
• Now encouraging results
Endoscopic
drainage

18. Pseudocyst /WOPN Endoscopic drainage
• Small size, without debris
• Communication with PD
• Possible only for pseudocystTrans-papillary
• Moderate to large size, opposing to lumen,
accessible
• Provide window for necrosectomyTransmural
• Percutaneous drain need to upgraded
• Tract dilatation and debridement can be done
• Need fluoroscopy
Percutaneous
endoscopic
ASGE Guidelines 2016 G I Endoscopy
Scopes Stent
Side viewing
scope
Plastic stent,
Nasocystic drain
Side viewing
scope
EUS scope
Plastic stent,
Metal Stent
Forward
viewing scope
Nephroscope
No stent ,
Percutaneous
drain

19. PANTER Trial -- Open Necrosectomy vs. Step up
Step up
n-43
Open Necrosectomy
n-45
P value
Organ failure 12 40 <0.005
Death 19% 16% 0.5
Incisional hernia 7% 24% <0.05
Diabetes 16% 38% <0.05
Santvoort Vn et al NEJM 2010

20. Direct endoscopy Necrosectomy vs. Step up approach
Direct Endoscopy Necrosectomy
n-12
Step Up Min invasive Approach
n-12
Total No. Procedures 1.5 2.8
Complications (n) 1 8
ICU Stay (days) 0 10
Ward Stay (days) 3 19
Pancreas Kumar 2015

21. Endoscopic vs. Minimally Invasive vs. Open
Gut 2018

22.  Lumen apposing
stents
 Introduced in 2010
 Revolutionized
management
EUS/SVE guided SEMS placement

23. • Single 1.6 cm wide stent
placed
• Drains most of the debris
• UGI endoscope can be
taken inside cavity (9-10
mm diameter)
• Costly equipment
• Technically demanding
• No head to head trial
with previous modalities
ADVANTAGES
DISADVANTAGES
EUS/SVE guided SEMS placement

26. GIPMER Data 2016-2017
Total admissions of acute pancreatitis : 219
• Conservatively managed =145(66%)
• Intervention =74(34%)
66%
34%
TOTAL AP(219 PATIENTS)
CONSERVATIVE INTERVENTION

27. Acute Pancreatitis Interventions
Surgery 2(3%)
Minimal invasive therapies
72(97%)
PCD 37(50%)
Endoscopic therapy 29(39%)
Combination therapy 6(8%)
3%
50%
39%
8%
INTERVENTIONS(74/219)
SURGERY PCD
ENDOSCOPIC THERAPY COMBINATION

28. Pancreatic leak
• Ascites
(pancreatico-peritoneal fistula) - rare
• Pleural effusion
(pancreatico-pleural fistula)-rare
• Endoscopic therapy –Drainage f/b ERCP-
Pancreatic sphincterotomy f/b stenting
Bracher GA 1999 Gastroint Endoscopy

29. Role of endoscopic ultrasound in
diagnosis
Rai et al Endoscopy 2004,WJG 2015
Small stones < 5mm (Sensitivity
93%,specificity -96%)
Doubtful stone/ Pseudo calculus sign
P Divisum (Sensitivity
95%,specificity -97%)

30. • Thank you.
THANK YOU