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Radiofrequency ablation of malignant biliary strictures has been offered for the last 3 years, but only limited data have been published. To assess the safety, efficacy, and survival outcomes of patients receiving endoscopic radiofrequency ablation. Between April 2010 and December 2013, 69 patients with unresectable neoplastic lesions and malignant biliary obstruction underwent 98 radiofrequency ablation sessions with stenting. A total of 69 patients (22 male, aged 66.1 ± 13.3) were included in the registry. The etiology of malignant biliary stricture included unresectable cholangiocarcinoma (n = 45), pancreatic cancer (n = 19), gallbladder cancer (n = 2), gastric cancer (n = 1), and liver metastasis from colon cancer (n = 3). Seventy-eight percentage of patients had prior chemotherapy. All strictures were stented post-radiofrequency ablation with either plastic stents or metal stents. The mean stricture length treated was 14.3 mm. There was a statistically significant improvement in stricture diameter post-ablation (p

The accurate diagnosis of cystic neoplasms of the pancreas (CNP) with current diagnostic methods is limited. Endoscopic ultrasound (EUS)-guided needle-based confocal laser endomicroscopy (nCLE) is a new technique which can obtain images from the cyst wall during EUS-fine needle aspiration (EUS-FNA). The aim of this study was to assess the safety, feasibility, and diagnostic value of nCLE for CNP. Patients who underwent EUS-FNA to evaluate a CNP larger than 2 cm were enrolled. The cyst was punctured with 19-G FNA needle preloaded with an nCLE probe. The images from different areas of the cyst wall were recorded. Using the final diagnosis defined by surgery or EUS-FNA cyst fluid analysis, the accuracy of the confocal images was defined. The procedure and image acquisition was successful in 18 of the 20 patients. Predefined typical structures for mucinous cysts were visualized in 8 of 12 (66%) cysts but none of the non-mucinous cysts. The superficial vascular network which is a typical finding of serous cysts was observed in 2 of 3 patients. The sensitivity, specificity, and diagnostic accuracy of the findings of epithelial structures by nCLE were 66, 100, and 80%, respectively, for a mucinous cyst diagnosis. All patients tolerated the procedure well, and no adverse effects were determined. nCLE was found to be safe and feasible with high technical success, in this pilot study. With an overall accuracy of 80%, it has the potential to contribute to the diagnosis of CNP with specific imaging.

The objective of this study was to evaluate the efficacy of EUS-guided CPN for pain relief in patients with chronic pancreatitis and pancreatic cancer. An initial search identified 1,439 reference articles, of which 130 relevant articles were selected and reviewed. Data was extracted from 8 studies (N = 283) for EUS-guided CPN for pain due to pancreatic cancer and nine studies for chronic pancreatitis (N = 376) which met the inclusion criteria. With EUS-guided CPN, the pooled proportion of patients with pancreatic cancer that showed pain relief was 80.12% (95% CI = 74.47-85.22). In patients with pain due to chronic pancreatitis, EUS-guided CPN provided pain relief in 59.45% (95% CI = 54.51-64.30). In conclusion, EUS-guided CPN offers a safe alternative technique for pain relief in patients with chronic pancreatitis or pancreatic cancer. In patients with pain due to chronic pancreatitis, better techniques or injected materials are needed to improve the response.

Cyst fluid amylase is a potential marker for pseudocysts and intraductal papillary mucinous neoplasms (IPMN). This study aimed to evaluate the diagnostic role of cyst fluid amylase and to determine the optimal cutoff values of cyst fluid amylase and carcinoembryonic antigen (CEA) for the differential diagnosis of pancreatic cysts. Based on the pancreatic cyst database at Massachusetts General Hospital, a total of 78 patients with histologically proven cysts [pancreatic pseudocyst (PP), n = 16; mucinous cystic neoplasm, mucinous cystic neoplasm (MCN), n = 22; IPMN, n = 40] were selected. Complete cyst fluid amylase and CEA values were analyzed. Thirty two of 78 patients were male with median age of 60.4 years (range, 24–84). Cyst diameter ranged from 5 to 130 mm. For cyst fluid amylase, there was significant difference between PP and MCN (median, 30,034.50 vs. 4,723.50 U/L; p

Extracorporeal shock wave lithotripsy and dissolution agents are useful nonsurgical therapies for gallstones. Their effect on gallbladder emptying is unclear. We evaluated emptying by ultrasonography before and after lithotripsy in 50 patients on ursodeoxycholic acid or placebo and in nine controls. At baseline, patients had normal (68.8 +/- 3.2%) or delayed emptying (14.5 +/- 3.3%). In a subset of 24 patients, lithotripsy increased fasting volume (26.6 +/- 3.0 to 43.8 +/- 5.0 ml, P0.005), postprandial volume (11.3 +/- 3.1 ml to 22.9 +/- 3.0 ml, P0.05), and decreased ejection fraction (70.0 +/- 4.1% to 42.7 +/- 6.0%, P0.0005). There was an inverse linear correlation between power and ejection fraction, r = -0.43, P0.005. Ursodeoxycholic acid increased fasting (23.3 +/- 2.2 ml to 36.7 +/- 4.6 ml, P0.005) and postprandial volume (11.1 +/- 1.8 to 17.6 +/- 2.5, P0.005). Treatment with ursodeoxycholic acid resulted in a greater decrease in fragment size compared to placebo after lithotripsy in patients with fragment size greater than 6 mm. In conclusion, both lithotripsy and ursodeoxycholic acid have an effect on gallbladder emptying.

Previous studies have suggested that chronic alcohol consumption in man is associated with an increased secretion of pancreatic enzymes. Precise quantitation of the output of protein and trypsin in the interdigestive state has not been possible because of large variations and small volume of pancreatic juice. We utilized a multilumen, markerperfused duodenal catheter to simultaneously monitor intraluminal pressures and collect mixed duodenal juice at the ligament of Treitz in five groups of patients: normal volunteers (group I), alcoholics without pancreatitis (group II), alcoholics who had recovered from acute pancreatitis (group III), alcoholics with chronic pancreatitis (group IV), and nonalcoholics who had recovered from acute pancreatitis secondary to biliary tract disease (group V). The output of trypsin and protein during 30 min of phase II and 60 min of CCK-OP 40 ng/kg/hr was determined in each group. The output of trypsin during phase II was 1.3±1.2 and 3.0±2.5 mg/kg/hr in groups II and III, respectively, compared to 0±0.1 in group IV (normal=0.6±0.5). The outputs in group V were similar to normals. The output of protein during the interdigestive state was 15.7±13.7 mg/min in group III, compared to 4.5±3.6 in normals (group I). The duodenal contraction rate was 4.6±3.0 and 3.3±2.7 contractions/min in groups III and II, respectively (significantly greater than the normal rate of 2.2±1.5). The pancreatic response to CCK-OP 40 ng/kg/hr was similar in all groups except group IV which had a decreased output of trypsin and protein (0.1±0.2 mg/kg/hr and 2.2±0.9 mg/min compared to group I: 3.4 mg/kg/hr and 7.7±1.9 mg/min). In summary, alcoholics and alcoholics who had recovered from acute pancreatitis were found to have a greater output of trypsin and a greater phase II duodenal contraction rate in the interdigestive state.

Lactoferrin, a nonenzyme protein normally secreted in small amounts in pancreatic juice, has been reported by several investigators to be secreted in large amounts in chronic pancreatitis. Whether this increased secretion first occurs at an early or late stage of alcoholic pancreatic disease is unknown. In this study we measured lactoferrin and enzyme outputs in duodenal juice from 10 healthy subjects and three groups of alcoholic subjects: asymptomatic chronic alcoholics without evidence, clinically or biochemically, of pancreatitis (10), those recovered from acute pancreatitis (8), and those with established chronic pancreatitis (8). A multilumen, marker-perfused duodenal catheter was used to aspirate basal pancreatic secretions at the ligament of Treitz. The mean (±se) lactoferrin concentration in duodenal juice for the four groups of subjects was: healthy, 0.7±0.1 μglml; asymptomatic alcoholics, 5.5±1.5 μgl; alcoholics who had recovered from acute pancreatitis, 7.4±0.8 μg/ml; and alcoholics with chronic pancreatitis 7.1± 1.9 μg/ml. The three groups of alcoholics each had a greater lactoferrin concentration than the normals (P

In this study we have utilized a sensitive and specific radioimmunoassay for cholecystokinin (CCK) to determine the effects of a jejunal infusion (5 cc/min) of amino acids (44 g/liter), saline, and amino acids with intravenous atropine (20 micrograms X lg-1 X hr) on pancreatic exocrine secretion. Amino acids were found to stimulate pancreatic output of trypsin and release CCK, while a saline infusion at the same rate and osmolality (320 mosm/liter) failed to do so. In the presence of atropine, the amino acid infusion did not stimulate the pancreatic output of trypsin, despite an augmented CCK release. The total CCK released above baseline was greatest with the infusion of amino acids with atropine, while the total trypsin output above baseline was greatest with the infusion of amino acids. These results indicate that CCK release is not under cholinergic control and that cholinergic blockade inhibits pancreatic secretion by interrupting stimulating cholinergic fibers to the pancreas.

To test the hypothesis that there is an early stage of cholesterol gallstone formation in man characterized by symptoms of chronic cholecystitis, poor gallbladder emptying, and biliary cholesterol crystals, we studied cholecystokinin-stimulated gallbladder emptying by DISIDA scintigraphy and examined bile for cholesterol crystals in symptomatic patients with normal oral cholecystography and gallbladder sonography. Of 36 patients studied, 16 had biliary cholesterol crystals; their mean 30-min gallbladder ejection fraction was 25.9 +/- 14.8%. Among the 20 patients without crystals, the mean ejection fraction was 60.3 +/- 23.3%. Fifteen patients, 11 with crystals and four without, had cholecystectomy because of persistent symptoms. All with crystals preoperatively and three without had chronic cholecystitis histologically. One patient without crystals had normal histology. We conclude that poor gallbladder contractility, well-established as an etiologic factor in animal models of cholesterol cholelithiasis, is now linked to acalculous cholecystitis, an early stage of human cholesterol cholelithiasis.

The pancreatic Schilling test (PST), a noninvasive, sensitive pancreatic function test, was studied to determine its ability to detect pancreatic proteolytic enzyme replacement in patients with pancreatic insufficiency. Seven subjects with well-documented pancreatic insufficiency and an abnormal PST consistent with pancreatic insufficiency were studied with three enzyme regimens: (1) Viokase (four tablets), (2) Pancrease (three capsules), and (3) Pancrease (10 capsules). The effect of cimetidine on the results of the PST with high-dose Pancrease was also determined in two subjects with pancreatic insufficiency and in two normal volunteers. The results of the investigation demonstrate that the PST is a sensitive noninvasive test for the presence of orally administered proteolytic enzymes in subjects with pancreatic insufficiency and in normals. Furthermore, the studies illustrate that the administration of enzymes in a form of enteric-coated microspheres does not enhance the delivery of proteolytic enzymes to the small intestine when compared to conventional high-dose enzyme replacement. Cimetidine appears to decrease the inactivation of the proteolytic enzymes in enteric-coated microspheres, suggesting that a low pH in the small intestine and stomach are responsible for the poor delivery of the enzymes into the small intestine.

Esophageal involvement in systemic amyloidosis is common. Manometric studies have been few in number and have revealed a variety of findings compatible with deposition of amyloid in myopathic as well as neuropathic patterns. This report describes a patient with primary amyloid whose esophageal dysfunction was limited to the lower esophageal sphincter, with both a hypertensive sphincter and impaired relaxation after swallows. Pharmacologic testing confirmed a mild abnormality of the inhibitory pathway to the LES with an intact excitatory pathway and sphincter muscle. This case suggests that amyloidosis, like idiopathic achalasia and carcinoma of the lower esophagus, can produce dysphagia by selective impairment of the inhibitory neural pathway to the lower esophageal sphincter.

Clinical and experimental evidence has suggested that the use of cimetidine might be harmful to patients with acute pancreatitis. We conducted a randomized study comparing cimetidine to nasogastric (NG) suction in 95 patients with 103 episodes of mild to moderately severe, acute or relapsing pancreatitis (86.4% alcohol related). The groups were comparable on entry to the study, and daily evaluation of several clinical and laboratory criteria revealed no consistent differences between the two groups. When these same criteria were evaluated for time of return to normal, if abnormal on entry to the study, no differences were found. The cimetidine group had a significantly shorter stay in the hospital than did the NG group (6.8 +/- 2.7 vs 8.5 +/- 4.8 days). Neither the incidence of relapse or complication nor the duration and extent of hyperamylasemia were significantly different between patients treated with cimetidine or NG suction. We conclude that cimetidine is safe to use in patients with mild to moderately severe alcohol-related pancreatitis, but it offers minimal advantage over NG suction.