appears to be more invasive, more costly, and does not show a superior outcome [65]. Pancreatic necrosis Necrosis of pancreatic tissue complicates acute pancreatitis in a variable percentage of cases, is seen less often in acute exacerbations of chronic pancre- atitis, and accounts for many of the complications and much of the mortality (Fig. 11.8). Etiologies may have an impact on severity with the pancreatitis CHAPTER 11292 Fig. 11.6 Endoscopic transmural pseudocyst puncture and drainage. (a) Identification of bulge into the duodenal bulb. (b) Puncture for localization with injection of contrast and aspiration. (c) 10 mm balloon dilation after guidewire placement. (d) Stents in placeatwo 10 Fr silicone pigtails and a 7 Fr nasocystic drain. (a) (b) (d)(c) This is trial version www.adultpdf.com Table 11.3 Methods of drainage and success rates in recent studies of endoscopic pseudocyst drainage. Cystgastrostomy Cystduodenostomy Pancreatic duct stent All patients alone alone alone Combined procedure Reference Patients Resolution Patients Resolution Patients Resolution Patients Resolution Patients Resolution Barthet et al. [55] 30 23 (77%) 0 0 20 16 (80%) 10 7 (70%) Grimm et al. [62] 53 47 (89%) 20 total 16 (80%) 29 27 (93%) 4 4 (100%) b (site not specified) a Catalano et al. [56] 21 17 (81%) 0 0 21 17 (81%) 0 Smits et al. [51] 37 24 (65%) 10 3 (30%) 7 7 (100%) 12 7 (58%) 8 7 (88%) Total 141 111 (79%) Of a total of 37 patients, 26.(70%).had_resolution 82 67 (82%) 22 18 (82%) a Resolution refers to initial, complete drainage of a pseudocyst. b These results are not explicitly given in the study, but are inferred. This is trial version www.adultpdf.com Table 11.4 Complications, recurrence rates, and types of retreatment in recent studies of endoscopic pseudocyst drainage. Retreatment after Complications according to drainage type a recurrence Initial Reference Patients Total Transmural Transpapillary resolution Recurrence Endoscopic Surgical Barthet et al. [55] 30 4 (13%) 1 (3%) b 4 (13%) b 23 (77%) 3 (13%) 0 3 Grimm et al. [62] 53 6 (11%) 5 (9%) 1 (2%) 47 (89%) 11 (23%) 7 c 2 c Catalano et al. [56] 21 1 (5%) N/A 1 (5%) 17 (81%) 1 (6%) Unclear Unclear Smits et al. [51] 37 6 (16%) 5 (14%) 1 (3%) 24 (65%) 3 (13%) 0 3 Total 141 17 (12%) 11 (8%) b 7 (5%) b 111 (79%) 18 (16%) 7 8 N/A = not applicable; all patients in this study underwent transpapillary drainage. a Excludes stent migration. Percentages refer to the proportions of the total number of patients who underwent this type of treat ment, including those who had combined therapy. b One complication occurred in a patient undergoing combined treatment, and is listed under both headings. c Two patients in this study declined further treatment after recurrence. This is trial version www.adultpdf.com caused by hypertriglyceridemia producing necrosis in perhaps the highest per- centage of at-risk cases [66]. In a large single institutional review, Blum et al. [21] reported a respectably low overall mortality rate of 5% amongst 368 cases of acute pancreatitis, again with about half being earlier than 2 weeks and the remainder later. To emphasize the importance of necrosis, only 36 cases (10%) had documented necrosis but accounted for nine of the overall 17 deaths. Thus, the presence of necrosis res- ulted in an eventual death rate of 25%. Finally, the authors noted that late deaths in the absence of necrosis were seen in only four of 212 patients at risk (2%). At present, the exact mechanism of necrosis is unknown but ischemic infarc- tion is held as most likely. Poor perfusion secondary to rapid third space loss has COMPLICATIONS OF PANCREATITIS 295 Fig. 11.7 EUS of pseudocyst behind the gastric wall showing intervening vessels consistent with varices. Fig. 11.8 Extensive pancreatic necrosis with extensive non- perfused debris and fluid within the pancreatic bed. Dynamic bolus helical CT is by far the most accurate radiological technique for detecting these changes. This is trial version www.adultpdf.com been postulated but recent data suggest that the process of necrosis may be underway very rapidly before perfusion is affected. In a retrospective case ana- lysis, patients with necrosis presented earlier but had a similar incidence of hemoconcentration compared to patients with interstitial pancreatitis [67]. Resuscitation volumes were similar retrospectively in both groups. However, patients whose hematocrits continued to rise despite large volumes of fluid resuscitation were all subsequently proven to have necrosis. A cause and effect of inadequate resuscitation could not be established. The consequence of necrosis is a high likelihood of developing infection in the devitalized tissue, and the loss of a functioning pancreas with consequent diabetes, fistula formation, and various vascular injuries. Many of these com- plications result in the need for operative and, more recently, endoscopic management. Since pancreatic necrosis produces significant morbidity and a large propor- tion of the late mortality caused by acute pancreatitis, a search for necrosis using dynamic CT is generally felt justified [68]. Management of necrosis initially is conservative, with the expectation of most patients who do not develop infection eventually spontaneously resolving [69]. However, once the necrotic tissue becomes infected, intervention is almost always required. At present, the majority of these patients are still best managed with surgical debridement and drainage, almost always externally [15]. Pro- longed hospitalization with multiple procedures often follows, with surgical centers favoring either closed drainage with subsequent radiologically assisted catheter drainage or open drainage with surgically placed abdominal mesh to permit planned repeated debridements [70]. A few cases of attempted retroperitoneal laparoscopic necrosectomy have been reported [71,72]. At present this experience is anecdotal and no comparative tri- als have yet been reported. The risk of sudden and severe bleeding and the need for multiple repeat interventions have prevented wide adoption of the technique. In an attempt to prevent the development of infection in the setting of ne- crosis, the use of broad-spectrum antibiotics, especially imipenem, has reached a consensus. All eight recently reviewed trials demonstrated benefit in the patients receiving broad-spectrum antibiotics [73]. Many questions remain as to the use of newer antibiotics, the duration of therapy, the timing of onset of use, and the need for fungal coverage [74,75]. Organizing necrosis As stated earlier, persistent necrotic material organizes and encapsulates into a complex collection containing a mixture of solid and semisolid debris and fluid. Simple catheter drainage will be insufficient to evacuate this material and infec- CHAPTER 11296 This is trial version www.adultpdf.com tion will often complicate such efforts. When approaching apparent pseudocyst patients, it is of paramount importance to assess for necrosis, and then plan and treat patients appropriately [76]. Endoscopic treatment of organizing necrosis is possible but demands techniques of wider drainage such as the placement of multiple stents, creation of a large cyst gastrostomy, and at times nasocystic lavage [29] (Fig. 11.9). Repeated endoscopic procedures should be anticipated since cavity infec- tions will occur in greater than 50%. When prompt reintervention is performed, COMPLICATIONS OF PANCREATITIS 297 Fig. 11.9 Endoscopic drainage of infected organized necrosis. (a) Needle localization. (b) Purulent drainage noted upon puncture. (c) Endoscopic view of necrotic material coming through an endoscopically created cystogastrostomy during endoscopic drainage of organizing necrosis. (d) Following 10 mm balloon dilation, two 10 Fr stents are positioned. A nasocystic lavage catheter was then placed. (a) (c) (b) (d) This is trial version www.adultpdf.com these infections can usually be managed with lavage and repeat or additional stent placement. Nevertheless, a multidisciplinary approach to these cases is mandatory for optimal patient outcome. The interventional disciplines of sur- gery, gastroenterology, and radiology all have roles to play in specific situations [66]. Miscellaneous complications Pancreatic fistulas These occur in both interstitial and necrotizing pancreatitis. In the presence of an intact pancreatic sphincter or a ductal stricture, the initial leak continues and, as discussed earlier, is often the etiology of pseudocyst formation. At times and for unclear reasons, some collections do not wall-off and the fistula may track throughout the retroperitoneum. Fistulous communication under the diaphrag- matic cruri can result in amylase-rich pleural effusions, broncho-pleural fistulas, or even pericardial tamponade [77,78]. Cases of inguinal, scrotal, femoral, and other hernias developing with amylase-rich fluid tracking down these potential spaces have been reported. Internal fistulas adjacent to hollow organs are perhaps the most frequently recognized. Fistulization to the duodenum may result in resolution of an other- wise expanding pseudocyst as mentioned earlier [48]. Communication between a pseudocyst and the colon will be complicated by sepsis and generally will require surgery. However, Howell et al. reported successful endoscopic treat- ment of two such cases without requiring surgery [79]. Perhaps the most dramatic consequence of a pancreatic ductal fistula is pancreatic ascites. Easily diagnosed by routine testing of paracentesis fluid for amylase, these rather rare cases are often overlooked and treated mistakenly as cirrhotic ascites since liver and pancreatic disease often coexist in the alcoholic. Finally, cutaneous pancreatic fistulas occur after attempts at external drain- age have been performed. Although these very severe, disabling fistulas are occasionally unavoidable, they are often a consequence of imprecise knowledge of the true diagnosis or the lack of appreciation of the importance of ductal anatomy (Fig. 11.10). Currently, many of these complex fistulas can be managed endoscopically providing the duct is intact to the papilla. Various authors advocate pancre- atic stent placement or nasopancreatic drainage with or without pancreatic sphincterotomy. Rapid closure of these fistulas can be expected with effective endoscopic transpapillary drainage. If no infection is present, endoscopic man- agement is often definitive and should be attempted before external drainage establishes a cutaneous fistula [80]. CHAPTER 11298 This is trial version www.adultpdf.com Ductal disruption Severe ductal disruption is the rule in necrosis cases but can be seen in well- perfused interstitial pancreatitis. To define the term, disruption occurs when the main pancreatic duct has been transected by the inflammatory process of pan- creatitis, most likely by direct proteolytic digestion or ischemic infarction. Ductal disruption greatly complicates the approach to treatment and worsens outcome in both acute and chronic pancreatitis. Spontaneous resolution with- out intervention is very unlikely to occur. External cutaneous fistulas usually follow a percutaneous or surgical drainage approach due to the presence of a viable but disconnected gland. Although the downstream pancreas can be drained and diverted endoscopically by transpapillary therapy, the upstream pancreas continues to contribute to persistence of the fistula. This so-called ‘disconnected tail syndrome’ often results in pseudocyst recurrence after inter- nal transmural endoscopic or surgical internal cystgastrostomy drainage [51] (Fig. 11.11). A few authors have reported successful endoscopic drainage by bridging the disruption to reconnect the tail, but the long-term outcome of these efforts remains unclear. More often these patients will experience a long illness with TPN and repeated interventions until the disconnected tail eventually autolyses, atrophies due to stricturing, or is surgically resected [81]. Vascular complications Venous thrombosis A frequent vascular complication of acute pancreatitis is thrombosis of the COMPLICATIONS OF PANCREATITIS 299 Fig. 11.10 Pancreatic fistula from a small side branch with a persistent fistula for over 3 months to a surgically placed drain. This fistula closed promptly following endoscopic pancreatic sphincterotomy and stent placement. This is trial version www.adultpdf.com splenic vein and, less frequently, of the portal vein [82]. The cause is an intense inflammatory response surrounding these venous structures, often with com- pression by the resulting edematous reaction. Stasis and activation of clotting factors then produce acute thrombosis with resulting left-sided portal hyperten- sion. Because the obstruction to portal inflow to the liver is usually partial, esophageal varices usually do not occur. Nonetheless, bleeding from gastric varices can be severe, especially when coagulopathy coexists (Fig. 11.12). During the period of convalescence, where often surgical debridement or pseudocyst drainage must be undertaken, a secondary venous thrombosis may be a major determinant in treatment selection. Furthermore, the failure to recognize this form of portal hypertension prior to such interventions can prove disastrous. Significant gastric wall varices often contraindicate endoscopic or even surgical pseudocyst gastrostomy. Helical dynamic contrast CT scanning should detect venous thrombosis and predict left-sided portal hypertension accurately (Fig. 11.13). EUS has proven particularly valuable in assessing for gastric varices. One or both studies should be performed near the time of any invasive intervention. Arterial complications Thrombotic arterial complications secondary to acute pancreatitis are less com- mon, but when they occur they can be severe. Splenic artery thrombosis with CHAPTER 11300 Fig. 11.11 CT scan revealing an obvious disconnected tail as the cause of a pseudocyst recurrence, 3 months after successful endoscopic cystgastrostomy. Note the dilated duct within the free tail. This is trial version www.adultpdf.com resulting splenic infarction is generally survivable with splenectomy. However, superior mesenteric artery thrombosis resulting in small and, at times, large bowel infarction is accompanied by a high mortality. The middle colic artery is perhaps the most frequent artery to thrombose, often resulting in a more limited large bowel infarction which may respond to resection and temporary surgical colostomy. A more frequent arterial complication of pancreatitis is the formation of a pseudoaneurysm resulting in hemorrhage. Various series report this serious complication in up to 10% of cases of severe acute pancreatitis and it can com- plicate chronic pancreatitis as well [83,84]. If the pseudoaneurysm has formed in an expanding pseudocyst wall, sudden hypotension with syncope followed by intense pain has been termed ‘pancreatic COMPLICATIONS OF PANCREATITIS 301 Fig. 11.12 Multiple duodenal and gastric varices which bled, detected on endoscopy, in a patient with a large pseudocyst and secondary splenic and portal vein thrombosis. (a) Ampulla with surrounding edema. (b) Duodenal varices of the second portion. (c) Duodenal bulb varices. (d) Extensive varices in the gastric fundus. (e) Angiographic embolization of the splenic artery to control gastric varices bleeding. Note that there is no flow beyond the farthest coils. (a) (c) (b) (d) (e) This is trial version www.adultpdf.com [...]... Guelrud 2000 (unpublished) 22 11 9 20 40 75 50 184 19 (86 %) 3 (27%) 4 (45%) 18 (90%) 36 (95%) 66 (88 %) 43 (86 %) 172 (93%) Total 411 361 (88 %) This is trial version www.adultpdf.com ERCP IN CHILDREN Table 12.2 Successful cannulation during ERCP in children older than 1 year Author, year Number of patients Success Cotton and Laage 1 982 [12] Kunitomo et al 1 988 [17] Buckley and Connon 1990 [11] Putnam et... [56] Lemmel et al 1994 [ 18] Portwood et al 1995 [20] Abu-Khalaf 1995 [8] Manegold et al 1996 [19] Su et al 1996 [22] Tagge et al 1997 [23] Graham et al 19 98 [14] Guitron et al 19 98 [15] Hsu et al 2000 [16] Poddar et al 2001 [24] Guelrud 2000 (unpublished) 25 16 42 42 19 121 25 55 26 16 38 162 26 17 50 22 72 220 24 (96%) 14 (88 %) 41 ( 98% ) 39 (93%) 19 (100%) 116 (96%) 25 (100%) 54 ( 98% ) 26 (100%) 16 (100%)... hepatis Table 12.4 ERCP findings in patients with neonatal cholestasis Visualization of the biliary tree Author, year No patients Complete Partial Visualization of only the PD Derkx et al 1994 [2] Mitchell and Wilkinson 1994 [5] Ohnuma et al 1997 [6] Guelrud et al 1997 [27] Iinuma et al 2000 [4] 18 36 66 147 43 5 ( 28% ) 21 ( 58% ) 20 (30%) 85 ( 58% ) 14 (33%) 6 (33%) 10 ( 28% ) 11 (17%) 41 ( 28% ) 5 (12%) 7 (39%)... pancreaticojejunostomy Gastrointest Endosc 1999; 49: 382 –3 87 Balthazar EJ Acute pancreatitis: assessment of severity with clinical and CT evaluation Radiology 2002; 223: 603–13 88 Flati G, Andren-Sandberg A, La Pinta M, Porowska B, Carboni M Potentially fatal bleeding in acute pancreatitis: pathophysiology, prevention, and treatment Pancreas 2003; 26: 8 14 89 Dasgupta R, Davies MJ, Williamson RC, Jackson... 2001; 8: 140–7 92 Bank S, Singh P, Pooran N, Stark B Evaluation of factors that have reduced mortality from acute pancreatitis over the past 20 years J Clin Gastroenterol 2002; 35: 50–60 This is trial version www.adultpdf.com Advanced Digestive Endoscopy: ERCP Edited by Peter B Cotton, Joseph Leung Copyright © 2005 Blackwell Publishing Ltd CHAPTER 12 ERCP in Children MOISES GUELRUD Synopsis ERCP has... Gastrointest Endosc Clin N Am 19 98; 8 (1): 143–62 [Review] 54 Parsons WG, Howell DA (19 98) Endoscopic management of pancreatic pseudocysts In: ERCP and its Applications (ed Jacobson IM), pp 193–207 Lippincott-Raven, Philadelphia 55 Barthet M, Sahel J, Bodlou-Bertel C et al Endoscopic transpapillary drainage of pancreatic pseudocysts Gastrointest Endosc 1995; 42: 2 08 13 56 Catalano MF, Geenen JE, Schmalz... of postsurgical external pancreatic fistulas Endoscopy 2001; 33: 317–22 81 Kozarek RA Endoscopic therapy of complete and partial pancreatic duct disruptions Gastrointest Endosc Clin N Am 19 98; 8: 39–53 [Review] 82 Isbicki JR, Yekebas EF, Strate T et al Extrahepatic portal hypertension in chronic pancreatitis Ann Surg 2002; 236: 82 –9 83 Sawlani V, Phadke RV, Baijal SS et al Arterial complications of pancreatitis... 1996; 40 (4): 381 –6 [Review] 84 Marshall GT, Howell DA, Hansen BL et al Multidisciplinary approach to pseudoaneurysms complicating pancreatic pseudocysts: impact of pretreatment diagnosis Arch Surg 1996; 131: 2 78 83 85 Koizumi J, Inoue S, Yonekawa H, Kunieda T Hemosuccus pancreaticus: diagnosis with CT and MRI and treatment with transcatheter embolization Abdom Imaging 2002; 27: 77 81 86 Born LJ, Madura... encouraging results [40] This is trial version www.adultpdf.com ERCP IN CHILDREN Fig 12.9 Choledochal cyst Type I-C in a 3-year-old female Note an anomalous Type B–P union Fig 12.10 Choledochal cyst Type IC with cystolithiasis (arrow) This is trial version www.adultpdf.com 321 322 CHAPTER 12 Fig 12.11 Choledochal cyst Type IV-A in a 12-year-old female Note an anomalous Type B–P union Fusiform choledochal... year vary according to the system studied, biliary or pancreatic The overall incidence is approximately 4.7% [8 24] In our unpublished experience with 220 ERCPs in children older than 1 year, ERCP was performed for diagnostic purposes in 1 08 cases with two (1 .8% ) complications In 112 therapeutic ERCPs, complications occurred in 12 (10.7%) Biliary findings (Table 12.3) Biliary atresia vs neonatal hepatitis . [51] 37 24 (65%) 10 3 (30%) 7 7 (100%) 12 7 ( 58% ) 8 7 (88 %) Total 141 111 (79%) Of a total of 37 patients, 26.(70%).had_resolution 82 67 (82 %) 22 18 (82 %) a Resolution refers to initial, complete. (77%) 0 0 20 16 (80 %) 10 7 (70%) Grimm et al. [62] 53 47 (89 %) 20 total 16 (80 %) 29 27 (93%) 4 4 (100%) b (site not specified) a Catalano et al. [56] 21 17 (81 %) 0 0 21 17 (81 %) 0 Smits et al 317–22. 81 Kozarek RA. Endoscopic therapy of complete and partial pancreatic duct disruptions. Gastro- intest Endosc Clin N Am 19 98; 8: 39–53 [Review]. 82 Isbicki JR, Yekebas EF, Strate T et al. Extrahepatic