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Endoscopic Drainage of Pancreatic Pseudocysts, Abscesses, and Walled-Off (Organized) Necrosis

Pancreatic pseudocysts, abscesses, and walled-off necrosis (WON) are types of pancreatic fluid collections (PFCs) that arise as a consequence of pancreatic injury. These sequelae of pancreatic injury result from a disruption of the main pancreatic duct (PD) and/or side branches. Ductal disruption can occur secondary to acute pancreatic injury (i.e., acute pancreatitis, trauma, surgical resection, or inadvertent damage to the pancreas during abdominal surgery) or chronic…

Chronic Pancreatitis : Stones and Strictures

Chronic pancreatitis (CP) is a rare disease in Western countries (incidence 2 to 10/100,000 per year). It ultimately leads to irreversible damage of the pancreas, with exocrine and endocrine insufficiency. In the majority of cases pain is the major clinical symptom and present early in the course of the disease. With the exception of tropical and hereditary CP, the etiology of CP has not yet been…

Pancreatic Interventions in Acute Pancreatitis: Ascites, Fistulae, Leaks, and Other Disruptions

Background Over time, the role of endoscopic retrograde cholangiopancreatography (ERCP) in the setting of acute pancreatitis has evolved. Previously, ERCP was commonly used after resolution of an acute attack, or more commonly multiple attacks, in an attempt to define pancreatic ductal anatomy and determine an etiology for unexplained pancreatitis. Congenital variants, including duodenal duplication, anomalous pancreaticobiliary union, annular pancreas, and pancreas divisum, can be diagnosed, as…

Biliary Intervention in Acute Gallstone Pancreatitis

Gallstones are the most common cause of acute pancreatitis (AP), accounting for approximately 35% of cases in the United States and Europe and up to 65% of cases in Asia. The majority of patients with acute gallstone pancreatitis (AGP) will follow a benign clinical course. However, up to 25% will progress to severe acute pancreatitis (SAP), which causes a significant increase in morbidity and mortality. Although…

Unexplained Acute Pancreatitis and Acute Recurrent Pancreatitis

Determining the cause of acute pancreatitis (AP) is usually not difficult. AP results most commonly from alcohol abuse or gallstone disease. These etiologies account for 60% to 90% of the cases ( Box 52.1 ). Box 52.1 Etiologies of Acute Pancreatitis Alcohol Autoimmune pancreatitis Biliary calculous disease Macrolithiasis (bile duct stone) Microlithiasis (biliary crystals) Biliary cystic disease Choledochal cyst Choledochocele/duplication cyst Congenital anomaly Annular pancreas Anomalous…

Cystic Lesions of the Pancreas

Pancreatic cystic lesions comprise a spectrum ranging from benign to premalignant to invasive malignancies. Pancreatic cystic neoplasms (PCNs) are relatively rare, accounting for less than 10% of all pancreatic neoplasms. Their diagnostic frequency increases with age and has noticeably increased with widespread availability of cross-sectional imaging. Although most cystic lesions are detected incidentally in patients who undergo abdominal imaging for an unrelated reason, large or invasive…

Recurrent Pyogenic Cholangitis

Introduction and Scientific Basis Recurrent pyogenic cholangitis (RPC) is a condition characterized by repeated attacks of bacterial infection of the biliary tract. It is believed that the initiating event is the entry of enteric flora into the biliary tree, which causes infection, inflammation, and the formation of primary biliary stones through bacterial deconjugation of bilirubin diglucuronide. Persistent inflammation results in biliary strictures and stasis of bile…

Tropical Parasitic Infestations

Parasitic infestation of the biliary tract is a common cause of hepatobiliary disease in developing countries and in rural areas of developed countries. With increasing international travel and immigration, clinicians in developed countries will likely encounter these conditions with increasing frequency. Ascariasis, hydatid liver disease, clonorchiasis, opisthorchiasis, and fascioliasis are the commonly encountered parasitic infestations of the biliary tract. They may present with cholestasis, obstructive jaundice,…

Sclerosing Cholangitis

Background Primary sclerosing cholangitis (PSC) is a chronic inflammatory disease of the biliary tree. It is characterized by stricturing and dilation of the intrahepatic and/or extrahepatic bile ducts, with concentric obliterative fibrosis of intrahepatic biliary radicles. PSC is closely associated with inflammatory bowel disease, particularly ulcerative colitis, which is found in approximately two-thirds of northern European PSC patients. The disease leads to chronic cholestasis, but patients…

Pancreaticobiliary Pain and Suspected Sphincter of Oddi Dysfunction

The diagnosis and treatment of sphincter of Oddi dysfunction (SOD) presents a significant challenge. This chapter is intended to provide readers with a practical guide to the evaluation and management of patients with pancreaticobiliary-type pain and suspected SOD by providing a pragmatic approach to the clinical evaluation and decisions regarding treatment. The specific goals are to (1) describe pancreaticobiliary pain patterns; (2) define SOD and the…

Choledocholithiasis

Gallstones and their related complications have a prevalence ranging from 7% to 10% in developed countries to more than 70% among high-risk groups such as Pima Indians. Direct and indirect costs related to gallstones in the United States in 2004 amounted to more than 6 billion dollars. Gallstones have also been associated with increased overall and cardiovascular-specific mortality, even after adjustment for demographics and cardiovascular risk…

ERCP and EUS for Acute and Chronic Adverse Events of Pancreatic Surgery and Pancreatic Trauma

Chronic pancreatitis, cystic neoplasms, and suspected or established malignancy are the main indications for pancreatic surgery. The various types of pancreatic surgery are outlined in Box 45.1 . This chapter focuses on types of pancreatic surgery, their associated adverse events, and the role of endoscopy in management of adverse events. Finally, we highlight the role of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of pancreatic trauma.…

Biliary Surgery Adverse Events, Including Liver Transplantation

Iatrogenic bile duct injury (BDI) continues to be an important clinical problem after biliary surgery, resulting in serious morbidity and occasional mortality. The management, operative risk, and outcome of BDIs vary considerably and are highly dependent on the type of injury, the severity, and location. Although perioperative complications are frequent, nearly all can be managed nonoperatively. Early referral to a tertiary care center with experienced hepatobiliary…

Benign Biliary Strictures

Benign biliary strictures (BBS) are most commonly caused by iatrogenic surgical injury, usually after cholecystectomy, or may occur at the site of biliary anastomosis after hepatic resection or liver transplantation (LT). Other causes of BBS include primary sclerosing cholangitis (PSC), chronic pancreatitis (CP), immunoglobulin G4 (IgG4)–related cholangiopathy, and a variety of other causes ( Box 43.1 ). Box 43.1 Causes of Benign Biliary Strictures Postoperative Anastomotic…

Endoscopic Approaches to Concomitant Malignant Biliary Obstruction and Gastric Outlet Obstruction

Gastric outlet obstruction (GOO) and biliary obstruction (BO) occur commonly in patients with primary or metastatic periampullary malignancies. In pancreatic cancer, for example, GOO occurs in up to 10% to 25% of patients, whereas 70% of the patients present with BO. Clinically, BO and GOO are accompanied by debilitating symptoms, and GOO is also generally associated with poor prognosis. As such, one of the main goals…

Indeterminate Biliary Stricture

Biliary obstruction results from diverse benign and malignant processes, and patients can present with acute or chronic signs and symptoms that vary greatly in severity ( Table 41.1 ). The nature of an obstruction is often immediately clear at the time of initial investigation, whereas at other times obstruction is readily apparent but the nature of the pathologic process remains uncertain. No single definition exists for…

Malignant Biliary Obstruction of the Hilum and Proximal Bile Ducts

Malignant biliary obstruction of the hilum and proximal intrahepatic bile ducts can result from primary pancreaticobiliary cancers, primary liver cancers, portal lymphadenopathy, or metastatic disease. Primary pancreaticobiliary cancers affecting the proximal bile ducts and hilum include cholangiocarcinoma (CCA) and gallbladder cancer. CCA can cause obstruction at any level of the biliary tract. Cancer of the gallbladder can present with hilar or right intrahepatic duct obstruction caused…

Malignant Biliary Obstruction: Distal

Malignant strictures of the pancreaticobiliary tree are often difficult to diagnose and treat. Therefore the majority present in more advanced stages of disease, contributing to poor prognosis and outcome. Jaundice is the most common presenting sign and symptom of malignant biliary obstruction. Different etiologies cause distal malignant biliary obstruction and include pancreatic cancer, carcinoma of the ampulla of Vater, distal cholangiocarcinoma (CCA), and metastatic disease that…

Ampullary Neoplasia

Malignant tumors of the ampulla of Vater are uncommon. Fewer than 1 in 50,000 people older than 40 years are diagnosed with ampullary malignancy each year. Much more common is a heterogeneous group of malignancies occurring in the peri ampullary region, including tumors of the adjacent part of the pancreatic head, the distal common bile duct, adjacent duodenal mucosa, and the ampulla of Vater. Before surgical…

The Dilated Pancreatic Duct

Background and Definitions The pancreas arises in utero from the fusion of the ventral and dorsal pancreatic buds. The dorsal pancreatic bud gives rise to the pancreatic body and tail, and the ventral pancreatic bud gives rise to the pancreatic head and uncinate process. The main pancreatic duct (also known as the duct of Wirsung) forms when the dorsal and ventral pancreatic buds fuse at the…