April 1995 Pancreatic Disorders A347

• DETERMINATION OF EARLY CHRONIC PANCREAT1TIS USING A MODIFIED ENDOSCOPIC ULTRASOUND (EUS) DIAGNOSTIC CRITERIA: COMPARISON WITH CONVENTIONAL PANCREATIC STUDIES. MF_ Catalano, JE Geenen, MJ Schmalz. GK Johnson, WJ Hogan. St. Luke's Medical Center, Milwaukee, Wl.

Chronic pancreatitis (CP) in its early stages may defy diagnosis despite existing diagnostic modalities. ERCP. secretin test (ST) and conventional ultrasound are insensitive in detecting the early stages of CP. AIM: To determine ifEUS high resolution imaging allows for the detection of early stages of CP compared to ERCP and ST. METHODS: 80 pts with recurrent pancreatitis (31M, 49F, age 10-62) underwent ERCP, EUS and ST. Etiology: Divisum 38, idiopathic 20, ETOH 18, familial 3, cystic fibrosis 1. EUS evaluated naronehvmai chaw,es: echoganic foci (calcification), prominent interlobular septae (fibrosis), small cystic cavities(edema), Iobulated outer margin(fibrosis/atrophy), inhomogeneity; duetal eban~es: dilation, irregularity, echogenic wall (fibrosis), side branch ectasia, echogenic loci (stones). EUS CRITERIA CP: mild (Mi) 1-2 features, moderate (Mo)3-5, severe (S)>5 Peak HCO3 levels > 85 mEq/l were normal ST. RESULTS: ERCP revealed 44 normal(N), 36 abnormal(A) ducts. ST revealed 55 N, 25 A. EUS revealed 17 N, 63A (30 Mi, 24 Mo, 9 S) T=Total.

SECRETIN ERCP

N A T N A T

E N 17 0 17 E N 17 0 17 E N 17 0

Mi 26 4 30 Mi 25 5 30 Mi 24 6 U U U

Mo 12 12 24 Mo 2 22 24 Mo 1 23 S S S

S 0 9 9 S 0 9 9 S 0 9

T 55 25 80 T 44 36 80 T 42 38

SECRETIN/ERCP

N A T

17

30

24

9

4O

bEUS correlated well with N-ST and N-ERCP (17/17= 100%). Severil correlated poorly between EUS and ERCP morphology. When ST and ERCP were collectively used to determine CP, excellent correlation was seen among N, Mo, S grades by EUS (49/50=98%). CONCLUSIONS: Using the above criteria EUS is considerably more sensitive than ST and ERCP in the diagnosis of CP. Excellent correlation can be expected between EUS and abn ERCP with the exception of Mi CP. Long term follow up of the CP pts with mild EUS changes will determine the validity of EUS in diagnosing the early stages of CP.

PANCREATIC DUCT APPEARANCE AT ERCP AND CORRELATION WITH PANCREATIC SECRETORY FUNCTION IN PATIENTS WITH SUSPECTED CHRONIC PANCREATITIS. MF Catalano, JE Geenen, GK Johnson, MJ Schmalz, DJ Geenen, L Jacob, WJ Hogan, Pancreatic Biliary Center, St. Luke's Medical Center, Milwaukee, Wisconsin.

Diagnosis of chronic pancreatitis (CP) requires documentation of structural (ERCP) and/or functional (secretin test) abnormalities in association with clinical presentation. The degree of association between pancreatic duetal morphology and pancreatic secretory function has not been clearly established. AIM: To determine if the degree of pancreatic structural abnormality correlates with pancreatic secretory function. METHODS: 80 Pts (31M, 49W, age 19-62) with acute recurrent pancreatitis were prospectively evaluated by ERCP and secretin test (ST). All pancreatograms were evaluated using the Cambridge Classification (I- V) as follows: (N)Normal, (Eq)equivocal ( < 3 abnormal branches), (Mi) mild ( > 3 abnormal branches, normal PD), (Mo) moderate (abnormal PD and branches), (S) severe (gross irregularity, stones, obstruction). Following secretin stimulation, peak HCO3 concentrations >85 mEq/1 were considered normal. Results of abnormal ST were correlated to the stage of CP by Cambridge Classification. RESULTS: 44 of 80 pts demonstrated abnormal ductular anatomy, while only 25 pts had peak HCO3 concentration < 85 mEq/1. The percentage of pts with abnormal ST increased in direct relationship with advancing ductal changes.

SECRETIN

Normal Abnormal Total

N=Normal 35 1 36

E=Equivocal

Mi =Mild 6 2 8

10 7 17

Mo=Moderate 3 10 13

S = Severe 1 5 6 T----Total .~.~ 2~; g0

CAMBRIDGE STAGE

ST(%)ABN I I ~ i l m l ~ v l v q% 9_5% 41% 77% ~q%

2ONCLUSIONS: Based on the result of this study, change in pancreati duct morphology usually precedes a decrease in pancreatic secretor~ function. Only in advanced stages (IV,V) of pancreatic duetal change was it possible to predict abnormal pancreatic secretory function.

PANCREATIC DUCT ENDOPROSTHESIS: DIAGNOSIS OF STENT OCCLUSION BY SECRETIN STIMULATED ENDOSCOPIC ULTRASOUND (SSEUS). M.F. Catalano, J.E. Geenen, M.J. Schmalz, G.K. Johnson, D.J. Geenen, R. Kaikaus, W.J. Hogan, St. Luke's Hospital, Racine, St. Luke's Medical Center, Milwaukee, Wisconsin

The treatment of a variety of obstructive pancreatic diseases, including pancreas divisum, and pancreatic duct strictures (benign and malignant) with pancreatic duct endoprosthesis has become widely accepted. The major problem of pancreatic stent is occlusion prior to scheduled removal. Currently there is no diagnostic method to determine patency except for stent removal. AIM: To evaluate the affect of secretin stimulation on the pancreatic duct diameter in pts with suspected pancreatic duct stent occlusion. METHODS: To identify a normal response, 20 pts with no pancreatic disease underwent SSEUS. EUS visualized the entire pancreas (head, body, tail and PD) in all pts. PD diameters were measured at baseline and 1-min intervals for 15 min. SSEUS in 20 control pts showed no change in 16 pts, while 4 pts had a 1 mm dilation at 2-3 min but was not sustained ~ 10 min). In addition, 20 pts (13M, 7W, age range 38-61) with in-situ pancreatic duct stents (13 dorsal duct, 7 ventral duct) presented with recurrent symptoms (pain, nausea, vomiting) and suspected stent occlusion were studied with SSEUS. All stents were subsequently removed following EUS to determine actual patency RESULTS: 14 of 20 patients were found to have occluded stents verified upon removal; 12 of these pts had abnormal SSEUS~ Conversely in the 6 patients with patent stents, only 1 had abnormal SSEUS.

STENT Pt SSEUS SENS SPEC PPV NPV STATUS (n) Normal Abnormal (%) (%) (%) (%)

Patent 6 5 1 86 83 92 72

Occluded 14 2 12

SSEUS accuratel 3 predicted occluded stents in 12 of 14 pts (86%). SS accurately predicted patent stents in 5 of 6 pts (83%). CONCLUSION: Secretin stimulated EUS is a safe and simple imaging modality. It can accurately predict stent occlusion or patency in pts with in situ pancreatic duct stents with recurrent symptoms and may prevent premature, unnecessary removal of functional stents.

CHRONIC OBSTRUCTIVE PANCREATITIS (COP) IN MAN IS A LITIIIASIC DISEASE. G Cavallini, P ]8ovo, M Filippini, B Vaona, L Frulloni, V Di Franossco, L Rigo, MP Bnmori, M Marcori, A Gaudio, MB Casarini, G Angelini, C Procacci*, P Pederzoli °. Gastroea~rology Unit, °Surgical 12pt.and Radiology*, University of Verona, Verona, Italy.

In experimental animals the chronic administration of ~mnol is able to produce neither the lesions typical of chronic pancreatitis nor duetal stones, except when there is an associated partial legation of the pancreatic duet. In man COP is thought to be a disease devoid of intraduetal stones. The aim of our study was to verify the presence and frequency of calcifications in patients with COP and to compare them with those of patients with ehronin calcifying/caleifie paner~atitis (CCP). By means of ERCP performed by 2 independent observers (G.A., C.P.), we retrospentively investigated 91 patients definitively known to have been suffering from chronic panereatitis over the past 4 years. Only 60 patie~ats could be classified with certainty as COP or CCP. Fourtythree patients (M:F ratio = 6:1; mean age 38.3±12 yrs) were suffering CCP; 36 of these (83.7%) presented calcifications. Seventeen patients (M:F ratio = 3:1; mean age 45.9~14:p<0.05 vs CCP) presented a picture of COP at ERCP; 7 of these (41.2%) showed duetal calcifications (p<0.001 vs CCP). COP was secondary to acute panereatitis in 8 patients, to odditis in 7 and to ampultoma and hypertrophy of Oddi's sphincter, respectively, in the other 2 eases. The two patients groups showed no differences in drinking and smoking habits, in the number of painful relapses, in duration of the disease or in incidence of diabetes, gallstones and need for surgery. Conclusions: 1) the formation of duetal stones is a by no means infrequent event in the course of COP; 2) this latter nosologieal entity should be classified in the lithiasic pancreatic group: 3) the findings of stones in the course of chronic panereatitis does not necessarily mean that the diagnosis must be CCP.