Sphincter of Oddi dysfunction and bile duct microlithiasis in acute idiopathic pancreatitis

Although there are numerous causes of acute panc-reatitis, an etiology cannot always be found. Two potential etiologies, microlithiasis and sphincter of Oddi dysfunction, are discussed in this review. Gallbladder microlithiasis, missed on transcutaneous ultrasound, is reported as the cause of idiopathic acute pancreatitis in a wide frequency range of 6%-80%. The best diagnostic technique for gallbladder microlithiasis is endoscopic ultrasound although biliary crystal analysis and empiric cholecystectomy remain as reasonable options. In contrast, in patients who are post-cholecystectomy, bile duct microlithiasis does not appear to have a role in the pathogenesis of acute pancreatitis. Sphincter of Oddi dysfunction is present in 30%-65% of patients with idiopathic acute recurrent pancreatitis in whom other diagnoses have been excluded. It is unclear if this sphincter dysfunction was the original etiology of the first episode of pancreatitis although it appears to have a causative role in recurring episodes since sphincter ablation decreases the frequency of recurrent attacks. Unfortunately, this conclusion is primarily based on small retrospective case series; larger prospective studies of the outcome of pancreatic sphincterotomy for SOD-associated acute pancreatitis are sorely needed. Another problem with this diagnosis and its treatment is the concern over potential procedure related complications from endoscopic retrograde cholangiopancreatography (ERCP), manometry and pancreatic sphincterotomy. For these reasons, patients should have recurrent acute pancreatitis, not a single episode, and have a careful informed consent before assessment of the sphincter of Oddi is undertaken.

CT colonography:Friend or foe of practicing endoscopists

AIM:To investigate the perceived impact of computed tomographic colonography(CTC) on endoscopists' current and future practice.METHODS:A 21-question survey was mailed to 1570 randomly chosen American Society for Gastrointestinal Endoscopy(ASGE) members.Participants reported socio-demographics,colonoscopy volume,percentage of colonoscopies performed for screening,and likelihood of integration of CTC into their practice.RESULTS:A total of 367 ASGE members(23%) returned the questionnaire.Respondents were predominantly male(> 90%) and white(83%) with an average age of 49 years.Most respondents(58%) had no plans to incorporate CTC into daily practice and only 7% had already incorporated CTC into daily practice.Private practice respondents were the least likely to incorporate this modality into their daily practice(P=0.047).Forty-three percent of participants were willing to take courses on CTC reading,particularly those with the highest volume of colonoscopy(P=0.049).Forty percent of participants were unsure of CTC's impact on future colonoscopy volume while 21% and 18% projected a decreased and increased volume,respectively.The estimated impact of CTC volume varied significantly by age(P=0.002).Respondents > 60 years felt that CTC would increase colonoscopy,whereas those < 40 years thought CTC would ultimately decrease colonoscopy.CONCLUSION:Practicing endoscopists are not enthusiastic about the incorporation of CTC into their daily practice and are unsure of its future impact on their practice.

A survey of ampullectomy practices

AIM:To investigate the endoscopic ampullectomy practices of expert biliary endoscopists.METHODS:An anonymous survey was mailed to 79 expert biliary endoscopists to assess ampullectomy practices.RESULTS:Forty six(58%) biliary endoscopists returned the questionnaire.Of these, 63% were in academia and in practice for an average of 16.4 years(± 8.6).Endoscopists performed an average of 1.1(± 0.8) ampullectomies per month.Prior to ampullectomy, endoscopic ultrasound was"always"utilized by 67% of respondents vs"sometimes"in 31% of respondents.Empiric biliary sphincterotomy was not utilized uniformly, only 26%"always"and 37%"sometimes"performed it prior to resection.Fifty three percent reported"never"performing empiric pancreatic sphincterotomy prior to ampullectomy.Practitioners with high endoscopic retrograde cholangiopancreatography volumes were the most likely to perform a pancreatic sphincterotomy(OR = 10.9;P = 0.09).Participants overwhelmingly favored"always"placing a prophylactic pancreatic stent, with 86% placing it after ampullectomy rather than prior to resection(23%).Argon plasma coagulation was the favored adjunct modality(83%) for removal of residual adenomatous tissue.Practitioners uniformly(100%) preferred follow-up examination to be within 6 mo post-ampullectomy.CONCLUSION:Among biliary experts, there is less variation in ampullectomy practices than is reflected in the literature.