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Pancreatic Cancer: The Use of Endosonography
 

Pancreatic Cancer: The Use of Endosonography

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    Pancreatic Cancer: The Use of Endosonography Pancreatic Cancer: The Use of Endosonography Presentation Transcript

    • Endoscopy in Crohn’s Disease Peter Darwin, MD Director of Gastrointestinal Endoscopy University of Maryland Hospital Division of Gastroenterology
    • Outline
      • Case histories
      • Diagnosis
      • Assessment of response
      • Dysplasia and surveillance
      • Bleeding
      • Stricture management
      • Emerging technology
    • Case 1
      • The patient is a 28 year old man with isolated iliocolonic Crohn’s disease resected 8 years prior.
      • Was without symptoms but has developed intermittent abdominal distension, bloating and emesis requiring admission.
      • SBFT shows a 1 cm tight anastamotic stenosis
      • Is attempt at endoscopic management appropriate?
    • Case 2
      • 19 year old student presents with several months of vague epigastic discomfort, night sweats and weight loss.
      • Evaluation shows a microcytic anemia and thrombocytosis.
      • Abdominal CT shows a thickened mid-ileum without lymphadenopathy. Attempts to intubate the TI during colonoscopy were unsuccessful.
      • Is tissue needed prior to treatment ?
    • Diagnosis
      • Asymmetric patchy inflammation
      • Skip lesions
      • Rectal sparring
      • Ulcerations
      • Biopsy
        • Erosions and normal mucosa
        • Granulomas in 15 to 35% of specimens
    •  
    • Assessment of Response
      • Endoscopic monitoring may have a role with biologic agents
      • Subgroup of the ACCENT-1 trial
        • Mucosal healing with infliximab, time to relapse is significantly prolonged
          • 9 with endoscopic healing remained in remission for a median of 20 weeks
          • 4 clinical remission only, relapse after a median of 4 weeks
    •  
    • Dysplasia and Surveillance
      • Extensive colitis > 8 years
      • Accuracy in predicting dysplasia correlates with # of biopsies
      • Annual colonoscopy with multiple biopsy specimens
        • 4 circumferential each 10 cm
    • Approach to Polypoid Lesions Adenoma like DALM Outside colitis Within colitis Polypectomy/biopsy Non-IBD adenoma Polypectomy Regular surveillance No dysplasia No carcinoma Indeterminate Flat dysplasia carcinoma Polypectomy Increased surveillance Colectomy Chawla A, Lichtenstein G. Gastrointest Endoscopy Clin N Am 12 (2002) 525-534
    • Hemorrhage in Crohn’s
      • Acute major hemorrhage is uncommon
      • Bleeding can occur in any segment
      • Massive hemorrhage is usually from an ulcer eroding into a vessel
      • Resuscitation
      • Endoscopy vs tagged RBC scan to localize a bleeding segment
      • Avoid embolization if possible
    • Hemorrhage in Crohn’s
      • No data to support cautery or injection therapy
      • Surgical intervention
      • Consider tattooing of the site
      • Database review from 1989 to 1996
        • 1739 patients / 31 (1.8%) due to IBD
        • 3 with UC and 28 with CD / 1 UGI source
        • None hematemesis
        • GI hemorrhage in 0.1% UC and 1.2% CD
      • Diagnostic evaluation
        • Source found by colonoscopy in 25 patients (25%) and EGD in 2 patients
      Pardi D, Loftus E, et al. Gastrointest Endosc 1999;49:153-7. Acute Major GI hemorrhage in IBD
    • Endoscopic Therapy for Patients with CD and Focal Sites of hemorrhage Patient Site Stigmata Endoscopic Rx Medical Rx 1 Duodenum clot Injection Corticosteroids ranitidine 2 Jejunum oozing ulcer Injection Corticosteroids ranitidine 3 Colon clot Injection with Corticosteroids coagulation metronidazole
    • Clinical Course
    • Balloon Dilation of Strictures
    • Descending Colon Stricture
    • Colonic Strictures
      • No randomized clinical trials
      • Consider nonsurgical management if:
        • Endoscopically accessible
        • Multiple prior resections
        • Shorter strictures (less than 5 cm)
        • Steroid injection if significant inflammation
    • Malignant Potential
      • Increased incidence of colonic and small bowel carcinoma
      • Higher risk with longer duration of disease
      • Stricture biopsy required
      • Utilize thin caliper scopes to evaluate proximal to the stenosis
    •  
    • Balloon Dilation of Strictures
      • High success rate for anastamotic strictures
      • Used for colonic and duodenal stenosis
      • TTS balloons 15 to 18 mm for 1 minute
      • Fluoroscopy only if needed
      • Successful if scope passed post
      • Medical treatment
      • Complications
    • Injection of Corticosteroids
      • Post dilation
      • Sclerotherapy needle
      • Triamcinolone 40 mg/ml – 1 cc in 4 quadrants at site of maximal inflammation/stenosis
    •  
    • Intestinal Stents
      • Limited data
      • Migration is common
      • Coated metal enteral stents / plastic stents may be of benefit
    • Endoscopic Balloon Dilation of Ileal Pouch Strictures
      • Aim: evaluate outpatient ileal pouch stricture dilation
      • Methods: Nonfluroscopy, nonsedated dilation with 11-18 mm TTS balloons in 19 consecutive patients
      Shen B, Fazio V, Remzi F, et al. Am J Gastro 2004;99:2340-47.
    • Inlet and Outlet Strictures
    • Clinical Presentation n (%) Diarrhea Abdominal pain Perianal pain Bloating Nausea or vomiting Bleeding Daily use of antidiarrheal agents Fistulas Weight loss 18 (94%) 19 (100%) 15 (79%) 9 (47%) 3 (16%) 4 (21%) 8 (42%) 6 (32%) 5 (26%)
    • Types of Strictures Number Inlet Outlet of cases strictures strictures Crohn’s disease of the pouch Cuffitis Pouchitis Total 11 14 6 5 0 5 3 0 3 19 14 14
    • Pouch Disease Activity Index
    • Strictures Scores
    • Cleveland Global Quality of Life Scores
    • Emerging Technology
      • Double balloon enteroscopy
      • Endoscopic ultrasound
      • Optical coherence tomography
      • Magnification chromoendoscopy
    •  
    •  
    •  
    • Takayuki Matsumoto, Tomohiko Moriyama, et. al. Gastrointest Endosc 2005;62 :392-8
    • `
    •  
    • Optical Coherence Tomography
      • Based on low-coherence
      • interferometry
      • High resolution imaging
      • Uses light (not sound)
      • Resolution 10X greater than EUS
      • No acoustic coupling
    • Magnification Chromoendoscopy
      • Utilizes magnifying endoscopes with tissue stains to better characterize the mucosa
      • May improve efficacy of surveillance colonoscopy
        • 165 patients with UC randomized to conventional screening vs CE.
        • Targeted biopsies
        • Identified more areas of dysplasia
      Kiesslich R, Fritch J, et. al. Gastro 2002;124:880-8.
    • Colonic Pit Pattern Huang Q, Norio F, et. al. Gastrointest Endosc 2004; 60:520-6.
    •  
    • Case 1
      • The patient is a 28 year old man with isolated iliocolonic Crohn’s disease resected 8 years prior.
      • Was without symptoms but has developed intermittent abdominal distension, bloating and emesis requiring admission.
      • SBFT shows a 1 cm tight anastamotic stenosis
      • Is attempt at endoscopic management appropriate?
    • Case 2
      • 19 year old student presents with several months of vague epigastic discomfort, night sweats and weight loss.
      • Evaluation shows a microcytic anemia and thrombocytosis.
      • Abdominal CT shows a thickened mid-ileum without lymphadenopathy. Attempts to intubate the TI during colonoscopy were unsuccessful.
      • Is tissue needed prior to treatment ?