儿童及青少年胰腺分裂伴急性复发性胰腺炎的内镜诊治分析

目的 评价经内镜逆行胰胆管造影术（ERCP）诊治儿童及青少年胰腺分裂（PD）伴急性复发性胰腺炎（RAP）的安全性及效果。方法 2011年1月至2015年1月，经ERCP明确RAP型症状性PD诊断，并行内镜下副乳头括约肌切开联合副胰管支架置入术（ESCS）及主副乳头双括约肌切开联合副胰管支架置入术（Bi-ESCS）治疗，年龄在18周岁以下的9例患儿纳入回顾性分析，汇总诊治完成情况、并发症发生情况以及随访结果。结果 9例均为首次确诊，共行18例次治疗性ERCP，副胰管插管成功率为100.0％（18／18）。并发症发生率为11.1％（2／18），均较轻微，包括术后轻型胰腺炎和高淀粉酶血症各1例次。随访3～60个月，9例术后腹痛均获得改善（其中7例未再出现腹痛或复发胰腺炎），复查MRCP、CT等均未见胰管扩张，患儿体重增加，身体及智力发育正常。结论 ERCP可明确RAP型症状性PD诊断，还可采用ESCS及Bi-ESCS技术对确诊的儿童及青少年患儿进行安全和有效的治疗。     

超声内镜引导下胰管穿刺术联合经内镜逆行副胰管造影术治疗胰腺分裂症1例

1例慢性胰腺炎、胰管结石伴梗阻性黄疸患者,因经内镜逆行胰胆管造影术主乳头胰管反复插管困难,副乳头开口难辨,最后选择在全麻下行超声内镜引导下胰管穿刺术联合经内镜逆行副胰管造影术+副乳头扩张术+胰管探条扩张术+胰管支架置入术,术中补充诊断：胰腺分裂。本文报道了该疑难病例的内镜治疗过程及护理配合要点。     

治疗性经内镜逆行胰胆管造影在慢性胰腺炎患者中的应用

目的：探讨治疗性经内镜逆行胰胆管造影（ERCP）在慢性胰腺炎（CP）治疗中的价值。方法对2008年1月－2012年12月间在南京医科大学附属苏州市立医院应用 ERCP 治疗的30例 CP 患者进行回顾性分析。观察术前及术后24h 血淀粉酶变化,动态观察患者治疗前后腹痛缓解情况,随访脂肪泻、焦虑患者病情,定期复查腹部影像学或 ERCP 明确胰腺病变及胰管支架情况。结果所有患者均顺利完成 ERCP 并放置胰管支架,术后72 h 腹痛缓解率83．3％,1例因症状改善不明显至外科手术,术后病死率为0。结论ERCP 是治疗 CP 的有效手段,具有安全、有效、创伤小等优点。     

超声内镜引导下胰管穿刺术联合经内镜逆行副胰管造影术治疗胰腺分裂症1例

1例慢性胰腺炎、胰管结石伴梗阻性黄疸患者, 因经内镜逆行胰胆管造影术主乳头胰管反复插管困难, 副乳头开口难辨, 最后选择在全麻下行超声内镜引导下胰管穿刺术联合经内镜逆行副胰管造影术+副乳头扩张术+胰管探条扩张术+胰管支架置入术, 术中补充诊断:胰腺分裂。本文报道了该疑难病例的内镜治疗过程及护理配合要点。     

假性胰腺囊肿的内镜治疗

目的 观察经十二指肠乳头引流治疗胰腺假性囊肿的疗效以及并发症，探讨新的微创治疗方法。方法 选择胰腺假性囊肿患者8例，均有2次以上外科手术史，再次外科手术难度较大。经内镜逆行胰胆管造影(ERCP)后，十二指肠乳头、主胰管括约肌切开，行内引流管置人或主胰管探条扩张治疗，囊肿消失后经内镜取出内引流管。结果 ERCP提示，3例囊肿与主胰管相通，l例囊肿压迫造成胆总管下段狭窄梗阻。置入内引流管5例；探条扩张治疗3例。术后l～4个月囊肿完全消失7例；l例囊肿缩小约l／3，临床症状消失，随访6个月囊肿未再缩小，转外科手术治疗。术后2例出现一过性血、尿淀粉酶升高，无严重并发症发生。结论：ERCP及其派生的治疗技术，治疗胰腺假性囊肿有效、安全，可作为胰腺假性囊肿的微创治疗方法。     

ERCP诊治胰腺分裂一例

患男．43岁．因“反复上腹痛5年”入院。患5年前饮酒后出现中上腹痛，呈烧灼样痛，并向腰背部放射，无恶心、呕吐、腹泻等。于当地医院查血淀粉酶1500U／L，诊断为“急性胰腺炎”，予抗炎对症治疗后症状缓解。之后患上腹痛反复发作3次，均于当地医院诊断为“急性胰腺炎”。患入院前3d上腹痛再发，拟“复发性胰腺炎”收住入院。体检：皮肤巩膜无黄染，右上腹压痛，无反跳痛。患入院后查血淀粉酶500U／L。腹部B超及MRcP未见明显异常。腹部CT示：胰腺尾部形态增大，密度与正常胰腺类似，周边血管迂曲，考虑胰腺解剖变异可能。ERCP检查于十二指肠降部见主乳头和副乳头，前呈半球形，开口呈绒毛状；后较小．开口明显。主乳头插管造影显示主胰管短小．长约3cm．呈短树枝状．无扩张，分支胰管显示欠清；副乳头插管造影显示副胰管长约12．2cm，直径约0．4cm，管壁光滑，行走自然，分支胰管显示良好，主副胰管未融合，即确诊为胰腺分裂症。术中于副乳头行小切开，插入导丝后，循导丝推入胰管支架（5F，9cm），见胰液从支架内流入肠腔。患术后腹痛症状消失。     

儿童胰腺炎ERCP术后并发症研究

目的分析儿童胰腺炎患者经内镜逆行胰胆管造影(endoscopic retrograde cholangiop-ancreatography, ERCP)术后高淀粉酶血症、胰腺炎及出血等并发症的发生率,探讨其安全性.方法回顾分析1997年2月～2002年2月间入住我科确诊为儿童胰腺炎并行ERCP术的27例患者的临床资料,其中急性胰腺炎(acute pancreatitis,AP)14例,慢性胰腺炎(chronic pancreatitis,CP)13例;诊断性ERCP 9例,治疗性ERCP18例.结果 27例患者ERCP术后总体并发症发生率为51.85%(14/27),其中,高淀粉酶血症发生率22.22%(6/27),术后4、24 h血清淀粉酶水平分别为(410.75±230.31) U/L、(367.25±233.90) U/L,48～72h后均恢复正常;胰腺炎发生率22.22%(6/27),均为轻型胰腺炎;乳头切开处出血、黑便发生率7.41%(2/27),均发生于胆总管结石行十二指肠乳头括约肌切开(endoscopic sphincterotomy,EST)+取石术后;诊断性ERCP组并发症的发生率低于治疗性ERCP组,但无统计学意义.结论儿童胰腺炎患者ERCP术后具有较高的并发症发生率,内镜医师于ERCP术中应高度重视,采取必要的预防措施以减少并发症的发生.     

内镜诊治胰腺导管内乳头状粘液性肿瘤的应用

目的探讨胰腺导管内乳头状粘液性肿瘤(IPMN)的诊断、内镜下治疗,以提高对该疾病的认识及内镜对其诊断及治疗的意义。方法回顾性分析经内镜诊治的IPMN患者12例,总结并分析他们的一般情况、临床症状、影像学检查、实验室检查、内镜下治疗等方面资料。结果 12例IPMN患者以老年男性为主,无特异性临床表现,主要发生部位为胰头或钩突部,CT主要表现为囊实性低密度影,其内可有壁结节,胰管扩张伴或不伴胆管扩张,2例侵及胰腺实质。磁共振胰胆管造影(MRCP)主要表现为胰管扩张,胰腺萎缩,胰头部圆形高信号影。内镜下逆行胰胆管造影(ERCP)显示十二指肠乳头膨大,开口扩张,可见胶冻样粘液流出,胰管造影显示胰管全程扩张或胰头部囊状扩张,3例伴胆总管、肝内胆管扩张。9例行ERCP治疗,清除粘液栓并置入胰管支架,3例同时置入胆管支架。结论 IPMN是一种特殊类型的胰腺囊性疾病,影像学检查有其独特的表现,ERCP对其诊断及治疗有重要意义。     

胰腺分裂内镜治疗价值

目的探讨内镜下治疗胰腺分裂的疗效和安全性。方法收集2006年6月至2013年6月在南京大学医学院附属鼓楼医院消化科就诊的8例胰腺分裂患者的临床资料,对术中及术后情况进行回顾性分析。结果8例胰腺分裂患者共行经内镜逆行胰胆管造影术28例次,均置入胰管支架,其中7例同时行副乳头括约肌切开术,6例行内镜下扩张术,1例行胰管取石术。术后出现1例次轻度胰腺炎。随访2～47个月,1例死于胰腺癌,3例已拔出支架,3例定期复查,1例失访。患者术后慢性胰腺炎急性发作频率及腹痛程度均较术前明显降低。结论内镜下治疗胰腺分裂安全有效,可减少胰腺炎发作频率,减轻术后腹痛程度,术后并发症发生率低。     

内镜治疗慢性胰腺炎的探讨

目的 探讨内镜治疗慢性阻塞性胰腺炎疗效及并发症。方法 经内镜治疗２９例慢性胰腺炎中胰管括约肌切开术２７例（１９例为７内镜治疗前处置）,副乳头切开８例,乳头括约肌切开术５例,网篮邓胰石９例,胰管内引流７例,鼻胰管引流３例,辅助探条或球囊扩张共１４例。１３例治疗前、后检测胰腺内分泌功能。结果 ２９例中２６例（８９．７％）治疗后腹痛消失或明显减轻,９例胰腺结石患者中６例取出胰石;７例胰管内引流管未阻塞。     

内镜综合治疗慢性胰腺炎

目的探讨内镜在慢性胰腺炎治疗中的临床应用价值方法回顾性分析经内镜治疗的37例慢性胰腺炎患者的临床资料,总结治疗的体会。结果37例均经内镜下胰胆管造影明确诊断,患者均有不同程度的胰管扩张,其中胰管狭窄21例,伴有钙化9例,行乳头括约肌切开术37例,胰管括约肌切开术18例,网篮、球囊取胰石6例,胰管内支架引流17例,鼻胰管引流5例。37例中34例治疗后腹痛消失。结论内镜治疗慢性胰腺炎是较安全、有效的,而内镜下多种治疗方法的综合应用明显改善了传统慢性胰腺炎治疗的现状,提高了治疗水平。     

Endoscopic treatment for biliary stricture secondary to chronic pancreatitis

The causes of benign biliary stricture include chronic pancreatitis, primary/immunoglobulin G4-related sclerosing cholangitis and complications of surgical procedures. Biliary stricture due to fibrosis as a result of inflammation is sometimes encountered in patients with chronic pancreatitis. Frey's procedure, which can provide pancreatic duct drainage with decompression of biliary stricture, can be an initial treatment for chronic pancreatitis with pancreatic and bile duct strictures with upstream dilation. When patients are high-risk surgical candidates or hesitate to undergo surgery, endoscopic treatment appears to be a potential second-line therapy. Placement of multiple plastic stents is currently considered to be the best choice as endoscopic treatment for biliary stricture due to chronic pancreatitis. Temporary placement with a fully covered metal stent has become an attractive option due to the lesser number of endoscopic retrograde cholangiopancreatography (ERCP) sessions and its large diameter. Further clinical trials comparing multiple placement of plastic stents with placement of a covered metal stent for biliary stricture secondary to chronic pancreatitis are awaited.     

Comparison of the Secretin Stimulated Endoscopic Pancreatic Function Test to Retrograde Pancreatogram

Duodenal intubation techniques with hormonal stimulation are the most accurate at diagnosing early chronic pancreatitis. Pancreatography (ERCP), the radiologic gold standard, can accurately diagnose chronic pancreatitis, but is expensive, may expose the patient to radiation, and/or induce acute pancreatitis. We have developed an endoscopic pancreatic function test (ePFT) that can assess pancreatic secretory function during upper endoscopy. We sought to determine the accuracy of the endoscopic secretin pancreatic function test using retrograde pancreatogram as the gold standard. Patients referred to The Pancreas Clinic for the evaluation and management of chronic abdominal pain and suspected chronic pancreatitis who had both endoscopic function testing and pancreatic duct imaging (ERCP) were studied. Pancreatograms were scored for duct morphologic characteristics (Cambridge classification) and compared to peak bicarbonate concentration in secretin stimulated duodenal juice. The ePFT consisted of a test dose of intravenous synthetic porcine secretin (0.2 microg), full-dose intravenous secretin (0.2 microg/kg) over 1 min, (3) upper endoscopy with moderate sedation, (4) gastric fluid aspirated and discarded, (5) duodenal fluid aspirations at 0, 15, 45, and 60 min after secretin injection, and (6) fluid analysis with lab autoanalyzer for bicarbonate concentration (historical normal cutpoint >80 mEq/L). Thirty-six patients had both the endoscopic function test and ERCP. Seventeen had chronic abdominal pain with normal pancreatograms, and nineteen had chronic abdominal pain with abnormal pancreatograms, consistent with chronic pancreatitis. The sensitivity and specificity of the endoscopic function test were 94% and 79%, respectively. The positive and negative predictive values were 80% and 94%, respectively. Overall agreement with ERCP was 86%. The ePFT with synthetic porcine secretin has excellent correlation with abnormal pancreatogram (chronic pancreatitis). Furthermore, a normal bicarbonate (negative function test, HCO(3) >80 mEq/L) essentially rules out chronic pancreatitis as a diagnostic cause of abdominal pain. Endoscopic pancreatic function testing may decrease the need for ERCP in patients with chronic abdominal pain.     

Analysis of the risk factors for severity in post endoscopic retrograde cholangiopancreatography pancreatitis: The indication of prophylactic treatments

AIM To determine the risk factors of severe post endoscopic retrograde cholangiopancreatography pancreatitis(s PEP) and clarify the indication of prophylactic treatments.METHODS At our hospital, endoscopic retrograde cholangiopancreatography(ERCP) was performed on 1507 patients from May 2012 to December 2015. Of these patients, we enrolled all 121 patients that were diagnosed with post endoscopic retrograde PEP. Fourteen of 121 patients diagnosed as s PEP were analyzed.RESULTS Forty-one patients had contrast media remaining in the pancreatic duct after completion of ERCP. Seventy-one patients had abdominal pain within three hours after ERCP. These were significant differences for s PEP(P 0.05). The median of Body mass index, the median time for ERCP, the median serum amylase level of the next day, past histories including drinking and smoking, past history of pancreatitis, sphincter of Oddi dysfunction, whether emergency or not, expertise of ERCP procedure, diverticulum nearby Vater papilla, whether there was sphincterotomy or papillary balloon dilation, pancreatic duct cannulation, use of intraductal ultrasonography enforcement, and transpapillary biopsies had no significant differences with s PEP.CONCLUSION Contrast media remaining in the pancreatic duct and the appearance of abdominal pain within three hours after ERCP were risk factors of s PEP.     

Transpapillary incision of refractory circumscript pancreatic duct stricture using wire-guided snare forceps

Endoscopic therapy of pancreatic duct(PD)strictures using balloon dilation and pancreatic duct stent(PS) placement has been reported to improve the severity of abdominal pain in selected patients with chronic pancreatitis(CP).However,some strictures are refractory and require frequent PS exchange to control symptoms.We describe two cases of successful endoscopic PD incision for difficult PD stricture using a wireguided snare.The snare is partially opened within the strictured pancreatic duct while applying ...     

Magnetic resonance study of the pancreatic duct.

AIM: to prospectively determine the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) in the evaluation of the normal and diseased pancreatic duct. METHODS: patients seen during a 6-month period with a diagnosis of biliary tract or pancreatic disease underwent endoscopic retrograde cholangiopancreatography (ERCP) after a previous MRCP. The pancreatic duct was evaluated with both techniques in 37 patients. RESULTS: the pancreatic duct appeared normal in ERCP in 27 patients, and also appeared normal in MRCP in 25 of these patients (specificity 93%). ERCP showed moderate-severe pancreatic duct dilation in 8 patients, in whom the same diagnosis was reached with MRCP (sensitivity 100%). The causes of dilation were chronic pancreatitis (2 patients), pancreatic cancer (3 patients) and ampullary tumor (2 patients); in 1 patient the findings with both techniques were suggestive of neoplasm of the head of the pancreas or focal chronic pancreatitis. Pancreas divisum was diagnosed in 2 patients by both methods, and the predominant dorsal duct as well as the ventral duct were visualized by MRCP. CONCLUSIONS: MRCP is an accurate technique for evaluating the normal or diseased pancreatic duct, and for determining the underlying disease.     

Bile duct dilation with chronic methadone use in asymptomatic patients: ERCP findings in 6 patients

BACKGROUND: Bile duct dilation in patients being treated by chronic narcotic substitution with methadone has been described but has not been systematically evaluated with ERCP. Retrograde cholangiographic findings in 6 patients taking methadone who were referred for evaluation of a dilated bile duct are described. METHODS: Six patients with chronic hepatitis (5 because of hepatitis C virus, 1 hepatitis B virus) who were taking methadone were evaluated by ERCP because of biliary dilation. Data were obtained regarding surgery, abdominal pain, weight loss, excessive ingestion of alcohol, liver disease, pancreatitis, and the dose and duration of methadone treatment. OBSERVATIONS: ERCP revealed bile duct dilation without evidence of choledocholithiasis, stricture, or obstructing mass. There was one complication (postprocedure pain thought to be due to methadone withdrawal). CONCLUSIONS: Chronic methadone use can lead to bile duct dilation without evidence of other significant pathology in asymptomatic patients. EUS may be safer than ERCP for evaluation of these patients, given that a need for therapeutic biliary intervention is unlikely.     

内窥镜逆行胰胆管造影术对胰腺分裂症的诊断、治疗价值研究

目的:探讨内窥镜逆行胰胆管造影术(ERCP)对胰腺分裂症(PD)的诊断、治疗方法及其效果的价值。方法:回顾性分析本院2008年6月至2012年9月明确诊断的20例PD患者的临床表现、诊断及治疗方法,比较治疗前后患者的体重变化,用直观模拟标度尺(VAS)评分来评估腹痛症状改善的情况。结果:患者症状以腹痛为主,急性胰腺炎或慢性胰腺炎急性发作的发生率为75%。经ERCP确诊的患者中,磁共振胆胰管成像(MRCP)的检出率为24%。内镜下治疗包括行内镜下十二指肠主和(或)副乳头切开引流(95%)、胰管支架置入(65%)及鼻胰管引流(55%)。治疗后患者体重增加(P<0.05),疼痛VAS评分下降(P<0.05)。结论:PD患者主要症状为腹痛,急性胰腺炎或慢性胰腺炎急性发作的发生率较高,内镜下治疗可有效减少PD患者腹痛的程度并增加患者体重。