ENDOSCOPIC ULTRASOUND AS A PREDICTOR AND GUIDE TO SUCCESSFUL ENDOTHERAPY IN CHRONIC PANCREATITIS

Aims:

Pancreatic calculi (PC), are a sequelae of chronic pancreatitis (CP) and may obstruct and produce ductal hypertension leading to pain. Indications for endotherapy include stones < 5 mm size, non-impacted stones in head of pancreas and absence of downstream strictures. The assessment prior to the procedure is done by MRCP or CT. However, problems are encountered during ERCP clearance which are not anticipated despite MRCP/CT. EUS can help by providing concordance or discordance with MRCP images and may help in further clarification.

To evaluate the role, feasibility and management changes of EUS prior to ERCP in patients planned for endotherapy in CP. Another objective was to evaluate whether EUS features of PD stones can serve as a predictor of successful removal during ERCP.

Methods:

The data of 412 patients during study period (2009 – 2016) with CP was retrospectively analysed. 143 were associated with stones in head/papillary region of pancreas. Out of these, 75 were excluded and remaining 68 were evaluated by EUS.

Results:

Out of 68 cases, 48 were associated with hard stones with acoustic shadowing while 20 were associated with soft stones without acoustic shadowing. In 20 soft stones cases, ERCP was successful in 18 patients. In 48 with hard stones, there was failure of endotherapy in 40 which required ESWL/surgery. The presence of large (≥5 mm), hard, immobile stones were negative predictors of successful endotherapy. Small, ampullary/papillary stones were positive predictors.

Conclusions:

EUS can differentiate “soft PD stones” from “hard PD stones”. “Hard PD stones” are better managed by ESWL. An EUS can make a diagnosis of ampullary/papillary stones and biliary obstruction which can be treated endoscopically. It can guide whether endotherapy needs to be performed through major or minor papilla. EUS by diagnosing pancreatic tumour/strictures missed on other imaging modalities allows early surgical reference and hence improves long term prognosis.