Endoscopic ultrasonography in the diagnosis of pathology of the gastrointestinal tract

Endoscopic ultrasonography is a relatively new endoscopic method of examination to determine the invasion of tumors of the gastrointestinal tract, detection and sizing of pancreatic tumors, diagnosis of chronic pancreatitis, pathology of the biliary tract. The method combines the possibilities of two studies: endoscopic and ultrasound. The study is performed using a video endoscope, at the end of which is a scanning ultrasound sensor. The advantages of endoscopic ultrasound over traditional ultrasound examination through the anterior abdominal wall are that the ultrasound sensor under visual control through the lumen of the digestive tract can be carried out directly to the investigated object. The use of very high frequencies of ultrasound provides high image quality with a resolution of less than 1 mm, inaccessible to other research methods (ultrasound, computer tomography and magnetic resonance imaging, endoscopic cholangiopancreatography).

SP3.1.2 The influence of frailty on outcomes for older adults admitted to hospital with benign biliary and pancreatic disease

Aims To study the prevalence and complications of biliary disease with increasing age. We describe the prevalence of frailty in older patients hospitalised with benign biliary and pancreatic disease and establish its association with mortality and duration of hospital stay. Methods Prospective observational cohort study of patients aged 75 years and over admitted with acute biliary disease between 17/09/2014 and 20/03/2017. Clinical Frailty Scale (CFS) score was recorded on admission. Results 200 patients with a median age of 82 (75-99), 60% females, 154 (77%) were independent for personal and 99 (49.5%) for instrumental activities of daily living. Acute cholecystitis was the most common diagnosis (43%), acute cholangitis (36%) and acute pancreatitis (21%). 99 patients were non-frail (NF = CFS 1-4) and 101 were frail (F= CFS ≥5). 104 patients received medical treatment only. Surgery was more common in non-frail (F 2% vs. NF 11%), percutaneous drainage more frequently carried out in frail patients (15% vs. NF 5%) and endoscopic cholangiopancreatography (ERCP) was similar in both groups (F 32%vs. NF 31%). Frailty was associated with worse clinical outcomes. F vs. NF: functional deconditioning (34% vs. 11%), increased care level (19% vs 3%), length of stay (12 vs. 7 days), 90-day (8% vs. 3%) and 1 year-mortality (48% vs. 24%). Conclusions : Higher frailty scoring is associated with increased mortality in acute biliary disease. Individuals living with frailty were less likely to undergo surgical treatment, spent longer in hospital and were less likely to remain alive at 12 months after hospital discharge.

Diagnosis and Treatment of Acute Pancreatitis: Bibliographic Review

Introduction: Acute pancreatitis (AP) is a sudden, reversible inflammatory process of the pancreas, caused by self-digestion. In Ecuador in 2016, 4715 cases were presented, with a mortality of 2.99%. The etiology includes gallstones, alcoholism, hypertriglyceridemia. It presents with upper abdominal pain, nausea and vomiting, it is hospital management. Methodology: It is a descriptive review of the literature on the diagnosis and treatment of BP, based on 31 articles in English and Spanish. Discussion and Results: AP is diagnosed by the clinic and by the serum measurement of lipase and pancreatic amylase. You can also perform other studies such as C-reactive protein, alanine aminotransferase, aspartate aminotransferase, ultrasonography, computed tomography, magnetic resonance imaging, among others. The management of the intake as the main points of perfusion, analgesia, nutrition, clinical, radiology, retrograde endoscopic cholangiopancreatography, antibiotic and surgery. Conclusion: Although the diagnosis is generally clinical and laboratory, for atypical cases, imaging studies are very useful to confirm or exclude the diagnosis. The treatment of PA is summarized in the PANCREAS nemotechnics. (P perfusion, A analgesia, N nutrition, C clinical, R radiology, E endoscopic retrograde cholangiopancreatography, A antibiotic, S surgery). Keywords: pancreatitis, inflammation, diagnosis, treatment. RESUMEN Introducción: La pancreatitis aguda (PA) es un proceso inflamatorio repentino, reversible del páncreas, causado por autodigestión. En Ecuador en el 2016 se presentaron 4 715 casos, con una mortalidad del 2,99%. En la etiología constan: Cálculos biliares, alcoholismo, hipertrigliceridemia. Se presenta con dolor abdominal superior, náuseas y vómito, es de manejo hospitalario. Metodología: Es una revisión bibliográfica descriptiva, sobre el diagnóstico y tratamiento de la PA, en base a 31 artículos en inglés y español. Discusión y Resultados: La PA se diagnostica mediante la clínica y por la medición sérica de lipasa y amilasa pancreática; también se pueden realizar otros estudios como proteína C reactiva, alanina aminotranferasa, aspartato aminotransferasa, ultrasonografía, tomografía computarizada, imagen por resonancia magnética, entre otros. El tratamiento apunta a brindar una adecuada perfusión de tejidos, buena analgesia y principalmente evitar complicaciones. El manejo toma como como principales puntos perfusión, analgesia, nutrición, clínica, radiología, colangiopancreatografia retrograda endoscópica, antibiótico y cirugía. Conclusiones: A pesar de que el diagnóstico es generalmente clínico y de laboratorio, para casos atípicos son de gran utilidad los estudios de imagen para confirmar o excluir el diagnóstico. El tratamiento de PA se resume en la nemotecnia PANCREAS. (P perfusión, A analgesia, N nutrición, C clínica, R radiología, E colangiopancreatografía retrógrada endoscópica, A antibiótico, S cirugía). Palabras clave: pancreatitis, inflamación, diagnóstico, tratamiento.

513 THE INFLUENCE OF FRAILTY ON OUTCOMES FOR OLDER ADULTS ADMITTED TO HOSPITAL WITH BENIGN BILIARY AND PANCREATIC DISEASE

Introduction The prevalence and complications of biliary disease increase with age. We describe the prevalence of frailty in older patients hospitalised with benign biliary and pancreatic disease and establish its association with mortality and duration of hospital stay. Methods Prospective observational cohort study of patients aged 75 years and over admitted with a diagnosis of acute biliary disease to a surgical hospital unit between 17/09/2014 and 20/03/2017. Clinical Frailty Scale (CFS) score was recorded on admission. Results We included 200 patients with a median age of 82 (75–99), 60% females, 89% lived in their homes, 154 (77%) were independent for personal and 99 (49.5%) for instrumental ADLs, 95% mobilised independently, 17.5% had memory impairment and 8% low mood. Acute cholecystitis was the most common diagnosis (43%) followed by acute cholangitis (36%) and acute pancreatitis (21%). 99 patients were non-frail (NF = CFS 1–4) and 101 were frail (F = CFS ≥5). 104 patients received medical treatment only. Surgery was more common in non-frail (F 2% vs. NF 11%), percutaneous drainage more frequently carried out in frail patients (15% vs. NF 5%) and endoscopic cholangiopancreatography (ERCP) was similar in both groups (F 32%vs. NF 31%). Frailty was associated with worse clinical outcomes in F vs. NF: functional deconditioning (34% vs. 11%), increased care level (19% vs 3%), length of stay (12 vs. 7 days), 90-day (8% vs. 3%) and 1 year-mortality (48% vs. 24%). Conclusion Half of patients in our cohort of older adults hospitalised with acute biliary disease were frail. Higher scores of frailty are associated with increased mortality. Compared with non-frail patients, individuals living with frailty were less likely to undergo surgical treatment, spent longer in hospital and were less likely to remain alive at 12 months after hospital discharge.

Gallstone Disease Complicated by Choledocholithiasis: Modern Aspects of Diagnostics

Choledocholithiasis is an urgent problem of modern hepatobiliary surgery and accounts for 60% of all obstructive jaundice. Stones of the common bile duct cause cholestasis and mechanical jaundice syndrome and in case of untimely diagnostics lead to the development of such severe complications as acute cholangitis and biliary sepsis. The criteria for determining the sequence, stages and volume of diagnostic measures with choledocholithiasis have not been determined by now. The purpose of the study. Optimization of the instrumental stage of the diagnostics of patients with choledocholithiasis. Materials and methods. 56 patients with choledocholithiasis were studied. The diagnostic program was expanded due to the instrumental stage using ultrasound, duodenopapiloscopy, endoscopic retrograde cholangiopancreatography and magnetic resonance tomography. The criterion for the patients selection was the syndrome of distal choledochal patency violation and the presence of stones in it according to echosonography and endoscopic cholangiopancreatography. Results and discussion. At sonography bilious hypertension was established in all 72 (100%) patients. Mechanical jaundice was present in 54 (96.4%) patients. Hepatic dysfunction with 84±9.6 mmol/l hyperbilirubinemia and an increase in AST and ALT levels to 1.2±0.9 mmol/l and 1.5±1.1 mmol/l, were verified respectively. At endoscopic retrograde cholangiopancreatography choledocholithiasis was found in 54 (96.4%) patients. Single stones were present in 18 (32.1%) and multiple – in 38 (67.9%) patients. In 52 (92.9%) cases, stones up to 1.5 cm in diameter were removed with a Dormia basket at one time or after mechanical lithotripsy. In 4 (7.1%) patients stones from 1.7 to 2.0 cm could not be removed endoscopically. Choledoch stenting was performed in 12 (21.4%) patients. One-stage transpapillary treatment was carried out in 38 (67.9%) patients, two and three stage treatment – in 14 (25%) cases, and «open» choledocholithotomy – in 4 (7.1%) cases. Conclusion. The program of choledocholithiasis diagnostics with the gradual use of clinical, laboratory, radiological and endoscopic data allows carrying out correct detailing of the cause, level, degree of common bile duct obstruction and the complicated course of the disease in 100% of cases

DOES AGE INFLUENCE IN ENDOSCOPIC THERAPEUTIC SUCCESS ON THE BILIARY TRACT?

ABSTRACT Background: Retrograde endoscopic cholangiopancreatography (ERCP) effectively treats biliary and pancreatic disorders. Its indications are limited and precise, since its misuse delays adequate treatment, increases costs and to patient´s adverse events. Aim: To compare clinical, radiological and exploratory characteristics in relation to therapeutic success in patients undergoing ERCP in relation to age. Method: 421 patients who underwent the method were retrospectively studied; those who were not able to access the duodenal papilla were excluded. The patients were divided into two age groups: <60 years (group 1) and >60 years (group 2), and the variables of gender, examination indications, radiological findings, therapeutic success, diagnosis and the occurrence of immediate adverse events were analyzed. Results: 177 patients were allocated to group 1 and 235 to group 2. The main indication found in both groups was choledocholithiasis. In group 2, the number of cases of acute cholangitis (p=0.001), biliary stenosis (p=0.002) and papilla cancer (p=0.046) was higher. In this group, urgent indication for ERCP was higher (p=0.042), as well as the diagnosis of biliary tract dilatation (p<0.001). The placement of prostheses was the most common procedure performed in both groups, but the greatest number of patients in absolute quantity occurred in group 2. In group 1, the success in catheterization and the chance of achieving clearing of the biliary tract was significantly higher in compared to group 2 (p=0.016, OR=2.1). Conclusion: The success of catheterization and complete clearance of the bile duct was significantly higher in the group of young patients.

Endoscopic Ultrasonography Findings of Early and Suspected Early Chronic Pancreatitis

Chronic pancreatitis (CP) is associated with a risk of pancreatic cancer and is characterized by irreversible morphological changes, fibrosis, calcification, and exocrine and endocrine insufficiency. CP is a progressive disease with a poor prognosis and is typically diagnosed at an advanced stage. The Japan Pancreas Society proposed criteria for early CP in 2009, and their usefulness has been reported. Recently, a mechanism definition was proposed by the International Consensus Guidelines and early CP was defined as a disease state that is not based on disease duration. CP is diagnosed by computed tomography, magnetic resonance imaging, and endoscopic cholangiopancreatography, which can detect calcification and dilation of the pancreatic ducts; however, detecting early CP with these modalities is difficult because subtle changes in early CP occur before established CP or end-stage CP. Endoscopic ultrasonography (EUS) is useful in the diagnosis of early CP because it allows high-resolution, close-up observation of the pancreas. In addition to imaging findings, EUS with elastography enables measurement of the stiffness of the pancreas, an objective diagnostic measure. Understanding the EUS findings of early CP is important because a histological diagnosis is problematic, and other modalities are not capable of detecting subtle changes in early CP.