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Endoscopy in the Treatment of Pancreatic Diseases
What is pancreas?
Pancreas is an important digestive organ located behind the stomach and connected to the intestines. It is primarily useful for the digestion of fat and other food substrates. It also helps in control of blood sugar by virtue of various hormones including insulin and glucagon etc.
What are the pancreatic diseases we come across?
Pancreatitis means inflammation and swelling of the pancreatic gland. 1) Acute pancreatitis manifests with severe pain in the upper abdomen and vomiting and organ failure (in some cases) affecting lungs, kidneys and heart which carries high mortality. The initial treatment includes hydration, pain control, antibiotics and restoration of organ function in ICU 2) Chronic pancreatitis can cause recurrent episodes of pain abdomen, vomiting, weight loss, diarrhoea, diabetes etc. The management includes pain control, pancreatic enzyme replacement, antioxidants, control of diabetes 3) Pancreatic tumors and cysts again present with pain abdomen, weight loss, recent onset of diabetes etc. Once proved to be a cancer, further treatment includes, chemotherapy alone or in combination with surgery depending on the tumor stage.
What is endoscopic ultrasound (EUS) and ERCP ? How is it different from regular endoscopy ?
EUS is a new hybrid technology wherein a special ultrasound probe is fitted on the tip of endoscope allowing us to scan the internal organs from within. Pancreas, given its location, has been a difficult organ to reach. But with EUS, pancreas can be closely evaluated within a few millimetre distance and appropriate treatment can be offered. Similarly other organs like liver, gallbladder, lymph nodes can be scanned, evaluated, biopsied and treated using EUS.
ERCP is a different endoscopic technology where in the bile duct (outflow tract from liver into the intestines) and pancreatic ducts can be evaluated and treated.
How does endoscopy help in the treatment of acute pancreatitis ?
Infected collections complicate in the later course of acute pancreatitis. Therapeutic endoscopy like EUS helps in their treatment. EUS helps in internal drainage of the infected collections without any external scar, wound or stitch. This procedure is called EUS guided cystogastrostomy and necrosectomy. > 95% patients can avoid invasive surgery with this approach.
How does endoscopy help in the treatment of chronic pancreatitis ?
Stones, scarring and narrowing of ducts complicate the course of chronic pancreatitis. ERCP helps in achieving the patency of pancreatic ducts. Placement of stents, removal of stones, dilatation of the narrowed segments in pancreatic duct is done during ERCP. In refractory cases, EUS can guide in injecting medicines into the nerve endings around the pancreas for adequate pain control thus improving the quality of life.
How does endoscopy help in treatment of pancreatic tumors, cancers and cysts ?
Since EUS is the best modality to scan and reach pancreas, it can detect the tumors and cysts even at millimetre size. These suspicious areas can be biopsied under EUS guidance via internal approach using special needles and diagnosis of early cancers can be made easily. Similarly cysts can be aspirated and fluid can be sent for further analysis using EUS. Medicines can be injected into the nerve endings around the pancreatic tumors for a better pain control under EUS guidance. Pancreatic tumors can cause obstructive jaundice due to blockage of the bile ducts which run in close proximity. The obstructed system can be opened up for relief of jaundice with ERCP using metal stents. In difficult cases, EUS is also used in the drainage of obstructed system by internally bypassing the bile duct into the stomach or small intestine with the help of dedicated stents. This relieves jaundice which can be a major problem in patients with pancreatic cancers. Additionally pancreatic cancers and cysts can be ablated under EUS guidance using radio frequency energy or chemical injections.
Dr. Chalapathi Rao Achanta
Consultant Medical Gastroenterologist, Liver Specialist, Interventional Endoscopist
KIMS ICON Hospital, Vizag