The first presentation was on benign biliary strictures, given by Dr. Greg Cote of Indiana University. Dr. Cote divided etiologies into extrinsic vs. intrinsic and noted which ones require only bridging plastic stents while treating the underlying cause. The etiologies that require endoscopic therapy include chronic pancreatitis, postoperative (both post cholecystectomy and post transplant), primary sclerosing cholangitis, and the rare common bile duct stone–induced stricture. For primary sclerosing cholangitis, dilation therapy alone is usually sufficient and safer than dilation plus stenting. Strictures that are postoperative or due to chronic pancreatitis require aggressive endo-therapy combining dilation and placement of the maximal number of plastic stents possible vs. fully covered metal stent placement.
Dr. David Lichtenstein gave the second talk on indeterminate and malignant bile duct strictures. He discussed the multiple diagnostic methods needed to determine whether a stricture is benign or malignant. At endoscopic retrograde cholangiopancreatography it is useful to combine both brush cytology (+/– FISH) and intraductal biopsy. Even higher sensitivities are obtained by utilizing endoscopic ultrasound (EUS)/fine-needle aspiration (FNA), although if the patient is a resection or transplant candidate, some surgeons are fearful of tumor seeding with FNA. Other techniques discussed included cholangioscopy and probe-based confocal microscopy. The pros and cons of various palliative stents were also thoroughly discussed, as were experimental endoscopic therapies including photodynamic therapy and endobiliary radiofrequency ablation.
Dr. Grace H. Elta
Dr. Robert Hawes discussed the management of chronic pancreatitis pain with medical, endoscopic, and surgical therapy. He reviewed the causes of pain in chronic pancreatitis, the variable clinical presentations (main pancreatic duct obstruction or not, and ongoing inflammation or not), and the fact that placebo response rates are high. Medical therapies, including pancreatic enzymes, antioxidants, and octreotide are not well proven although often tried. Celiac axis blockade has at best a 50% chance of benefit and is not long lasting. Endoscopic therapy (often combined with extracorporeal shock wave lithotripsy has some efficacy for obstructive disease. Surgery is most effective for obstructive disease and surgical resection carries the risk of insulin dependence.
Dr. Martin Freeman discussed acute idiopathic recurrent pancreatitis and its likely multifactorial causes with interaction of genetic, anatomic, and environmental factors. He pointed out the frequent overlap presentation of acute pancreatitis versus chronic pancreatitis. He also pointed out the key diagnostic role of endoscopic ultrasound and the value of secretin-stimulated magnetic resonance cholangiopancreatography. The controversial role of endoscopic therapy was discussed.
Dr. Elta is professor of internal medicine, University of Michigan, Ann Arbor. She moderated the course at the 2014 Digestive Diseases Week.
