Pancreatic Cancer: The Use of Endosonography

Endoscopy in Crohn’s Disease
By:Peter Darwin, MD
Director of Gastrointestinal Endoscopy
University of Maryland Hospital
Division of Gastroenterology

Outline
* Case histories
* Diagnosis
* Assessment of response
* Dysplasia and surveillance
* Bleeding
* Stricture management
* Emerging technology

Case 1
Case 2

Diagnosis

* Asymmetric patchy inflammation
* Skip lesions
* Rectal sparring
* Ulcerations
* Biopsy
o Erosions and normal mucosa
o Granulomas in 15 to 35% of specimens

Assessment of Response
* Endoscopic monitoring may have a role with biologic agents
* Subgroup of the ACCENT-1 trial
o Mucosal healing with infliximab, time to relapse is significantly prolonged
+ 9 with endoscopic healing remained in remission for a median of 20 weeks
+ 4 clinical remission only, relapse after a median of 4 weeks


Dysplasia and Surveillance
* Extensive colitis > 8 years
* Accuracy in predicting dysplasia correlates with # of biopsies
* Annual colonoscopy with multiple biopsy specimens
o 4 circumferential each 10 cm


Approach to Polypoid Lesions
Adenoma like DALM
Outside colitis
Within colitis
Polypectomy/biopsy
Non-IBD
adenoma
Polypectomy
Regular surveillance
No dysplasia
No carcinoma
Indeterminate
Flat dysplasia
carcinoma
Polypectomy
Increased surveillance
Colectomy

Chawla A, Lichtenstein G. Gastrointest Endoscopy Clin N Am 12 (2002) 525-534

Hemorrhage in Crohn’s

* Acute major hemorrhage is uncommon
* Bleeding can occur in any segment
* Massive hemorrhage is usually from an ulcer eroding into a vessel
* Resuscitation
* Endoscopy vs tagged RBC scan to localize a bleeding segment
* Avoid embolization if possible

Hemorrhage in Crohn’s
* No data to support cautery or injection therapy
* Surgical intervention
* Consider tattooing of the site


* Database review from 1989 to 1996
o 1739 patients / 31 (1.8%) due to IBD
o 3 with UC and 28 with CD / 1 UGI source
o None hematemesis
o GI hemorrhage in 0.1% UC and 1.2% CD
* Diagnostic evaluation
o Source found by colonoscopy in 25 patients (25%) and EGD in 2 patients


Pardi D, Loftus E, et al. Gastrointest Endosc 1999;49:153-7.

Acute Major GI hemorrhage in IBD

Endoscopic Therapy for Patients with CD and Focal Sites of hemorrhage
Patient Site Stigmata Endoscopic Rx Medical Rx

1 Duodenum clot Injection Corticosteroids ranitidine

2 Jejunum oozing ulcer Injection Corticosteroids ranitidine

3 Colon clot Injection with Corticosteroids

coagulation metronidazole


Clinical Course
Balloon Dilation of Strictures


Descending Colon Stricture

Colonic Strictures
* No randomized clinical trials
* Consider nonsurgical management if:
o Endoscopically accessible
o Multiple prior resections
o Shorter strictures (less than 5 cm)
o Steroid injection if significant inflammation

Malignant Potential
* Increased incidence of colonic and small bowel carcinoma
* Higher risk with longer duration of disease
* Stricture biopsy required
* Utilize thin caliper scopes to evaluate proximal to the stenosis


Balloon Dilation of Strictures
* High success rate for anastamotic strictures
* Used for colonic and duodenal stenosis
* TTS balloons 15 to 18 mm for 1 minute
* Fluoroscopy only if needed
* Successful if scope passed post
* Medical treatment
* Complications

Injection of Corticosteroids
* Post dilation
* Sclerotherapy needle
* Triamcinolone 40 mg/ml – 1 cc in 4 quadrants at site of maximal inflammation/stenosis

Intestinal Stents
* Limited data
* Migration is common
* Coated metal enteral stents / plastic stents may be of benefit

Endoscopic Balloon Dilation of Ileal Pouch Strictures

* Aim: evaluate outpatient ileal pouch stricture dilation
* Methods: Nonfluroscopy, nonsedated dilation with 11-18 mm TTS balloons in 19 consecutive patients

Shen B, Fazio V, Remzi F, et al. Am J Gastro 2004;99:2340-47.


Inlet and Outlet Strictures

Clinical Presentation
n (%)
Diarrhea
Abdominal pain
Perianal pain
Bloating
Nausea or vomiting
Bleeding
Daily use of antidiarrheal agents
Fistulas
Weight loss

Types of Strictures
Number Inlet Outlet of cases strictures strictures
Crohn’s disease of the pouch Cuffitis
Pouchitis

Total
Pouch Disease Activity Index

Strictures Scores
Cleveland Global Quality of Life Scores

Emerging Technology

* Double balloon enteroscopy
* Endoscopic ultrasound
* Optical coherence tomography
* Magnification chromoendoscopy


Takayuki Matsumoto, Tomohiko Moriyama, et. al.
Gastrointest Endosc 2005;62 :392-8


Optical Coherence Tomography
* Based on low-coherence

interferometry
* High resolution imaging
* Uses light (not sound)
* Resolution 10X greater than EUS
* No acoustic coupling

Magnification Chromoendoscopy
* Utilizes magnifying endoscopes with tissue stains to better characterize the mucosa
* May improve efficacy of surveillance colonoscopy
o 165 patients with UC randomized to conventional screening vs CE.
o Targeted biopsies
o Identified more areas of dysplasia

Kiesslich R, Fritch J, et. al. Gastro 2002;124:880-8.

Colonic Pit Pattern
Huang Q, Norio F, et. al. Gastrointest Endosc 2004; 60:520-6.

Case 1

* The patient is a 28 year old man with isolated iliocolonic Crohn’s disease resected 8 years prior.
* Was without symptoms but has developed intermittent abdominal distension, bloating and emesis requiring admission.
* SBFT shows a 1 cm tight anastamotic stenosis
* Is attempt at endoscopic management appropriate?

Case 2

* 19 year old student presents with several months of vague epigastic discomfort, night sweats and weight loss.
* Evaluation shows a microcytic anemia and thrombocytosis.
* Abdominal CT shows a thickened mid-ileum without lymphadenopathy. Attempts to intubate the TI during colonoscopy were unsuccessful.
* Is tissue needed prior to treatment ?

Pancreatic Cancer: The Use of Endosonography