Liver Review - Issue 6 - Summer 2001
- Liver Program Expands Role in Pancreatico-biliary Disease Management
- Motility Expertise Aids in Treating Biliary Pain
- MRCP Offers Non-Invasive Option for Evaluating Pancreas and Bile Ducts
- Endoscopic Ultrasound Enables Precise Imaging of Pancreas and Biliary Tract
- Laparoscopic Management and Treatment of Pancreas and Bile Duct Disease
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Liver Program Expands Role in Pancreatico-biliary Disease Management
Leading-Edge Techniques Offered for Gastrointestinal, Colorectal Cancers and Motility Impairments
Robert Gish, M.D., Director, Liver Disease Management & Transplant Program
Advancements in technology and the expertise of physicians at California Pacific Medical Center have expanded our Liver Program into management of pancreatico-biliary disorders, liver disease and gastrointestinal oncology. This expertise, paired with interventional, minimally invasive techniques, means that we can offer new options for diagnosis and treatment of abdominal pain, hepatobiliary masses and disease.
This issue of Liver Review examines new techniques used at California Pacific for pancreatico-biliary disease. By using a team approach in which physicians from our Liver Program, Minimally Invasive Surgery and Departments of Gastroenterology and Radiology work together to manage patient care, remarkable outcomes result. Some of the innovative programs the Medical Center has initiated in the past six months include:
Motility Program
Directed by William Snape, Jr., M.D., a nationally recognized authority on motility and manometric studies, California Pacific offers leading-edge motility evaluation for chronic and unexplained abdominal pain or muscular disorders.
Interventional Endoscopy Service(IES)
With interventional endoscopy, our team can further evaluate gastrointestinal conditions. Kenneth Binmoeller, M.D., a leading authority in advanced endoscopy, recently joined California Pacific Medical Center as Director of Interventional Endoscopy. Among the procedures offered by IES include:
• Diagnostic and interventional endoscopic ultrasound (EUS)
• Bilio-pancreatic endoscopy
• Treatment of bleeding (hemostasis)
• Early cancer detection and treatment (mucosectomy)
• Motility and manometric studies
• Endoscopic anti-reflux techniques
To obtain further information about our program offerings or if you have patient referrals, contact our Specialty Referral Program at 1-888-637-2762.
Motility Expertise Aids in Treating Biliary Pain Top of Page
William Snape, Jr., M.D., director, Motility Program
While gallstones are the most common cause of biliary pain, an interesting clinical problem occurs when patients develop such pain but have no stones or have undergone a previous cholecystectomy. In these patients, motility studies—-as well as interventional endoscopy techniques—-can help diagnose movement impairment and offer therapeutic relief.
Biliary Pain With a Normal Gallbladder
When patients with biliary pain are referred to California Pacific's Liver Disease Management Program, the team assesses gallbladder function with an ultrasound and HIDA scan. If the gallbladder appears normal, possible causes of biliary pain may include:
William Snape, Jr., M.D., director, Motility Program
While gallstones are the most common cause of biliary pain, an interesting clinical problem occurs when patients develop such pain but have no stones or have undergone a previous cholecystectomy. In these patients, motility studies—as well as interventional endoscopy techniques—can help diagnose movement impairment and offer therapeutic relief.
Biliary Pain With a Normal Gallbladder
When patients with biliary pain are referred to California Pacific's Liver Disease Management Program, the team assesses gallbladder function with an ultrasound and HIDA scan. If the gallbladder appears normal, possible causes of biliary pain may include:
• Biliary Movement Impairment (dyskinesia)
In patients with gallbladder impairment, the gallbladder does not fully empty after stimulation of the cholecystokinin, causing severe abdominal pain. To measure gallbladder emptying, radionuclide studies using HIDA are employed. If the gallbladder empties less than 35%, the causes are either an abnormality in its smooth muscle wall or in the emptying coordination. A cholecystectomy can resolve either of these problems, thereby eliminating patients' symptoms.
Biliary Pain Without a Gallbladder
Biliary pain occurring after gallbladder removal is frustrating to both patients and physicians. The first line of treatment is an endoscopic retrograde cholangiopancreatography (ERCP) to verify no gallstone retention. If the ERCP shows no stones, other non-anatomic causes may be considered including:
• Sphincter of Oddi Dysfunction
Sometimes, the Sphincter of Oddi undergoes a spasm, causing partial obstruction and pain in the bile duct, and mimicking symptoms seen in patients with obstruction. Biliary manometry is used to make a definitive diagnosis. If sphincter pressure is elevated, a sphincterotomy-—endoscopic incision of the sphincter-—is used to treat dysfunction and relieve symptoms.
• Small Intestine Motility Disorder
A disorder in this region may alter the flow of contents through the biliary system, causing abdominal pain. In some patients, excessive contractions of the small intestinal muscle wall surrounding the Ampulla of Vater can be associated with motility disorders. The abnormal small intestinal contractions may be part of a generalized gastrointestinal motility disturbance, resulting in slow transit times, constipation and biliary pain.
MRCP Offers Non-Invasive Option for Evaluating Pancreas and Bile Ducts Top of Page
Kirk Moon, M.D., medical director, Magnetic Resonance Imaging
Offering images similar to those from endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) studies, magnetic resonance cholangiopancreatography (MRCP) is a newer, non-invasive method for evaluating the hepatobiliary and pancreatic ductal systems.
Unlike other techniques, MRCP does not use injections, anesthesia, instrumentation or radiation. Even so, its sensitivity and specificity is similar to ECRP in displaying anatomical abnormalities, stones, strictures, tumors and inflammatory conditions. While the anatomic resolution and diagnostic accuracy of this technique is slightly lower than ERCP, the differences are minimal. MRCP offers the advantage of being fast, non-invasive, safer, less operator dependent and cheaper than MRCP. Its only disadvantage is the lack of therapeutic capabilities.
To undergo an MRCP exam, patients must be eligible for MRI scanning in general (no implanted electronic devices) and able to hold their breath for 20 seconds to obtain motion-free images. The entire examination takes less than 30 minutes and requires no special preparation.
MRCP Indications
Currently, principal indications for MRCP include:
1) Screening for patients with low to intermediate probability of bile duct stones. MRCP has a 95 -100% accuracy for this application and is particularly useful in patients with suspected gallstone pancreatitis and in patients with non-specific abdominal pain and normal liver enzymes. In these cases, a normal MRCP can prevent an unnecessary diagnostic ERCP.
2) Failed or incomplete ERCP or for patients who are not ERCP candidates due to conditions such as surgical diversion of the biliary tree.
3) Variant ductal anatomy. MRCP can effectively demonstrate anatomic variants and congenital anomalies. It may also have a role prior to laparoscopic cholecystectomy in identifying and defining variant anatomy that could complicate the surgical procedure.
4) Patients with surgically altered biliary or upper gastrointestinal anatomy in which ERCP may be difficult or impossible.
5) Primary Sclerosing Cholangitis (PSC). MRCP can show ductal irregularities, strictures and stones that characterize PSC—including the ducts' proximity to a complete obstruction—and avoids the risk of ERCP-induced sepsis.
6) Complications of chronic pancreatitis. MRCP can demonstrate ductal dilatation, strictures, intraductal stones, fistulas and pseudocysts and can serve as a planning tool prior to surgical drainage procedures.
In patients for whom the probability of therapeutic intervention is low, or in whom one of the above conditions exist, MRCP is an excellent and safe alternative to ERCP and a useful diagnostic technique.
Endoscopic Ultrasound Enables Precise Imaging of Pancreas and Biliary Tract Top of Page
Kenneth Binmoeller, M.D., director, Interventional Endoscopy 
Endoscopic ultrasound (EUS)—-one of the most significant advances in endoscopy-—enables visualization into and beyond the gastrointestinal wall, opening a new dimension of pancreatico-biliary diagnosis. To perform EUS, a flexible endoscope equipped with a tiny television camera is inserted into the digestive tract, providing real-time ultrasound images of the pancreas, bile duct, liver and gallbladder (see illustrations). Among the indications for EUS include:
Bile Duct and Gallbladder Stones
EUS has a sensitivity of more than 90% in detecting bile duct and gallbladder stones according to multiple studies. In fact, EUS is preferred to ERCP in patients with a low probability of bile duct stones because it has a much lower rate of complications. Related indications for EUS include:
• Exclusion of bile duct stones prior to laparoscopic cholecystectomy;
• Exclusion of an extrahepatic component to cholestasis; and
• Exclusion of bile duct stones as an etiology of acute pancreatitis.
Ampulla Evaluation
A particular advantage of EUS is ampulla evaluation. Other imaging modalities such as computed tomography (CT) and ultrasound frequently fail to detect ampullary pathology. EUS, however, allows detailed inspection enabling one to differentiate between a “bulging” papilla caused by a gallstone and an ampullary tumor. If a tumor is visualized, EUS can accurately stage its depth to guide therapy.
Tumor Detection
With a nearly 100% imaging sensitivity, EUS is the preferred modality for detecting small (< 2 cm) pancreatic tumors. For patients suspected to have a neuroendocrine tumor (insulinoma, gastrinoma) based on clinical symptoms, EUS should be used as a first-line study. For larger pancreatic tumors, EUS' superior resolution enables more accurate staging than CT or MRI in identifying patients with unresectable disease. In addition to local unresectability, EUS may also detect distant metastatic spread (ascites, lymph nodes, liver metastases).
Fine-needle aspiration (FNA)cytology can also be obtained with EUS to identify a tumor that will benefit from nonsurgical therapy, such as a lymphoma or small cell carcinoma. A tissue diagnosis of the primary malignancy is important for those who will be offered palliative chemoradiotherapy.
Pancreatitis
EUS is the best test available for evaluating pancreatic structure and detecting subtle ductal and parenchymal changes of mild pancreatitis. Unlike ERCP, EUS does not carry a risk of inducing pancreatitis, making it a safer procedure. In patients with severe abdominal pain resulting from chronic pancreatitis, a celiac axis neurolysis or block can be delivered via EUS.
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Laparoscopic Management and Treatment of Pancreas and Bile Duct Disease
Gregg Jossart, M.D., director, Minimally Invasive Surgery
For patients with tumors in or around the pancreas and bile ducts, diagnostic laparoscopy with laparoscopic ultrasound—-termed staging laparoscopy—-is an ideal procedure that complements endoscopic ultrasound (EUS). In tumors that appear resectable by EUS, an operative approach that starts with staging laparoscopy can diagnose small liver metastases and extrahepatic spread of tumor. Additionally, staging laparoscopy can obtain larger core biopsies that allow for a definitive pathologic diagnosis. Approximately 25% of patients with resectable tumors can ultimately be diagnosed and treated laparoscopically.
Laparoscopic Treatment of the Pancreas
Cystic lesions of the pancreas are notoriously difficult to diagnose. Diagnostic laparoscopy, however, can be used to biopsy and treat most of these lesions. Simple cysts can be aspirated via ultrasound imaging while pancreatic pseudocysts can be treated using a transgastric laparoscopic technique to drain the cyst into the stomach.
With laparoscopic techniques, cystic neoplasms can be diagnosed and resected. Usually, these types of lesions occur in the tail end of the pancreas and can be treated with a laparoscopic distal pancreatectomy to preserve the spleen (see illustration).
Laparoscopic Treatment of the Bile Duct
Bile duct lesions such as strictures, stones and tumors can be diagnosed and sometimes treated with diagnostic laparoscopy and ultrasound or cholangiogram. Laparoscopic treatment is indicated when conventional ERCP is not available, or can be used as an alternative to ERCP.
For patients with pain related to gallstones and common bile duct stones, a laparoscopic cholecystectomy can be performed along with a cholangiogram and common bile duct exploration.