The advent of endoscopic retrograde cholangiopancreatography (ERCP) three decades ago had a dramatic impact on the treatment of common bile duct (CBD) stones. The advantages of ERCP over open surgery led to its widespread dissemination ad the predominant method of treating choledocholithiasis. After sphincterotomy, 85% to 90% of CBD stones can be removed with a Dormia basket or balloon catheter. These techniques are described as having both advantages and disadvantages. Methods for managing "difficult stones" include mechanical lithotripsy (ML), intraductal shock wave lithotripsy, such as electrohyhydroulic lthotripsy (EHL), laser-induced shock wave lithotripsy (LISL), extracoporeal shock wave lithotripsy, chemical dissolution, and biliary stenting. The local expertise and availability of equipment determines the choice of method used. In general, EHL or LISL is used for impacted CBD stones including stones in Mirizzi syndrome refractory to ML. ESWL is best suited for intrahepatic stones. Using currently bile duct stones still require surgical intervention.
Bile Ducts ; Catheters ; Cholangiopancreatography, Endoscopic Retrograde ; Choledocholithiasis ; Common Bile Duct ; Lithotripsy ; Mirizzi Syndrome ; Shock ; Stents

Pancreas transplantation is the most effective cure for type I diabetes because it is able to restore normal glucose homeostasis. Over the last 2 decades, improvements in immunosuppressive therapy have been paralleled by a marked decrease in surgical complications, by superior antimicrobial prophylaxis and therapy, and by better techniques for diagnosing and treating pancreas graft rejection. The result has been a steady increase in the number of pancreas transplants. However, differently from heart, lung and liver transplantation, pancreas transplantation cannot be considered a life-saving procedure and the advantages in the long term should be carefully considered and balanced with the morbidity and mortality associated to the surgical procedure and the side-effect of immunosuppression.
Glucose ; Graft Rejection ; Heart ; Homeostasis ; Immunosuppression ; Islets of Langerhans Transplantation ; Korea ; Liver Transplantation ; Lung ; Pancreas ; Pancreas Transplantation ; Transplants

Older age (> 55), obesity (BMI > 30), organ failure at admission, and pleural effusion and/or infiltrates are risk factors for severity that should be noted at admission. Tests at admission that are also helpful in distinguishing mild from severe acute pancreatitis include APACHE-II score > or = 8 and serum hematocrit (a value < 44 strongly suggests mild acute pancreatitis). An APACHE-II score that continues to increase for the first 48 h strongly suggests the development of severe acute pancreatitis. In general, an APACHE-II score that increases during the first 48 h is strongly suggestive of the development of severe pancreatitis. Contrast-enhanced CT scan is the best available test to distinguish interstitial from necrotizing pancreatitis, particularly after 2-3 days of illness. Mortality of sustained multisystem organ failure in association with necrotizing pancreatitis is generally > 36%. Transfer to an intensive care unit is recommended if there is sustained organ failure or if there are other indications that the pancreatitis is severe including oliguria, persistent tachycardia, and labored respiration. The early severity assessment is very important to appropriate treatment of acute pancreatitis.
Hematocrit ; Intensive Care Units ; Obesity ; Oliguria ; Pancreatitis ; Pleural Effusion ; Respiration ; Risk Factors ; Tachycardia

When diagnosing the nature of biliary strictures, it is sometimes difficult to perform non-invasive methods such as ultrasound, spiral computed imaging, magnetic resonance imaging, or endoscopic ultrasonography. Thus, treatment decisions are usually based on biopsy results. However, brush cytology or biopsy, which is widely used for biliary stenosis, has limitations owing to its low sensitivity and negative predictive value for malignancy. Currently, the most accurate method is bile duct tissue biopsy under direct cholangioscopy. On the other hand, intraductal ultrasonography administered under the guidance of a guidewire has the advantages of easy administration and being less invasive, allowing for adequate examination of the biliary tract and surrounding organs. This review discusses the usefulness and drawbacks of intraductal ultrasonography for biliary strictures.

Accurate diagnosis of pancreatic solid lesions is often difficult using conventional imaging modalities. With the recent introduction of contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS), it is now possible to evaluate the microvascular environment and dynamic enhancement of a variety of pancreatic lesions. With CEH-EUS, three patterns of pancreatic lesion enhancement compared with the normal pancreatic tissue (fast, simultaneous, or slow), two washout patterns (fast or slow) and two distribution patterns (homogeneous, inhomogeneous) can be described. By evaluating the microvasculature, enhancement speed, and washout pattern, CEH-EUS may help to differentiate pancreatic adenocarcinoma from other masses and differentiate between pancreatic neuroendocrine tumor (pNET) and inflammatory masses. The finding of a hyperenhancing lesion on CEH–EUS, both with homogeneous and inhomogeneous patterns, was a strong predictor of histology different from adenocarcinoma (94% positive predictive value). pNET was the most common hyperenhancing lesions overall. Although CEH-EUS is useful for ruling out pancreatic ductal adenocarcinoma, making the differential diagnosis between pNETs and pseudotumoral pancreatic masses is difficult because both may share an isovascular or hypervascular appearance. Currently the interpretation of CEH-EUS findings is examiner-dependent. In the future, digital image analysis by image-processing techniques should allow more objective interpretation.
Adenocarcinoma ; Diagnosis ; Diagnosis, Differential ; Microvessels ; Neuroectodermal Tumors, Primitive ; Neuroendocrine Tumors ; Pancreatic Ducts ; Ultrasonography*

The prognosis for hilar cholangiocarcinoma is limited by tumor spread along the biliary tree leading to refractory obstructive cholestasis, cholangitis, and liver failure. Palliation with biliary endoprostheses results in median survival times of 4-6 months for advanced bile duct cancer. Photodynamic therapy (PDT) is a local photochemical tumor treatment consisting of a photosensitizing agent combined with laser irradiation of a distinct wavelength. Tumor ablation with PDT combined with biliary stenting reduces cholestasis and significantly improves median survival time. However, the treatment is not widely available, and the photosensitizers used for PDT cause prolonged photosensitivity. Optimum control of tumor spread along the bile ducts and control of cholestasis and cholangitis will prolong survival in one to two thirds of patients, and renders them suitable for other antitumor therapies.
Bile Duct Neoplasms/*drug therapy ; *Bile Ducts, Intrahepatic ; Cholangiocarcinoma/*drug therapy ; Humans ; *Photochemotherapy ; Treatment Outcome

Acute pancreatitis remains the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP), with reported incidence rates that have changed little over several decades. Patient- and procedure-related risk factors for post-ERCP pancreatitis (PEP) are well-defined. Effective measures to prevent PEP have been identified, including improvements in cannulation techniques and pancreatic stenting, as well as pharmacological intervention. Pharmacotherapy has been widely studied in the prevention of PEP, but the effect in averting PEP has been inconclusive. Although pharmacological prophylaxis is appealing, attempts to find an ideal drug are incomplete. Most available data on the efficacy of pharmacological agents for PEP prophylaxis have been obtained from patients at average risk for PEP. However, recently, a randomized prospective controlled trial of rectal nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent PEP in high-risk patients was published. The results revealed that rectal indomethacin reduced the incidence of PEP significantly. Thus, rectal administration of diclofenac or indomethacin immediately before or after ERCP is used routinely to prevent PEP. However, additional studies with NSAIDs using large numbers of subjects are necessary to confirm the prophylactic effect of these drugs and to establish whether they act synergistically with other prophylactic interventions, including pancreatic stenting.
Acute Disease ; Administration, Rectal ; Animals ; Anti-Inflammatory Agents, Non-Steroidal/administration & dosage/*therapeutic use ; Cholangiopancreatography, Endoscopic Retrograde/*adverse effects ; Humans ; Pancreatitis/etiology/*prevention & control ; Treatment Outcome

To date, endoscopic manometry is the best method for evaluating the function of the sphincter. Sphincter of Oddi manometry (SOM) remains the gold standard to correctly diagnose the sphincter of Oddi dysfunction (SOD) and stratify therapy. Several dynamic abnormalities relating to the intensity, frequency, and propagation of sphincter contractions have been described. However, their clinical use generally has been abandoned in favor of basal sphincter pressure alone, because this measurement is stable over time, and has stronger interobserver reliablility, reproducibility on repeating testing, and is associated with the responsiveness to therapy. A significant elevated risk of pancreatitis was attributed to the technique. The risk of pancreatitits associated with manometric evaluation of the pancreatic sphincter is markedly reduced when manometry is performed with continous aspiration from the pancreatic duct via one of the 3 catheter lumens. This section reviews indications, conscious sedative drugs, techniques, and the appropriate interpretations of SOM.
Catheters ; Contracts ; Manometry ; Pancreatic Ducts ; Pancreatitis ; Sphincter of Oddi ; Sphincter of Oddi Dysfunction

No abstract available.

Ultrasound (US) is an essential diagnostic tool in almost every medical area. Therefore, abdominal US education for internal medicine residents was mandated by the Korean Association of Internal Medicine. However, US education for physicians has been conducted only in some university hospitals that directly perform abdominal US examinations in internal medicine, or some education is provided with the help of radiologists. US technology continues to become increasingly widespread, portable, and miniaturized. Furthermore, point-of-care US, i.e., US executed at the patient’s bedside to obtain real-time objective information with diagnostic and clinical monitoring purposes or to guide invasive procedures, has been incorporated in many specialties. Despite the increasing role of US, there is no systemized abdominal US education program. Therefore, the authors are trying to develop a structured abdominal US education program through cooperation with related US organizations.