questions/help needed re ercp results

[Guest guest]

Hi everyone, I am a relatively new member and I would be really

grateful for your views and help regarding my recent ERCP results.

This was my 2nd ERCP, the first one was normal in Dec 2005.

So Dr reported that the CBD was normal at 6mm, but that all my

intrahepatic ducts were very narrow & were less than 1mm in diameter

(I believe 2mm is normal). He said was difficult to see the usual

beading with ducts this narrow but there was a suggestion that they

were irregular. He basically said he couldn't see inside them they

were that narrow! He confirmed that the appearance was not due to

underfilling as he selectively cannulated the right hepatic duct and

also used a balloon. He said the appearances are consistent with PSC.

He also noted that the main pancreatic duct was also very narrow (2mm

instead of 4mm) but looked normal.

I also experienced severe pain in the ducts when injected with the

dye which he said he had not seen before. The pain replicated my

right upper quadrant pain that I have everyday (though it was more

severe). This at last explained the reason for my pain. The theory

is that as all the ducts are narrow the bile struggles to get through

constantly and builds pressure resulting in pain, and that the ducts

are going into spasm.

I am not showing signs of jaundice and my liver numbers are deranged

but only mildly so and have been for over 5 years. I am not on URSO

yet and so I hope this will help with the pain.

My questions are:

Has anyone else got this presentation or is it unusual?

Has anyone else had severe pain during ERCP when dye injected?

If all my ducts are this narrow how do we relieve the constant

pressure, from what I have read stents aren't of any use here?

Does the Drs theory sound correct?

Is there any literature out there that covers this presentation and

its treatment? I couldn't find any, have you got anything in

your database?

Is it possible that this isn't PSC but something else entirely? Any

ideas anyone please, I know there isn't a lot else it can be

What is the significance of the narrow pancreatic duct? Seems too

much of a coincidence to me to not have any significance?

For info my symptoms are RUQ pain daily currently not relieved by

painkillers, chest pain, central abdominal pain, bile reflux, nausea,

vomiting and severe fatigue, sometimes itching bouts. I have given up

work.

Sorry for the long post but I thought you would want as much

background info as possible.

I would be really grateful for any help/thoughts, it is such a

comfort to have you all a few clicks away

Best wishes

(UK)

PSC 07, recurrent esophagitis & gastritis, gastro paresis,

osteopenia, endometriosis leading to total hysterectomy 2004,

gallbladder removed 2005

[Guest guest]

Hi ;

The pancreatic duct narrowing that you mention leaves open the

possibility of autoimmune pancreatitis:

____________________

Radiology. 2004 Nov;233(2):345-52.

Autoimmune pancreatitis: imaging features.Sahani DV, Kalva SP,

Farrell J, Maher MM, Saini S, Mueller PR, Lauwers GY, Fernandez CD,

Warshaw AL, Simeone JF

Department of Radiology, Massachusetts General Hospital, White Bldg

270F, 55 Fruit St, Boston MA 02114, USA. dsahani@....

PURPOSE: To retrospectively determine imaging findings in patients

with autoimmune pancreatitis. MATERIALS AND METHODS: Twenty-nine

patients (25 male and four female; mean age, 56 years; range, 15-82

years) with histopathologic diagnosis of autoimmune pancreatitis were

examined. Data were reviewed by two radiologists in consensus.

Imaging findings for review included those from helical computed

tomography (CT), 25 patients; magnetic resonance (MR) imaging with MR

cholangiopancreatography (MRCP), four patients; endoscopic

ultrasonography (US), 21 patients; endoscopic retrograde

cholangiopancreatography (ERCP), 19 patients; and percutaneous

transhepatic cholangiography, one patient. Images were analyzed for

appearances of pancreas, biliary and pancreatic ducts, and other

findings, such as peripancreatic inflammation, encasement of vessels,

mass effect, pancreatic calcification, peripancreatic nodes, and

peripancreatic fluid collection. Follow-up images were available in

nine patients. Serologic markers such as serum immunoglobulin G (IgG)

and antinuclear antibody levels were available in 12 patients.

RESULTS: CT showed diffuse (n = 14) and focal (n = 7) enlargement of

pancreas. Seven patients had minimal peripancreatic stranding, with

lack of vascular encasement, calcification, or peripancreatic fluid

collection. Nine patients had enlarged peripancreatic lymph nodes. MR

imaging showed focal (n = 2) and diffuse (n = 2) enlargement with

rimlike enhancement in one. MRCP revealed pancreatic duct strictures

in two and sclerosing cholangitis-like appearance in one. Endoscopic

US showed diffuse enlargement of pancreas with altered echotexture in

13 patients and focal mass in the head in six. ERCP showed stricture

of distal common bile duct in 12 patients, irregular narrowing of

intrahepatic ducts in six, diffuse irregular narrowing of pancreatic

duct in nine, and focal stricture of proximal pancreatic duct in six.

Serologic markers showed increased IgG and antinuclear antibody

levels in seven of 12 patients. At follow-up, CT abnormalities and

common bile duct strictures resolved after steroid therapy in three

patients. CONCLUSION: Features that suggest autoimmune pancreatitis

include focal or diffuse pancreatic enlargement, with minimal

peripancreatic inflammation and absence of vascular encasement or

calcification at CT and endoscopic US, and diffuse irregular

narrowing of main pancreatic duct, with associated multiple biliary

strictures at ERCP. PMID: 15459324.

http://radiology.rsnajnls.org/cgi/content/full/233/2/345

____________________

It's very difficult to distinguish between PSC and sclerosing

cholangitis with autoimmune pancreatitis (SC-AIP). But a serum IgG4

test might help, as described in the following article. It's

important to distinguish between the two because PSC does not respond

to steroids, which SC-AIP does!

____________________

J Gastroenterol. 2007 Jul;42(7):550-9.

Clinicopathological differentiation between sclerosing cholangitis

with autoimmune pancreatitis and primary sclerosing cholangitis.

Nishino T, Oyama H, Hashimoto E, Toki F, Oi I, Kobayashi M, Shiratori

K

Institute of Gastroenterology, Department of Medicine, Tokyo Women's

Medical University, School of Medicine, 8-1 Kawada-cho, Shinjuku-ku,

Tokyo 162-8666, Japan.

BACKGROUND: The present study was undertaken to identify the

clinicopathological differences between sclerosing cholangitis with

autoimmune pancreatitis (SC-AIP) and primary sclerosing cholangitis

(PSC). METHODS: We retrospectively compared the clinical,

cholangiographic, and liver biopsy findings between 24 cases of PSC

and 24 cases of SC-AIP. RESULTS: Patient age at the time of diagnosis

was significantly lower in the PSC group than in the SC-AIP group.

The peripheral blood eosinophil count was significantly higher in the

PSC group than in the SC-AIP group, but the serum IgG4 level was

significantly higher in the SC-AIP group. Cholangiography revealed

band-like strictures, beaded appearance, and pruned-tree appearance

significantly more frequently in PSC, whereas segmental strictures

and strictures of the distal third of the common bile duct were

significantly more common in SC-AIP. Liver biopsy revealed fibrous

obliterative cholangitis only in the PSC specimens. No advanced

fibrous change corresponding to Ludwig's stages 3 and 4 was observed

in any of the SC-AIP specimens. IgG4-positive plasma cell

infiltration of the liver was significantly more severe in SC-AIP

than in PSC. Subsequent cholangiography showed no improvement in any

of the PSC cases, but all SC-AIP patients responded to steroid

therapy, and improvement in the strictures was observed cholangio-

graphically. CONCLUSIONS: Based on the differences between the

patients' ages and blood chemistry, cholangiographic, and liver

biopsy findings, SC-AIP should be differentiated from PSC. PMID:

17653651.

Best regards,

Dave

(father of (22); PSC 07/03; UC 08/03)

[Guest guest]

,

I'm not sure if any of this will help. I am always knocked out for

my ERCP's so I have no idea if it hurts when they inject the dye. I

also have pain that my dr. said he believes is related to spasms in

my bile ducts.

Darcy

I also experienced severe pain in the ducts when injected with the

dye which he said he had not seen before. The pain replicated my

right upper quadrant pain that I have everyday. This at last

explained the reason for my pain. The theory is that as all the ducts

are narrow the bile struggles to get through constantly and builds

pressure resulting in pain, and that the ducts are going into spasm.

> My questions are:

>

> Has anyone else got this presentation or is it unusual?

>

> Has anyone else had severe pain during ERCP when dye injected?

>

>

>

>

>

>

[Guest guest]

..amanda-

i also have a lot of pain on my right side. some hepatologists don't

seem to understand this, as hepatitis patients don't seem to have

pain. i do take 1/2 vicodin when i have to for the pain. as far as

pain after ercp, i sometimes just feel sore in my ducts, but always

thought it was strictly from the probing that the doctor does

inside. i have had about 30 ercps or more and never had a bad

reaction or had to be hospitalized, except when a stent was put in

once and i could not stand the pain and had it taken out as soon as

they could, less than 24 hours later. sorry for the longgggggg

sentence. you will eventually get used to the pain, except when it

gets excruciating. but pain on a daily basis will become normal,

unfortunately. your doctor may not give you anything for it. ask

though and see. there is really no reason to suffer the pain, when

we already have itching, nausea, loss of appetite, etc. that's the

way i look at it.

pam

dx 2001

[Guest guest]

Thanks a lot , Darcy & Pam for your useful replies to my long post!

, very interesting that you mentioned autoimmune pancreatitis with

sclerosing cholangitis I too came across this and thought it could be a

possibility. Something to mention to Prof Neuberger when I see him. I

Think I will ask if worth checking my IGg4.

Darcy, when you say you were knocked out was this sedation or

anesthetic? I was heavily sedated at the time and still felt severe

pain, apparently I was fighting them, showing myself up again!

Pam, thanks, I think I need to revisit my pain medication, I am already

on 2 presecription drugs to help with pain but they are not doing the

trick at the mo. I agree that you do get used to living with the pain

but my condition has worsened significantly in the last 12 months & the

pain has now become unbearable so back to the docs I go, AGAIN!

Hopefully once on URSO this will help, did it with you?

Thanks again for taking the time to reply. Have an enjoyable weekend.

Best wishes

(UK)