Endoscopic evaluation and management of pancreatic duct strictures

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Pancreatic duct strictures, encountered at ERCP, may contribute to chronic pain of chronic pancreatitis or flares of acute pancreatitis. Once underlying malignancy is ruled out, endoscopic therapies similar to those used in the biliary tree may be applied. This paper reviews current methods used to evaluate these strictures, and discusses management strategies available to the therapeutic endoscopist.

Section snippets

Differential diagnosis

When a pancreatic duct stricture is encountered at endoscopic retrograde cholangiopancreatography (ERCP), the endoscopist faces a diagnostic dilemma as to the etiology of the stricture. While chronic pancreatitis is most likely in the alcoholic patient with a chronic pain syndrome, other possibilities include pancreatic neoplasms, pseudocysts and traumatic injury. Less frequently, mucus or protein plugs, or pancreatic stones may resemble a stricture. Pancreas divisum may also mimic a stricture

Therapy

While the pain in chronic pancreatitis is likely multifactorial in origin, pancreatic duct and parenchymal pressures are generally increased in chronic pancreatitis whether the main pancreatic duct is dilated or normal in diameter. Such elevated parenchymal and duct pressures contribute to pancreatic ischemia, which appears to play a significant role in the pain of chronic pancreatitis. Therapeutic efforts, therefore, are directed at reducing pancreatic parenchymal and ductal hypertension.

Complications associated with pancreatic stents

Several complications, both immediate and late, may occur after pancreatic duct stent placement, and are listed in Table 3. True complication rates are difficult to decipher, however, due to: 1) the simultaneous performance of other procedures (eg, pancreatic sphincterotomy, stricture dilation); 2) the heterogeneous patient populations treated (ie, patients with acute or chronic pancreatitis), and 3) the lack of uniform definitions of complications and a grading system of their severity.26 The

Conclusion

Endoscopic therapy of chronic pancreatitis and pancreatic duct strictures is an expanding area for the interventional endoscopist. The techniques employed are very similar to the endoscopic interventions utilized in the biliary tree but tend to be more tedious. Once appropriate evaluation (when applicable) has been performed to exclude pancreatic malignancy, the appropriate selection of candidates for pancreatic intervention appears to be important to obtain optimal results of therapy. Over the

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