Pancreatic fluid collections (PFCs) are a frequent complication of acute pancreatitis. PFCs have been categorized according to their content and duration after an episode of pancreatitis. Acute collections (<4 week) and asymptomatic late collections (>4 weeks) can be usually managed conservatively. Late collections including walled off necrosis (WON) and pancreatic pseudocysts (PP) have a well-defined wall. Consequently, it is easier and safer to drain these collections when required. The most common indication to drain PFCs is infection and the available means of drainage include surgical, endoscopic, and percutaneous. Open surgical interventions carry a high risk of morbidity and mortality. Therefore, in the current era, a step up approach is preferred to minimize morbidity over the more aggressive surgical treatments. Endoscopic step-up approach is effective and favored over minimally invasive surgical or percutaneous drainage due to reduced risk of organ failure and external pancreatic fistula. However, the approach to PFCs should be individualized for optimal outcomes. A small subgroup of patients does not respond to endotherapy or percutaneous interventions and requires open surgical debridement. Similarly, not all PFCs are amenable to endoscopic drainage and demand alternative modalities like percutaneous or minimally invasive surgical drainage.
Part of the book: Pancreatitis
The evaluation of small bowel in inflammatory bowel disease (IBD) is mainly performed in cases with newly diagnosed or suspected Crohn’s disease (CD). The available modalities for small bowel evaluation include radiological imaging (barium meal follow through, magnetic resonance enteroclysis, computed tomography enteroclysis) and small bowel endoscopy also known as enteroscopy. The main advantage of small bowel endoscopy over radiological imaging is that it allows for obtaining biopsy specimen required for histological confirmation of the diagnosis. Various endoscopic modalities for endoscopic evaluation of small bowel include push enteroscopy and device assisted enteroscopy (DAE). Push enteroscopy allows only limited evaluation of proximal small bowel. Therefore, DAE is generally preferred over push enteroscopy for small bowel evaluation. DAE includes single balloon enteroscopy, double balloon enteroscopy, and spiral enteroscopy. The available literature suggests that there is no significant difference in the diagnostic yield among the available DAE devices. Therefore, the choice of DAE is largely dependent on the availability as well as local expertise. More recently, motorised spiral enteroscopy has been introduced. The main advantage of this novel DAE is ease of use with the possibility of evaluating the entire small bowel via per-oral route. However, the data regarding the use of motorised spiral enteroscopy is limited and comparative trials are required in future.
Part of the book: Endoscopy in Small Bowel Diseases