Cahpter 2 - Training in Biliary Tract Diseases and Pancreatic Disorders

Importance

Biliary Tract Diseases

Biliary tract diseases occupy a significant portion of the practice of gastroenterology. The diagnosis of and therapy for these diseases represent major challenges to practicing gastroenterologists because rapid advances in technology require skills not previously taught (e.g., invasive endoscopic and radiological procedures, endoscopic ultrasound, scintigraphy). To achieve maximal effectiveness, minimize risk, reduce costs, and provide the best possible care for patients, specialized training is required that emphasizes knowledge of anatomy, physiology, pathophysiology, and clinical presentation of biliary tract diseases. Gastroenterologists must be familiar with new technology and be in a position to apply it for the benefit of their patients.

Pancreatic Disorders

Pancreatic disorders are common diseases that present multifaceted challenges to gastroenterologists. For example, acute pancreatitis may lead to the rapid development of a variety of potentially lifethreatening complications; chronic pancreatitis is a long-standing, frequently debilitating disease. In caring for patients with pancreatic cancer, gastroenterologists must make an expeditious and costeffective diagnosis and weigh possible curative or palliative treatment options. Because of the complexity of these diseases, the wide assortment of potential diagnostic modalities, and the lack of consensus in many aspects of diagnosis and management, gastroenterologists are commonly the primary consultants or direct caregivers for patients with pancreatic disease.

Goals of Training

During fellowship, trainees should gain an understanding of the following:

Biliary

1. Basic embryology and anatomy of the biliary tree and congenital structural anomalies, including duplications and cysts. 2. Hormonal and neural regulation of bile flow and gallbladder function. 3. Physiology of bile secretion and its derangement in cholestatic disorders. 4. Bile composition in health and disease. 5. Cholelithiasis—epidemiology, etiology, clinical manifestations and complications, treatment modalities. 6. Other disorders of the bile ducts, including recurrent pyogenic cholangitis, parasitic and opportunistic infections. 7. Other inflammatory disorders of the gallbladder such as acalculous cholecystitis. 8. Neoplastic diseases of the gallbladder and bile ducts. 9. Motility disorders including gallbladder dyskinesia, sphincter of Oddi dysfunction. 10. Principles of evaluation and treatment of common clinical syndromes:

a. Cholestasis

b. RUQ and “biliary-type” pain

c. Incidental findings on radiographic testing

11. Radiographic evaluation of the biliary tree: basic principles, utility and lesion recognition:

a. Ultrasonography

b. CT

c. MRI

d. Scintigraphic techniques

e. MRCP

12. Principles, utility, and complications of biliary surgery.

13. Procedural competence—see below. Pancreatic

1. The embryological development and anatomy of the pancreas and the pancreatic duct system and congenital disorders such as pancreas divisum, annular pancreas.

2. The physiological processes involved in pancreatic exocrine secretion of digestive enzymes, water, and electrolytes.

3. The types of digestive enzymes secreted by the pancreas, their mechanisms of activation and their roles in the digestive process.

4. The factors that protect the pancreas from autodigestion.

5. The epidemiology, etiology, pathophysiology, natural history, and management of acute pancreatitis in all spectra of severity and its complications.

6. The epidemiology, etiology, pathophysiology, natural history, and management of chronic pancreatitis with particular emphasis on management of exocrine insufficiency and chronic pain.

7. The epidemiology, etiology, natural history, and management of pancreatic cancer and its complications.

8. The molecular genetics of pancreatic disease with particular reference to hereditary pancreatitis and cystic fibrosis, their diagnosis and management.

9. Radiographic evaluation of the pancreas: basic principles, utility, and lesion recognition:

a. Ultrasonography

b. EUS

c. CT

d. MRI

e. MRCP

10. Principles, utility, and complications of pancreatic surgery.

11. The basis and indications for and the interpretation of diagnostic test results in the diagnosis and management of diseases of the pancreas, in particular, serum amylase and lipase determination, markers for chronic pancreatitis (fecal elastase, serum tryspinogen-like immunoreactivity, etc.) serum tumor markers (e.g., CA 19-9), radiological and endoscopic imaging studies (see Training in Endoscopy and Training in Radiology), indirect tests of pancreatic secretory function, direct tests of secretory function (e.g., secretin and secretin/cholecystokinin stimulation tests, test meals), duodenal drainage with analysis for biliary crystals, fine-needle aspiration of pancreatic masses, and analysis of cytology in endoscopic aspirates of pancreatic juice.

12. Principles and practice of nutritional support for patients with both acute and chronic pancreatitis.

13. Procedural competence—see below.

Training Process

As with most specialties a combination of cognitive/ clinical skills and knowledge, along with procedural proficiency is necessary for training in the care of patients with these disorders. Two levels of training should be offered. Level 1 training is for those trainees who will be a part of the general gastroenterology program and have exposure to diseases of the biliary tract and pancreas. Level 2 training is intended for those who will be selected to spend the entire third year of training and/or an additional fourth year of training in biliary tract diseases and/or pancreatic diseases.

Clinical/Cognitive Training

Level 1

At this level, all trainees should acquire the fundamental core of information outlined above in the first 18 months (core clinical) of training through individual reading, presentation of core curriculum at gastroenterological/ radiological/surgical clinical conferences, lectures by invited speakers, journal clubs, and daily contact with the attending physicians.

Level 2

The major goal for trainees at level 2 (see also Training in Endoscopy) is to acquire an in-depth knowledge of pathophysiology, clinical presentation, diagnosis, epidemiology, and therapy of biliary and pancreatic diseases. In general, trainees in biliary and pancreatic diseases at this level should have completed at least 18 months of training in general gastroenterology and should spend up to an additional year specializing in biliary and pancreatic diseases. Trainees will be provided the opportunity to perform an adequate number of procedures, receive supervised teaching, and to be involved in clinical research. While the endoscopic training is important, level 2 training should aim to produce an expert in managing all aspects of biliary tract diseases. In terms of cognitive and diagnostic acumen, level 2 trainees should be expected to know physiology, pathophysiology, diagnosis, and therapy of biliary and pancreatic diseases in greater detail than those at level 1 of training.

All trainees at level 2 should also be given the opportunity to be involved in clinical or basic research. Trainees in the biliary and pancreatic sections will be expected to acquire an understanding of clinical research, including study design, methodology, statistical analysis, writing the protocols, submitting protocols to institutional review boards, writing informed consent, enrolling patients into studies, analyzing and interpreting data, presenting at national meetings, and writing papers. Individual preceptors should teach basic or clinical research on a one-on-one basis and at research conferences. It is anticipated that most physicians participating in level 2 training will enter an academic environment, which will allow them to continue in the multidisciplinary area of treating patients with biliary and pancreatic diseases as well as teaching and conducting clinical research.

Procedural Training

All trainees should have a thorough knowledge of the endoscopic techniques used in the diagnosis and treatment of biliary tract diseases and pancreatic diseases, including their potential risks, limitations, and costs. Trainees also must understand the role of alternative diagnostic and therapeutic modalities (medical, surgical, and radiological) in the evaluation and management of biliary tract and pancreatic diseases. They should understand the advantages and disadvantages of the different diagnostic and therapeutic procedures available.

Endoscopic retrograde cholangiopancreatography and endoscopic ultrasound are the primary tools for accessing the biliary tree and the pancreatic ductal system and a major route for therapeutic intervention. Trainees should attain an understanding of percutaneous transhepatic cholangiography and the performance and interpretation of endoscopic retrograde cholangiopancreatography and endoscopic ultrasound (indications, contraindications, limitations, complications, and interpretation) through participation in and observance of those procedures under supervision of the attending physician and with the assistance of a radiologist.

These complex procedures require extensive training, which is difficult to give to all trainees. The level of experience required for performing endoscopic retrograde cholangiopancreatography may vary with the career expectations of the trainees. As above, training can be stratified into two levels (see also Training in Endoscopy).

Level 1

This level involves minimal exposure to biliary and pancreatic endoscopy for those trainees who do not plan to perform them. “Minimal exposure” is defined as an understanding of the indications and contraindications of ERCP and EUS, the advantages and disadvantages, complications, alternative diagnostic and therapeutic options, and interpretation of findings. This knowledge could be acquired through conferences, teaching rounds, courses, and 1- to 2-month rotations through the biliary tract service. Hands-on experience in biliary procedures is encouraged but not required in this group of trainees.

In addition to a knowledge and understanding of endoscopic procedures, all level 1 trainees should have a general understanding of the indications, advantages, and disadvantages of imaging procedures, such as plain film of the abdomen, cholecystogram, ultrasound, computed tomography, magnetic resonance imaging, and scintigraphy. As part of this process, they should have a basic understanding of how to interpret these studies. This knowledge will be acquired through regular and frequent contacts with radiologists and nuclear medicine specialists and/or a 1- to 2- month rotation through radiology. Lastly, trainees should be exposed to the performance and the interpretation of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography and should observe several surgical biliary and pancreatic procedures during the course of training (see Training in Radiology and Training in Surgery).

Level 2

This level involves at least 12 months of advanced training in pancreaticobiliary endoscopy (see Training in Endoscopy) and is aimed at individuals who seek to be true experts in endoscopic management of biliary tract diseases (level 2). The experience necessary to become proficient in the diagnosis and therapy of biliary tract diseases should be offered only in institutions that have a large patient referral base, a wide range of patients with biliary tract diseases, and experienced faculty in gastroenterology, radiology, surgery, and clinical pathology.

Trainees in gastroenterology must understand the role the following disciplines play in the diagnosis and management of pancreatic disorders and must have direct experience working with these disciplines in the care of individual patients: therapeutic endoscopy, surgery, interventional radiology, anatomic pathology and cytopathology, nutritional support service, pain management service, medical oncology, and radiation oncology (see Training in Endoscopy, Training in Surgery, Training in Radiology, Training in Hepatic Pathology, and Training in Nutrition).

Assessment of Competence

Knowledge of biliary tract diseases and pancreatic disorders should be assessed as part of the overall evaluation of trainees in gastroenterology during and after the fellowship, as outlined in Overview of Training in Gastroenterology. Questions relating to biliary tract diseases and pancreatic disorders should be included on the board examination and should reflect a general knowledge of this content.