Outcomes and timing of endoscopic retrograde cholangiopancreatography for acute biliary pancreatitis

BackgroundIndication of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis (ABP) is challenging.AimsIn this retrospective study, we analyzed real-world data to understand the ERCP practice in ABP in Hungarian centers.MethodsClinical data on ABP patients (2013–2015) were extracted from our large multicentric database. Outcomes, quality indicators and the role of early timing of ERCP (<24 h from admission) were analyzed.ResultsThere were 356 patients with ABP. ERCP was performed in 267 (75%). Performance indicators of ERCP proved to be suboptimal with a biliary cannulation rate of 84%. Successful vs unsuccessful cannulation of naïve papilla resulted in lower rates of local [22.9% vs 40.9%, (P = 0.012)] and systemic [4.9% vs 13.6%, (P = 0.042)] complications. Successful vs unsuccessful clearance resulted in lower rates of local complications [22.5% vs 40.8%, (P = 0.008)]. Successful cannulation and drainage correlated with less severe course of ABP [3.6% vs 15.9%, (P = 0.001) and 4.1% vs 12.2%, (P = 0.033)] respectively. A tendency of an increased rate of local complications was observed if ERCP was performed later [<24 h: 21.1% (35/166); between 24–48 h: 23.4% (11/47); >48h: 37.2% (16/43) (P = 0.088)].ConclusionOptimization of ERCP indication in ABP patients is critical as suboptimal ERCP practices in ABP without definitive stone detection are associated with poorer clinical outcomes.     

Early endoscopic ultrasonography in acute biliary pancreatitis: A prospective pilot study

AIM: To investigate the clinical usefulness of early endoscopic ultrasonography(EUS) in the management of acute biliary pancreatitis(ABP).METHODS: All consecutive patients entering the emergency department between January 2010 and December 2012 due to acute abdominal pain and showing biochemical and/or radiological findings consistent with possible ABP were prospectively enrolled. Patients were classified as having a low,moderate,or high probability of common bile duct(CBD) stones,according to the established risk stratification. Exclusion criteria were: gastrectomy or patient in whom the cause of biliary obstruction was already identified by ultrasonography. All enrolled patients underwent EUS within 48 h of their admission. Endoscopic retrograde cholangiopancreatography was performed immediately after EUS only in those cases with proven CBD stones or sludge. The following parameters were investigated:(1) clinical: age,sex,fever;(2) radiological: dilated CBD; and(3) biochemical: bilirubin,AST,ALT,g GT,ALP,amylase,lipasis,PCR. Association between presence of CBD stone at EUS and the individual predictors wereassessed by univariate logistic regression. Predictors significantly associated with CBD stones(P 0.05) were entered in a multivariate logistic regression model.RESULTS: A total of 181 patients with pancreatitis were admitted to the emergency department between January 2010 and December 2012. After exclusion criteria a total of 71 patients(38 females,53.5%,mean age 58 ± 20.12 years,range 27-89 years; 33 males,46.5%,mean age 65 ± 11.86 years,range 41-91 years) were included in the present study. The probability of CBD stones was considered low in 21 cases(29%),moderate in 26(37%),and high in the remaining 24(34%). The 71 patients included in the study underwent EUS,which allowed for a complete evaluation of the target sites in all the cases. The procedure was completed in a mean time of 14.7 min(range 9-34 min),without any notable complications.The overall CBD stone frequency was 44%(31 of 71),with a significant increase from the group at low pretest probability to that at moderate(OR = 5.79,P = 0.01) and high(OR = 4.25,P = 0.03) pretest probability.CONCLUSION: Early EUS in ABP allows,if appropriate,immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.     

内镜超声和经内镜逆行胰胆管造影在慢性胰腺炎诊断中的价值

目的 评价EUS和ERCP对慢性胰腺炎(CP)的诊断灵敏度和特异度,探讨在CP诊断中EUS和ERCP的价值.方法 采用多中心联合调查方法,回顾分析1994年5月至2004年5月全国22个分研究中心的确诊的CP病例,以组织学诊断为"金标准",采用接受者工作曲线(receiver operating characteristic,ROC)分析EUS和ERCP的诊断灵敏度和特异度.结果 共人选CP患者1994例,男1298例,女696例.年龄5～85(48.9 ±15.0)岁.所有CP患者中,有组织学诊断239例(11.98%);胰腺外分泌功能试验(BT-PABA)261例(13.09%),腹部平片416例(20.86%),腹部B超1424例(71.41%),CT 889例(44.58%),MRI和MRCP245例(12.29%),ERCP628例(31.49%),EUS258例(12.94%).各诊断方法的诊断灵敏度和特异度分别为EUS(88%和93%)、ERCP(87%和93%)、MRI和MRCP(66%和85%)、CT(61%和85%)、B超(69%和82%)、腹部平片(32%和80%)、BT-PABA(83%和80%).结论 在CP诊断方法中,EUS和ERCP对CP且具有较高的灵敏度和特异度,EUS较ERCP灵敏度和特异度更高.     

Risk of pancreatitis after endoscopic retrograde cholangiopancreatography and endoscopic biliary drainage

Background:

Pancreatitis is the most common and serious complication to occur after endoscopic retrograde cholangiopancreatography (ERCP). It is often associated with additional diagnostic modalities and/or treatment of obstructive jaundice. The aim of this study was to determine the risk of post-ERCP pancreatitis associated with pancreaticobiliary examination and endoscopic biliary drainage (EBD).

Methods:

A total of 740 consecutive ERCP procedures performed in 477 patients were analysed for the occurrence of pancreatitis. These included 470 EBD procedures and 167 procedures to further evaluate the pancreaticobiliary tract using brush cytology and/or biopsy, intraductal ultrasound and/or peroral cholangioscopy or peroral pancreatoscopy. The occurrence of post-ERCP pancreatitis was analysed retrospectively.

Results:

The overall incidence of post-ERCP pancreatitis was 3.9% (29 of 740 procedures). The risk factors for post-ERCP pancreatitis were: being female (6.5%; odds ratio [OR] 2.5, P= 0.02); first EBD procedure without endoscopic sphincterotomy (ES) (6.9%; OR 3.0, P= 0.003), and performing additional diagnostic procedures on the pancreatobiliary duct (9.6%; OR 4.6, P < 0.0001). Pancreatitis after subsequent draining procedures was rare (0.4%; OR for first-time drainage 16.6, P= 0.0003). Furthermore, pancreatitis was not recognized in 59 patients who underwent ES. Seven patients with post-EBD pancreatitis were treated with additional ES.

Conclusions:

Invasive diagnostic examinations of the pancreaticobiliary duct and first-time perampullary biliary drainage without ES were high-risk factors for post-ERCP pancreatitis. Endoscopic sphincterotomy may be of use to prevent post-EBD pancreatitis.     

Role of endoscopic retrograde cholangiopancreatography in acute pancreatitis

Endoscopic retrograde cholangiopancreatography （ERCP） is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound （EUS） and magnetic retrograde cholangiopancreatography （MRCP）, ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.     

Selective biliary cannulation techniques for endoscopic retrograde cholangiopancreatography procedures and prevention of post- endoscopic retrograde cholangiopancreatography pancreatitis

Numerous endoscopic retrograde cholangiopancreatography (ERCP) techniques have been reported to achieve selective biliary cannulation success. For standard biliary cannulation procedures, the wire-guided cannulation technique has been reported to reduce the rate of post-ERCP pancreatitis (PEP) and increase the biliary cannulation success rate, although conflicting reports exist. The pancreatic or double-guidewire technique and several precut techniques have been reported as useful techniques in difficult biliary cannulation cases. Although ERCP is a useful endoscopic procedure, the risk of adverse events, particularly post-ERCP pancreatitis, is inevitable. Previous studies and analyses have revealed the risk factors for PEP. The efficacy of prophylactic pancreatic duct stent placement and the administration of rectal nonsteroidal anti-inflammatory drugs for preventing PEP has also been reported. Herein, we reviewed reports in the literature regarding the current status of selective biliary cannulation techniques and PEP prevention.     

Hyperamylasaemia and acute pancreatitis following endoscopic retrograde cholangiopancreatography

Hyperamylasaemia and acute pancreatitis are the more common complications of endoscopic retrograde cholangiopancreatography (ERCP). Ninety patients who underwent ERCP +/- endoscopic papillotomy were monitored for rises in the serum amylase and the development of acute pancreatitis. The incidence of hyperamylasaemia (greater than 300 IU/L) was significantly greater (p = 0.01) when the pancreatic duct was imaged (75%) than with bile duct imaging alone (33%). The incidence of acute pancreatitis following imaging of the pancreatic duct +/- bile duct was 11.3% and was found to be significantly increased in those patients (n = 9) who also underwent endoscopic papillotomy. Imaging of the biliary tree only +/- endoscopic papillotomy carried no significant risk of acute pancreatitis. In those patients who developed pancreatitis, the rise in serum amylase occurred early and was significantly higher at 2 h following ERCP. These findings may help to identify patients who are at risk of developing this complication.     

Biliary ascariasis: ultrasonography, endoscopic retrograde cholangiopancreatography, and biliary drainage

Roundworms migrating into the biliary tract are a relatively common cause of biliary symptoms in areas where the parasite is endemic. Visualization of worms by conventional radiologic methods is often unsatisfactory, whereas ultrasonography offers a rapid, safe, and noninvasive approach to the diagnosis. Using real-time ultrasonographic scanning we demonstrated for the first time the characteristic morphology of the worms in a patient with biliary ascariasis. In addition, the motility of the worms in the biliary tract could be confirmed. Ultrasonography is also a convenient method for the follow-up of patients. Endoscopic biliary drainage and instillation of piperazine citrate through a nasobiliary drain is a logical therapy and was used successfully in this patient.     

Ulinastatin for pancreatitis after endoscopic retrograde cholangiopancreatography: a randomized, controlled trial.

BACKGROUND & AIMS: Pancreatitis remains the major complication of endoscopic retrograde cholangiopancreatography (ERCP), and hyperenzymemia after ERCP is common. Because ulinastatin, a protease inhibitor, has proved effective in the treatment of acute pancreatitis, the aim of this study was to assess the efficacy of ulinastatin for the prevention of post-ERCP pancreatitis and hyperenzymemia. METHODS: In a multicenter, randomized, double-blind, placebo-controlled trial, patients undergoing a first ERCP were randomized to receive ulinastatin (150,000 U) or placebo by intravenous infusion for 10 minutes starting immediately before ERCP. All patients were hospitalized at least 24 hours after ERCP for evaluation of clinical symptoms. Serum pancreatic enzyme levels were measured before and at 4 and 18 hours after ERCP. The primary end point was the incidence of post-ERCP pancreatitis and the secondary objective was the occurrence of hyperenzymemia. RESULTS: A total of 406 patients were enrolled (204 in the ulinastatin group and 202 in the placebo group). There were no differences between the 2 groups regarding baseline characteristics, details of fluoroscopic findings, or endoscopic procedure. The incidence of hyperenzymemia was significantly lower in the ulinastatin group than in the placebo group (amylase, P = .011; lipase, P = .008). Six patients in the ulinastatin group and 15 patients in the placebo group developed pancreatitis (2.9% vs. 7.4%, P = .041). There was no case of severe pancreatitis in either group. Patients who received ulinastatin did not present any side effects related to the medication. CONCLUSIONS: Prophylactic short-term administration of ulinastatin decreases the incidence of pancreatitis and hyperenzymemia after ERCP.     

经内镜逆行胰胆管造影在治疗妊娠合并急性胆源性胰腺炎中的作用

目的 探讨ERCP在妊娠合并急性胆源性胰腺炎(ABP)中的治疗作用.方法 选择2002年1月至2007年1月共收治的24例妊娠合并ABP患者,其中轻症14例,重症10例.在内科治疗的基础上,在无x线透视下急诊行ERCP.先行内镜鼻胆管引流术(ENBD)以减压、减黄,待患者病情稳定后,对明确有胆总管结石的患者,若早、中期妊娠则行内镜胆道塑料内支架引流术(ERBD),若晚期妊娠则在终止妊娠后再次行ERCP取石.结果 24例患者均顺利完成急诊ERCP+ENBD,有4例见壶腹部结石嵌顿,用针型刀剖开十二指肠乳头,取出结石;15例明确有胆总管结石,其中5例行ERBD,10例终止妊娠后再次行ERCP取石成功.无孕妇死亡,无转外科手术治疗,均治愈出院.重症患者中有2例胎儿死亡.结论　对妊娠合并ABP患者急诊行ERCP+ENBD,病情稳定后行ERBD或再次行ERCP取石是安全、有效的.     

The role of endoscopic retrograde cholangiopancreatography in acute and chronic pancreatitis

Endoscopic retrograde cholangiopancreatography (ERCP) plays a pivotal role in the management of patients with acute and chronic pancreatitis. Whereas endoscopic observation during ERCP permits recognition of abnormalities involving the major and minor duodenal papillae such as papillary tumors or choledochocele, radiographic evaluation enables the detection of structural abnormalities of pancreaticobiliary ducts like strictures or calculi. Sphincter of Oddi manometry, a technical advance of ERCP, is essential for the diagnosis of sphincter of Oddi dysfunction, which may present clinically as recurrent pancreatitis. Because structural alterations of the pancreatic duct forms the hallmark of chronic pancreatitis, ERCP is highly sensitive and specific in diagnosing chronic pancreatitis. Apart from its diagnostic role, ERCP offers a variety of possibilities for therapeutic interventions in selected problems associated with pancreatitis. Endoscopic papillectomy and mucosal resection for tumors of the papilla, unroofing of a choledochocele, and sphincterotomy for sphincter ablation in sphincter of Oddi dysfunction are some of the therapeutic interventions possible during ERCP. Pancreatic ductal hypertension, which is considered to be the major pathophysiologic mechanism for disabling abdominal pain in chronic pancreatitis, also can be managed by ERCP-directed treatments. Pancreatic sphincterotomy, dilation of strictures, lithotripsy, extraction of calculi, and deployment of endoprosthesis constitute the commonly used therapeutic techniques in this situation. Besides offering a noninvasive alternative, these treatments are associated with a favorable clinical outcome comparable with that of operative treatments. Nevertheless, complications such as acute pancreatitis, bleeding, perforation, or sepsis may occur in 5% to 10% of patients undergoing these procedures. Therefore, careful selection of patients, appropriate preoperative care, and a team approach, including surgeon, interventional radiologist, and endoscopist, are important.     

Ulinastatin shows preventive effect on post-endoscopic retrograde cholangiopancreatography pancreatitis in a multicenter prospective randomized study

BACKGROUND AND AIM: Endoscopic retrograde cholangiopancreatography (ERCP) is a useful diagnostic and therapeutic procedure; however, ERCP occasionally causes post-ERCP pancreatitis. The administration of gabexate mesilate has been reported to be effective for the prevention for post-ERCP pancreatitis when given during and after the procedure. The aim of the present study was to investigate the preventive effect of the novel protease inhibitor ulinastatin on post-ERCP pancreatitis. METHODS: One hundred and thirty-nine patients who underwent the ERCP procedure were studied. These patients were randomly divided into three groups based on the agent and dose given during and following the ERCP procedure: gabexate mesilate (900 mg), high-dose ulinastatin (450 000 units) and low-dose ulinastatin (150 000 units). Serum amylase, interleukin (IL)-6 and IL-8 levels and plasma polymorphonuclear leukocyte elastase (PMN-E) activity were measured after ERCP. In addition, post-ERCP hyperamylasemia and post-ERCP pancreatitis were recorded. RESULTS: There were no significant differences in serum amylase, IL-6 and IL-8 levels and PMN-E activity after ERCP procedure between the three groups. Post-ERCP pancreatitis was observed in two (4.3%), three (6.5%) and four (8.5%) cases in the gabexate mesilate, high-dose ulinastatin and low-dose ulinastatin groups, respectively. Multiple logistic regression analysis showed that the addition of endoscopic sphincterotomy during the ERCP procedure was the only significant risk factor for the development of post-ERCP hyperamylasemia and post-ERCP pancreatitis (P = 0.03 and P = 0.04, respectively), but there was no significant difference in the occurrence of post-ERCP hyperamylasemia and post-ERCP pancreatitis between the three groups receiving different preventative treatments. CONCLUSION: The administration of low- and high-dose ulinastatin has similar effects to high-dose gabexate in the prevention of post-ERCP pancreatitis.     

Comparison of early pre-cutting vs standard technique for biliary cannulation in endoscopic retrograde cholangiopancreatography： A personal experience

AIM： To compare the results and complications of early pre-cutting technique with standard technique.
METHODS： From January 2003 to December 2004, a total of 426 consecutive therapeutic biliary ERCP procedures were performed by one endoscopist （T.A.）. Data were retrospectively collected according to procedure indication and results. Of these, 293 procedures （70.4%） were done with standard technique （group A） and 223 procedures （29.6%） with early pre-cutting technique in case of difficult cannulation （group B）. The results and complications of ERCP were compared.
RESULTS： Success rate of first attempt cannulation was 98.0% in group A and 87.8% in group 13. The overall incidence of post-ERCP pancreatitis, hemorrhage, perforation and cholangitis was 0%, 0.2%, 0.5% and 0.5%, respectively. Morbidity rate was not significantly different. No procedure-related mortality was occurred.
CONCLUSION： For an experienced hand, the early pre-cutting technique for biliary cannulation is safe and effective as standard technique.     

Patient satisfaction after endoscopic retrograde cholangiopancreatography for biliary stones: A prospective multicenter study in Lombardy

Aims:  To measure patients' satisfaction after endoscopic retrograde cholangiopancreatography (ERCP) for biliary stones in a large number of unselected endoscopy units.
Methods:  A prospective study using a questionnaire (Group Health Association of America—9 [GHAA-9], modified) was administered 24 h and 30 days after the procedure. Patients undergoing endoscopy for biliary stones for the first time were enrolled in a large number of endoscopy units, regardless of their size and workload.
Results:  In all, 700 patients were enrolled in 15 units. A high proportion of patients expressed satisfaction (80%). Satisfaction was less extensive for pain control and the quality of information provided before the procedure. There were no differences in the replies to questionnaires at 24 h and 30 days.
Conclusion:  It is feasible to record patients' satisfaction and in this series most patients were very satisfied. Criticisms concerned pain control and explanations provided before the procedure.     

Diclofenac reduces the incidence of acute pancreatitis after endoscopic retrograde cholangiopancreatography

BACKGROUND & AIMS: Acute pancreatitis following endoscopic retrograde cholangiopancreatography presents a unique opportunity for prophylaxis and early modification of the disease process because the initial triggering event is temporally well defined and takes place in the hospital. We report a prospective, single-center, randomized, double-blind controlled trial to determine if rectal diclofenac reduces the incidence of pancreatitis following cholangiopancreatography. METHODS: Entry to the trial was restricted to patients who underwent endoscopic retrograde pancreatography or had manometrically verified sphincter of Oddi hypertension. Immediately after endoscopy, patients were given a suppository containing either 100 mg diclofenac or placebo. Estimation of serum amylase levels and clinical evaluation were performed in all patients. RESULTS: A total of 220 patients entered the trial, and 110 received rectal diclofenac. Twenty-four patients developed pancreatitis (11%), of whom 7 received rectal diclofenac and 17 received placebo (P < 0.05). CONCLUSIONS: This trial shows that rectal diclofenac given immediately after endoscopic retrograde cholangiopancreatography can reduce the incidence of acute pancreatitis.