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.     

Endoscopic retrograde cholangiopancreatography and endoscopic ultrasound for diagnosis of chronic pancreatitis

The diagnosis of chronic pancreatitis is based on altered pancreatic morphology and function. A spectrum of disease exists, and milder forms of disease may be missed by CT but demonstrated by endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS). The accuracy of ERCP and EUS for diagnosis of “minimal change” or “early” chronic pancreatitis is controversial, particularly when the results from these imaging procedures are discordant with each other or with tests of pancreatic function; in some cases ERCP and EUS should be considered indeterminate for diagnosis. This review discusses recent data concerning the accuracy of ERCP and EUS for diagnosis of chronic pancreatitis, the use of EUS fine-needle aspiration for differential diagnosis of pancreatic masses, and the use of EUS and EUS-guided TruCut biopsy for diagnosis of autoimmune 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.     

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.     

ERCP术后急性胰腺炎并发症的危险因素及预防研究进展

内镜逆行性胰胆管造影(ERCP)以及相关治疗技术已成为胆胰疾病的重要治疗手段,ERCP 术后急性胰腺炎(AP)是常见且严重的并发症之一,目前研究发现．治疗性ERCP、Oddi括约肌运动功能障碍、Oddi括约肌压力检测、内镜下乳头括约肌气囊扩张术、插管困难与多次胰管注射、操作者的经验不足为ERCP术后急性胰腺炎的常见危险因素．关于预防ERCP 术后AP的药物研究被广泛开展,生长抑素和加贝酯被多数学者认为对AP有显著的预防作用．更广泛的药物研究其具体效果尚待进一步的研究证实．在内镜技术方面,选择性插管技术的改进、胰管支架和胆道引流技术被认为可有效地防止ERCP术后AP的发生．     

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.     

Propofol use in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound

Compared to standard endoscopy,endoscopic retrograde cholangiopancreatography(ERCP)and endoscopic ultrasound(EUS)are often lengthier and more complex,thus requiring higher doses of sedatives for patient comfort and compliance.The aim of this review is to provide the reader with information regarding the use,safety profile,and merits of propofol for sedation in advanced endoscopic procedures like ERCP and EUS,based on the current literature.     

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.     

经内镜逆行胰胆管造影术后急性胰腺炎与高淀粉酶血症对比观察

目的 比较经内镜逆行胰胆管造影术(ERCP)后急性胰腺炎(PEP)与高淀粉酶血症(PEHA)患者的临床特点及影响因素,为预防病情进展提供依据。 方法 选取武汉大学人民医院2017年1月-2019年8月住院行ERCP的患者117例,所有患者术前均预防性使用双氯芬酸钠栓塞肛。术后发生PEHA组77例,PEP组40例,比较2组患者临床特点及影响因素。符合正态分布的计量资料2组间比较采用t检验;不符合正态分布的计量资料2组间比较采用Mann-Whitney U检验;计数资料2组间比较采用χ2检验;采用多因素logistic回归分析PEP的独立影响因素。结果 术前ALP(Z=-2.518,P=0.012)、GGT(Z=-2.313,P=0.021)、TBil(Z=-2.978,P=0.003)、DBil(Z=-3.069,P=0.002)水平及术中是否行导丝进入胰管检查(χ2=4.176,P=0.041)在两组之间差异显著。进一步logistic回归分析结果显示,导丝进入胰管次数≥3次[优势比(OR)=2.469,95%可信区间(95%CI): 1.199~5.188,P=0.047]、ALP<125 U/L(OR=5.499,95%CI: 1.452~18.830,P=0.012)、TBil<22 μmol/L(OR=4.249,95%CI: 1.023~17.648,P=0.046)是影响PEP发生的独立危险因素。结论 即使预防性使用双氯芬酸钠栓剂,术前ALP、TBil水平正常及术中导丝多次进入胰管的患者更易发生PEP,需引起手术医师警惕。根据病情,术前及术后采取早期干预措施可能减少PEHA向PEP进展,减少中重度PEP的发生,改善预后。     

Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone-induced acute cholangitis and pancreatitis

Urgent or emergency endoscopic retrograde cholangiopancreatography (ERCP) is indicated for gallstone-induced acute cholangitis and pancreatitis. The technique and optimal timing of ERCP depend on the disease state, its severity, anatomy, patient background, and the institutional situation. Endoscopic transpapillary biliary drainage within 24 h is recommended for moderate to severe acute cholangitis. The clinical outcomes of biliary drainage with nasobiliary drainage tube placement and plastic stent placement are comparable, and the choice is made on a case-by-case basis considering the advantages and disadvantages of each. The addition of endoscopic sphincterotomy (EST) is basically not necessary when performing drainage alone, but single-session stone removal following EST is acceptable in mild to moderate cholangitis cases without antithrombotic therapy or coagulopathy. For gallstone pancreatitis, early ERCP/EST are recommended in cases with impacted gallstones in the papilla. In some cases of gallstone pancreatitis, a gallstone impacted in the papilla has already spontaneously passed into the duodenum, and early ERCP/EST lacks efficacy in such cases, with unfavorable findings of cholangitis or cholestasis. If it is difficult to diagnose the presence of gallstones impacted in the papilla on imaging, endoscopic ultrasonography can be useful in determining the indication for ERCP.     

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.     

Oral allopurinol to prevent hyperamylasemia and acute pancreatitis after endoscopic retrograde cholangiopancreatography

AIM： To assess the efficacy of allopurinol to prevent hyperamylasemia and pancreatitis after endoscopic retrograde cholangiopancreatography （PEP）.
METHODS： One hundred and seventy patients were enrolled and randomized to two groups： a study group （n = 85） who received 300 mg of oral allopurinol at 15 h and 3 h before endoscopic retrograde cholangiopancreatography （ERCP） and a control group （n = 85） receiving an oral placebo at the same times. Main Outcome Measurements included serum amylase levels and the number severity of the episodes of pancreatitis. Serum amylase levels were classified as normal （〈 150 IU/L） or hyperamylasemia （〉 151 IU/L）. Episodes of PEP were classified following Ranson＇s criteria and CT severity index.
RESULTS： Gender distribution was similar between groups. Mean age was 53.5 ±18.9 years for study group and 52.8 ± 19.8 years for controls. Also, the distribution of benign pathology was similar between groups. Hyperamylasemia was more common in the control group （P = 0.003）. Mild PEP developed in two patients from the study group （2.3%） and eight （9.4%） from control group （P = 0.04）, seven episodes were observed in high-risk patients of the control group （25%） and one in the allopurinol group （3.3%, P = 0.02）. Risk factors for PEP were precut sphincterotomy （P = 0.02）, pancreatic duct manipulation （P = 0.002） and multiple procedures （P = 0.000）. There were no deaths or side effects.
CONCLUSION： Oral allopurinol before ERCP decreased the incidences of hyperamylasemia and pancreatitis in patients submitted to high-risk procedures.     

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.     

细胞因子与内镜逆行胰胆管造影术后胰腺炎关系的研究进展

内镜逆行胰胆管造影术(enoscopiC retrograde cholangiopancreatography,ERCP)是当前诊治肝、胆、胰疾病的重要手段之一.急性胰腺炎是ERCP术后最常见、最严重的并发症,目前其发病机制仍未完全阐明.近年来研究的普遍共识是炎性细胞因子在轻症胰腺炎向重症胰腺炎演进过程中发挥了重要作...     

治疗性内镜下逆行胰胆管造影术后急性胰腺炎高危因素分析

[目的]探索治疗性内镜下逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)术后急性胰腺炎(PEP)的高危因素与防治策略。[方法]运用单因素分析方法分析592例治疗性ERCP术后患者并发PEP的原因及防治措施。[结果]592例患者中,35例(5.9%)并发PEP,其中33例均为轻型胰腺炎,均经内科综合治疗后痊愈;2例为重症胰腺炎,1例治愈出院,1例死亡。与诱发PEP相关的高危因素有:女性,插管困难,既往有胰腺炎或胰腺癌,胰腺管显影或导丝插入胰管。[结论]治疗性ERCP发生PEP的因素不仅与患者自身临床因素有关,且与医师的操作技术有很大关系,改善患者身体条件、提高医师操作水平可减少PEP的发生。     

治疗性经内镜逆行胰胆管造影在慢性胰腺炎患者中的应用

目的：探讨治疗性经内镜逆行胰胆管造影（ERCP）在慢性胰腺炎（CP）治疗中的价值。方法对2008年1月－2012年12月间在南京医科大学附属苏州市立医院应用 ERCP 治疗的30例 CP 患者进行回顾性分析。观察术前及术后24h 血淀粉酶变化,动态观察患者治疗前后腹痛缓解情况,随访脂肪泻、焦虑患者病情,定期复查腹部影像学或 ERCP 明确胰腺病变及胰管支架情况。结果所有患者均顺利完成 ERCP 并放置胰管支架,术后72 h 腹痛缓解率83．3％,1例因症状改善不明显至外科手术,术后病死率为0。结论ERCP 是治疗 CP 的有效手段,具有安全、有效、创伤小等优点。     

Hemobilia, a rare cause of acute pancreatitis after percutaneous liver biopsy: diagnosis and treatment by endoscopic retrograde cholangiopancreatography

We here report the case history of a 75-yr-old woman who developed pancreatitis and recurrent symptomatic, cholestasis-induced hemobilia after percutaneous liver biopsy. An endoscopic sphincterotomy with clot extraction led to relief of symptoms. The risk of hemobilia after percutaneous liver biopsy is less than one per 1000 procedures, and only two cases of acute pancreatitis after percutaneous liver biopsy have previously been reported. To our knowledge, this is the first case in which endoscopic retrograde cholangiopancreatography was used to both diagnostic and therapeutic ends.