ERCP is more challenging in cases of acute biliary pancreatitis than in acute cholangitis – Analysis of the Hungarian ERCP registry data

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is an important therapeutic modality in acute biliary pancreatitis (ABP) cases with cholangitis or ongoing common bile duct obstruction. Theoretically, inflammation of the surrounding tissues would result in a more difficult procedure. No previous studies examined this hypothesis.ObjectivesABP and acute cholangitis (AC) without ABP cases were compared to assess difficulty of ERCP.MethodsThe rate of successful biliary access, advanced cannulation method, adverse events, cannulation and fluoroscopy time were compared in 240 ABP cases and 250 AC cases without ABP. Previous papillotomy, altered gastroduodenal anatomy, and cases with biliary stricture were excluded.ResultsSignificantly more pancreatic guidewire manipulation (adjusted odds ratio (aOR) 1.921 [1.241–2.974]) and prophylactic pancreatic stent use (aOR 4.687 [2.415–9.098]) were seen in the ABP than in AC group. Average cannulation time in the ABP patients (248 vs. 185 s; p = 0.043) were longer than in AC cases. No difference was found between biliary cannulation and adverse events rates.ConclusionERCP in ABP cases seem to be more challenging than in AC. Difficult biliary access is more frequent in the ABP cases which warrants the involvement of an experienced endoscopist.     

ERCP in acute pancreatitis

BACKGROUND: The role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of acute pancreatitis has evolved over years since its introduction in 1968. Its importance in diagnosing the etiology of pancreatitis has steadily declined with the advent of less invasive diagnostic tools. The therapeutic implications of ERCP in acute pancreatitis are many fold and are directed towards management of known etiological factors or its related complications. This article highlights the current status of ERCP in acute pancreatitis. DATA SOURCES: An English literature search using PubMed database was conducted on ERCP in acute pancreatitis, the etiologies and complications of pancreatitis amenable to endotherapy and other related subjects, which were reviewed. RESULTS: ERCP serves as a primary therapeutic modality for management of biliary pancreatitis in specific situations, pancreatitis due to microlithiasis, specific types of sphincter of Oddi dysfunction, pancreas divisum, ascariasis and malignancy. In recurrent acute pancreatitis and smoldering pancreatitis it has a definite therapeutic utility. Complications of acute pancreatitis including pancreatic-duct disruptions or leaks, benign pancreatic-fluid collections and pancreatic necrosis can be beneficially dealt with. Intraductal ultrasound and pancreatoscopy during ERCP are useful in detecting pancreatic malignancy. CONCLUSIONS: The role of ERCP in acute pancreatitis is predominantly therapeutic and occasionally diagnostic. Its role in the management continues to evolve and advanced invasive procedures should be undertaken only in centers dedicated to pancreatic care.     

Early ercp in biliary pancreatitis: A macho mistake?: Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis

In a prospective, randomized, multicenter study from Germany, 238 patients were assigned to early ERCP and possible papillotomy or conservative treatment of acute biliary pancreatitis. Randomization occurred within 72 h after the onset of pancreatitis symptoms. In the invasive treatment group, 121 of 126 patients successfully underwent ERCP. Papillotomy with extraction of bile duct stones was successful in 57 of 58 patients with choiedocholithiasis. The overall 3-month mortality rate and the mortality directly related to the biliary pancreatitis was not different in the two groups. The complication rate was similar in the two groups, but the invasive treatment group had a higher incidence of more severe and pulmonary complications. Jaundice occurred more frequently in the conservative treatment group, and 22 of the 112 in this group eventually required ERCP.     

Should routine spiral computed tomography be performed in adult patients with acute abdominal pain of the right lower quadrant?

BACKGROUND AND AIMS: To determine whether spiral computed tomography (SCT) is helpful in the management of adult patients with acute pain of the right lower quadrant. PATIENTS AND METHODS: The prospective study included 204 patients with acute pain of the right lower quadrant during two periods: 104 before and 100 after the introduction of SCT. A questionnaire was completed for each patient before and after standard clinical and laboratory assessment and SCT, indicating the suspected diagnosis and a provisional therapeutic option. RESULTS: In the pre-SCT period the negative laparotomy rate was 29% vs. only 13% in the SCT period. During the SCT period 10 of the 24 nonoperated patients were discharged on the same day, and 14 were hospitalized 1.6+/-1 days, and only one was readmitted for operation on day 7. The accuracy of SCT assisted by results of clinical and laboratory findings (true positives + true negatives/total of patients) was 86% (vs. 73% for standard clinical and laboratory assessment): 93% in men (vs. 76% for standard clinical and laboratory assessment) but only 63% in women (vs. 60% for standard clinical and laboratory assessment). SCT changed the therapeutic decision guided by standard clinical and laboratory assessment in 18 cases, accurately in 16 cases (90%). CONCLUSION: SCT is helpful in the management of adult patients with acute abdominal pain of the right lower quadrant. In our study it reduced negative laparotomy rate from 29% (guided by standard clinicobiological evaluation) to only 13%.     

Should anticoagulants be administered for portal vein thrombosis associated with acute pancreatitis?

Venous complications in patients with acute pancreatitis typically occur as a form of splenic, portal, or superior mesenteric vein thrombosis and have been detected more frequently in recent reports. Although a well-organized protocol for the treatment of venous thrombosis has not been established, anticoagulation therapy is commonly recommended. A 73-year-old man was diagnosed with acute progressive portal vein thrombosis associated with acute pancreatitis. After one month of anticoagulation therapy, the patient developed severe hematemesis. With endoscopy and an abdominal computed tomography scan, hemorrhages in the pancreatic pseudocyst, which was ruptured into the duodenal bulb, were confirmed. After conservative treatment, the patient was stabilized. While the rupture of a pseudocyst into the surrounding viscera is a well-known phenomenon, spontaneous rupture into the duodenum is rare. Moreover, no reports of upper gastrointestinal bleeding caused by pseudocyst rupture in patients under anticoagulation therapy for venous thrombosis associated with acute pancreatitis have been published. Herein, we report a unique case of massive upper gastrointestinal bleeding due to pancreatic pseudocyst rupture into the duodenum, which developed during anticoagulation therapy for portal vein thrombosis associated with acute pancreatitis.     

Should cisapride be avoided in patients with diabetic gastroparesis?

The gastrointestinal motility stimulants, cisapride and erythromycin, have been used in the management of diabetic gastroparesis. However, drug interactions may result in prolongation of the electrocardiographic QT interval with the risk of ventricular arrhythmias. These drugs should, therefore, not be used in combination. We report two cases that illustrate inappropriate use of these agents. Moreover, patients with recurrent severe hypoglycemia or renal impairment may be at increased risk from cisapride-related cardiotoxicity. Thus, even as monotherapy, cisapride may pose dangers for high-risk diabetic patients.     

Should hyperhomocysteinemia be treated in patients with atherosclerotic disease?

Numerous retrospective and prospective observational studies support an association between elevated homocysteine and increased risk for myocardial infarction, stroke, and peripheral vascular disease. Although folic acid therapy substantially reduces homocysteine levels, recent large, randomized controlled trials failed to translate folic acid-induced homocysteine reduction into clinical benefit for the secondary prevention of cardiovascular events. These studies are compelling and have generated some newfound skepticism regarding a clinical role for folic acid therapy. Because these intervention trials have been limited to patients with mild hyperhomocysteinemia, the results of the trials imply that folic acid therapy may be best suited for individuals with more robustly elevated homocysteine levels. Furthermore, the potential benefit of folic acid therapy for primary prevention in individuals at low-or intermediate-risk for atherothrombotic disease has not been studied to date. Thus, at this time, folic acid therapy for borderline or mild hyperhomocysteinemia is not recommended. However, the role of folic acid therapy in patients with intermediate or severe hyperhomocysteinemia, or for primary prevention of cardiovascular diseases, remains unresolved.     

Should patients undergoing ERCP be placed in the prone or supine position?

Endoscopic retrograde cholangiopancreatography (ERCP) is generally performed in the prone or semi-prone position. Compared with the supine position, the left lateral and prone positions are believed to carry a lower risk of aspiration, allow easier intubation of the esophagus and provide a more comfortable position for the endoscopist. However, the supine position might be advantageous for the evaluation of pancreatic and biliary anatomy and for enhanced control of the airway. In this Practice Point commentary, I discuss the findings and limitations of a prospective, randomized study conducted by Tringali et al. that compared the performance of ERCP in the prone and supine positions by both experienced endoscopists and trainees. The results suggest no difference in the difficulty of the procedure on the basis of patient position. Objective measurements including mean time to visualize the papilla and opacification of the desired duct were no different. Likewise, overall technical success and complication rates were equivalent. These results suggest that either the supine or prone positions are adequate for the technical performance of ERCP. This commentary highlights the issues to consider when interpreting and generalizing these results in clinical practice.     

Diagnostic evaluation of acute pancreatitis in two patients with hypertriglyceridemia

We present two diagnostically challenging cases of acutepancreatitis with hypertriglyceridemia accompanied withchylomicronemia caused with a deficiency of lipoproteinlipase and with the presence of type Ⅴ hyperlipidemia.Both cases suffered from acute abdomen following theingestion of fatty food and revealed the increase inparameters of inflammation without significant elevationof serum amylase levels.The imaging examination ofultrasonography could not detect significant findings ofacute pancreatitis and a computer tomography scaneventually confirmed the findings of acute pancreatitis.Bothcases responded to a low fat diet and administration of acholecystokinin receptor antagonist,exhibiting a relief ofabdominal symptoms.As in the present cases with acuteabdomen following the ingestion of fatty food,the identificationof serum hypertriglyceridemia and an abdominal computertomography scan might be useful in establishing thediagnosis of acute pancreatitis and in developing thetherapeutic regimen,when hypertriglyceridemia interfereswith the evaluation of pancreatic enzyme activities andultrasound examination provides poor pancreatic visualization.