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.     

胆总管结石与胆源性胰腺炎的相关性研究

目的 探讨胆总管结石的大小、部位等相关因素与胆源件胰腺炎的相关性.方法 回顾性分析2002年1月至2008年12月收治的3497例胆总管结石患者的临床资料,并根据胆总管结石的大小,结石部位分组,比较各组并发胰腺炎的发病率.结果 胆总管结石患者并发胆源性胰腺炎时,以发热、腹痛、黄疸等症状更为明显,血清淀粉酶显著增高,其中胆总管结石的大小与胆源性胰腺炎严重程度呈负相关,位于胆总管下段与壶腹部的结石者易并发胰腺炎.结论 对位于胆总管下段或壶腹部的小结石应早期行内镜下取石治疗,以预防急性胆源性胰腺炎的发生.     

Role of endoscopic ultrasound during hospitalization for acute pancreatitis

Endoscopic ultrasound(EUS)is often used to detect the cause of acute pancreatitis(AP)after the acute attack has subsided.The limited data on its role during hospitalization for AP are reviewed here.The ability of EUS to visualize the pancreas and bile duct,the sonographic appearance of the pancreas,correlation of such appearance to clinical outcomes and the impact on AP management are analyzed from studies.The most important indication for EUS appears to be for detection of suspected common bile duct and/or gall bladder stones and microlithiasis.Such an approach might avoid diagnostic endoscopic retrograde cholangio-pancreatography with its known complications.The use of EUS during hospitalization for AP still appears to be infrequent but may become more frequent in future.     

Diagnostic value of magnetic resonance cholangiopancreatography to detect bile duct stones in acute biliary pancreatitis

Objectives

This study aims to evaluate the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) in detecting common bile duct (CBD) stones in acute biliary pancreatitis (ABP).

Failure of sequential biliary stenting for unsuccessful common bile duct stone removal

AIM: To determine the factors associated with the failure of stone removal by a biliary stenting strategy.METHODS: We retrospectively reviewed 645 patients with common bile duct (CBD) stones who underwent endoscopic retrograde cholangiography for stone removal in Siriraj GI Endoscopy center, Siriraj Hospital from June 2009 to June 2012. A total of 42 patients with unsuccessful initial removal of large CBD stones that underwent sequential biliary stenting were enrolled in the present study. The demographic data, laboratory results, stone characteristics, procedure details, and clinical outcomes were recorded and analyzed. In addition, the patients were classified into two groups based on outcome, successful or failed sequential biliary stenting, and the above factors were compared.RESULTS: Among the initial 42 patients with unsuccessful initial removal of large CBD stones, there were 37 successful biliary stenting cases and five failed cases. Complete CBD clearance was achieved in 88.0% of cases. The average number of sessions needed before complete stone removal was achieved was 2.43 at an average of 25 wk after the first procedure. Complications during the follow-up period occurred in 19.1% of cases, comprising ascending cholangitis (14.3%) and pancreatitis (4.8%). The factors associated with failure of complete CBD stone clearance in the biliary stenting group were unchanged CBD stone size after the first biliary stenting attempt (10.2 wk) and a greater number of endoscopic retrograde cholangio-pancreatography sessions performed (4.2 sessions).CONCLUSION: The sequential biliary stenting is an effective management strategy for the failure of initial large CBD stone removal.     

Endoscopic sphincterotomy in acute biliary pancreatitis: A question of anesthesiological risk

Two consecutive surveys of acute pancreatitis in Italy, based on more than 1000 patients with acute pancreatitis, reported that the etiology of the disease indicates biliary origin in about 60% of the cases. The United Kingdom guidelines report that severe gallstone pancreatitis in the presence of increasingly deranged liver function tests and signs of cholangitis (fever, rigors, and positive blood cultures) requires an immediate and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). These guidelines also recommend that patients with gallstone pancreatitis should undergo prompt cholecystectomy, possibly during the same hospitalization. However, a certain percentage of patients are unfit for cholecystectomy because advanced age and presence of comorbidity. We evaluated the early and long-term results of endoscopic intervention in relation to the anesthesiological risk for 87 patients with acute biliary pancreatitis. All patients underwent ERCP and were evaluated according to the American Society of Anesthesiology (ASA) criteria immediately before the operative procedure. The severity of acute pancreatitis was positively related to the anesthesiological grade. There was no significant relationship between the frequency of biliopancreatic complications during the follow-up and the ASA grade. The frequency of cholecystectomy was inversely related to the ASA grade and multivariate analysis showed that the ASA grade and age were significantly related to survival. Finally, endoscopic treatment also appeared to be safe and effective in patients at high anesthesiological risk with acute pancreatitis. These results further support the hypothesis that endoscopic sphincterotomy might be considered a definitive treatment for patients with acute biliary pancreatitis and an elevated ASA grade.     

急性胆源性胰腺炎内镜治疗的临床对比研究

目的:通过对比观察给予不同治疗方案的3组急性胆源性胰腺炎(ABP)患者,探讨ABP经内镜治疗的优劣.方法:将119例ABP(包括SABP)患者分为内镜组(40例)、药物组(42例)、手术组(37例).对比观察3组患者治疗后症状、实验室指标恢复情况、并发症发生率、死亡率以及住院天数.结果:内镜组总并发症发生率12.5%(5/40),死亡率5.0%(2/40).手术组并发症发生率29.7%(11/37),死亡率5.4%(2/37);保守组并发症发生率23.8%(10/42),死亡率7.1%(3/42).在3组SABP中,内镜组患者在症状恢复时间、实验室指标恢复时间、及住院天数方面较手术组及保守组均明显缩短、并发症发生率较手术组及保守组均降低(P<0.05).结论:内镜治疗ABP(尤其SABP)是一项较安全、有效、经济简便、并发症少、可重复操作的治疗措施,值得临床大力推广.     

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.     

ERCP in acute biliary pancreatitis

The role of urgent endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis is for many years a subject for disagreement among physicians. Although the evidence seemed to be in favor of performing ERCP, endoscopists usually hesitate to conform to the guidelines. ERCP is an invasive procedure, with complications which can affect patients' outcome. Recent evidence suggests that we should probably modify our policy, recruiting less invasive procedures, like magnetic resonance cholangiopancreatography and endoscopic ultrasound, before conducting ERCP in patients with acute biliary pancreatitis. In this editorial the different aspects regarding the role of ERCP in acute biliary pancreatitis are discussed.     

Poorly expandable common bile duct with stones on endoscopic retrograde cholangiography

AIM: To describe characteristics of a poorly expandable (PE) common bile duct (CBD) with stones on endoscopic retrograde cholangiography.METHODS: A PE bile duct was characterized by a rigid and relatively narrowed distal CBD with retrograde dilatation of the non-PE segment. Between 2003 and 2006, endoscopic retrograde cholangiography (ERC) images and chart reviews of 1213 patients with newly diagnosed CBD stones were obtained from the computer database of Therapeutic Endoscopic Center in Chang Gung Memorial Hospital. Patients with characteristic PE bile duct on ERC were identified from the database. Data of the patients as well as the safety and technical success of therapeutic ERC were collected and analyzed retrospectively.RESULTS: A total of 30 patients with CBD stones and characteristic PE segments were enrolled in this study. The median patient age was 45 years (range, 20 to 92 years); 66.7% of the patients were men. The diameters of the widest non-PE CBD segment, the PE segment, and the largest stone were 14.3 ± 4.9 mm, 5.8 ± 1.6 mm, and 11.2 ± 4.7 mm, respectively. The length of the PE segment was 39.7 ± 15.4 mm (range, 12.3 mm to 70.9 mm). To remove the CBD stone(s) completely, mechanical lithotripsy was required in 25 (83.3%) patients even though the stone size was not as large as were the difficult stones that have been described in the literature. The stone size and stone/PE segment diameter ratio were associated with the need for lithotripsy. Post-ERC complications occurred in 4 cases: pancreatitis in 1, cholangitis in 2, and an impacted Dormia basket with cholangitis in 1. Two (6.7%) of the 28 patients developed recurrent CBD stones at follow-up (50 ± 14 mo) and were successfully managed with therapeutic ERC.CONCLUSION: Patients with a PE duct frequently require mechanical lithotripsy for stones extraction. To retrieve stones successfully and avoid complications, these patients should be identified during ERC.     

Relapses of biliary acute pancreatitis in patients with previous attack of biliary pancreatitis and gallbladder in situ

AIM: To evaluate relapse of acute pancreatitis in patients with biliary pancreatitis in whom coexisting diseases or patient refusal have excluded cholecystectomy. PATIENTS AND METHODS: Forty-seven patients presenting a first episode of biliary acute pancreatitis underwent urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES). RESULTS: ERCP with ES was successful in all but one patient (97.8%) who was then cholecystectomised. Complications related to the endoscopic procedure were reported in five patients (10.6%). During the follow-up period (median time 12 months; range 1-84 months), 10 patients (21%) suffered from biliary complications. Three patients (6.4%), all with lithiasis of the gallbladder, had relapses of acute pancreatitis, two of them within 2 months of the previous episode, and one about a year later after ingestion of a rich meal and alcoholic beverages. The first two were cholecystectomised. Two patients died during the follow-up period from unrelated diseases. CONCLUSIONS: In subjects who are at high risk for anaesthesia, endoscopic procedures may be utilised.     

高脂血症性急性胰腺炎与胆源性胰腺炎的临床对比分析

目的对比分析高脂血症性急性胰腺炎（hyperlipidemic acute pancreatitis,HLAP）与急性胆源性胰腺炎（acute biliary pancreatitis,ABP）的临床特点。方法回顾性对比分析我院2005年8月～2010年8月间收治的28例HLAP和64例ABP患者的临床资料。结果 HLAP组BMI、重症患者比例、Ranson评分≥3、CT分级为D、E及APACHEII≥8分者均较ABP组高（P〈0.05）。HLAP组血清TG、GLU、UA均显著高于ABP组,而ALT、AKP、TBIL、DBIL及血AMY均显著低于ABP组（P〈0.05）。两组患者平均住院时间无统计学差异（P〉0.05）。HLAP组患者死亡率为14.3%）,显著高于ABP组的1.5%（P〈0.05）。结论与ABP组相比,HLAP组通常病情较重,多为SAP且常不伴有血淀粉酶的显著升高,且死亡率高。     

Endoscopic management of acute cholangitis in elderly patients

INTRODUCTIONAcute cholangitis is a difficult diagnostic and therapeutic problem.Classically,Charcot’s triad of jaundice,abdominal pain and fever have been the main basis of diagnosis however30%-45%of the patients with acute cholangitis do not satisfy the criteria of Charcot’s triad[1].Altered sensorium,hypotension and renal failure can often be seen in patients with suppurative cholangitis[2].In many cases,bile duct infection is latent and does not cause symptoms.Cholangitis varies in …     

Balloon dilation itself may not be a major determinant of post-endoscopic retrograde cholangiopancreatography pancreatitis

Endoscopic retrograde cholangiopancreatography(ERCP)is the essential first modality for common bile duct(CBD)stone therapy.The conventional endoscopic treatment for CBD stones is stone removal after endoscopic sphincterotomy(EST).Stone removal after papillary stretching using balloon dilation instead of the conventional method has been widely adopted.There are many reports regarding endoscopic papillary balloon dilation(EPBD)utilizing a small balloon(<10 mm)instead of EST for the removal of small CBD stones.In contrast,two cases of mortality due to postERCP pancreatitis(PEP)were reported after an EPBD clinical trial in the Western world,and the psychological barrier caused by these incidences hinders the use of this technique in Western countries.Endoscopic papillar large balloon dilation(EPLBD),which is used to treat large CBD stones,was not widely adopted when firstintroduced due to concerns about perforation and severe pancreatitis from the use of a large balloon(12-20mm).However,as experience with this procedure accumulates,the occurrence of PEP with EPLBD is confirmed to be much lower than with EPBD.This report reviews whether EPBD and EPLBD,two procedures that use balloon dilation but differ in terms of indications and concept,contribute to the occurrence of PEP.     

Factors and outcomes associated with pancreatic duct disruption in patients with acute necrotizing pancreatitis

Background and aimsAcute necrotizing pancreatitis (ANP) can affect main pancreatic duct (MPD) as well as parenchyma. However, the incidence and outcomes of MPD disruption has not been well studied in the setting of ANP.MethodsThis retrospective study investigated 84 of 465 patients with ANP who underwent magnetic resonance cholangiopancreatography and/or endoscopic retrograde cholangiopancreatography. The MPD disruption group was subclassified into complete and partial disruption.ResultsMPD disruption was documented in 38% (32/84) of the ANP patients. Extensive necrosis, enlarging/refractory pancreatic fluid collections (PFCs), persistence of amylase-rich output from percutaneous drainage, and amylase-rich ascites/pleural effusion were more frequently associated with MPD disruption. Hospital stay was prolonged (mean 55 vs. 29 days) and recurrence of PFCs (41% vs. 14%) was more frequent in the MPD disruption group, although mortality did not differ between ANP patients with and without MPD disruption. Subgroup analysis between complete disruption (n = 14) and partial disruption (n = 18) revealed a more frequent association of extensive necrosis and full-thickness glandular necrosis with complete disruption. The success rate of endoscopic transpapillary pancreatic stenting across the stricture site was lower in complete disruption (20% vs. 92%). Patients with complete MPD disruption also showed a high rate of PFC recurrence (71% vs. 17%) and required surgery more often (43% vs. 6%).ConclusionsMPD disruption is not uncommon in patients with ANP with clinical suspicion on ductal disruption. Associated MPD disruption may influence morbidity, but not mortality of patients with ANP. Complete MPD disruption is often treated by surgery, whereas partial MPD disruption can be managed successfully with endoscopic transpapillary stenting and/or transmural drainage. Further prospective studies are needed to study these items.     

Restoration of common bile duct diameter within 2 weeks after endoscopic stone retraction is a preventive factor for stone recurrence

Background: Little information is available about the relationship between restoration of common bile duct(CBD) diameter after endoscopic stone retraction and recurrence of CBD stones in elderly patients.The present study was to determine whether restoration of CBD diameter is a preventive factor for CBD stone recurrence in elderly patients who underwent endoscopic retrograde cholangiopancreatography(ERCP).Methods: From January 2006 to December 2010, 238 patients underwent the first and the second session of ERCP for the removal of CBD stones. Among them, 173 were over 65 years old. These patients were divided into recurrent group and non-recurrent group. Restoration of CBD diameter and patients' characteristics were compared.Results: There was no statistical difference in patients' characteristics, associated diseases, or ERCP-related complications between the two groups. Reduction of CBD diameter was significantly larger in the nonrecurrent group(2.7 ± 1.7 mm) compared to that in the recurrent group(1.4 ± 2.3 mm, P = 0.002). The proportion of patients with restoration of CBD diameter were significantly lower in the recurrent group(6/42, 14.3%) compared with that in the non-recurrent group(67/131, 51.1%)(P 0.01).Conclusions: There is an inverse relationship between restoration of CBD diameter and CBD stone recurrence. Therefore, patients without restoration of CBD diameter within 2 weeks after endoscopic stone removal should be monitored more frequently.     

Role of prophylactic endoscopic sphincterotomy in patients with acute biliary pancreatitis due to transient common bile duct obstruction

BACKGROUND AND AIM: The role of prophylactic endoscopic sphincterotomy in patients with transient common bile duct obstruction is controversial. The aim of this study was to assess the value of performing prophylactic endoscopic sphincterotomy in patients suffering from acute biliary pancreatitis and absent common bile duct stones on endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Hospital notes of patients admitted to our unit with a diagnosis of acute pancreatitis from January 2000 to January 2005 were reviewed. Endoscopic sphincterotomy was performed when patients were deemed unfit for cholecystectomy, suffering from a severe attack of acute pancreatitis and/or showing evidence of transient common bile duct obstruction. The outcomes of patients with and without endoscopic sphincterotomy were compared. RESULTS: A total of 427 patients were admitted with a diagnosis of acute pancreatitis during the study period. Eighty-eight patients with absent common bile duct stones on ERCP were identified. Endoscopic sphincterotomy was performed in 71 patients and not performed in 17 patients. There was no significant difference in recurrent pancreatitis rates (1.4% vs 5.8%, P = 0.35), recurrent biliary complication rates (5.6% vs 5.9%, P = 1) or mortality rates (5.8% vs 1.5%, P = 0.35). The time to recurrent complications (38.4 days vs 41.0 days, P = 0.38) was not significantly different between the two groups. There was no ERCP-related morbidity or mortality. CONCLUSION: Prophylactic endoscopic sphincterotomy is not recommended in patients with transient common bile duct obstruction or as an option to cholecystectomy in elderly patients. Early cholecystectomy should be performed.     

急诊十二指肠镜治疗急性胆源性胰腺炎94例

目的:探讨急诊十二指肠镜行胆胰管引流治疗急性胆源性胰腺炎的价值及可行性,扩大完善内镜在胆胰疾病中的治疗范围.方法:2004-01/2005-12急诊十二指肠镜治疗急性胆源性胰腺炎94例,治疗方式以经内镜鼻胆管引流(ENBD)为主,必要时行Oddi′s括约肌切开(EST).结果:94例患者中成功91例,成功率96.81%.无发展为重症胰腺炎患者.上腹痛症状平均症状缓解时间42.3 h;尿淀粉酶平均56 h下降到正常.内镜治疗后1 wk,复查B超,61例伴有胰腺水肿患者49例水肿消退,形态恢复正常:29例伴有胰周积液患者中21例胰周积液完全吸收,8例积液量明显减少,无伴随临床症状.结论:急诊十二指肠镜治疗急性胆源性胰腺炎是安全可靠的,可以阻止胰腺向恶性转化.