Acute biliary conditions

Acute biliary complications may result from several medical conditions such as gallstone pancreatitis, acute cholangitis, acute cholecystitis, bile leak, liver abscess and hepatic trauma. Gallstones are the most common cause of acute pancreatitis. About 25% of theses patients will develop clinically severe acute pancreatitis, usually due to necrotizing pancreatitis. Choledocholithiasis, malignant and benign biliary strictures, and stent dysfunction may cause partial or complete obstruction and infection in the biliary tract with acute cholangitis. Bile leaks are most commonly associated with hepatobiliary surgeries or invasive procedures such as open or laparoscopic cholecystectomy, hepatic resection, hepatic transplantation, liver biopsy, and percutaneous transhepatic cholangiography. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) may have an essential role in the management of these complications.     

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.     

Acute Biliary Pancreatitis: Diagnosis and Treatment

Gallstones are the commonest cause of acute pancreatitis (AP), a potentially life-threatening condition, worldwide. The pathogenesis of acute pancreatitis has not been fully understood. Laboratory and radiological investigations are critical for diagnosis as well prognosis prediction. Scoring systems based on radiological findings and serologic inflammatory markers have been proposed as better predictors of disease severity. Early endoscopic retrograde cholangiopancreatography (ERCP) is beneficial in a group of patients with gallstone pancreatitis. Laparoscopic cholecystectomy with preoperative endoscopic common bile duct clearance is recommended as a treatment of choice for acute biliary pancreatitis. The timing of cholecystectomy, following ERCP, for biliary pancreatitis can vary markedly depending on the severity of pancreatitis     

Management of gallstone pancreatitis: cholecystectomy or ERCP and endoscopic sphincterotomy

BACKGROUND: Currently, cholecystectomy is recommended for patients with gallstone-induced pancreatitis. ERCP with endoscopic sphincterotomy (ES) within 24 to 48 hours is also suggested for the treatment of acute gallstone pancreatitis. The aim of this study was to determine outcome after cholecystectomy versus ES alone in patients with gallstone pancreatitis. METHODS: One hundred seventeen patients with gallstone pancreatitis were included in this prospective observational study. Inclusion criteria were typical abdominal pain; serum amylase level 3 times or greater than normal; and gallbladder stones and a dilated bile duct, with or without stones, by US, CT, or ERCP. RESULTS: Eighty-three patients (Group A) underwent cholecystectomy after initial evaluation including ERCP in 43 (53%) and ERCP with ES in 38 (47%). The remaining 34 (Group B) underwent successful ERCP with ES alone. Mean follow-up was 33 months for Group A and 34 months for Group B. Recurrent gallstone pancreatitis was noted in 2 patients (2.4%) in Group A (bile duct stone in 2, sludge and papillary stenosis in 1), and in 1 patient (2.9%) in Group B. Ten patients in Group B had follow-up US of the gallbladder that showed disappearance of stones in 3. During follow-up, there was no significant difference in the rates of biliary complications (Group A, 3.6% vs. Group B, 11.6%; p = 0.19) or serious complications (pancreatitis, cholecystitis, cholangitis) (Group A, 3.6% vs. Group B, 5.8%). Also, there was no significant difference in procedure-related complications. CONCLUSIONS: Recurrence of pancreatitis after ERCP with ES alone for gallstone pancreatitis is rare. In patients who have undergone ES alone, cholecystectomy should be considered only if there are overt manifestations of gallbladder disease (e.g., biliary pain, cholecystitis, cystic duct obstruction) and not for prevention of recurrent gallstone pancreatitis. Because treatment by ES alone may be associated with a higher risk of biliary complications during follow-up compared with cholecystectomy, these patients may require close surveillance.     

Biliary sphincterotomy reduces the risk of acute gallstone pancreatitis recurrence in non-candidates for cholecystectomy

BackgroundPopulation aging and comorbidity are leading to an increase in patients unfit for cholecystectomy.AimsTo evaluate whether endoscopic biliary sphincterotomy after a first episode of acute gallstone pancreatitis reduces the risk of pancreatitis recurrence and gallstone-related events in non-surgical candidates.MethodsRetrospective study of patients admitted for a first episode of acute gallstone pancreatitis rejected for cholecystectomy between 2013–2018. The role of endoscopic sphincterotomy was evaluated by adjusting for age, severity of pancreatitis, and presence of choledocholithiasis.ResultsWe included 247 patients (mean age 80 ± 12 years; Charlson index: 5; severity of pancreatitis: 72% mild). Sphincterotomy was performed in 23.9%. Recurrence of pancreatitis occurred in 17.4% patients (median follow-up: 426 days). The one-year cumulative incidence of a new episode of pancreatitis was 1.8% (95% confidence interval [CI]: 0.2–12%) and 23% (95% CI: 17–31%) in patients with and without sphincterotomy, respectively (p = 0.006). In multivariate analysis, sphincterotomy showed a protective role for recurrence of pancreatitis (adjusted hazard ratio [HR]: 0.29, 95% CI: 0.08–0.92, p = 0.037) and for any gallstone-related event (HR 0.46, 95% CI: 0.21–0.98, p = 0.043).ConclusionsEndoscopic biliary sphincterotomy reduced the risk of gallstone pancreatitis recurrence and other biliary-related disorders in patients with a first episode of pancreatitis non-candidates for cholecystectomy.     

急性胆源性胰腺炎早期内镜治疗的临床评价

目的 :评价急性胆源性胰腺炎患者早期行内镜逆行胰胆管造影 (ERCP)治疗的安全性和临床疗效。方法 :对 2 6例急性胆源性胰腺炎住院患者 ,早期行ERCP检查和治疗 ,观察其疗效和并发症 ,评价急性胆源性胰腺炎患者内镜治疗的安全性和疗效。结果 :本组 2 6例患者均治愈 ,无明显并发症发生 ,未见因ERCP检查和治疗而使病情加重者。结论 :对于急性胆源性胰腺炎患者早期行ERCP检查及治疗是安全的 ,急性胆源性胰腺炎经有效的内镜治疗可缩短平均住院时间、降低平均住院费用     

急性胆源性胰腺炎早期内镜治疗价值

目的探讨急性胆源性胰腺炎早期内镜治疗的价值及其安全性。方法选择92例急性胆源性胰腺炎患者早期（72h内）行ERCP及内镜治疗（ERCP组），并与同期保守治疗40例（对照组）进行比较。结果ERCP组全部成功实施十二指肠乳头切开取石，72例胆总管结石者行网篮及气囊取石，所有92例均行鼻胆管引流，重症组10例同时行胰管支架引流。ERCP组平均腹痛消失时间、血清淀粉酶恢复时间、平均住院天数及平均费用均明显低于对照组。ERCP组重症组病死率8．3％，对照组重症组病死率33．3％。结论急性胆源性胰腺炎早期ERCP治疗是安全的，能降低患者的病死率，减少患者住院天数和费用。     

Management of patients after recovering from acute severe biliary pancreatitis

Cholelithiasis is the most common cause of acute pancreatitis,accounting 35%-60% of cases. Around 15%-20% of patients suffer a severe attack with high morbidity and mortality rates. As far as treatment is concerned,the optimum method of late management of patients with severe acute biliary pancreatitis is still contentious and the main question is over the correct timing of every intervention. Patients after recovering from an acute episode of severe biliary pancreatitis can be offered alternative options in their management,including cholecystectomy,endoscopic retrograde cholangiopancreatography(ERCP) and sphincterotomy,or no definitive treatment. Delaying cholecystectomy until after resolution of the inflammatory process,usually not earlier than 6 wk after onset of acute pancreatitis,seems to be a safe policy. ERCP and sphincterotomy on index admission prevent recurrent episodes of pancreatitis until cholecystectomy is performed,but if used for definitive treatment,they can be a valuable tool for patients unfit for surgery. Some patients who survive severe biliary pancreatitis may develop pseudocysts or walled-off necrosis. Management of pseudocysts with minimally invasive techniques,if not therapeutic,can be used as a bridge to definitive operative treatment,which includes delayed cholecystectomy and concurrent pseudocyst drainage in some patients. A management algorithm has been developed for patients surviving severe biliary pancreatitis according to the currently published data in the literature.     

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.     

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.     

Role and timing of endoscopy in acute biliary pancreatitis

The role and timing of endoscopy in the setting of acute biliary pancreatitis (ABP) is still being debated. Despite numerous randomized trials have been published, there is an obvious lack of consensus on the indications and timing of endoscopic retrograde cholangiopancreatography (ERCP) in ABP in meta-analyses and nationwide guidelines. The present editorial has been written to clarify the role of endoscopy in ABP. In clinical practice the decision to perform an ERCP is often based on biochemical and radiological criteria despite they already have been shown to be unreliable predictors of common bile duct stone presence. Endoscopic ultrasonography (EUS) is not currently a worldwide standard diagnostic procedure early in the course of acute biliary pancreatitis, but it has been shown to be accurate, safe and cost effective in diagnosing biliary obstructions compared with magnetic resonance cholangiopancreatography and ERCP and therefore in preventing unnecessary ERCP and its related complications. Early EUS in ABP allows, if appropriate, immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.     

Should elective endoscopic sphincterotomy replace cholecystectomy for the treatment of high-risk patients with gallstone pancreatitis?

Since the introduction of endoscopic sphincterotomy approximately 15 years ago, the indications for this procedure have expanded. Currently endoscopic sphincterotomy is the procedure of choice for management of retained common bile duct stones following cholecystectomy. It is also being used more frequently for choledocholithiasis with an intact gallbladder in high-risk patients and in some patients with acute gallstone pancreatitis. In patients recovering from an episode of gallstone pancreatitis, standard practice has been subsequent cholecystectomy with possible exploration of the common bile duct. To avoid surgery in high-risk patients, we propose that an elective endoscopic sphincterotomy may be a reasonable therapeutic option regardless of whether common bile duct stones are present at the time of ERCP. A prospective trial is needed to examine this issue since to date there is no literature on endoscopic sphincterotomy in the absence of choledocholithiasis for gallstone pancreatitis in patients with intact gallbladders.     

Should urgent ERCP be performed in patients with acute biliary pancreatitis without acute cholangitis?

Endoscopists who perform endoscopic retrograde cholangiopancreatography (ERCP) are frequently pressured to perform urgent (usually night or weekend) ERCP in patients with acute biliary pancreatitis in the belief that this procedure reduces morbidity and mortality. However, with the exception of those patients with concurrent acute cholangitis, data that urgent ERCP with biliary compression is helpful in all patients with acute gallstone pancreatitis are lacking. In this Practice Point commentary, I discuss the findings and limitations of a meta-analysis conducted by Petrov et al. that pooled data from three randomized, controlled trials that included 450 patients in total. Four other randomized, controlled trials on this topic were excluded from the analysis because of methodologic problems. The authors concluded that early ERCP was not associated with a significant reduction in complications or mortality in patients with predicted mild or severe acute biliary pancreatitis.     

Risk factors for acute biliary pancreatitis

BACKGROUND: Few studies have analyzed both stone-related and pancreatobiliary anatomical factors that predispose to acute biliary pancreatitis. Both of these factor types were studied by multivariate analysis. METHODS: A total of 143 patients with (n=43) or without (n=100) recent acute biliary pancreatitis who underwent cholecystectomy for gallbladder stones after ERCP were prospectively studied. The interval between the onset of pancreatitis and ERCP ranged from 12 to 35 days (mean, 20 days). Univariate and multivariate analyses for 15 potential risk factors for acute biliary pancreatitis, including operative and ERCP findings, were performed. RESULTS: Univariate analysis identified 5 significant predictive factors for pancreatitis: a diameter of the smallest gallbladder stone of 5 mm or less, a cystic duct diameter of 5 mm or more, 20 or more gallbladder stones, a diameter of the largest gallbladder stone of 5 mm or less, and irregular gallstone surface. Of these 5 factors, the first 3 remained significant in the multivariate analysis. CONCLUSIONS: Both stone-related factors (small and multiple stones) and an anatomical factor (enlarged cystic duct) may contribute to the development of biliary pancreatitis. These features should be carefully considered during management of patients with gallstones.     

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.     

急性胆源性胰腺炎的内镜下介入治疗

目的 :综合评价早期内镜下介入治疗急性胆源性胰腺炎的方法、疗效及并发症等。方法 :10 3例胆源性胰腺炎患者中 ,5 7例在 72h内行早期内镜下介入治疗 ,4 3例保守治疗 ,保守治疗中的 19例择期内镜检查及治疗 ,3例外科手术治疗。结果 :早期内镜治疗组 80 .70 %患者临床症状得到迅速缓解 ;保守治疗组 6 2 .79%也可迅速缓解。全部内镜治疗后 3例出现胰腺炎加重。结论 :早期内镜介入治疗对于急性胆源性胰腺炎是一种有效而安全的方法 ,对于有明显黄疸、感染、结石嵌顿的病例应急诊内镜下治疗 ;对于病情较轻、黄疸不重的患者可先保守治疗后再行择期内镜治疗     

Nationwide epidemiological study of severe gallstone disease in Taiwan

Background

Our study aimed to assess the nationwide trends in the incidence of severe gallstone disease in Taiwan among adults aged ≥20.

Methods

A retrospective longitudinal study was conducted using Taiwan National Health Insurance Research Database collected during 1997–2005. Patients with incident severe gallstone disease (acute cholecystitis, biliary pancreatitis, acute cholangitis) and gallstone-related procedures (elective and non-elective cholecystectomy, endoscopic retrograde cholangiopancreatography [ERCP]) that led to hospital admission were identified using ICD-9-CM diagnostic and procedure codes. Annual incidence rates of gallstone-related complications and procedures were calculated and their 95% confidence intervals (CI) were estimated assuming a Poisson distribution.

Results

The hospital admission rate for severe gallstone disease increased with advancing age and the age-standardized rate (95% CI) per 1000 population was 0.60 (0.59–0.60) for men and 0.59 (0.59–0.60) for women. Men had a higher rate of acute cholecystitis, probably due to the substantially lower rate of elective cholecystectomy among men than women. For those aged 20–39, hospital admissions for all gallstone-related complications and procedures increased significantly. For those aged ≥60, incidences of biliary pancreatitis, acute cholangitis, and hospital admission for gallstone receiving ERCP increased significantly without substantial change in the incidence of acute cholecystitis and despite a decreased rate of elective cholecystectomy.

Conclusion

This population-based study found a substantial increase in the rate of admission for severe gallstone disease among those aged 20–39. Concurrently, the incidences of biliary pancreatitis and acute cholangitis have risen among those aged ≥60.     

Trends in same-admission cholecystectomy and endoscopic retrograde cholangiopancreatography for acute gallstone pancreatitis: A nationwide analysis across a decade

Background/objectivesGallstones are the leading cause of acute pancreatitis in developed countries. National and international guidelines recommend that a cholecystectomy should be performed during the index hospitalization for acute gallstone pancreatitis. We aimed to delineate the national trends for same-admission cholecystectomy and ERCP for acute gallstone pancreatitis over the last ten years.MethodsWe used the 2004, 2009 and 2014 National Inpatient Sample database including patients with a principal diagnosis of acute pancreatitis and a secondary diagnosis of choledocholithiasis or cholelithiasis. Exclusion criteria were age <18 years and elective admission. Primary outcome was the trend in incidence rate of same admission cholecystectomy from 2004 to 2014. The secondary outcomes were: 10-year trend in 1) Incidence of gallstone pancreatitis, 2) proportion of gallstone pancreatitis compared to all other etiologies of acute pancreatitis, 3) incidence rate of same-admission ERCP, 4) length of hospital stay, and 5) total hospitalization costs and charges.ResultsThe proportion of admissions during which a same-admission cholecystectomy was performed decreased from 48.7% in 2004 to 46.9% in 2009 to 45% in 2014 (trend p < 0.01). During the same time interval, the percentage of admissions during which an ERCP was performed decreased from 25.1% to 18.7% (Trend p < 0.01).ConclusionsAdherence to the guidelines for same-admission cholecystectomy for patients admitted with acute gallstone pancreatitis have been declining over the past decade. On the other hand, decline in rate of ERCP in patients with acute gallstone pancreatitis and no signs of cholangitis demonstrates adherence to guidelines in this regard.     

内镜诊治急性胆源性胰腺炎的临床分析

目的：评价内镜诊治急性胆源性胰腺炎（ABP）的临床价值。方法：回顾性分析内镜治疗的114例ABP患者以及内科常规治疗的106例ABP患者的临床资料,评价内镜诊治ABP的临床价值。结果：内镜治疗组114例均顺利完成逆行胰胆管造影（ERCP）检查并确诊,其中107例同时经内镜分别进行十二指肠乳头括约肌切开、胆管取石/蛔虫/血凝块、鼻胆管引流、胆管内置管/金属支架引流等治疗,术后所有患者均治愈出院,无明显并发症发生;与常规治疗组相比内镜治疗组平均住院时间明显缩短（12.1±4.2dvs.18.7±8.9d,P〈0.05）,平均住院费用明显降低（P〈0.05）。结论：内镜治疗ABP是一项安全、有效的措施;早期ERCP检查可明确ABP的病因,同时内镜治疗可及时去除其病因。可明显缩短患者平均住院时间、降低平均住院费用。     

The frequency of bile duct crystals in patients with presumed biliary pancreatitis.

BACKGROUND: Previous studies of biliary microlithiasis in acute pancreatitis of uncertain etiology were conducted a few weeks to months after the acute episode. Bile obtained during urgent ERCP (less than 24 hours after admission) was studied for the presence of microlithiasis during the acute phase of acute pancreatitis of suspected biliary origin. METHODS: Fifteen consecutive patients with acute pancreatitis of suspected biliary origin were recruited from a population of 309 patients with acute pancreatitis (5%) treated during the last 4 years. Patients with gallstones on US and/or ERCP and those in whom the etiology of acute pancreatitis was certain were excluded. RESULTS: Microlithiasis (mostly calcium bilirubinate granules) was found in 12 (80%) cases. Despite endoscopic sphincterotomy 3 patients died within 2 weeks because of multisystemic organ failure. Among the 12 remaining patients, 2 (16%) developed gallbladder stones and 1 underwent cholecystectomy for cholecystitis (8%) during follow-up. The average length of follow-up was 30 months. No episodes of acute pancreatitis were noted during follow-up. CONCLUSIONS: In the acute phase of acute pancreatitis of suspected biliary origin, biliary microlithiasis was found in most cases. Endoscopic sphincterotomy appears to protect patients from further episodes of acute pancreatitis.