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PubMed2004

[Diagnostic value of secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP)].

BACKGROUND AND AIMS: To evaluate the value of S-MRCP in patients in whom ERCP performed by experts in a tertiary center were unsuccessful. PATIENTS AND METHODS: From January 2000 to June 2003, 22 patients fulfilled the inclusion criteria. The indications for ERCP were obstructive jaundice (n = 9), abnormal liver enzymes (n = 8), suspected chronic pancreatitis (n = 2), recurrent pancreatitis (n = 2) or suspected pancreatic cancer (n = 1). The reasons for the ERCP failure were postsurgical anatomy (n = 7), duodenum stenosis (n = 3), duodenal diverticulum (n = 2), or technical failure (n = 10). MRCP images were evaluated before and 5 and 10 min after the i.v. administration of 0.5 IU/kg secretin. RESULTS: The MRCP images were diagnostic in all but 1 patient. Five patients gave normal MR fadings and required no further intervention. S-MRCP detected abnormalities (primary sclerosing cholangitis, chronic pancreatitis, cholangitis, cholecystolithiasis or common bile duct dilatation) in 10 patients, who were followed up clinically. Four patients subsequently underwent laparotomy (hepatico-jejunostomy owing to common bile duct stenosis caused by unresectable pancreatic cancer; hepaticotomy + Kehr drainage because of narrow biliary-enteric anastomosis; choledocho-jejunostomy, gastro-jejunostomy and Wirsungo-gastrostomy in consequence of chronic pancreatitis or choledocho-jejunostomy because of common bile duct stenosis caused by chronic pancreatitis). Three patients participated in therapeutic percutaneous transhepatic drainage; the indications were choledocholithiasis in one patient choledocho-jejunostomy anastomosis, narrow biliary-enteric anastomosis, or cholangiocarcinoma. CONCLUSION: S-MRCP is the method of choice in cases where ERCP is not possible.

Adult↗

PubMed2004

Spontaneous closure of a persistent post-traumatic pancreatic fistula in a child: incidental therapeutic effect of ERCP.

A child with a post-tramatic pancreatic pseuodocyst developed pancreatic fistula, following percutaneous drainage of the cyst. The fistula output was about 120ml/day and lasted for a month. A diagnostic ERCP revealed main pancreatic duct disruption. The fistula output ceased over the next two days following the ERCP. The patient has been well for the past four years. This patient's immediate recovery after ERCP could possibly be due to dislodgement of a mucus plug by the contrast injected during ERCP. Such a mechanism can explain the previous sporadic reports of spontaneous cure of persistent pancreatic fistulae in children.

Child↗

PubMed2005

US, MRCP, CCT and ERCP: a comparative study in 131 patients with suspected biliary obstruction.

BACKGROUND: Recent years have witnessed a rapid and continuous evolution in the diagnosis of biliary obstructive disease. Traditional methodologies, such as US (ultrasonography), CT (computed tomography), ERCP (endoscopic retrograde cholangiopancreatography) and PTC (percutaneous transhepatic cholangiography), have been supplemented by MRCP (magnetic resonance cholagiopancreatography) and CCT (cholangio computed tomography) The purpose of our study was to compare the reliability of diagnostic US, MR and other imaging techniques in intrinsic biliary obstructive disease. MATERIAL/METHODS: Between June 1999 and July 2003 we conducted a prospective study on 131 patients--60 males and 71 females--ranging in age from 37 to 79 years, with clinical features of biliary obstructive disease. Imaging studies were done on each patient using several different techniques. The US, MRCP, CCT and ERCP results were read by radiologists blinded to other imaging findings. RESULTS: US is generally accurate in diagnostic imaging of obstructive biliary disease. MRCP and CCT are significantly more accurate only in completing the staging of malignant stenosis. CONCLUSIONS: If the suspicion posed by clinical and laboratory findings is not confirmed at US, the diagnosis must be achieved with the aid of MRCP or--where MRCP does not provide a diagnosis--CCT, so as to select candidates for therapeutic ERCP, PTC or surgery. If laboratory and clinical findings are supported by US, ERCP is required for therapeutic purposes, or--if necessary--surgery is performed.

Adult↗

PubMed2005

Can a single dose corticosteroid reduce the incidence of post-ERCP pancreatitis? A randomized, prospective control study.

BACKGROUND: Acute pancreatitis is one of the complications after Endoscopic retrograde cholangio pancreatography (ERCP) and it could be fatal. Several drugs were used to prevent or decrease this complication. Corticosteroid is one of the medications which may have such potential. It is affordable and available everywhere. OBJECTIVES: To compare the incidence of post-ERCP pancreatitis in patients receiving single dose corticosteroid prior to the procedure with that of the control group . RESEARCH DESIGN: A prospective randomized controlled double-blinded study. MATERIAL AND METHOD: A total of 120 patients were randomized to receive either intravenous hydrocortisone 100 mg. or normal saline 1 hour prior to the procedure. The serum amylase levels were recorded 4 and 24 hours after the procedure. Abdominal pain and back pain were also recorded. Patients were diagnosed as having post-ERCP pancreatitis if ones had new or worsened epigastric pain with or without radiation to the back combined with elevation of serum amylase more than 2.5 times the upper limit. RESULTS: The overall incidence of pancreatitis was 6.67% with 1.64% in the study group compared with 11.86% in the control group (p = 0.031). The groups were similar with regard to age, gender, type of procedure performed (diagnostic or therapeutic), difficulty of cannulation, concentration of contrast media and pre operative amylase level. CONCLUSION: The results of the present trial indicate that hydrocortisone could reduce the risk of post-ERCP pancreatitis.

Acute Disease↗

PubMedDate not supplied

ERCP in the management of early versus late biliary leaks after liver transplantation.

The role of endoscopy in the management of bile leaks following liver transplantation has been controversial. Bile leak after liver transplantation has an incidence of approximately 10% to 15%, and the choice of observation, laparotomy, or endoscopic retrograde pancreatography (ERCP), usually with sphincterotomy and/or placement of a bile duct stent, has depended on the transplant groups' experience and the availability of skilled endoscopists. We report our experience in the management of bile leaks following orthotopic liver transplantation. Between July 11, 1995, and January 22, 2003, there were 174 whole-liver-graft orthotopic liver transplant procedures performed at the University of Kentucky. In 158 of these, the initial bile duct management was by choledochocholedochostomy (duct-to-duct anastomosis) over a small-caliber T-tube. Bile leaks were diagnosed in 21 of 158 patients, with an incidence of 13.3%. Of the early leaks (<30 days post-transplantation), 2 were managed with observation alone, and 12 underwent ERCP. This revealed five anastomotic leaks requiring laparotomy. Of the seven leaks occurring later, six were managed by ERCP and one required laparotomy. With a median follow-up period of 18 months, 18 patients (85.7%) are alive with no further biliary tract problems. ERCP remains a useful adjunct in the management of post-liver transplant bile leaks. It is, however, less likely to be successful in the definitive management of early leaks.

Adult↗

PubMed1989

[ERCP in the diagnosis of bilio-pancreatic pathology. Comparison with echography and CT].

The authors have evaluated both sensitivity and specificity of ERCP in comparison with other imaging methods, such as US and CT, on the basis of a study of 63 patients with suspected pancreatobiliary pathologies. Our results show ERCP of chronic pancreatitis to have 83% sensitivity and 66% specificity. As for biliary pathologies, sensitivity was 94% and specificity 88%. In pancreatic pathologies, CT sensitivity was 99% and its specificity was 70%. The combined use of ERCP and CT determines a considerable rise in the percentages, and allows the evaluation of both the excretory tree and the parenchyma. As for biliary pathologies, the role of ERCP is fundamental, since its combination with the other methods (CT: sensitivity 72%, specificity 3.5%; US: sensitivity 70%, specificity 3.5%) has not determined but a slight increase in sensitivity, and no significant increase in specificity.

Adult↗

PubMed1984

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with jaundice and suspected biliary obstruction.

During a 4-year period (1978-1982), 206 patients were examined with endoscopic retrograde cholangiopancreatography (ERCP) because of jaundice with suspected biliary obstruction. The total of examinations was 223. Duodenoscopy with ERCP gave a positive primary diagnosis in 160 cases (78%), six (4%) of which later proved to be incorrect. Extrahepatic obstruction could be excluded in 16 patients with normal cholangiogram (8%). Clinically relevant information thus was obtained in 176 cases (85%). The main cause of extrahepatic obstruction was common bile duct stone(s), which were found in 73 patients. Immediate endoscopic sphincterotomy was performed in 64 of them and cleared the duct of stones in 54 (84%). Benign stenosis of the ampulla of Vater was relieved with endoscopic sphincterotomy in six patients. Malignant bile duct obstruction was diagnosed in 56 patients, and in three of them an endoprosthesis for internal drainage of the biliary tract was endoscopically inserted. Immediate complications after ERCP without endoscopic sphincterotomy occurred in 5 of 136 patients (4%), one of whom died. The authors conclude that ERCP is a rapid, reliable and safe diagnostic method in patients with extrahepatic biliary obstruction.

Adult↗

PubMed1995

Endoscopic ultrasonography in chronic pancreatitis: a comparative prospective study with conventional ultrasonography, computed tomography, and ERCP.

The usefulness and accuracy rate of endoscopic ultrasonography (EUS) in the diagnosis of chronic pancreatitis (CP) were prospectively evaluated in 81 patients with suspected pancreatic disease. All underwent EUS, abdominal ultrasonography (AUS), and computed tomography (CT), and endoscopic retrograde cholangiopancreatography (ERCP) was performed in 55 of the cases. The diagnosis of CP was established in 44 patients (CP group) including 24 with a calcified form. No pancreatic disease was observed in 18 patients (control group), and 19 patients had a pancreatic tumor. In the CP group AUS was less accurate than EUS in visualizing the pancreas, performances of CT scan being identical to EUS in this respect. A good correlation was observed between EUS and ERCP for visualization and measurement of the Wirsung duct. The most significant changes observed by EUS in the CP group were dilatation of the main pancreatic duct, heterogeneous echogenicity of the pancreatic parenchyma, and cysts < 20 mm in size even in noncalcified CP or with normal pancreatograms. Sensitivity of EUS for diagnosis of CP was 88% (AUS, 58%; ERCP, 74%; CT scan, 75%), the specificity being 100% for ERCP and EUS, 95% for CT scan, and 75% for AUS. The good performances of EUS allow early diagnosis of CP in symptomatic patients since heterogeneous echogenicity of the pancreatic parenchyma seems to be almost specifically associated with the disease.

Adult↗

PubMed1994

Role of ERCP in the management of bile duct lesions post bile duct surgery.

INTRODUCTION: Therapeutic Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is an established mode of treatment for bile duct lesions. AIM: This paper reviews the role of ERCP in the management of bile duct lesions developing after biliary surgery. PATIENTS AND METHODS: Of the 894 ERCPs performed in our department between January 1990 and May 1992, 23 (13 female, 10 male) were for patients with post-operative bile duct lesions. The mean age of these 23 patients was 59 years (range 38-91 years). The previous biliary surgical procedures were conventional cholecystectomy (n = 19), laparoscopic cholecystectomy (n = 3) and a cholecystectomy with choledochojejunostomy. Associated medical conditions of ischaemic heart disease, unstable angina, hypertensive heart disease, chronic obstructive airway disease and hepatitis B cirrhosis were present in 7 of these patients. RESULTS: Ten patients had benign biliary strictures. Endoscopic stenting (with one or 2 stents) was successful in 9. The strictures reopened in 2 patients after a total stenting duration of 12 and 18 months respectively. Four patients had biliary leakages that were successfully treated with stenting. Two patients had spontaneous sealing of biliary leak at 3 and 6 months respectively. Nine patients had retained stones (7 with solitary stone, 2 with multiple stones) that were successfully removed with Dormia basket after sphincterotomy. Complications were few and manageable. CONCLUSIONS: Therapeutic ERCP is safe and effective. It is a useful adjunct in the management of patients with post-operative biliary lesions.

Adult↗

PubMed1994

[Radiation burden in diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP)].

UNLABELLED: The increasing expansion of diagnostic and, in particular, of therapeutic ERCP calls for greater consideration of the radiation dose to which the investigator and assistant personal are exposed and emphasizes the question of additional radiation protection measures such as leadshielded glasses and thyroid protection. MATERIALS AND METHODS: Local radiation doses were measured in 19 ERCP sessions at head level of the endoscopist, assistant staff and the radiologist, respectively. The fluoroscopic time, the area dose product (ADP) and the measuring height were recorded. A quotient based on the measured local dose and the ADP was formed which includes all variables having an effect on the scattered radiation. Using this quotient and the known ADP-values radiation exposure levels were mapped over a period of three months and then extrapolated to obtain the annual dose. RESULTS: Not only the FT, but also the ADP, the measuring height, and the source-image-distance (SID) are found to influence the magnitude of the radiation dose to which the investigator and his assistants are exposed at head level. For an assumed rate of 1200 ERCPs per year a median radiation at head level of 16.5 mSv/a is calculated for the investigator, and a corresponding head-level dose of 5.5 mSv/a for the assistants. This shows that the eye dose to which the investigator (and his assistants) are exposed amounts to 10% (5%) and the thyroid dose to 5% (1.5%) of the legally prescribed limit dose. If fewer ERCPs are performed, or if the investigations are divided up among several doctors and assistants, radiation exposure is reduced accordingly. CONCLUSIONS: Under the prevailing investigation conditions additional radiation protection measures such as leadshielded safety glasses or thyroid protection do not appear necessary.

Body Burden↗

PubMedDate not supplied

Diagnostic and therapeutic ERCP in patients with Billroth II gastrectomy.

Diagnostic and therapeutic endoscopic cholangio- pancreatography (ERCP) are more difficult in patients with Billroth II gastrectomy. A six-year experience including 274 ERCP in 175 Billroth II patients is reviewed. Overall diagnostic success-rate was 88.3% while a complete endoscopic treatment could be accomplished in 92.8% when indicated. Endoscopy related morbidity and mortality were 5.1% and 0 respectively, while in-hospital mortality was 2.3%. Diagnostic and therapeutic ERCP techniques in Billroth II patients are then discussed with special reference to the choice of the scope and of the accessories to perform a safe endoscopic sphincterotomy. The use of the lateral-viewing duodenoscope and of the long-nose sigmoid inverted sphincterotome (originally modified by our group) are emphasized. ERCP and endoscopic sphincterotomy in Billroth II subjects are today as safe and nearly as effective as in the non-gastrectomized patient.

Adult↗

PubMed1993

[Indications, findings and complications of ERCP in pediatrics].

Endoscopic retrograde cholangio-pancreatography presents the only method which not only produces exact results concerning the morphology of the pancreatic and biliary ducts but also enables therapeutic access to these structures. In childhood ERCP is indicated if other non invasive diagnostic procedures do not help to establish a diagnosis or if further informations concerning indication or planning of an operation can be expected. In 25 children and 13 adolescents ERCP established the correct diagnosis in 95%. The success rate in newborns after the second month reaches 90%. For children before the age of 2 months a pediatric duodenoscope with a diameter of 7-9 mm is necessary. In obstructive jaundice, after trauma of the upper abdomen and especially in pancreatitis of unknown origin ERCP should be performed liberally, because a lot of exploratory laparotomies can be prevented, and significant findings for operative intervention can be collected. Moreover the causes of pancreatitis can be evaluated and treated definitely. With EST impressive improvements in the clinical course of obstructive jaundice, cholangitis and acute pancreatitis even in children and adolescents can be reached. In our own series 9 children (3 acute biliary pancreatitis, 3 chronic obstructive pancreatitis, 1 acute pancreatitis, 2 biliary duct stones with cholangitis or ampullary stenosis) were treated successfully without any significant complications. In acute pancreatitis an ERCP should be performed as early as possible (during 24-48 hours after onset of symptoms) because only in this instance the etiologic factors can be evaluated reliably and using endoscopic sphincterotomy of the sphincter proprius choledochi and/or the sphincter proprius pancreatis be treated adequately and with the lowest risk in time.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗

PubMed1996

Early recognition of post-ERCP pancreatitis by clinical assessment and serum pancreatic enzymes.

BACKGROUND: This study evaluates the relative value of clinical assessment and serum pancreatic enzymes in the discharge management of outpatients undergoing ERCP. METHODS: Two hundred thirty-one patients who underwent ERCP had a detailed clinical assessment performed 2 h after the procedure and blood drawn for amylase and lipase. RESULTS: One-third of the patients who later developed pancreatitis had no pain 2 h after the end of the procedure, whereas an equal number who had no pancreatitis did complain of pain. Values below 276 U/L for amylase and 1000 U/L for lipase were useful in ruling out pancreatitis with negative predictive values of 0.97 and 0.98, respectively. Based on the data of this study a discharge algorithm for outpatients undergoing ERCP is proposed. CONCLUSIONS: In contrast to clinical assessment, which is unreliable, it is possible to stratify patients according to their risk of developing pancreatitis according to their 2-h serum amylase and lipase values. This helps to rationalize the discharge management of outpatients undergoing ERCP at a time when careful utilization of resources, especially the avoidance of unnecessary hospital admissions, becomes increasingly more important.

Abdominal Pain↗

PubMed1996

[Importance of ERCP in laparoscopic cholecystectomy in comparison with classical cholecystectomy].

The authors compare the value of ERCP in laparoscopic and classical cholecystectomy. They analyze groups of 1356 classical and 527 laparoscopic cholecystectomies. The number of ERCP indicated before surgery rose in laparoscopic cholecystectomies 17x, as compared with classical surgery. In ERCP indicated after surgery the number increased 2.3x. In choledocholithiasis ERCP proved to be a reliable diagnostic and therapeutic method. The number of laparotomies in residual choledocholithiasis in laparoscopic cholecystectomies should not exceed 10-12%.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed1998

Periampullary diverticula: consequences of failed ERCP.

Periampullary diverticula (PAD) are associated with biliary disease and contribute to failure of endoscopic retrograde cholangiopancreatography (ERCP), especially in elderly patients. The presence of PAD and causes of failure to cannulate the ampulla were noted in 1211 consecutive patients undergoing ERCP. Case notes of 100 consecutive patients with PAD were reviewed retrospectively. Overall prevalence of PAD was 9%. Prevalence was higher in patients > or = 75 years when compared with those < 75 years (19.2% vs 4.8%, P < 0.0001). Ampullary cannulation was successful in 62.4% of patients with PAD and 92.7% without PAD (P < 0.0001). Success rates were lower in patients with intradiverticular papillae than in those with juxtapapillary diverticula (38.1% vs 77.6%; P < 0.0001). Of 19 patients with PAD who did not have any imaging other than ultrasound, 16 were asymptomatic over a median follow-up of 20 months. Biliary surgery was performed on 35 patients, with no major complication. PAD are a major cause of failed ERCP. Failure rates are higher in patients with intradiverticular papillae than juxtapapillary diverticula. Though a large proportion of patients not imaged remain asymptomatic on follow-up, it is difficult to predict which patients may form this group. Surgery, when indicated, is safe and effective in elderly patients in whom ERCP has failed.

Adult↗

PubMedDate not supplied

Pancreas divisum--the role of ERCP in children.

Pancreas Divisum (PD) is the most common congenital anomaly of the pancreas leading to chronic pancreatitis in children. The best diagnostic procedure to establish this diagnosis is Endoscopic Retrograde Cholangiopancreatography (ERCP). Utilizing ERCP as a therapeutic modality (sphincterotomy, stone removal), enables the clinician to improve symptoms and reduce morbidity. In this report, we describe the clinical presentation and outcome of three children with chronic pancreatitis who were subsequently diagnosed with PD by ERCP. We recommend that ERCP should be considered in children with chronic pancreatitis of unknown etiology.

Adolescent↗

PubMed1987

Acute cholangitis in association with acute pancreatitis: incidence, clinical features and outcome in relation to ERCP and endoscopic sphincterotomy.

Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) have been shown to be valuable in managing patients with acute cholangitis, their role in patients who have simultaneous acute cholangitis and acute pancreatitis is not known. We have reviewed 32 consecutive patients presenting with both conditions over ten years which represents 23.0 per cent of all cases of gallstone-related acute cholangitis and 14.4 per cent of all cases of biliary acute pancreatitis admitted during the same period. The majority of patients were elderly (median 76 years) and female (75 per cent). Five patients had previously undergone cholecystectomy. Eleven patients were clinically shocked (34 per cent) and blood cultures were positive in 9/14 cases (64 per cent). Twenty patients (63 per cent) had a predicted severe attack of acute pancreatitis (modified Glasgow criteria). Common bile duct (CBD) stones were identified in 15 of 23 patients with successful ERCP. Of these 23 patients, 9 were treated by endoscopic sphincterotomy (ES) alone, 5 by ES and surgery, 4 by surgery alone and 5 were treated conservatively. There was one death (4.3 per cent). Nine patients were managed without cholangiography; four had surgery and five were treated conservatively. There were three deaths (33 per cent; P = 0.10). Evidence of recent CBD stone passage was apparent in eight patients (25 per cent) compared with five out of eighty-seven patients (5.7 per cent) with acute cholangitis alone (P less than 0.005). The results indicate that ERCP and ES may have an important role in the management of these patients.

Acute Disease↗

PubMed2026

Acetate- Versus Lactate-Buffered Crystalloids for Prevention of Post-ERCP Pancreatitis in Patients Without Access to Rectal NSAIDs: A Multicentre Double-Blind Randomized Trial.

BACKGROUND: Aggressive peri-procedural intravenous fluid (IVF) therapy with lactated Ringer's solution (LR) reduces the risk of post-ERCP pancreatitis (PEP), but the standard 8-h protocol is impractical in outpatient settings and the optimal fluid type remains uncertain. We compared LR with an acetate-buffered balanced crystalloid (AC) using a symptom-guided 4-h aggressive IVF protocol. METHODS: This multicentre, double-blind, randomized superiority trial was conducted at three academic hospitals in Korea where rectal NSAIDs are unavailable. Adults with native papillae and moderate-to-high PEP risk were randomized to receive LR or AC. The IVF protocol comprised 10 mL/kg boluses before and after ERCP, followed by 3 mL/kg/h for 4 hours and extended to 8 hours if abdominal pain developed or worsened. The primary outcome was PEP incidence; secondary outcomes included early post-ERCP pain and adverse events. RESULTS: Of 813 patients (404 LR, 409 AC), PEP occurred in 12.4% of the LR group and 11.5% of the AC group (relative risk [RR] 0.93; 95% CI, 0.64-1.35; P = 0.70). Rates of mild (7.9% vs. 7.1%) and moderate (4.5% vs. 4.4%) PEP were similar, and no severe PEP or fluid overload occurred. Among the 68.3% of patients who remained asymptomatic at 4 hours and required only 4-h IVF, PEP occurred in 7.4%, with no cases of severe PEP. CONCLUSION: In this superiority trial, acetate-buffered crystalloid did not reduce PEP compared with lactated Ringer's solution, and no significant safety differences were observed between the two agents. Lactated Ringer's remains the recommended first-line crystalloid for aggressive hydration when rectal NSAIDs are unavailable. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05832047).

Humans↗