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Endoscopic retrograde cholangiopancreatography (ERCP) is a safe diagnostic and therapeutic procedure. Splenic injury after ERCP is extremely rare and only two cases have been reported in the English literature. A subcapsular splenic hematoma is reported after ERCP and the mechanism of injury and possible preventive measures are discussed.
Endoscopic retrograde cholangiopancreatography (ERCP) has become a routine examination in a number of medical centers within the past several years. We report a life-threatening case of acute pancreatitis with Pseudomonas aeruginosa sepsis immediately following ERCP. Cultures of the blood, the inner channel of the duodenoscope, and irrigating water bottles all were positive for Pseudomonas aeruginosa. The Pseudomonas aeruginosa isolated from the blood and endoscope both reacted to three common antisera: serotypes 2, 15, and 16, suggesting a common source of infection. Although it is obvious that the ERCP procedure cannot be sterile, attempts should be made to prevent transmission of nosocomial pathogens by this procedure.
Fiberoptic endoscopy is practiced everyday in the field of gastroenterology and, for diagnostic purposes, carries a risk of complications and an estimated mortality of 1:5,000, which is multiplied several times during interventional procedures. Half of these complications have a cardiopulmonary origin which may be anticipated by the use of pulse oximetry to measure hemoglobin saturation (SaO2). We studied 132 patients undergoing diagnostic or procedural endoscopic retrograde cholangiopancreatography (ERCP) under sedation, and 51 undergoing esophagogastroduodenoscopy (EGD) without sedation. In the ERCP group, SaO2 fell from 95.7 +/- 2.4% (mean +/- standard deviation) to 88.9 +/- 6.4% (p less than 0.001) with a corresponding rise in pulse from 95 +/- 19 to 116 +/- 18/min (p less than 0.001) followed by recovery. The largest falls followed positioning of the endoscope (rather than following administration of the sedative or the procedure), particularly during introduction of the endoscope within 1 minute of administering diazemuls (diazepam). The EGD group also had a fall in SaO2 (97.3 +/- 1.9% to 93.9 +/- 3.3%, p less than 0.001), although the patients were younger and undergoing shorter examinations. Again, the largest falls occurred 1 minute after introduction of the endoscope. In subgroups of patients undergoing ERCP, analysis of respiratory patterns using spectral techniques and electrocardiogram during endoscopy (n = 25), or peripheral perfusion using transcutaneous oximetry and laser Doppler velocimetry (n = 12) was undertaken. No correlations were found in relation to changes in SaO2. The cause of the fall in SaO2 during endoscopy is multifactorial.(ABSTRACT TRUNCATED AT 250 WORDS)
Twenty-nine patients with symptomatic hydatid disease of the liver were evaluated preoperatively by endoscopic retrograde cholangiopancreatography (ERCP) in the years 1982-1987. In the same period, 6 patients who previously underwent surgery for the parasitic disease also underwent ERCP because of postoperative symptoms of biliary obstruction. Findings at ERCP excluded biliary tract involvement in 11 cases. Positive findings were shown in 24 patients, including compression of the bile ducts in 4, small cysto-biliary communications in 5, intrabiliary rupture in 9, residual hydatid material in the common bile duct, and sclerosing cholangitis in 3. Endoscopic removal of migrated hydatid debris was achieved in 8 patients, avoiding reoperation in 4.
Emphysematous cholecystitis is a rare variant of acute cholecystitis, most frequently seen in elderly, debilitated, or diabetic patients. This report documents the development of fulminant sepsis due to acalculous cholecystitis after endoscopic retrograde cholangiopancreatogram (ERCP) in an otherwise healthy patient with suspected malignant obstructive jaundice. Three other cases of acute cholecystitis have been reported in the literature after ERCP. Although not proven to prevent infectious complications during ERCP, strong consideration should be given to prophylactic antibiotics in patients with suspected malignant obstruction and/or coexistent medical illness, eg, diabetes. When attempts at decompression of the obstructed biliary system by endoscopy fail, decompression by percutaneous or surgical routes should be considered in a timely fashion.
Therapeutic applications of endoscopic retrograde cholangiopancreatography (ERCP) have increased dramatically, and endoscopic sphincterotomy (ES) is the cornerstone of these techniques. Indications include treatment of retained biliary duct stones, papillary stenosis, benign and malignant strictures, and acute cholangitis and pancreatitis. We reviewed our recent experience to assess the spectrum of procedures done and their results. Medical records and radiographic examinations in 60 consecutive patients undergoing therapeutic ERCP were studied. Patients were placed into one of three treatment groups; Group 1, ES alone (N = 21); Group 2, ES plus stone retrieval (N = 15); and Group 3, ES plus stent placement (N = 24). In Group 1, all of eight patients with ductal stones had spontaneous passage. In 11 patients with papillary stenosis, nine had relief of symptoms following ES. Two patients with pancreatitis improved after ES. In Group 2, all 15 patients with ductal stones had successful retrieval. In Group 3, patients were treated for biliary stricture alone (4), retained stones (7), pancreatitis (5), neoplasms (6) and papillary stenosis (2). In these 24 patient, 21 (88%) were treated successfully or had palliation of their symptoms. In our series, a wide variety of therapeutic applications of ERCP was used to manage simple and complex biliary disease. ES alone or in combination with other techniques was done in all patients. Overall, 55 (92%) of 60 interventional procedures were successful as defined by removal of stones and relief or palliation of symptoms.
This study studied the use of ERCP and nasobiliary tube in the diagnosis of fungal infection of biliary tract and the efficacy of combined use of local administration via nasobiliary tube and intravenous antifungal treatment for severe biliary tract fungal infection. 5 patients in our series, with age ranging from 47 to 68 y (mean 55.8), were diagnosed as having mixed bacterial and fungal infection of biliary tract as confirmed by smear or/and culture of bile obtained by ERCP and nasobiliary drainage. Besides routine anti-bacteria therapy, all patients received local application of fluconazole through nasobiliary tube and intravenous administration of fluconazole or itraconazole in terms of the results of in vitro sensitivity test. The mean duration of intravenous fluconazole or itraconazole was 30 days (24-40 days), and that of local application of fluconazole through nasobiliary drainage tube was 19 days (8-24 days). During a follow-up period of 3-42 months, all patient's fungal infection of biliary tract was cured. It is concluded that on the basis of typical clinical features of biliary tract infection, fungal detection of smear/culture of bile obtained by ERCP was the key for the diagnosis of fungal infection of biliary tract. Local application antifungal drug combined with intravenous anti-fungal drugs might be an effective and safe treatment for fungal infection of biliary tract.
Complications associated with ERCP have been well defined, clinically recognized, and effectively managed conservatively. Few patients require surgery or prolonged hospitalization. The morbidity and mortality associated with ERCP and sphincterotomy have remained low, and, although the outcome of endoscopy is equivalent or better than surgical or radiologic techniques, the complications are less. Despite the general acceptance of ERCP, its therapeutic applications, its more universal performance, and the morbidity and mortality rates have remained the same or lower since its introduction a quarter of a century ago.
BACKGROUND: Endoscopic retrograde cholangio pancreatography (ERCP) is a technically challenging procedure. Glyceryl trinitrate (GTN) has been shown to reduce tone in the sphincter of Oddi (SO), cannulation of which is a rate-limiting factor. A double-blind randomized control trial was performed to assess whether topical GTN on the SO would facilitate cholangiography and/or bile duct cannulation. METHODS: 104 patients requiring ERCP for biliary symptoms were randomized into two groups, 52 controls pretreated with 5 ml 0.9% normal saline (NS) and 52 pretreated with 5 ml GTN (concentration 1 mg/ml). RESULTS: There was no significant between the control group and the GTN group in primary cannulation rate (p = 0.76), time taken to cholangiography (p = 0.58), or time to cannulation (p = 0.43). CONCLUSION: Topically administered GTN to the SO does not aid in obtaining a cholangiogram or cannulation during an ERCP.
BACKGROUND: The aim of this study was to evaluate the degree of occult pancreatobiliary reflux by measuring the biliary amylase levels in the common bile duct (CBDA) and gallbladder (GBA) at endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Eligible patients included 86 consecutive cases of pancreaticobiliary disease with prospective implementation of bile collection during an ERCP procedure. Patients with pancreatobiliary maljunction (PBM) were excluded. Nineteen cases of eligible patients had simultaneous collection of gallbladder bile. Bile was further collected by cholecystectomy in 8 cases. RESULTS: Twenty-two cases (26%) revealed a CBDA level higher than serum amylase (high bile amylase level, HBA group) and 64 cases exhibited a CBDA level lower than serum (LBA group). The mean values of CBDA in the HBA and LBA groups were 5502 IU/l and 29 IU/l, respectively. The rate of HBA was significantly higher in patients who were elderly, had a dilated common bile duct, and those with choledocholithiasis (P <0.05). Three cases (16%) showed a CBDA greater than twice the GBA. Eleven cases (58%) exhibited a GBA higher than the CBDA. The values of GBA obtained during ERCP and cholecystectomy were consistent. CONCLUSIONS: These findings suggest that even non-PBM cases can exhibit occult pancreatobiliary reflux, which can thereby cause biliary disease.
In the treatment of pancreatic pseudocysts, percutaneous and endoscopic drainage have, in certain cases, become alternatives to surgery. However, each treatment modality carries risks of complications and recurrences that may be minimized by the appropriate allocation of therapy. This article proposes the use of an endoscopic retrograde cholangiopancreatography (ERCP)-based algorithm as a means to allocate pseudocyst therapy based on the findings of pancreatic duct obstruction or pseudocyst communication. To evaluate this algorithm, the records of a series of patients with pancreatic pseudocysts seen at Duke University Medical Center from 1984 to 1990 were reviewed. Of 102 patients, 73 had symptomatic pseudocysts that required treatment. Forty of the 69 elective interventions were preceded by ERCPs and retrospectively applied to the algorithm. The number of adverse outcomes (treatment failures + complications) of the group that followed the algorithm was 3 of 26 (12%), while the number of adverse outcomes of the group that did not follow the algorithm was 6 of 14 (43%) (p less than 0.04 by Fisher's exact test). These two subgroups were similar in all other characteristics examined. Therefore, this ERCP-based algorithm may be used to allocate pseudocyst treatment; however, a prospective trial is necessary to prove its efficacy.
BACKGROUND: Droperidol is a known effective adjunctive agent for sedation/analgesia during endoscopic procedures, particularly in patients who are difficult to sedate with narcotics and benzodiazepines alone. However, the Food and Drug Administration (FDA) warning about potential droperidol-related fatal cardiac arrhythmias, issued in December 2001, led to concern about its safety in current clinical practice. OBJECTIVE: In this study, we evaluated the effects of droperidol on the Bazett's corrected QT interval (QTcB) administered to patients undergoing ERCP and frequency of cardiac arrhythmias. DESIGN: We retrospectively reviewed the medical records of patients who, at our institute, underwent ERCP while under sedation/analgesia and who received droperidol. Our protocol for patients who are considered to be candidates for droperidol use includes obtaining an ECG before and 1 to 3 hours after the procedure. RESULTS: From April 2002 to October 2004, 6292 ERCPs were performed, of which 3113 patients with normal baseline QTcB (2001 women, 1112 men) received droperidol. Mean dosages were 4.3 mg (range, 1.25-10 mg) in women and 4.5 mg (range, 1.25-13.75 mg) in men. A total of 233 patients (7.48%; 133 women, 100 men) developed QTcB prolongation. Mean increases of the QTcB above the upper limit of normal were 16 milliseconds in women (range, 1-194 milliseconds) and 22 milliseconds in men (range, 1-310 milliseconds). Of these, 15 patients (0.48%; 8 women, 7 men) had marked prolongation of the QTcB (defined QTcB, >500 milliseconds). No serious dysrhythmias occurred. CONCLUSIONS: Droperidol at usual doses during sedation/analgesia may precipitate QTcB prolongation above the normal range. However, no QT-related arrhythmias were noted in this study. Clinically significant cardiac events are probably rare with droperidol, despite documented QTcB effects. Baseline electrocardiogram for excluding patients with prolonged baseline QTcB and 1 to 3 hours afterward monitoring appears adequate when using droperidol. The study is still too small to detect very infrequent arrhythmia events.
BACKGROUND: Microlithiasis has been implicated in the etiology of idiopathic pancreatitis and biliary-type pain in patients with intact gallbladders. Contrast injection at endoscopic retrograde cholangiopancreatography (ERCP) is used to confirm access into the bile duct and bile is also aspirated to look for microlithiasis. It is not known whether contrast agents contain crystals that could mimic true microlithiasis. METHODS: Four mL of 2 contrast agents (Hypaque and Omnipaque) were examined after centrifugation under polarizing microscopy. In the second part of the study, bile aspirated during ERCP with contrast injection was examined for microlithiasis and contrast pseudomicrolithiasis. RESULTS: Contrast agents exhibited pseudomicrolithiasis that mimicked calcium bilirubinate granules. Pathologists participating in the study were not aware of contrast pseudomicrolithiasis. Nine of twelve (75%) patients would have been reported as having microlithiasis and would possibly have undergone an unnecessary cholecystectomy. CONCLUSION: When bile collected during ERCP is to be examined for microlithiasis, it should be collected without contamination by a contrast agent. If this is not possible, pathologists should be aware that contrast can cause pseudomicrolithiasis.
BACKGROUND: Catheter/guidewire exchanges during ERCP require the coordinated efforts of an endoscopist and endoscopy assistant. A prototype duodenoscope was developed to improve the control of catheter/guidewire exchange by enabling fixation of guidewires at the elevator lever. METHODS: An initial prototype duodenoscope and a subsequent modification of this instrument were used to perform ERCP in 7 and 10 patients, respectively. The following were recorded: total procedure time, fluoroscopy time, catheter/guidewire exchange time, guidewire repositioning, loss of guidewire access, success or failure of fixation, and endoscopist satisfaction. OBSERVATIONS: The initial and the modified prototype duodenoscopes were used in a variety of catheter/guidewire exchanges (n=46). Guidewire fixation was achieved in 75% of catheter/guidewire exchanges with the initial prototype and in 93% with the modified prototype and was reflected in shorter exchange times. Access to the desired duct was not lost during any exchange, and the need for repositioning was eliminated. CONCLUSIONS: A new prototype duodenoscope with an elevator lever that enables guidewire fixation will improve the ease and efficiency of catheter/guidewire exchange during ERCP. Modifications made to the original prototype improved reliability of guidewire fixation.
Using monopolar electrocautery technique, we have used both an electrified guide wire and a needle-tipped sphincterotome to successfully enter the common bile duct, subsequently image it, and perform therapeutic procedures when by virtue of the patient's anatomy, or because of tumor, this had not been possible using conventional ERCP catheters. In an initial group of 45 patients using the needle-tipped sphincterotome, clinically significant complications occurred in 3 patients but were not of a serious nature. The technique was an effective method for achieving both diagnostic ERCP and therapeutic maneuvers in 43 of 45 patients. We stress that this technique should only be attempted by those with long experience in ERCP and related procedures.
Malignant obstruction of the pancreaticobiliary system is a frequent indication for ERCP. Twenty-five patients with abnormalities suggestive of malignancy were encountered during ERCP at our institution and brush cytology was obtained. Positive cytology specimens were collected in 12 of 20 (60%) cases of malignancy causing biliary obstruction. Using a recently developed cytology brush for the biliary tree, detection of malignancy in strictures of the bile duct had a sensitivity of 50% and a specificity of 100%. Both cases of cholangiocarcinoma were diagnosed with cytology, as were 5 of 10 cases of pancreatic cancer. It is concluded that brush cytology is a diagnostically reliable, highly specific technique for malignant lesions encountered at ERCP. In experienced hands, a positive cytologic result may obviate the need for additional invasive diagnostic studies.
The reproduction of a patient's biliary-type pain upon initial injection of contrast material into the common bile duct during diagnostic ERCP is a dramatic experience for both patient and physician. The significance of this phenomenon is not clear, but it is touted by some to be a provocative test for sphincter of Oddi dysfunction. Sphincter of Oddi manometry was performed on 224 consecutive patients referred over a 2-year period for evaluation of post-cholecystectomy syndrome and suspected sphincter of Oddi dysfunction. All patients received only intravenous diazepam as premedication for ERCP. Delayed drainage time (greater than 45 min), bile duct dilation (greater than or equal to 12 mm), and a basal sphincter of Oddi pressure of greater than 40 mm Hg (mean +/- 3 SD) were considered elevated. We observed a reproduction of pain in 15 of 224 patients (6.7%) immediately following contrast injection. There was no correlation between pain on contrast injection and elevated basal sphincter of Oddi pressure, delayed common bile duct drainage, bile duct dilation, or abnormal liver enzymes. Therefore, we feel that reproduction of the patient's biliary-type pain associated with contrast injection of ERCP is not a provocative test for sphincter of Oddi dysfunction.
We evaluated a computerized report-generating system using voice recognition technology (EndoSpeak) for producing therapeutic ERCP reports. For 30 consecutive ERCP cases, reports using both EndoSpeak and standard dictation were generated at the end of the procedure. The cases were scored for overall difficulty and the number of component procedures performed. The time to generate a report with EndoSpeak was significantly longer than with dictation (10.0 +/- 2.9 (SD) min vs. 6.5 +/- 1.6 min, p less than 0.0001), and this difference was greater for more lengthy reports (r = 0.85, p less than 0.001). The procedure difficulty score and the number of component procedures were both significant predictors of the physician's report generation time for EndoSpeak and dictation. Dictated reports were judged to have a higher information content than EndoSpeak reports for 90% of the cases (p less than 0.00001). Several specific difficulties were encountered with the EndoSpeak software. Although EndoSpeak offers promise, substantial software modifications will be required before this system can become competitive with dictation for therapeutic ERCP reports.