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PubMedDate not supplied

Bacteremia following diagnostic and therapeutic ERCP.

The occurrence of bacteremia in association with diagnostic or therapeutic ERCP was studied in 180 patients undergoing a total of 194 examinations. Nineteen (15%) of 126 diagnostic procedures and 18 (27%) of 68 therapeutic procedures were associated with bacteremia (p less than 0.1). Nine patients had polymicrobial bacteremia and a total of 16 species were detected. Different streptococci, mainly alpha-hemolytic, were the most common bacteria which were identified in 38% of the bacteremic patients. There were no significant differences with regard to the occurrence of fever, pancreatitis, or septic complications between the diagnostic and therapeutic groups of patients. Neither did the complication rate in patients with bacteremia differ from that in patients without bacteremia, whether the procedure was diagnostic or therapeutic. Complication rates did not differ between patients with and patients without pancreaticobiliary obstruction. However, the majority of patients with biliary stasis had drainage with relief of the obstruction at the time of the diagnostic ERCP. We conclude that general routine antibiotic prophylaxis is not indicated in patients undergoing diagnostic or therapeutic ERCP. The question whether such prophylaxis should be given with certain diagnoses or treatments, or in patients with valvular heart disease, remains to be answered in controlled randomized studies.

Aged↗
PubMedDate not supplied

Post-ERCP pancreatitis: randomized, prospective study comparing a low- and high-osmolality contrast agent.

Diagnostic and therapeutic ERCPs are complicated by pancreatitis in 1% to 10% of patients, and evidence suggests that the contrast agent used for ERCP may be important in the pathogenesis of such pancreatitis. This prospective, double-blind study was undertaken to determine whether the use of a low-osmolality, nonionic contrast agent (Omnipaque 300; iohexol, 672 mOsm/kg H2O) would reduce the frequency and severity of postprocedure pancreatitis as compared to a high-osmolality, ionic contrast agent (Hypaque 50%; diatrizoate sodium, 1515 mOsm/kg H20). Six hundred ninety patients undergoing diagnostic ERCP (pancreatogram, cholangiogram, or both) either with or without sphincter of Oddi manometry and therapy were randomized to iohexol or diatrizoate sodium. Postprocedure pancreatitis was diagnosed when the serum amylase or lipase level was elevated to at least four times the upper limits of normal at 18 hours and was associated with increased abdominal pain persisting for at least 24 hours after the procedure that required administration of narcotic analgesics. The pancreatitis was graded as mild, moderate, or severe depending on the length of hospital stay and the need for intervention. The overall frequency (7.2% versus 7.5%) and severity (4.3% mild, 2% moderate, 0.9% severe for the diatrizoate sodium group versus 4.3% mild, 2.6% moderate, and 0.6% severe for the iohexol group) of postprocedure pancreatitis and the frequency and severity within each procedure category were similar for the two contrast agent groups (p > .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1995

Value of endoscopic ultrasonography in the diagnosis of common bile duct stones: comparison with surgical exploration and ERCP.

An accurate and safe preoperative method of imaging the common bile duct is essential for the proper diagnosis of calculous biliary tract disease, especially in the current era of laparoscopic cholecystectomy. The value of endoscopic ultrasonography in detecting common duct stones has been reported, albeit in small series. The aim of this retrospective study was to assess the accuracy of EUS in a large series of patients. We compared EUS to direct cholangiography in the evaluation of 422 patients for common duct stones. Ductal stones were imaged by EUS in 168 patients (43.4%). No complications were encountered. EUS failed in 2.3% of cases, ERCP failed in 8.3%, and surgical exploration failed in 0.5%. Comparison of EUS with surgical exploration in 185 patients showed a sensitivity of 94.9%, a specificity of 97.8%, and an accuracy of 95.9%. EUS was compared to ERCP in 219 patients. All common duct stones found by ERCP were evident by EUS. Concordance was obtained in 91.3% of cases. Review of videotapes disclosed 3 false-positives and 16 unequivocal true-positives. We conclude that EUS is a safe and highly accurate means of detecting common duct stones and should be proposed before laparoscopic cholecystectomy in patients at risk of choledocholithiasis.

Adolescent↗
PubMed1996

Should ERCP be routine after an episode of "idiopathic" pancreatitis? A cost-utility analysis.

BACKGROUND: Patients often recover from an episode of acute pancreatitis with conservative therapy and without an identified cause. The options include proceeding with ERCP to identify and treat an occult common bile duct stone or performing the procedure only after a second episode of idiopathic pancreatitis occurs. METHODS: Decision analysis (SMLTREE software) was used to determine incremental cost-utility. Variables were estimated from a search of the literature, a utility analysis involving health professionals familiar with the question, and a retrospective review of hospital charts and costs. RESULTS: This model estimates an incremental utility gain for the prompt ERCP approach of 1.0 quality-adjusted life weeks per patient at an incremental cost of $245 (Canadian). This yields a cost-utility ratio of $12,740 (Canadian) per quality-adjusted life year. The result was highly sensitive to the probability of finding an occult common bile duct stone. CONCLUSION: Routine ERCP is of marginal overall benefit, but is of more substantial benefit and is more cost-effective in a subgroup of patients with a greater probability of having an occult common duct stone.

Acute Disease↗
PubMed1996

Radiation exposure to patients and personnel during interventional ERCP at a teaching institution.

BACKGROUND: This study was designed to determine the radiation dose to patients and personnel during ERCP procedures. METHODS: Phantom studies were performed to compare dosimetry for two image capture systems and to determine the effectiveness of shielding in reducing stray radiation. Radiation techniques and dosimetry were recorded in 72 patients undergoing ERCP. RESULTS: Phantom studies indicated that increasing fluoroscopy voltage from 75 to 96 kV decreased entrance dose by 50%. Image capture by digital radiography decreased radiation exposure by 66%. Shielding decreased stray radiation exposure by 93%. All patients underwent cholangiography (n = 71) and/or pancreatography (n = 53). The mean number of interventional ERCP procedures performed per patient was 1.8 (range, 0 to 6). The mean measured patient entrance dose was 80 mGy (8 R; range, 0.2 to 73 R); however, the calculated mean entrance dose (based on measured intensifying screen doses) may have been as high as 3000 mGy (30 R; range, 0.8 to 300 R). Measured patient exposure increased with fluoroscopy time (r = 0.9) and with the number of interventions performed (r = 0.3). The mean dose to personnel was estimated at 0.04 mR. CONCLUSIONS: The patient radiation dose depended most on fluoroscopy time. The dose may be lowered by minimizing fluoroscopy time, using higher voltage and lower current for fluoroscopy, and using digital radiography for documentation. Personnel were adequately protected.

Adult↗
PubMed1997

A prospective, double-blind trial of L-hyoscyamine versus glucagon for the inhibition of small intestinal motility during ERCP.

BACKGROUND: Glucagon is often used to inhibit duodenal motility and enhance cannulation during ERCP. Levsin is an antimuscarinic, anticholinergic agent that may be as effective as glucagon. METHODS: Three hundred eight patients requiring an antimotility agent during ERCP were randomized in a double-blind prospective study to intravenous Levsin or glucagon. Parameters recorded included difficulty of procedure, predrug and postdrug motility grade, effectiveness of medication, patients requiring "crossover" drug, side effects, and cost per case. RESULTS: One hundred fifty-three patients were randomized to glucagon and 155 to Levsin. The two groups were equally matched with regard to patient and procedure characteristics. Of statistical significance were the following: (1) 12 patients in the Levsin group required crossover compared to 1 patient in the glucagon group, (2) Levsin was slightly less effective in inhibiting motility, but this did not adversely influence procedure difficulty, (3) Levsin was associated with more minor side effects (nausea, vomiting, and pain) at 2 hours after the procedure (Levsin 36 of 143, glucagon 24 of 152, p = 0.045) but there was no difference in pancreatitis (glucagon 6, Levsin 8), (4) Levsin was associated with a significant cost advantage (Levsin $10.45/case, glucagon $29.51/case, p < 0.001). CONCLUSION: Levsin may provide a reasonable alternative antimotility agent during ERCP. Levsin does not appear to alter the rate of significant postprocedure complications. The cost benefit advantage appears to be substantial.

Atropine↗
PubMed2006

Post-ERCP pancreatitis and its prevention.

Pancreatitis remains the most common severe complication of endoscopic retrograde cholangiopancreatography (ERCP), and typically develops in 5-7% of patients. Although most post-ERCP pancreatitis (PEP) is mild, severe pancreatitis and its complications (including a systemic inflammatory response or the development of pseudocysts or pancreatic necrosis) can occur, and in rare cases death can result. A means of preventing PEP in all patients who undergo the procedure remains elusive. Proper patient selection for ERCP is critical to avoid unnecessary risk. Pharmacologic attempts to prevent PEP have been largely unsuccessful; encouraging results have been difficult to validate. Prophylactic stenting of the pancreatic duct and minimally traumatic cannulation techniques offer the most promise as a means of preventing PEP. This manuscript reviews risk factors for PEP as well as pharmacologic and procedural means that can be used to reduce its incidence.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1999

Role of ERCP and endoscopic sphincterotomy in acute pancreatitis.

When assessing the indications for interventional endoscopy, obstructive and non-obstructive causes of acute pancreatitis should be distinguished. In non-obstructive (e.g. alcoholic) pancreatitis, no data are available proving any benefit for endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy. In obstructive (e.g. biliary) pancreatitis, the pathogenetic role of gallstones is controversial. The vast majority of gallstones initiating biliary pancreatitis pass spontaneously through the papilla of Vater into the duodenum without causing cholangitis or obstructive jaundice. Three prospective randomized published studies have attempted to answer the question of whether urgent removal of the stone improves the prognosis of patients suffering from acute pancreatitis. From these studies it can be concluded that the use of ERCP in acute biliary pancreatitis should depend on biliary symptoms: in cases of obstructive jaundice or cholangitis, bile duct stones should be removed as soon as possible; in patients without biliary complications, emergency ERCP is neither beneficial nor cost-effective; if retained stones (without biliary complications) are suspected, they can be removed electively.

Acute Disease↗
PubMed2002

ERCP and MRCP--when and why.

Since the introduction of endoscopic retrograde cholangiopancreatography (ERCP) in the 1970s, gastroenterologists have a wide spectrum of diagnostic and therapeutic options in the biliopancreatic ductal system at their disposal. With its arrival in the 1990s, magnetic resonance cholangiopancreatography (MRCP) developed as a potent diagnostic tool in biliopancreatic pathology. Currently, MRCP is widely replacing diagnostic ERCP and thereby avoiding complications related to endoscopic technique.We summarize evidence-based data and demonstrate indications and differential indications for MRCP and ERCP in pancreatic disease. Complications related to the procedures and possible medical prevention are discussed. The feasibility of interventional endoscopy in pancreatic disease is reported in detail. The role of gastroenterologists in performing MRCP is outlined on the basis of practical examples.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1978

ERCP, endoscopic papillotomy and gallstone removal by JFB2 Olympus and PFSB 1200 Machida.

ERCP is now used as routine technique and has provided a useful tool for both diagnostic and therapeutic purposes in diseases of the biliary tract. Until now this examination has been performed throughout the world including Italy, using preferably an Olympus JF and JF B2 sideviewing duodenoscope. In addition to 727 ERCP and 55 papillotomies performed using this instrument we have also employed a convertible endoscope Machida PFSB 1200; this fiberscope, with which front and side views are possible, can be used in the study of the oesophagus, stomach, duodenum, cannulation of the papilla of Vater and papillotomy. They results obtained and advantages offered by this instrument will be discussed. Since this endoscope is not usually employed, at least in Europe, for these purposes, we considered it of interest to report on the 251 ERCP and 9 papillotomies including stone removal performed in our department with the Machida PFSB 1200.

Aged↗
PubMed1979

ERCP and EPT: Italian experience.

The use of endoscopy has had a satisfactory development in Italy and today at least 70% of Italian hospitals have a fiberscope. Most of the examinations performed are in the diagnosis of diseases of the oesophagus, stomach or duodenum, whilst only a small percentage are represented by coloscopy which is usually carried out in specialized units. One of the examinations, that is most rarely performed, is ERCP, even if some hospitals have a duodenoscope suitable for catheterization of the papilla of Vater. Regardless of the fact that the usefulness of this method has been recognized and that positive results are being reported from various centers throughout the world, ERCP in Italy is performed by very few endoscopists and only in very highly specialized centres. In Rome, for example, ERCP is performed only in our Centre of Digestive Endoscopy which furthermore has the only important experience in Italy in endoscopic papillo-sphincterotomy (EPT); this type of operation has, in fact, so far been carried out only in a very limited number of patients, in a few other endoscopy units.

Ampulla of Vater↗
PubMed1977

Endoscopic retrograde cholangiopancreatography (ERCP) performed in children.

The value of ERCP in children is demonstrated on 3 cases. By using a usual duodenofiberscope (JF-B2), in 2 cases under general anesthesia and in one case after premedication with 1 ml Buscopan i.m., a similar technique is used as in adults. In congenital choledochal cyst only ERCP allowed the exact judgement of the distal part of the common bile duct and its relation to the pancreatic duct. Therefore, an exact preoperative diagnosis can be established. When duodenofiberscope will be more improved ERCP will also be possible in the newborn infant. Than the differential diagnosis of congenital biliary atresia, other congenital failures in infants causing jaundice and hepatitis in infant will be established endoscopically.

Adolescent↗
PubMed1979

[Upper-abdominal ultrasonography and ERCP? (author's transl)].

Endoscopic retrograde cholangiopancreatography (ERCP) as well as upper-abdominal ultrasonography were performed on 134 patients. Organ structure was optimally demonstrated by ultrasonography in 94 patients (70.2%) and partially in 29 (21.6%) Comparing the diagnostic assessment in 62 patients who had undergone 73 tests and had subsequently been operated on (57) or examined post-mortem (5) there was a statistically significant advantage of ERCP in diseases in which the choledochal duct had been involved. The method was successful in 95% of cases of choledocholithiasis (20 cases) compared with 45% by ultrasound and in 85% of cases of gall-bladder carcinoma which also involved the choledochal duct (38% by ultrasound). In clinically manifest carcinoma of the head of the pancreas (9 cases) and cholecystolithiasis (19 cases) ultrasonography provided the correct diagnosis in 89%, while the results for ERCP were 56% and 74%, respectively.

Biliary Tract Diseases↗
PubMed1980

Precut papillotomy: a method to improve success of ERCP and papillotomy.

The use of precut papillotomy as an aid to diagnosis with ERCP and an expedient method for endoscopic papillotomy is described. Precut papillotomy enables the experienced endoscopist to increase the successful opacification of the biliary tree in cases in which other techniques have failed, including ERCP, and to initiate a papillotomy or sphincterotomy when the papillotome cannot be introduced completely into the papilla without serious complications. Precut papillotomy is recommended when opacification of the biliary tree or introduction of the papillotome is precluded because of papillary stenosis, impacted calculi or anatomic variations, either natural or acquired, but should only be performed by the endoscopist with experience in both ERCP and papillotomy.

Ampulla of Vater↗
PubMed1985

[CT and ERCP for the combined study of biliary tract diseases].

The value of combined CT and ERCP for examining the bile ducts was studied retrospectively. CT on its own led to a correct diagnosis in 59% of cases. CT was valuable for estimating the calibre of the bile ducts, for localising the level of obstruction, for demonstrating calcified biliary concrements, and for showing peribiliary tumours. ERCP yielded a correct diagnosis in 67% of cases. The value of ERCP lies in the demonstration of poorly calcified and small concrements, strictures, tumours with ductal infiltration, and for investigating the post-cholecystectomy syndrome. Combining these two types of examination increases diagnostic accuracy to 82%.

Adult↗
PubMed1984

[CT and ERCP as a combination research method in pancreatic diseases].

The value of combined CT and ERCP for studying the pancreas has been assessed in a retrospective study. CT and ERCP used singly provided a correct diagnosis in 74 and 63% respectively; the combination of these methods increased diagnostic accuracy to 86%. ERCP is employed after CT and is indicated if the pancreas appears normal, if there is suspicion of chronic pancreatitis or neoplasia, for elucidating focal masses or if there is obstructive jaundice, without its cause being visible on CT.

Acute Disease↗
PubMed1992

[Laparoscopic cholecystectomy: ERCP as standard preoperative diagnostic technique].

In a prospective study 250 patients with proven cholelithiasis and clinical, biochemical and ultrasound indications for laparoscopic cholecystectomy (LC) underwent endoscopic retrograde cholangiography (ERCP) and (if bile-duct stones had been shown) endoscopic papillotomy (EPT). The biliary system was demonstrated in 229 patients (91.6%). Biliary tract stones were confirmed in 18 of 68 patients in whom they had been suspected clinically. In addition, ERCP revealed small stones in the bile-duct in eight of 154 patients with normal biochemical results and unremarkable ultrasound imaging, and in seven patients bile-duct anomalies which required EPT or open cholecystectomy. However, in retrospect five of the patients with cystic duct anomalies could have been treated by LC. The complication rate of ERCP/EPT was 3.2%. It is concluded from these results that, in view of the cost and potential risk to the patient, ERCP before LC can be limited to patients suspected of having bile-duct stones, even though small stones may be missed.

Adolescent↗
PubMed2001

Patient-maintained sedation for ERCP with a target-controlled infusion of propofol: a pilot study.

BACKGROUND: ERCP requires patient cooperation and often prolonged sedation. In different areas of anesthetic practice, patient-controlled sedation with a target-controlled infusion (TCI) of propofol provides effective sedation. The aim of this study was to assess the safety and efficacy of the same system in patients undergoing ERCP. METHODS: Twenty patients used the TCI system. Patients received oxygen at 2 L/min via nasal cannulae. By using pharmacokinetic TCI software modeling, an initial propofol target blood concentration (Ct) of 1.0 microg/mL was supplemented on patient demand with a handset that, when pressed twice within 1 second, increased the Ct of propofol by 0.2 microg/mL. The maximum permissible target concentration was set at 3.0 microg/mL to prevent oversedation. RESULTS: Sixteen patients used the system successfully throughout the procedure. The Ct propofol ranged from 1.2 to 2.6 microg/mL, and the number of successful handset activations (after commencement of the ERCP) ranged from 0 to 3. In 3 patients, the ceiling Ct propofol was attained without adequate sedation and the system was manually overridden. The system failed in 1 case because of patient confusion. There were no episodes of hemodynamic instability, airway obstruction, or significant oxygen desaturation. Endoscopist and patient satisfaction were high. Four patients were oversedated according to our criteria at the end of the procedure, but all were awake within 5 minutes of arrival in the recovery area. CONCLUSIONS: Patient-maintained sedation with TCI propofol was safe and fully effective in 16 patients. Ease of endoscopy was rated high by the endoscopists, and all patients were well satisfied with their sedation. Adjustments to the software programming are being evaluated to increase the safety profile to avoid oversedation.

Adult↗