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PubMed2000

Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data.

BACKGROUND: Simple endoscopic retrograde cholangiopancreatography (ERCP) outcome measures such as success and complication rates may not allow direct comparisons among endoscopists or centers because procedure degree of difficulty can vary tremendously from case to case. We propose a new grading scale designed to objectively quantify ERCP degree of difficulty. METHODS: A 1 to 5 scale was devised to grade ERCPs according to their level of technical difficulty. A retrospective pilot study was performed to assess ERCP outcomes at our institution according to difficulty grade. The scale was then prospectively applied to all ERCPs during a 1-year period. RESULTS: In the pilot study, 209 of 231 (90%) ERCPs were technically successful, and 8 (3%) were followed by complications. Grade 1 to 4 procedures were more likely to succeed (94% vs. 74%, p< 0.05) and less likely to have associated complications (2% vs. 10%, p< 0.05) than grade 5/5B ERCPs. Of 187 ERCPs assessed prospectively, 166 (89%) were successful and 10 (5%) were followed by complications; 132 of 138 (96%) grade 1 to 4 procedures succeeded compared with 30 of 46 grade 5 to 5B ERCPs (65%, p<0.001), but complications were not significantly more frequent in grade 5 to 5B ERCPs (8.7% vs. 4.3%, p = not significant). CONCLUSIONS: Technical success was dependent on ERCP degree of difficulty, but complications were not. Outcome data that incorporate degree of difficulty information may be more meaningful, allowing endoscopist-to-endoscopist and center-to-center comparisons.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2002

Nifedipine for prevention of post-ERCP pancreatitis: a prospective, double-blind randomized study.

BACKGROUND: Pancreatitis is the most common complication of ERCP. Calcium channel inhibitors have been shown to prevent the development of experimental pancreatitis. The aim of this randomized, placebo-controlled trial was to determine whether the calcium channel blocker nifedipine prevents post-ERCP pancreatitis. METHODS: Patients referred for ERCP were enrolled. Those being treated with a calcium channel inhibitor and those with acute or chronic pancreatitis were excluded. Nifedipine or placebo was administered orally less than 3 hours before and within 6 hours after ERCP. The main outcome measure was the number of cases of post-ERCP pancreatitis; a secondary outcome was the rate of post-ERCP pain (without pancreatitis) that persisted for 12 or more hours. RESULTS: One hundred fifty-five patients (70 women, 85 men; mean [SD] age 65.8 [18.2] years; range, 23-97 years) were enrolled and randomized to receive nifedipine (76 patients) or placebo (79 patients). The two groups were comparable. Procedures performed were retrograde diagnostic cholangiopancreatography alone (n = 33), biliary sphincterotomy (n = 31), stone extraction (n = 39), stent placement (n = 37), sphincteroplasty (n = 5), and other (n = 3). ERCP was unsuccessful in 5 patients. A single case of severe pancreatitis was observed (placebo group). The rate of post-ERCP pancreatitis was not different between groups (nifedipine, 10 patients, 13.2%; placebo, 14 patients, 17.7%; p = 0.4). The frequency of post-ERCP pain was not different between the groups. The only independent predictor of post-ERCP pancreatitis was difficult cannulation in both groups (OR = 3.78: 95% CI [1.25, 11.45]). CONCLUSION: This study failed to demonstrate a significant effect of nifedipine in the prevention of post-ERCP pancreatitis. A multicenter trial with greater statistical power would be needed to demonstrate a benefit for this drug.

Acute Disease↗
PubMed1997

CT before and after ERCP: detection of pancreatic pseudotumor, asymptomatic retroperitoneal perforation, and duodenal diverticulum.

BACKGROUND: A prospective study was done to investigate the occurrence of morphologic changes after ERCP that present as pancreatic pseudotumor on CT scan. Fifty-eight patients underwent CT before and after ERCP. In addition, post-ERCP complications and the value of routinely obtained CT before ERCP were assessed. RESULTS: Thirty-nine patients could be fully analyzed; 12 underwent a papillotomy (group 1). Pseudotumor of the pancreatic head was demonstrated on CT after ERCP in them (17%). No changes were seen in the 27 patients who underwent diagnostic ERCP (group 2) (p = 0.048). Asymptomatic retroperitoneal perforation after papillotomy was diagnosed in 3 patients (13%). Routinely obtained CT scans before ERCP defined a specific etiology of the biliary obstruction in 12% of patients not suggested by ultrasound. Duodenal diverticulum was found in 4 patients, resulting in a sensitivity of 36% and a specificity of 100% for CT. Oral contrast (600 ml) administered a few hours before endoscopy never hampered the endoscopist. CONCLUSION: Pancreatic pseudotumor on CT after ERCP occurred only when papillotomy was performed. CT remains a valuable diagnostic tool after diagnostic ERCP. Asymptomatic perforation may occur following ERCP with papillotomy. Routinely obtained CT before ERCP was not profitable for the endoscopist in more than 80% of our patients.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1998

ERCP in the management of pediatric pancreatitis.

BACKGROUND: Although ERCP is commonly performed in children, the effect of findings at ERCP on the subsequent management of pediatric pancreatitis is unknown. METHODS: We retrospectively reviewed charts to determine the impact of ERCP on the management of recurrent acute or chronic pancreatitis in 17 consecutive children (3 boys and 14 girls, 3 to 16 years, mean 11.2 years) with recurrent acute (n = 13) or chronic pancreatitis (n = 4) who underwent ERCP. Radiographs were reviewed in a blinded manner, and the effect of ERCP findings on subsequent management was determined. RESULTS: In 16 of 17 patients (94%), the pancreatic duct was successfully visualized. Of the 16 studies, 9 (56%) had abnormal findings. A change in therapy occurred in all 9 patients as a result of the findings at ERCP. Of the 7 patients with a prior abnormal CT or ultrasound, 5 (71%) had an abnormal ERCP, all resulting in a change in therapy. Three of the 9 patients (33%) without radiographic abnormalities had an abnormal ERCP that, in each case, resulted in a change in therapy. Overall, findings at ERCP altered therapy in 52% of pediatric patients studied with recurrent acute or chronic pancreatitis. A prior abnormal CT had a high predictive value with respect to ERCP resulting in a change in management (83%). CONCLUSIONS: ERCP is useful in the management of pediatric recurrent acute or chronic pancreatitis; abnormalities are found at a rate similar to those found in adults.

Acute Disease↗
PubMedDate not supplied

Post-ERCP pancreatitis: reduction by routine antibiotics.

Cholangitis and pancreatitis are severe complications of endoscopic retrograde cholangiopancreatography (ERCP). Antibiotics have been considered important in preventing cholangitis, especially in those with jaundice. Some have suggested that bacteria may play a role in the induction of post-ERCP pancreatitis. It is not clear, however, whether the incidence of post-ERCP pancreatitis could be reduced by antibiotic prophylaxis, as is the case with septic complications. In this prospective study, a total of 321 consecutive patients were randomized to the following two groups: (1) a prophylaxis group (n = 161) that was given 2 g of cephtazidime intravenously 30 minutes before ERCP, and (2) a control group (n = 160) that received no antibiotics. All patients admitted to the hospital for ERCP who had not taken any antibiotics during the preceding week were included. Patients who were allergic to cephalosporins, patients with immune deficiency or any other condition requiring antibiotic prophylaxis, patients with clinical jaundice, and pregnant patients were excluded. In the final analysis six patients were excluded because of a diagnosis of bile duct obstruction but with unsuccessful biliary drainage that required immediate antibiotic treatment. The diagnosis of cholangitis was based on a rising fever, an increase in the C-reactive protein (CRP) level, and increases in leukocyte count and liver function values, which were associated with bacteremia in some. The diagnosis of acute pancreatitis was based on clinical findings, and increases in the serum amylase level (>900 IU/L), CRP level, and leukocyte count with no increase in liver chemical values. The control group had significantly more patients with post-ERCP pancreatitis (15 of 160 in the prophylaxis group vs. 4 of 155 in the control group; P = 0.009) and cholangitis (7 of 160 vs. 0 of 155; P = 0.009) compared to the prophylaxis group. Nine patients in the prophylaxis group (6%) and 15 patients in the control group (9%) had remarkably increased serum amylase levels (>900 IU/L) after ERCP, but clinical signs of acute pancreatitis with leukocytosis, CRP reaction, and pain developed in four of nine patients in the prophylaxis group compared to 15 of 15 patients with hyperamylasemia in the control group (P = 0.003). In a multivariate analysis, the lack of antibiotic prophylaxis (odds ratio 6.63, P = 0.03) and sphincterotomy (odds ratio 5.60, P = 0.05) were independent risk factors for the development of post-ERCP pancreatitis. We conclude that antibiotic prophylaxis effectively decreases the risk of pancreatitis, in addition to cholangitis after ERCP, and can thus be routinely recommended prior to ERCP. These results suggest that bacteria could play a role in the pathogenesis of post-ERCP pancreatitis

Acute Disease↗
PubMed1999

Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals.

BACKGROUND AND STUDY AIMS: Increasing numbers of patients are undergoing endoscopic retrograde cholangiopancreatography (ERCP) prior to laparoscopic cholecystectomy, and more departments and doctors are performing ERCP, while new data from large prospective series have documented the risks of both diagnostic and therapeutic ERCP. The establishment in Denmark of a Patient Insurance Association, which has covered injury caused during investigation and treatment in public hospitals since July 1992, has made it possible to collect and analyze a large prospective series of ERCP complications for which compensation has been claimed. PATIENTS AND METHODS: Thirty-nine consecutive claims for compensation due to complications after ERCP occurring between 1 July 1992 and 31 December 1996 were investigated. Case notes were reviewed, along with laboratory reports and radiographs. The complications were classified according to the international consensus. RESULTS: Claims for compensation were made in 39 cases from 25 hospitals. The indication for ERCP was appropriate in 31. Precut papillotomy for access had been performed in seven. The severity of the complications was mild in one patient, moderate in three patients, severe in 24, and fatal in nine; in two cases, the severity was not classifiable. The complications were: pancreatitis in 23 patients (seven cases fatal, one of which had involved a precut procedure), bleeding in two, perforation in nine (six had a precut procedure, one died), and other reasons in five (including one fatal case). Among the nine fatal cases, cannulation had not been achieved in two and the endoscopic retrograde cholangiogram was normal in four, one of whom underwent a sphincterotomy. One patient with a previous adenoma had an endoprosthesis removed, developed gangrenous cholecystitis afterward, and died. Thirty patients were eligible for compensation. The rejected cases included mild and moderate pancreatitis, a case of fatal hemorrhagic pancreatitis in which the patient had refused blood transfusion, and one patient who had pancreatitis prior to ERCP. CONCLUSIONS: ERCP, even for diagnostic purposes, may be associated with very serious and even fatal complications. The use of the precut procedure for access should still be considered dangerous. Other means of investigating the bile ducts should be developed. If endoscopic ultrasonography and magnetic resonance cholangiography prove to have the same diagnostic value as ERCP, which must be considered the gold standard for visualizing the ducts today, they might replace ERCP as the primary investigation in patients with an intermediate or low risk of bile duct stones; this would reduce the numbers of patients exposed to the risks of ERCP.

Adult↗
PubMed2002

ERCP-related perforations: risk factors and management.

BACKGROUND AND STUDY AIMS: Perforations during endoscopic retrograde cholangiopancreatography (ERCP) are rare, and the management of these perforations is variable, with some patients requiring immediate surgery and others only conservative management. We reviewed all ERCP-related perforations at our institution to determine: a) their incidence; b) clinical outcomes; c) which management approaches gave the best results; and d) which factors predict a perforation. PATIENTS AND METHODS: All patients who underwent ERCP and suffered perforation were reviewed. To compare the length of hospital stay of the perforation group with that of patients suffering a different complication, patients who developed post-ERCP pancreatitis were also reviewed. To evaluate predictors of ERCP-related perforations, three groups were compared: group 1 (n = 49), normal ERCP/no complications; group 2 (n = 52), ERCP complicated by pancreatitis; and group 3 (n = 33), ERCP with perforation. RESULTS: Of 33 patients with confirmed ERCP-related perforations, only seven patients required surgical intervention. The overall length of hospital stay (6.5 +/- 3.5 days) was significantly longer (P = 0.003) than that of a random group of patients with the complication of post-ERCP pancreatitis (4.7 +/- 2.6 days). According to univariate analysis, risk factors included: sphincterotomy (odds ratio [OR] 9.0, 95 % confidence interval [CI] 3.2 - 28.1); sphincter of Oddi dysfunction (OR 3.8, 95 % CI 1.4 - 11.0); and dilated common bile duct (OR 4.07, 95 % CI 1.63 - 10.18, P = 0.003). In the multivariate logistic regression analysis, additional predictive factors included the duration of procedure (OR 1.021, 95 % CI 1.006 - 1.036), and biliary stricture dilation (OR 7.2, 95 % CI 1.84 - 28.11). CONCLUSIONS: (i) The incidence of ERCP-related perforations is very low (0.35 %). (ii) Esophageal, gastric and duodenal perforations usually require surgery, but sphincterotomy- and guide wire-related perforations rarely do so. (iii) Factors which carry increased risk of an ERCP-related perforation include suspected sphincter of Oddi dysfunction, greater age, a dilated bile duct, sphincterotomy, and longer duration of the procedure.

Adult↗
PubMed2002

[Results of emergency ERCP in the treatment of acute biliary pancreatitis].

Indication for emergency ERCP (< 48 hours after onset of symptoms) with stone extraction from the common bile duct (CBD) in patients with biliary pancreatitis remains controversial. In our hospital emergency ERCP with stone extraction from CBD is part of the therapeutical concept in patients with biliary pancreatitis. The aim of the study was to elucidate retrospectively results and impact of this concept on morbidity and lethality in surgical intensive care patients. We included all patients with a documented indication for emergency ERCP. Among 4 466 patients (1. 1. 1999-31. 12. 2000) treated in the SICU, 37 (0.9 %) required an emergency ERCP due to a biliary pancreatitis. (26 females/11 males, 62.0 +/- 15.4 years). After ERCP stones were present in 32 of the 37 patients with subsequent successful endoscopic extraction in all cases but one. The mean duration from admission to ERCP was 11.6 +/- 10.1 hours. Bilirubin as well as amylase and lipase decreased after ERCP (p < 0.05). Only in one case an elevation of pancreatic enzymes over the pre-ERCP values was observed, an aggravation of pancreatitis was not seen in our series. In 5 of the 37 cases bile duct stones were not found after ERCP despite strong clinical suggestion (elevation of bilirubin and pancreatic enzymes, ultrasound). During the observational period 2 patients died, in one case possibly due to the ERCP. Emergency ERCP removed in our series the pancreatitis causing agent. Still considering the limitations of a retrospective study these positive results are stimulating us to continue with our therapeutical concept.

Adult↗
PubMed2001

Risk factors for post-ERCP pancreatitis: a prospective, multicenter study.

BACKGROUND: Post-ERCP pancreatitis is poorly understood. The goal of this study was to comprehensively evaluate potential procedure- and patient-related risk factors for post-ERCP pancreatitis over a wide spectrum of centers. METHODS: Consecutive ERCP procedures were prospectively studied at 11 centers (6 private, 5 university). Complications were assessed at 30 days by using established consensus criteria. RESULTS: Pancreatitis occurred after 131 (6.7%) of 1963 consecutive ERCP procedures (mild 70, moderate 55, severe 6). By univariate analysis, 23 of 32 investigated variables were significant. Multivariate risk factors with adjusted odds ratios (OR) were prior ERCP-induced pancreatitis (OR 5.4), suspected sphincter of Oddi dysfunction (OR 2.6), female gender (OR 2.5), normal serum bilirubin (OR 1.9), absence of chronic pancreatitis (OR 1.9), biliary sphincter balloon dilation (OR 4.5), difficult cannulation (OR 3.4), pancreatic sphincterotomy (OR 3.1), and 1 or more injections of contrast into the pancreatic duct (OR 2.7). Small bile duct diameter, sphincter of Oddi manometry, biliary sphincterotomy, and lower ERCP case volume were not multivariate risk factors for pancreatitis, although endoscopists performing on average more than 2 ERCPs per week had significantly greater success at bile duct cannulation (96.5% versus 91.5%, p = 0.0001). Combinations of patient characteristics including female gender, normal serum bilirubin, recurrent abdominal pain, and previous post-ERCP pancreatitis placed patients at increasingly higher risk of pancreatitis, regardless of whether ERCP was diagnostic, manometric, or therapeutic. CONCLUSIONS: Patient-related factors are as important as procedure-related factors in determining risk for post-ERCP pancreatitis. These data emphasize the importance of careful patient selection as well as choice of technique in the avoidance of post-ERCP pancreatitis.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2001

Can endoscopic ultrasound or magnetic resonance cholangiopancreatography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis.

OBJECTIVES: ERCP is the gold standard for pancreaticobiliary evaluation but is associated with complications. Less invasive diagnostic alternatives with similar capabilities may be cost-effective, particularly in situations involving low prevalence of disease. The aim of this study was to compare the performance of endoscopic ultrasound (EUS) with magnetic resonance cholangiopancreatography (MRCP) and ERCP in the same patients with suspected extrahepatic biliary disease. The economic outcomes of EUS-, MRCP-, and ERCP-based diagnostic strategies were evaluated. METHODS: Prospective cohort study of patients referred for ERCP with suspected biliary disease. MRCP and EUS were performed within 24 h before ERCP. The investigators were blinded to the results of the alternative imaging studies. A cost-utility analysis was performed for initial ERCP, MRCP, and EUS strategies for these patients. RESULTS: A total of 30 patients were studied. ERCP cholangiogram failed in one patient, and another patient did not complete MRCP because of claustrophobia. The final diagnoses (N = 28) were CBD stone (mean = 4 mm; range = 3-6 mm) in five patients; biliary stricture in three patients, and normal biliary tree in 20. Two patients had pancreatitis after therapeutic ERCP, one after precut sphincterotomy followed by a normal cholangiogram. EUS was more sensitive than MRCP in the detection of choledocolithiasis (80% vs 40%), with similar specificity. MRCP had a poor specificity and positive predictive value for the diagnosis of biliary stricture (76%/25%) compared to EUS (100%/100%), with similar sensitivity. The overall accuracy of MRCP for any abnormality was 61% (95% CI = 0.41-0.78) compared to 89% (CI = 0.72-0.98) for EUS. Among those patients with a normal biliary tree, the proportion correctly identified with each test was 95% for EUS and 65% for MRCP (p < 0.02). The cost for each strategy per patient evaluated was $1346 for ERCP, $1111 for EUS, and $1145 for MRCP. CONCLUSIONS: In this patient population with a low disease prevalence, EUS was superior to MRCP for choledocholithiasis. EUS was most useful for confirming a normal biliary tree and should be considered a low-risk alternative to ERCP. Although MRCP had the lowest procedural reimbursement, the initial EUS strategy had the greatest cost-utility by avoiding unnecessary ERCP examinations.

Adult↗
PubMed2006

Relationship among hospital ERCP volume, length of stay, and technical outcomes.

BACKGROUND: The relationship between hospital procedure volume and outcome has been recognized for various specialties and procedures. Although increasingly used and in existence for 40 years, to date, data on the relationship between hospital volume and outcome of ERCP are scant. OBJECTIVE: We sought to examine health-related outcomes after ERCP in relation to hospital procedure volume. DESIGN: Secondary analysis of a national administrative database. We used the National Inpatient Sample (NIS) database to evaluate health-related outcomes among patients who underwent ERCP from 1998 to 2001. MAIN OUTCOME MEASUREMENTS: Logistic and multiple regression models were used to estimate the association of hospital ERCP volume with length of stay (LOS), rates of procedural failure, and mortality. Fixed effect models were used to adjust for all time invariant hospital characteristics for each hospital within the dataset. RESULTS: Data from 2629 hospitals that performed 199,625 ERCPs were evaluated. The median number of ERCPs performed in participating hospitals was 49 per year (range, 1-1004), with 25% of hospitals performing > or =100 ERCPs per year and 5% performing > or =200 per year. Significant trends in the relationship between volume and outcome were observed with respect to LOS and procedural failure: the median LOS was lower in high-volume (> or =200 ERCP/y) than low-volume (< or =100 ERCP/y) hospitals (6.9 vs 7.8 days, p < 0.0001) and the mean difference in expected LOS was 1.08 days (p < 0.0001). Multivariate regressions with hospital level fixed effects found significant negative relationships between procedure volume and procedure failure rates, but no significant effect on inpatient mortality rates was detected. LIMITATIONS: NIS database permits analyses of only inpatient ERCPs. It precludes analysis of procedural complications, reinterventions, and influence of individual provider volume on outcomes. CONCLUSIONS: Inpatients who undergo ERCP at high-volume hospitals have shorter LOS and lower procedural failure rates than those undergoing ERCP at low-volume hospitals. These findings have important implications for health care policy decision making and resource utilization.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2003

Are drugs a risk factor of post-ERCP pancreatitis?

BACKGROUND: Pancreatitis is the most severe complication of ERCP. The aim of this study was to assess whether the use of potentially pancreatotoxic drugs is a risk factor for post-ERCP pancreatitis. METHODS: Risk factors for post-ERCP pancreatitis and all drugs taken during the month before ERCP were recorded retrospectively in a database. Patients with other causes of acute pancreatitis or chronic pancreatitis were excluded from the analysis. Post-ERCP pancreatitis was defined as abdominal pain and/or vomiting associated with amylase/lipase plasma levels equal to or greater than twice the upper normal value. RESULTS: A total of 173 patients (95 men, 78 women; mean age, 68 [16] years) were included. Post-ERCP pancreatitis occurred in 31 patients (18%). Several risk factors were identified in a multivariate analysis: difficulty in cannulation (p<0.001), endoscopic sphincterotomy (p<0.005), and female gender (p=0.02). Having taken potent pancreatotoxic drugs increased the occurrence of post-ERCP pancreatitis: odds ratio 3.7: 95% confidence intervals [1.1,12.4], p=0.04. CONCLUSIONS: Use of pancreatotoxic drugs before or during ERCP significantly increased the risk of post-ERCP pancreatitis. Thus, discontinuation of the use of such drugs before ERCP seems justified whenever possible.

Adolescent↗
PubMed2004

Efficacy of ERCP via the accessory papilla in children with choledochal cysts.

BACKGROUND: ERCP via the major duodenal papilla in children with choledochal cyst may not clearly visualize the entire pancreatic duct and the junction of the pancreatic and biliary ducts. This may be caused by obstruction of the pancreatic duct by a dilated common bile duct. METHODS: Patients with choledochal cysts who underwent ERCP with injection of contrast medium at the major duodenal papilla were classified as either belonging to a MP group, in which the entire pancreatic duct and junction of the pancreatic and biliary ducts were visualized, or to a M/AP group, in which these structures were either partially visualized or not visualized. ERCP via the accessory papilla subsequently was performed in the M/AP group by using 0.6- or 0.8-mm metal-tip catheters. The efficacy of ERCP via the accessory papilla in children with choledochal cysts was evaluated. OBSERVATIONS: ERCP was performed in 13 patients. Seven were assigned to the MP group and 6 to the M/AP group. ERCP via the accessory papilla in the M/AP group was successful in 5 of the 6 patients; pancreas divisum was demonstrated in one, a protein plug at the main pancreatic duct in another, and the entire pancreatic duct and junction of the pancreatic and biliary ducts in the remaining 3 patients. No patient developed pancreatitis as a result of ERCP, including ERCP via the accessory papilla. CONCLUSIONS: In children with choledochal cyst, ERCP via the accessory papilla is an effective method for visualization of the detailed structure of the entire pancreatic ductal system and junction of the pancreatic and biliary ducts when ERCP via the major duodenal papilla is unsuccessful.

Child, Preschool↗
PubMed2005

High-dose allopurinol for prevention of post-ERCP pancreatitis: a prospective randomized double-blind controlled trial.

BACKGROUND: Pancreatitis is the most common major complication of diagnostic and therapeutic ERCP. Allopurinol, a xanthine oxidase inhibitor that blocks generation of oxygen-derived free radicals, potentially may prevent post-ERCP pancreatitis. This study assessed the efficacy of high-dose oral allopurinol for prevention of post-ERCP pancreatitis. METHODS: A prospective, double-blind, placebo-controlled trial was conducted in 250 patients undergoing ERCP. Patients were randomized to receive allopurinol (600 mg) or placebo orally at 15 and 3 hours before the procedure. Patients were clinically evaluated, and serum amylase levels were determined before ERCP and at 6 and 24 hours thereafter. Standardized criteria were used to diagnose and to grade the severity of post-ERCP pancreatitis. RESULTS: A total of 243 patients were included in the analysis. The two groups were similar with regard to age; gender; underlying disease; indication for treatment; ERCP findings; and type of treatment, except for biliary sphincterotomy. Only 43 patients in the allopurinol group underwent biliary sphincterotomy vs. 87 in the placebo group ( p < 0.001). The frequency of acute pancreatitis was significantly lower in the allopurinol vs. the placebo group in the final multinomial regression analysis: allopurinol group, 4/125 (3.2%), with all 4 cases graded as mild, vs. placebo group, 21/118 (17.8%), of which 8/118 (6.8%) were graded as mild, 11/118 (9.3%) as moderate, and 2/118 (1.6%) as severe with fatal outcome ( p < 0.001). The protective effect of allopurinol was also apparent in the diagnostic ERCP and the biliary sphincterotomy subgroups when the frequency of post-ERCP pancreatitis was analyzed after stratification by procedure. The mean duration of hospitalization for pancreatitis was significantly shorter in the allopurinol compared with the placebo group (2.5 vs. 5.67 days; p < 0.001). CONCLUSIONS: Pretreatment with high-dose, orally administered allopurinol decreases the frequency of post-ERCP pancreatitis. Despite the promising results of this prospective, randomized trial, further studies are needed to verify these observations before allopurinol can be recommended for routine clinical use.

Adult↗
PubMed2001

[Interventional ERCP in patients with cholestasis. Degree of biliary bacterial colonization and antibiotic resistance].

Interventional ERCP in patients with cholestasis. Degree of biliary bacterial colonization and antibiotic resistance. Biliary obstruction together with bacterial colonization of the bile duct may lead to development of acute cholangitis. The aim of our prospective study was to investigate the presence and degree of biliary bacterial colonization by means of bile aspiration during ERCP in patients with biliary obstruction. Furthermore, we evaluated antibiotic therapy regimens, which would cover the bacterial species obtained by ERCP and subsequent culture in each patient. In addition, analysis of risk factors was performed that would predispose to the development of cholangitis.80 patients with clinical and laboratory evidence of biliary obstruction underwent ERCP with initial aspiration of bile via the cannulation catheter. This material was used to culture aerobic and anaerobic bacteria and determine the colony count/ml bile, followed by identification of each species and antibiotic resistance testing. The minimal inhibitory concentration for Levofloxacin, Ciprofloxacin, Piperacillin, Ampicillin, Ceftriaxone, Imipenem, Gentamycin und Metronidazole was determined. Immediately after the ERCP or if the body temperature (after ERCP) rose to > 38 degrees C blood cultures were obtained. In 45 (56 %) patients biliary colonization with bacteria could be identified (56 %). In 20 patients a single isolate was cultured, in 25 cases mixed infection was present. A total of 83 species were isolated. The most common bacteria were E. coli, Enterococcus and Klebsiella. 9.6 % of all isolates were obligatory anaerobes. In 9 of 80 patients bloodcultures tested positive for bacterial growth (rate of bacteremia: 11.3 %). 10 patients had acute cholangitis clinically before ERCP, 13 patients developed signs of infection after ERCP. Statistically significant factors contributing to the risk of infection were age of the patient, the clinical condition of the patient before ERCP and the biliary colony count. Patients with development of infection after ERCP showed a significantly higher incidence of bacterial colonization of the biliary tree and a higher colony count. In all bacterial species Imipenem (4.5 %) or Levofloxacin (2.2 %) exhibited the lowest rate of in-vitro resistance. Based on these data, the implementation of Levofloxacin in combination with anaerobic coverage is advantageous as a calculated therapy for patients with acute cholangitis.

Adult↗
PubMed2001

Patient satisfaction after MRCP and ERCP.

OBJECTIVE: Magnetic resonance cholangiopancreatography (MRCP) is an accurate diagnostic test for detecting abnormalities of the pancreaticobiliary system. Because it is noninvasive, MRCP appears to be more tolerable than ERCP, although this has not been studied. The purpose of this study is to compare patient satisfaction after MRCP and ERCP performed sequentially. METHODS: We prospectively recruited 34 patients undergoing ERCP, for whom an MRCP was able to be performed before ERCP. Patient satisfaction was assessed by validated questionnaires using seven-point Likhert scales (individual ratings and direct comparisons). The following dimensions were explored: anxiety, pain, discomfort, tolerability (relative to expectations), willingness to repeat the procedure, and overall preference. Chi2 and Student's t tests (paired and unpaired) were performed, and 95% CIs were provided. RESULTS: Two patients (5.9%) were unable to undergo MRCP because of claustrophobia. The remaining 32 completed both tests (94% same day) and all questionnaires. Average age was 56+/-18 yr, and 66% were women. In 23 patients, some degree of biliary obstruction was suspected; nine patients had pancreatitis. Patients reported a lower degree of pain (p < 0.001) and discomfort (p = 0.047) with MRCP, but MRCP was more difficult than they expected (p = 0.0 12). Patients were marginally more willing to repeat MRCP (ns, p = 0.09). On direct comparisons, patients were more satisfied with MRCP regarding anxiety (p = 0.04) and pain (p = 0.001). Patients displayed a higher overall preference for MRCP compared with ERCP (p = 0.01); however, only 59% clearly preferred MRCP over ERCP. The most common problem with MRCP was claustrophobia or noise (n = 15), and the differences were more striking in the subgroup without this problem. The subgroup undergoing purely diagnostic ERCPs showed clear preferences for MRCP. CONCLUSIONS: In many respects, MRCP is well tolerated, and certain subgroups, especially those undergoing diagnostic ERCPs, prefer MRCP over ERCP. As an endoscopist, one needs to be aware of the limitations of MRCP and relay these to the patient, as it seems that patients find MRCP more difficult than anticipated, and a significant number still prefer ERCP over MRCP. Patient satisfaction may be further improved by reducing noise and claustrophobia with selective premedication, earplugs, and the use of the new quieter fenestrated magnetic resonance imaging scanners.

Adolescent↗
PubMed1992

Stent placement for benign pancreatic diseases: correlation between ERCP findings and clinical response.

OBJECTIVE: We performed a study to determine if the appearance of the pancreatic duct on ERCP before and after placement of pancreatic duct stents correlates with the therapeutic response in patients treated for impaired pancreatic drainage. MATERIALS AND METHODS: Findings in 29 consecutive patients with a variety of benign pancreatic diseases in whom pancreatic stents were placed and subsequently removed within a 3-year period were reviewed retrospectively. Early (1-5 days) and late (1-3 months) clinical outcomes after stent placement were assessed. These findings were correlated with a blinded interpretation of ERCP findings (Cambridge criteria were used) before and after stent placement. RESULTS: ERCP findings before stent placement were normal in 10 patients. At the end of stent therapy, ERCP showed changes associated with chronic pancreatitis in all 10; five had focal narrowing at the tip of the stent. Subsequent ERCP studies in five of these 10 patients showed that ductal changes induced by stents diminished after stent removal. Of the 19 patients with abnormal findings on ERCP at the time of stent placement, ERCP at the end of stent therapy showed some improvement in seven patients, no change in eight, and deterioration in four. Changes seen on ERCP had no statistically significant correlation with clinical outcome (p = .36). CONCLUSION: Our findings show that pancreatic duct stents can induce abnormalities on ERCP indicative of chronic pancreatitis. However, diminution of these abnormalities after stent removal in some patients suggests that these changes may be due to edema rather than to fibrosis. Ductal changes seen on ERCP are not a useful guide for determining the degree of response to pancreatic stents.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2004

Complications of endoscopic retrograde cholangiopancreatography. A study in a small ERCP unit.

BACKGROUNDS AND AIM: endoscopic retrograde cholangiopancreatography (ERCP) is an established procedure to drain the biliary and pancreatic ducts. Nevertheless, there are complications which seem to be more common in centers performing less than 200 ERCPs per year. Sometimes, however, due to the distribution of health resources, it is necessary to perform this technique in centers with a smaller number of procedures. We present the experience of ERCP-related complications in a small unit. MATERIAL AND METHODS: this is a retrospective study on prospective data recorded during six years (1997-2002). In this period, two endoscopists working together performed 507 ERCPs, which yields an approximately average of 84 procedures per year. RESULTS: in 507 ERCPs performed during this period of time, 55 complications arose (10.85%), and four patients died (0.79%) as a consequence of the procedure. There were 28 pancreatitis (5.5%), eight post-sphincterotomy bleeding events (1.6%), seven bilioduodenal perforations (1.4%), eight sepsis episodes of biliary origin (1.6%), and other 4 different complications. There were 418 (82.4%) successful ERCPs--either diagnostic or therapeutic--,which gave rise to 46 (11%) complications. There were 89 (17.6%) failed diagnostic or therapeutic ERCPs, which gave rise to 9 (10.11%) complications (p = 0.8 between both groups). Thirty five (7%) ERCPs were exclusively diagnostic and caused 6 (17%) complications. The 187 procedures performed for choledocholithiasis originated 14 (7.4%) complications, and represented the group with the lowest morbidity rate (p = 0.04). CONCLUSIONS: the complications rate in our center is within the range of reported figures. ERCPs performed for choledocholithiasis was associated with the lowest complications rate. The risk-benefit ratio in the anticipated, purely diagnostic ERCP must be carefully weighed due to its morbidity.

Cholangiopancreatography, Endoscopic Retrograde↗