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PubMed2002

What are the predictors of post-ERCP pancreatitis, and how useful are they?

Acute pancreatitis is one of the major complications of ERCP. It is of paramount importance that we accurately identify which patients will go on to develop post-ERCP pancreatitis. As most ERCPs are performed on an outpatient basis, early evaluation can allow safe discharge of the majority of patients who will not develop post-ERCP pancreatitis or develop only mild symptoms that will be self-limited. Alternatively, early detection of those patients who will go on to develop moderate or severe post-ERCP pancreatitis can guide decisions regarding hospital admission and aggressive management and can help direct the use of targeted therapies that have the potential to prevent or mitigate pancreatic inflammation. Thus, significant efforts have focused on trying to identify predictors of post-ERCP pancreatitis. These parameters can be organized into three categories of tests: 1) pancreatic enzymes as markers of pancreatic injury: serum amylase/urine amylase; 2) markers of proteolytic activation: trypsinogen, trypsinogen activation peptide; 3) markers of systemic inflammation: C-reactive protein, various interleukins such as IL-6 and IL-10. A serum amylase level greater than 4-5 times the upper reference limit in conjunction with clinical symptoms has been shown to be an accurate and reliable predictor of post-ERCP pancreatitis. However, the exact timing and level of amylase elevation remains debatable. Urine testing of amylase and trypsinogen-2 in post-ERCP patients has also been shown to be highly sensitive and specific for detecting pancreatitis. The main advantage of these urinary markers is that they are available as rapid dipstick tests. Serum trypsinogen-2 levels have also been studied in post-ERCP pancreatitis patients; high levels seem to correlate with severity of disease. Among the markers of systemic inflammation, serum CRP is an accurate and readily available laboratory test for predicting severity of post-ERCP pancreatitis, but it appears to be helpful at 24-48 hours and, therefore, is not an early marker. Several other markers remain investigational and have not yet found wide clinical applicability.

Acute Disease↗

PubMed1995

Urgent ERCP in all cases of acute biliary pancreatitis? A prospective randomized multicenter study.

In this prospective multicenter study, the effect of early ERCP within 72 hours after the beginning of symptoms in the treatment of acute biliary pancreatitis was investigated. 100 patients with acute biliary pancreatitis but without biliary sepsis or obstructive jaundice were randomized in this trial. 48 patients of the invasive group received urgent ERCP within 72 hours after the beginning of pain. 52 patients of the conventional group received ERCP only if biliary sepsis or obstructive jaundice occurred during the clinical course of the disease (which was the case in 10 patients). Sphincterotomy and stone extraction were undertaken if bile duct stones were identified during ERCP. In the invasive group, ERCP was successfully performed in 44 cases (92%). In 19 of these patients (43%), common bile duct stones were identified and a sphincterotomy was performed. The stones could be removed completely during the first ERCP examination in 16 cases. In the conventional group, 2 patients died from pancreatitis within 3 months, versus 4 patients in the invasive group. Cholecystitis occurred significantly more often in the conventional group (11 versus 4; odds ratio OR = 5.1), but no patient with cholecystitis or cholangitis died. Cholangitis (OR = 3.3) and sepsis (OR = 3.5) were slightly more frequent in the conventional group (not significant) while renal failure (OR = 0.5) and pulmonary failure (OR = 0.8) were slightly more frequent in the invasive group (not significant). Jaundice (6 patients) only occurred in the conventional group. In this multicenter study, it is concluded that early ERCP is not superior to conventional treatment in patients with acute biliary pancreatitis. On the other hand, patients with biliary complications (jaundice, sepsis, cholangitis) should receive urgent ERCP. However, most bile duct stones which initiate a pancreatitis pass spontaneously into the duodenum. The vast majority of patients suffering from biliary pancreatitis without biliary sepsis or obstructive jaundice require only elective ERCP when remaining bile duct stones are assumed. The lethality of biliary pancreatitis without initial biliary complications (sepsis, jaundice) tends to be elevated rather than diminished by emergency ERCP.

Acute Disease↗

PubMed2004

Cost-minimization analysis of MRC versus ERCP for the diagnosis of primary sclerosing cholangitis.

Investigations examining the use of magnetic resonance cholangiography (MRC) for the diagnosis of primary sclerosing cholangitis (PSC) have described comparable accuracy when compared to endoscopic retrograde cholangiopancreatography (ERCP). The effectiveness of MRC based on overall cost, however, remains unknown. Our aim was to determine the average cost per correct diagnosis using MRC or ERCP as the initial testing strategy for the diagnosis of PSC. A decision analysis model was constructed employing diagnostic test parameters prospectively determined among 73 patients with clinically suspected biliary disease. ERCP was performed within 24 hours after MRC. Cost data were derived from average Medicare reimbursement fee schedules. The prevalence of PSC in the study cohort was 32%. The sensitivity and specificity of MRC for the diagnosis of PSC were 82% and 98%, respectively. The average cost per correct diagnosis of PSC was 724.00 US dollars for initial MRC (including the cost of ERCP following a negative MRC examination) versus 793.17 US dollars for initial ERCP. In the absence of biliary obstruction, the average cost per correct diagnosis of PSC was 549.64 US dollars with MRC versus 623.25 US dollars or ERCP. The average cost of managing post-ERCP-related complications among patients with PSC was 2902.20 US dollars (range, 1915.40-5031.54 US dollars). For ERCP to be the optimal initial test strategy, a prevalence rate of PSC greater than 45%, MRC specificity less than 85%, or reduction in the average cost per diagnosis to 538.30 US dollars would be required. In conclusion, MRC has comparable accuracy to ERCP and results in cost savings when used as the initial test strategy for diagnosing PSC.

Adult↗

PubMed1988

ERCP diagnosis of tumors in the region of the head of the pancreas. Analysis of criteria and computer-aided diagnosis.

During the period 1974-1983, 320 patients with pancreas carcinoma, papilla of Vater carcinoma, bile duct bifurcation carcinoma, or duodenal carcinoma were examined by ERCP. Using 30 ERCP criteria, a radiological diagnosis was made. A valid pathological diagnosis was available in 200 patients (62.5%). In 183 of the 200 patients (91.5%), the ERCP diagnosis and the pathological diagnosis were identical. We then performed an analysis using 52 ERCP criteria. In 192 of the 200 patients (96.0%), the ERCP diagnosis based on this reanalysis and the pathological diagnosis were identical. By discriminant analysis, 13 ERCP criteria with a maximal discriminatory value were selected in patients in whom all diagnostic structures (bile ducts, pancreatic duct, and duodenum) were visible. Using these 13 criteria selected by discriminant analysis, the diagnostic score was 98.9%. A computer program based on these 13 ERCP criteria was designed for use in practice. The diagnostic accuracy of this computer program was 98.4%. Finally we tested this computer program on 171 new patients who were seen in the period 1983-1986. In 143 of the 171 patients, a valid pathological diagnosis was available (83.6%). Comparing the ERCP diagnosis in all patients (even if not all structures were visible) with a valid pathological diagnosis, the prospective score of the computer program was 91.6%. Using this program it was possible to evaluate examinations in which not all structures were visible. When the ERCP diagnosis was uncertain, the doubt could be quantified.

Ampulla of Vater↗

PubMed2001

Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration.

BACKGROUND: There are a variety of approaches to the diagnosis and treatment of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy (LC). METHODS: Decision modeling was used to evaluate the cost-effectiveness of four strategies for managing CBD stones around the time of LC: (a) routine preoperative endoscopic retrograde cholangiopancreatography (ERCP) (preoperative ERCP), (b) LC with intraoperative cholangiography (IOC), followed by laparoscopic common bile duct exploration (LCDE), (c) LC with IOC, followed by ERCP (postoperative ERCP), and (d) expectant management (LC without any tests for CBD stones). Local hospital data were used to estimate costs. Cost-effectiveness was expressed in terms of the cost per case of residual CBD stones prevented (in excess of the cost of LC alone). Diagnostic test characteristics, procedure success rates, and adverse event probabilities were derived from a systematic review of the literature. Sensitivity analysis was used to explore the effect of uncertainty on the results of the model. RESULTS: LC alone was the least costly strategy, but it was also the least effective. Of the more aggressive strategies, LCDE and preoperative ERCP were associated with marginal costs of $5993.60 and $299,259.35, respectively, per case of residual CBD stones prevented. Postoperative ERCP was more costly and less effective than LCDE, but it had a lower cost-effectiveness ratio than preoperative ERCP when the prevalence of CBD stones was <80%. CONCLUSIONS: Compared to other common approaches, laparoscopic CBD exploration is a cost-effective method of managing CBD stones in patients who undergo LC. If expertise in LCDE is unavailable, selective postoperative ERCP is preferred over routine preoperative ERCP, unless the probability of CBD stones is very high (>80%).

Cholangiography↗

PubMed1987

A comparative study of computed tomography and ERCP in pancreaticobiliary disease.

Fifty-seven patients with suspected pancreaticobiliary pathology constituting a clinical subset in whom the diagnosis was problematic or nonspecific were evaluated with computed tomography and ERCP. The relative sensitivities, specificities, and accuracies of the two tests were compared. Computed tomography was successful in obtaining a diagnostic examination in 100% and ERCP was technically successful in 75%. Both tests were equally accurate in detecting an abnormality (computed tomography 95.7%; ERCP 95.3%) and offering a correct diagnosis (computed tomography 72%; ERCP 70%). Sensitivity and specificity of the two tests for detection of an abnormality was computed tomography 100% and 91.3%; ERCP 91.7% and 100%. Sensitivity and specificity for the correct diagnosis was computed tomography 59% and 91.3%; ERCP 46% and 100%. Computed tomography was also superior to ERCP in making a correct diagnosis in pancreatic carcinoma (80% versus 63%) and pancreatitis (75% versus 50%). Based on these results we conclude that computed tomography utilizing high doses of intravenous contrast material and thin collimation is the preferred screening examination for pancreaticobiliary disease. ERCP should be reserved for those cases where the pancreaticobiliary disease. ERCP should be reserved for those cases where the diagnosis on computed tomography is obscure or uncertain and/or the pancreatic or biliary ductal anatomy requires direct contrast imaging.

Biliary Tract Diseases↗

PubMed2006

Twenty-four hour prophylaxis with increased dosage of octreotide reduces the incidence of post-ERCP pancreatitis.

BACKGROUND: Acute pancreatitis is a common complication of ERCP, occurring in up to 10% of cases. Chemoprevention of post-ERCP pancreatitis remains a debated issue. OBJECTIVE: This study evaluated whether increased dosage of octreotide, a potent inhibitor of pancreatic secretion, could reduce the incidence of post-ERCP pancreatitis. DESIGN: In a randomized, double-blind, placebo controlled trial, the effect of 500 microg octreotide, given 3 times daily subcutaneously starting 24 hours before the ERCP procedure, was compared with that of placebo in patients who underwent diagnostic and/or therapeutic ERCP. PATIENTS: A total of 202 patients were included in the trial. The 2 groups were similar in regards to age, sex, indications for treatment, underlying diseases, and types of therapeutic procedures. Patients were clinically evaluated, and serum amylase levels were determined before ERCP and at 6 to 8 hours thereafter. Standardized criteria were used to diagnose and to grade the severity of post-ERCP pancreatitis. RESULTS: The medication was discontinued because of an allergic reaction in 1 patient in the octreotide group. The incidence of post-ERCP pancreatitis was significantly lower in the octreotide group compared with the placebo group (2/10 [2%] vs 9/101 [8.9%], P = .03). All cases of acute pancreatitis were mild, except 2 (1 moderate and 1 severe) in the placebo group. CONCLUSIONS: The results of this trial support the use of 24-hour prophylaxis with high dose of octreotide in the prevention of post-ERCP pancreatitis.

Aged↗

PubMed2004

ERCP or EUS for tissue diagnosis of biliary strictures? A prospective comparative study.

BACKGROUND: The accuracy of ERCP-based brush cytology or forceps biopsy for tissue diagnosis is relatively low (usually not exceeding 70%). By contrast, reported accuracy rates for EUS-guided FNA of pancreatobiliary masses are over 80%. This prospective study compared these two modalities for the first time in the diagnosis of indeterminate biliary strictures and pancreatic tumors. METHODS: Fifty consecutive patients (29 men, 21 women; mean age 62.1 years) with obstructive jaundice in whom a tissue diagnosis was required were included. During ERCP, intraductal specimens were obtained with a forceps and with two different types of brush (conventional and spiral suction) in random order. During EUS, only visible mass lesions or localized bile duct wall thickening were aspirated (22-gauge needle), with at least two passes yielding material sufficient for assessment. A cytopathologist was not present in the procedure room to evaluate specimen adequacy. The reference methods were surgery, other biopsy results, follow-up until death, or the conclusion of the study (mean follow-up 20 months). RESULTS: The final diagnoses were malignancy, 28 (16 pancreatic, 12 biliary), and benign biliary stricture, 22. Sensitivity and specificity for ERCP-guided biopsy were 36% and 100%, respectively; for ERCP-guided cytology (when using conventional and spiral suction brushes), 46% and 100%, respectively; and for EUS-guided FNA, 43% and 100%, respectively. If the punctured lesions are considered (n=28) alone, the sensitivity of EUS-guided FNA was 75%. In general, sensitivity was better for ERCP-based techniques in the subgroup biliary tumor (ERCP 75% vs. EUS 25%), whereas EUS-guided biopsy was superior for pancreatic mass (EUS 60% vs. ERCP 38%). CONCLUSIONS: For biliary strictures, combined ERCP- and EUS-guided tissue acquisition seems to be the best approach to tissue diagnosis. From a clinical standpoint, it appears reasonable, when a tissue diagnosis is required, to start with ERCP if biliary malignancy is suspected and with EUS when a pancreatic tumor is thought to be the cause of a biliary stricture.

Adult↗

PubMed1997

Therapeutic ERCP: a cost-prohibitive procedure?

BACKGROUND: ERCP is increasingly being performed for therapeutic purposes and engenders a proliferation of disposable equipment without a clear indication of cost-effectiveness. METHODS: We analyzed the financial impact of ERCP by prospectively analyzing ERCPs performed in our institution from June 1, 1994, to September 30, 1994, by calculating charges related to indirect costs, disposable equipment costs, and overall reimbursement. The data were analyzed according to insurance payor as well. RESULTS: Disposable equipment costs a mean of $149 per diagnostic ERCP and $532 per therapeutic ERCP. For diagnostic ERCP, disposable equipment accounted for 27% of reimbursement; for therapeutic ERCP, disposable equipment accounted for 68% of reimbursement. Although overall reimbursement was higher for therapeutic ERCP, the very high direct costs related to disposable equipment limited the ability of reimbursement to cover indirect costs. CONCLUSIONS: Depending on the complexity of cases, quantity of disposable equipment used, and patient-insurance mix, therapeutic ERCP may be cost prohibitive for a given endoscopy unit. Indirect costs should be more carefully and quantitatively analyzed. Disposable equipment should be evaluated in terms of cost, safety, and patient outcome.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed2002

Management of asymptomatically/minimally symptomatic post-ERCP serum liver test elevations: first do no harm.

Trauma to the major papilla and transient supraphysiologic biliary tract pressure during ERCP may produce transient serum liver test elevation. Further investigation of these abnormal serum tests may be costly, potentially hazardous, and unnecessary. Transient rises in post ERCP serum liver tests may be a common epiphenomenon that requires only careful clinical observation. Our aim was to study serum liver test results collected before and after ERCP in asymptomatic (or minimally symptomatic) patients and determine the natural clinical history of these patients, without further intervention. Data were collected prospectively as part of a larger study, and this subset of data on asymptomatic patients was then analyzed separately. All patients had serum liver tests done before ERCP, and 4 and 18-24 h after ERCP. Thirty-seven patients were evaluated. Sixteen of the 36 (43%) had an abnormal serum liver test after ERCP. Fifteen of the 36 had a biliary or pancreatic papillotomy done. Whether or not a patient had a papillotomy performed did not appear to influence the incidence of abnormal transient serum liver test rise. There were no biliary stents placed in any of the patients evaluated. There were two cases of post-ERCP pancreatitis (one mild; one moderate). There were no cases of cholangitis or persistent biliary tract obstruction. In conclusion, a transient rise in ERCP serum liver tests appears common following ERCP. In the absence of significant clinical signs or symptoms, these isolated serum laboratory test abnormalities should managed expectantly.

Adult↗

PubMed2003

Does a pancreatic duct stent prevent post-ERCP pancreatitis? A prospective randomized study.

BACKGROUND: Pancreatitis is the most frequent complication of ERCP. Injury to the papilla during ERCP could obstruct pancreatic duct outflow and initiate pancreatitis. A randomized prospective study was performed to evaluate the effect of pancreatic duct stent placement on the frequency and severity of post-ERCP pancreatitis in a selected group of patients. METHODS: The study group consisted of patients over 18 years of age at high risk for post-ERCP pancreatitis because of a difficult cannulation, sphincter of Oddi manometry, and/or the performance of endoscopic sphincterotomy. Patients were prospectively randomized to have a pancreatic duct stent placed or no stent upon completion of the ERCP. The endoprosthesis used was either a 5F nasopancreatic catheter or 5F, 2-cm long pancreatic stent. Study endpoints were the frequency and severity of post-ERCP pancreatitis. RESULTS: Patients undergoing pancreatic duct stent placement had a lower frequency of post-ERCP pancreatitis as compared with those in the control group (28% vs. 5%; p < 0.05). Pancreatitis tended to be less severe in patients who had pancreatic duct drainage. CONCLUSIONS: Pancreatic duct stent insertion after ERCP reduces the frequency of post-ERCP pancreatitis in patients at high risk for this complication.

Adult↗

PubMed2003

Perceptions of gastroenterology fellows regarding ERCP competency and training.

BACKGROUND: The adequacy of ERCP training in the United States may be suboptimal because many training programs do not provide fellows with the exposure to the procedures necessary to achieve competence. METHODS: A short survey questionnaire, which assesses the training program, the personal ERCP experience, the perceptions regarding training adequacy, and the post-training practice plans, was sent to all fellows graduating from gastroenterology training programs. RESULTS: Graduating fellows performed a median of 140 ERCPs and 35 sphincterotomies during training, with an associated median comfort level for independently performing sphincterotomy of 7.5 on a scale of 1 to 10. The median estimated success rate for independent free cannulation was 75%. Based on nonparametric correlation and regression analysis, 180 ERCPs would be necessary to achieve a free cannulation rate of 80% and 69 sphincterotomies to achieve a comfort level of 8 on a scale of 1 to 10. Thirty-six percent of fellows achieved the number of procedures and cannulation success determined by this study to indicate procedural competence. Sixty-four percent of fellows did not achieve procedural competence and 33% reported inadequate ERCP training. Nevertheless, 91% of fellows expected to perform unsupervised ERCP after training. CONCLUSIONS: The results of this study are consistent with those of previously published studies demonstrating that 160 to 200 ERCP procedures are necessary to achieve competence to perform ERCP. The majority of graduating fellows do not achieve an acceptable success rate during training, yet still intend to perform ERCP after training.

Attitude of Health Personnel↗

PubMed1995

Increased ERCP rate following the introduction of laparoscopic cholecystectomy.

Over the past 5 years there has been a remarkable change in the manner in which symptomatic gallstones are surgically managed. In this study we reviewed the experience of a large HMO to determine the relationship between the rate of increase of ERCP and that of cholecystectomy. All individuals enrolled in US Healthcare's HMO-PA, in the region of southeastern Pennsylvania from 1988 through 1993, were included in the analysis. Using the HMO claims database, patients who underwent an open or laparoscopic cholecystectomy during the study period were identified. We then identified those patients who had a pre- or post- operative ERCP. Over the study period, there has been a substantial increase in cholecystectomies per 1000 members-from 1.37 in 1988 to 2.16 (p < 0.0001) in 1993. In our study population there were 1261 ERCPs performed in 979 patients with an average of 1.3 ERCPs per patient during the study period. The ERCP rate per 1000 members has increased from 0.16 to 0.56 (p < 0.0001) from 1988 to 1993, at the same time that the cholecystectomy rate was substantially increasing. The correlation for the ERCP and cholecystectomy rates from 1988 to 1993 was 0.994 (p < 0.0001). Since the introduction of laparoscopic cholecystectomy in 1989-1990, many more ERCPs are now being performed. It is necessary to determine the implications related to the rapid diffusion of laparoscopic cholecystectomy, including the effect that this technology has had on other older and stable technologies such as ERCP. Our results describe the dramatic effect that laparoscopic cholecystectomy has had on the utilization of ERCPs.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed1996

Secretin-pancreozymin test (SPT) and endoscopic retrograde cholangiopancreatography (ERCP): both are necessary for diagnosing or excluding chronic pancreatitis.

Results of the SPT and the ERCP staged for their severity were compared in 202 patients. The correlation between both investigations was significant (p < 0.001); however, ERCP showed significantly more severe changes (p = 0.04). Furthermore, we found that 129 (64%) patients had parallel SPT and ERCP results, matching in all four gradings of severity. Forty-three (21%) patients had abnormal results for both SPT and ERCP, but the severity gradings did not parallel. Finally, 30 (15%) patients showed totally nonparallel results, a normal SPT and abnormal ERCP, or vice versa. Abnormal ERCP but normal SPT results were found in 23 of these 30 patients (group 1), and normal ERCP but abnormal SPT results in the seven remaining cases (group 2). In the first group, more patients had a history of acute pancreatitis compared to the second group (19 vs. one, p < 0.005). Based on medical history, laboratory and functional test results, and other morphological tests, chronic pancreatitis was diagnosed in two of 23 patients in group 1 and in all seven patients in group 2. Follow-up interviews (86 +/- 54 months) were possible in 20 of the remaining 21 patients in group 1 and showed definite chronic pancreatitis in one and probable chronic pancreatitis in another two of them, whereas in the other 17 patients no symptoms of acute pancreatitis or abdominal pain suggestive of chronic pancreatitis had occurred. In conclusion, both SPT and ERCP should be used to complement each other when chronic pancreatitis is suspected. ERCP seems to over-diagnose the disease since duct changes may only reflect scars after severe acute pancreatitis, or old age, and are not necessarily a sign of chronic pancreatitis. SPT seems to diagnose chronic pancreatitis with more reliability.

Adult↗

PubMed2005

The detection of bile duct stones in suspected biliary pancreatitis: comparison of MRCP, ERCP, and intraductal US.

OBJECTIVES: Early ERCP and endoscopic sphincterotomy for stone extraction can benefit the prognosis in patients with severe biliary pancreatitis, but are associated with complications. The ability to identify choledocholithiasis by noninvasive means in biliary pancreatitis is limited. The aim of this study was evaluation of the ability of MRCP to detect choledocholithiasis in patients with acute biliary pancreatitis. In addition, we investigated whether intraductal US (IDUS) could help manage these patients. METHODS: Thirty-two patients with suspected biliary pancreatitis were studied prospectively. MRCP was performed immediately before ERCP by separate blinded examiners within 24 h of admission. Wire-guided IDUS was performed during ERCP within 72 h of admission, regardless of the results of MRCP. Using endoscopic extraction of a stone as the reference standard, the diagnostic yield of MRCP was compared with transabdominal US, CT, ERCP, and IDUS. RESULTS: The sensitivity of US, CT, MRCP, ERCP, and IDUS for identifying choledocholithiasis was 20.0%, 40.0%, 80.0%, 90.0%, and 95.0%, respectively. The overall agreement between MRCP and ERCP was 90.6% for choledocholithiasis (kappa= 0.808, p < 0.01). The sensitivity of MRCP for detecting choledocholithiasis decreased with dilated bile ducts (bile duct diameter > 10 mm, 72.7% vs 88.9%). The combination of ERCP and IDUS improved accuracy in the diagnosis of choledocholithiasis. CONCLUSIONS: MRCP can be used to select patients with biliary pancreatitis who require ERCP. IDUS may be applied in the management of biliary pancreatitis if ERCP is performed.

Adult↗

PubMed2002

Musculoskeletal injuries among ERCP endoscopists in Canada.

BACKGROUND: There are few reports in the literature describing musculoskeletal complaints among endoscopists, and none are specific to those who perform endoscopic retrograde cholangiopancreatography (ERCP). PURPOSE: To examine the current practices of ERCP endoscopists and the prevalence of musculoskeletal injuries. METHODS: A self-report survey was sent to physicians practising ERCP across Canada identified through a pre-existing database. A second mailing was sent six weeks later to those who did not respond to the first mailing. RESULTS: Of 162 surveys sent, 122 responses were received, with five respondents indicating that they no longer performed ERCP and three declining to participate. Of the 114 participants, 67% reported at least one musculoskeletal complaint, and 58% reported two or more complaints. Seventy-four per cent attributed their symptoms to endoscopy and/or ERCP, and 79% reported that their condition was aggravated by performing ERCP. The most frequently reported pain symptoms were back pain (57%), neck pain (46%) and hand pain (33%), which are all consistent with the physical risks involved in performing ERCP. Only 51% reported taking regular breaks, and only 25% reported having fluoroscopy tables with adjustable heights. The room designs of the respondents' ERCP facilities were analyzed for ergonomic considerations: 67% had poor ergonomics and 33% had good ergonomics. Sixty-four per cent reported that they were interested in learning preventive strategies. CONCLUSIONS: Physicians who perform ERCP develop musculoskeletal injuries and are interested in learning about risk factor modification.

Canada↗

PubMed2003

Preventing post-ERCP pancreatitis: where are we?

Acute pancreatitis still represents the most common complication after procedures involving Vater's papilla; the reported incidence of this complication varies from less than 1% up to 40%. Attempts at preventing post-ERCP pancreatitis have been carried out using technical measures, pharmacological prophylaxis, or patient selection. Balloon sphincter of Oddi dilatation, difficult papillary cannulation, pancreatic sphincterotomy and multiple pancreatic duct injections have been found to be risk factors for postprocedure pancreatitis. Therefore, technique-related prevention of post-ERCP pancreatitis includes careful pancreatic duct injection, avoiding cannulation trauma, and maintaining adequate pancreatic drainage after the ERCP procedure. Pancreatic stent placement has been shown to be the most effective technique-related prevention of postprocedure pancreatitis. Apart from technique-related risk factors, operator experience also seems to be a potential risk-factor for post-ERCP/ES complications. The experience of the endoscopist rather than other patient- or technique-related conditions could probably constitute the major risk factor for postprocedure pancreatitis. Pharmacological prevention of pancreatitis after ERCP or sphincterotomy has been the topic of several investigations in recent years but still remains a debated question. Pharmacological prevention has been mainly aimed at either reducing the amount of intrapancreatic enzymes, preventing intra-cellular co-localization of enzymes and lysosomal hydrolases or blocking some steps of the enzyme-activated inflammatory cascade. Somatostatin, octreotide, gabexate mesilate and, more recently, recombinant interleukin-10 have been the most investigated drugs. Somatostatin, gabexate mesilate and recombinant interleukin-10, but not octreotide, have been found to be able to prevent post-ERCP pancreatitis in non-selected cases; however, a strategy of routine pharmacological prophylaxis in all patients is not likely to be cost-effective. A strategy of pharmacological prevention only in high-risk cases is cost-effective, but, up to now, only recombinant interleukin-10 has been proven effective. The "on demand" postprocedure treatment should also be of paramount importance, but no data are at present available regarding the potential efficacy of some drugs; on the basis of the mechanism of action, we can argue that recombinant interleukin-10 could be the only drug candidate for such a strategy. Post-ERCP pancreatitis can also be prevented by patient selection. Patient-related risk factors are now well-known, so an increased risk of developing pancreatitis is predictable "a priori" in these subjects, independently of the type of endoscopic procedure performed. Furthermore, the risk of pancreatitis escalates when multiple risk factors occur in the same patient or some technique-related risk factor comes up during the procedure. In these patients diagnostic ERCP should be avoided in routine practice and magnetic resonance cholangio-pancreatography should be used as the first diagnostic step. When either diagnostic or therapeutic ERCP is indicated, these high-risk patients should be informed about their own specific risk of postprocedure pancreatitis.

Animals↗

PubMedDate not supplied

ERCP in orthotopic liver transplanted patients.

BACKGROUND/AIMS: Biliary complications after orthotopic liver transplantation (OLT) are still common. The aim of the study was to assess the effectiveness of ERCP as a diagnostic and treatment tool in the management of biliary tract OLT complications. METHODOLOGY: The diagnostic and treatment effectiveness of ERCP in the management of biliary tract OLT complication from 1/1995 to 12/2001 was reviewed. RESULTS: 24/251 (9.6%) OLT patients presented biliary complications. These patients underwent a total of 31 ERCP (seven patients received two ERCP). The ERCP indication was cholestasis in 25 (80.6%). The success rate of these 31 ERCPs was 87%. In the 25 ERCPs indicated in patients with cholestasis, the procedure revealed strictures of the biliary anastomosis in 3, hepatic hilum strictures in 5, SOD in 4, lithiasis in 7 and sclerosing cholangitis in one. The final diagnosis of three patients with normal biliary tract was intrahepatic cholestasis. In three of the four patients with biliary leaks the ERCP's confirmed the diagnosis. The final treatment efficacy was 100% (7/7 patients), 50% (2/4 p.), 0% (0/3 p.), 75% (3/4 p.) and 100% (4/4 p.) for patients with biliary stones, strictures of the hilum, anastomotic strictures, biliary leaks and SOD, respectively. In the acute pancreatitis and in the PSC endoscopic treatment was not indicated. There were two mild cases of pancreatitis. CONCLUSIONS: Because of its availability, diagnostic accuracy, treatment efficacy and safety, ERCP should be used as the first-line procedure for treatment of biliary tract complications after OLT.

Biliary Tract Diseases↗