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PubMedDate not supplied

Prospective assessment of the role of antibiotic prophylaxis in ERCP.

BACKGROUND/AIMS: Despite the existence of published recommendations, various studies of antibiotic prophylaxis have reached conflicting conclusions, and controversy exists regarding the role of antibiotic prophylaxis in ERCP. The aim of this study was to analyze the efficacy of the intramuscular administration of clindamicine and gentamicine before ERCP. METHODOLOGY: Sixty-one consecutive patients referred for ERCP were prospectively randomized to receive either clindamicine 600mg and gentamicine 80mg, both intramuscularly one hour before the ERCP (group I; 31 patients) or not (group II; 30 patients). Two blood samples were obtained from every patient (just before endoscopy and within 5 minutes of withdrawal of the endoscope) and were incubated for 7 days and examined daily for growth of bacteria. Patients were closely monitored for 7 days after endoscopy to detect the development of infectious complications. RESULTS: Only 7 cultures from 7 patients were positive. Four were obtained post-ERCP (two patients in group I and two in group II) and the remaining three before endoscopy. The post-ERCP isolated bacteria were: Streptococcus mitis, Peptoestreptococcus anaerobious, Moraxella spp and Escherichia coli. Two patients, one from each group, developed post-ERCP cholangitis that were solved with medical treatment. CONCLUSIONS: Our findings indicate that ERCP induce bacteremia in a small group of patients and suggest that prophylactic administration of clindamicine plus gentamicine does not reduce the incidence of bacteremia and cholangitis, and do not support the routine use of prophylactic antibiotics prior to ERCP.

Aged↗
PubMed1995

Antibiotic prophylaxis for ERCP: a randomized clinical trial comparing ciprofloxacin and cefuroxime in 200 patients at high risk of cholangitis.

OBJECTIVE: To compare the efficacy and safety of oral ciprofloxacin and intravenous cefuroxime in patients at high risk of cholangitis after endoscopic retrograde cholangiopancreatography (ERCP). DESIGN: Prospective, randomized study. SETTING: A primary and tertiary referral centre. PATIENTS: A series of 232 consecutive patients who either had radiological evidence of biliary obstruction or were aged over 70 years were randomly assigned to receive either oral ciprofloxacin or intravenous cefuroxime before and after ERCP. Two-hundred and nine patients finished the study, with 23 being excluded because of withdrawal of consent or incomplete ERCP. INTERVENTIONS: Patients underwent ERCP: blood samples were taken for culture, full blood count and biochemistry before and after the procedure. Clinical follow-up was carried out 7 and 42 days after ERCP. MAIN OUTCOME MEASURES: Clinical, bacteriological or biochemical evidence of cholangitis, septicaemia or adverse drug reactions, and the cost of both protocols. RESULTS: Follow-up was recorded in all 209 patients who completed the study. By 42 days after ERCP, three patients had died (cholangiocancer, pancreatic cancer and renal failure). Cholangitis was diagnosed in one patient from each of the two trial groups. Blood cultures from the patient on ciprofloxacin gave negative results, but a post-ERCP blood sample from the patient on cefuroxime grew Pseudomonas aeruginosa, which was sensitive to ciprofloxacin. There were no serious side-effects in either study group, but two patients assigned to ciprofloxacin became too nauseous to take the medication. The cost of the cefuroxime protocol was l7.56 pounds per patient, compared with 4.76 pounds per patient for the ciprofloxacin protocol. CONCLUSION: A pre- and post-ERCP oral ciprofloxacin regime is safe and provides effective prophylaxis against ERCP-induced cholangitis and septicaemia in high-risk patients. It is also more economical than a regime of intravenous cefuroxime and does not require nursing staff with training in intravenous techniques.

Adult↗
PubMedDate not supplied

Difference of CBD width on US vs. ERCP.

PURPOSE: To investigate the relationship between US and ERCP in the measurement of common bile duct (CBD) width after application of Compound and Harmonic imaging on ultrasound. METHODS: We prospectively evaluated the CBD width as measured on endoscopic retrograde cholangiopancreatography (ERCP) and ultrasonography (US), applying Compound and Harmonic US techniques, on 100 patients. Furthermore, we retrospectively re-examined US and ERCP images of 48 patients who underwent ERCP and US during the same hospitalization period. RESULTS: The average difference in measurements by US compared to ERCP was 2.3 mm (P < 0.01) in the retrospective and 1.9 mm in the prospective study (P < 0.001). The average difference in measurements between US and ERCP in post-cholecystectomy patients was 4.0 mm in the retrospective study (10 patients), and 3.8 in the prospective study (25 patients). The difference between the measurements on both examinations decreased with increasing CBD width. There was a good correlation between ERCP and US measurements of CBD width (r = 0.73 for all patients and r = 0.88 for patients with intact gallbladder, P < 0.001). CONCLUSIONS: There is a gap between measurement of CBD width on US and ERCP of about 2 mm. The application of Compound and Harmonic techniques in the prospective study probably enabled a more accurate sonographic measurement.

Adult↗
PubMed2006

Efficacy and safety of therapeutic ERCP in patients 90 years of age and older.

BACKGROUND: Therapeutic ERCP has an established role in the treatment of pancreatobiliary diseases, but little information is available on the outcomes of this procedure in patients 90 years of age and older. OBJECTIVE: To evaluate the efficacy and the safety of therapeutic ERCP in an extremely elderly cohort. DESIGN: Retrospective study. SETTING: Two Greek cohorts of patients > or =90 and 70 to 89 years of age who underwent therapeutic ERCPs. PATIENTS: Sixty-three patients aged 90 years and older (group A) and 350 patients 70 to 89 years of age (group B). INTERVENTIONS: A retrospective review of therapeutic ERCPs was performed between 1994 and 2000 on both groups, identified by using a database linked to the endoscopy reporting system in our department. MAIN OUTCOME MEASUREMENTS: Efficacy and safety of therapeutic ERCPs. Concomitant diseases, complications, and outcome were also evaluated. RESULTS: Group A patients had a higher incidence of concomitant diseases than group B patients (100% vs 72.8%, respectively). The rate of post-ERCP early complications was low in both groups: 6.3% in group A and 8.4% in group B. The frequency of ERCP-related mortality was 1.6% (1 patient) in group A and 0.6% (2 patients) in group B. Group A required endoscopic sessions for stone clearance and mechanical lithotripsy more frequently than group B (20.6% vs 11.4% and 17.5% vs 10.3%, respectively). No patient in either group experienced subjective deterioration in mental status, and the 3 patients who died required ventilatory support before death. Late complications occurred in 2.3% of patients in group B. CONCLUSIONS: Therapeutic ERCP is safe and effective for the treatment of pancreatobiliary diseases in extremely elderly patients, and advanced age per se should not impinge on decisions relating to its use.

Age Factors↗
PubMed2004

Sphincter of Oddi manometry does not predispose to post-ERCP acute pancreatitis.

BACKGROUND: Sphincter of Oddi manometry is helpful in selecting patients with sphincter of Oddi dysfunction who will respond to sphincterotomy. However, studies have shown that sphincter of Oddi manometry is associated with a high risk of post-procedure pancreatitis. The primary objective of this study was to evaluate the safety of sphincter of Oddi manometry in patients with sphincter of 2Oddi dysfunction. The secondary objective was to determine the risk factors for post-ERCP pancreatitis in patients with sphincter of Oddi dysfunction. METHODS: Data were collected retrospectively for 268 patients who had elective ERCP performed at 3 tertiary care medical centers between 1996 and 2000. Consecutive patients with suspected sphincter of Oddi dysfunction formed the case group; the control group consisted of patients with bile duct stone. The case group was further subclassified into group A, patients who underwent sphincter of Oddi manometry followed by immediate ERCP, and group B, patients who had ERCP without manometry. The rate of post-ERCP acute pancreatitis was compared between case and control groups. RESULTS: Twenty-seven percent of patients in the case group with suspected sphincter of Oddi dysfunction developed acute pancreatitis compared with 3.2% of patients in the control group with bile duct stone (p<0.001). There was no significant difference in the rate of acute pancreatitis in patients with sphincter of Oddi dysfunction who underwent sphincter of Oddi manometry and ERCP compared with patients with sphincter of Oddi dysfunction who had ERCP without sphincter of Oddi manometry (odds ratio 0.72: 95% CI[0.08, 9.2]). Multivariable logistic regression analysis showed that biliary sphincterotomy (p=0.006) and pancreatography (p=0.03) were independent predictors of acute pancreatitis. CONCLUSIONS: Patients with suspected sphincter of Oddi dysfunction are at higher risk of post-ERCP acute pancreatitis. Sphincter of Oddi manometry by itself does not appear to predispose to this complication.

Acute Disease↗
PubMed1996

Outpatient therapeutic ERCP: a series of 262 consecutive cases.

BACKGROUND: Because of possible complications, it has been common practice to admit most if not all patients undergoing therapeutic ERCP. Therefore, little descriptive data exist on the safety of outpatient therapeutic ERCP. METHODS: We assessed 262 consecutive ERCPs in 209 patients undergoing outpatient therapeutic ERCP over a 5-year period, with particular attention to the development of complications. All outpatient endoscopic sphincterotomies and stent placements performed over a 5-year period were prospectively entered into an ongoing data base that was used for the analysis. In addition, hospital and office records for all patients were retrospectively reviewed, including a 30 to 45 day follow-up in a private office setting. RESULTS: Suspected or documented choledocholithiasis was the most common indication for ERCP and was present in 132 (50%), followed by malignant obstruction in 77 (29%), type I sphincter of Oddi dysfunction (on the basis of symptoms, liver test abnormalities, and bile duct dilatation) in 36 (14%), chronic pancreatitis in 10 (3.8%), HIV cholangiopathy in 4 (1.5%), and other conditions in 3 (1.1%). Overall, 181 patients (69%) underwent a sphincterotomy. The 30-day post-ERCP complication rate was 5.7% (95% CI: 3.2% to 9.3%), occurring in 15 of 262 cases. Complications necessitating hospitalization developed in 9 of the 262 ERCPs for a rate of 3.4% (95% CI: 1.6% to 6.4%). The mean duration of hospital stay among patients admitted for a complication was 2.7 +/- 1.8 days (range, 1 to 7 days). All patients were discharged without permanent sequelae. No 30-day procedure-related fatalities were reported. CONCLUSION: In this selected series of 262 consecutive cases, endoscopic sphincterotomy and stent placement were safely performed in an ambulatory setting. Prior to recommending a generalized change in existing practice, however, this finding requires validation with larger series of cases, including the performance of other outpatient therapeutic ERCP techniques.

Adolescent↗
PubMed1997

Therapeutic ERCP in outpatients.

BACKGROUND: We evaluated the safety of outpatient therapeutic ERCP since most complications are apparent within a few hours. METHODS: We reviewed 190 patients undergoing planned outpatient therapeutic ERCP from a cohort of 409 consecutive therapeutic ERCP procedures. Patients were selected for outpatient therapeutic ERCP based on relative good health and overnight accommodation near our institution. RESULTS: Outpatient therapeutic ERCPs included plastic biliary stent insertion (n = 71), biliary sphincterotomy (45), pancreatic stent insertion (28), Wallstent insertion (19), biliary balloon or catheter dilation (10), pancreatic balloon or catheter dilation (8), biliary stone extraction with prior sphincterotomy (7), pancreatic sphincterotomy (5), and duodenal ampullectomy (1). Admission was necessary in 31 (16%) because of complications in 22 (11.6%) and observation of post-ERCP symptoms in 9. Twenty-six (13%) of these patients were admitted directly from the endoscopy unit recovery room and 5 (3%) from home after a median interval of 24 hours following discharge (range 5 to 48 hours). Reasons for admission were pancreatitis in 17, hemorrhage in 3, cholangitis in 3, endoscopic but not clinical hemorrhage in 4, pain in 4, and vomiting in 1. Of the patients who were admitted from home, 3 had pancreatitis (following sphincterotomy in 1, pancreatic stenting in 1, pancreatic balloon dilation in 1) and 2 had hemorrhage (postsphincterotomy in 1 and ampullectomy in 1). In comparison, of the 219 consecutive inpatients undergoing therapeutic ERCP, 28 (13%) developed complications with 1 (0.4%) death. CONCLUSIONS: A policy of selective outpatient therapeutic ERCP, with admission reserved for those with established or suspected complication, appears to be safe and reduces health care costs.

Biliary Tract Diseases↗
PubMed1999

Prophylactic effect of somatostatin on post-ERCP pancreatitis: a randomized controlled trial.

BACKGROUND: Somatostatin is a potent inhibitor of pancreatic secretion and has been studied for its prophylactic effect on post-ERCP pancreatitis. However, results of previous trials have been inconclusive. METHODS: A prospective double-blind controlled study was performed to evaluate the effectiveness of somatostatin in preventing post-ERCP pancreatitis. Post-ERCP enzyme elevation, abdominal pain and pancreatitis were evaluated and compared between 109 patients randomized to receive somatostatin infusion and 111 patients randomized to receive normal saline infusion (placebo); both started 30 minutes before ERCP and continued for 12 hours. RESULTS: Post-ERCP elevation of serum amylase and lipase levels at 6 and 24 hours after ERCP was less frequent in the group given somatostatin but not statistically significant. There was a tendency toward lower mean serum amylase and lipase levels at 24 hours in patients given somatostatin, although the difference was not statistically significant either. Eight patients given somatostatin (7%) and 18 patients given placebo (16%) had significant abdominal pain after ERCP requiring analgesia (p = 0.04). The frequency of clinical pancreatitis was significantly lower in patients given somatostatin (3%) than in those given placebo (10%) (p = 0.03). CONCLUSIONS: Prophylactic treatment with somatostatin reduced the frequency of post-ERCP pancreatitis.

Aged↗
PubMed2004

Improved stent characteristics for prophylaxis of post-ERCP pancreatitis.

BACKGROUND & AIMS: Pancreatic stenting is an effective method to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in high-risk patients. This retrospective study evaluated the impact of modified stent characteristics on the rate of post-ERCP pancreatitis, spontaneous stent dislodgment, and stent-related sequelae. METHODS: A total of 2283 patients underwent 2447 ERCPs over a 6-year period with placement of 3-4F diameter, unflanged pancreatic stents. The indication for stenting was pancreatitis prophylaxis predominantly in suspected sphincter of Oddi dysfunction (SOD), pancreas divisum therapy, and precut sphincterotomy. An abdominal radiograph was obtained 10-14 days later to assess spontaneous stent passage. Post-ERCP pancreatitis was defined according to established criteria. A total of 479 patients underwent repeat ERCPs after an initial ERCP with pancreatic stent placement. The prestenting pancreatogram was then compared with follow-up studies. RESULTS: The pancreatitis rate with 3F, 4F, 5F, and 6F stents was 7.5%, 10.6%, 9.8%, and 14.6%, respectively (3F vs. 4F, 5F, 6F: P = 0.047). Spontaneous stent dislodgment was 86%, 73%, 67%, and 65%, respectively (3F vs. 4F, 5F, 6F: P < 0.0001). The frequency of ductal changes was 24% in patients with 3-4F stents compared with 80% with 5-6F stents. Ductal perforation from the stents occurred in 3 patients (0.1%). CONCLUSIONS: Small diameter (3-4F), unflanged pancreatic stents are more effective than the traditionally used stents (5-6F) in preventing post-ERCP pancreatitis. Stent-induced ductal changes and the need for endoscopic removal are also significantly less with 3-4F stents. The 3F stent appears to be superior in all aspects studied. Additional studies are needed to define the ideal method to eliminate post-ERCP pancreatitis.

Acute Disease↗
PubMed1998

Diagnostic relevance of interleukin pattern, acute-phase proteins, and procalcitonin in early phase of post-ERCP pancreatitis.

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis has been suggested as a model for acute pancreatitis (AP), which allows evaluation of early alterations in the time course of the disease. The influence of the clinical course on procalcitonin (PCT), serum amyloid A (SAA), and several proinflammatory and inhibitory cytokines was evaluated in patients with AP following ERCP. Blood samples were prospectively collected from patients undergoing ERCP. The incidence of ERCP-induced pancreatic damage, defined as abdominal complaints, a threefold increase of serum lipase, and elevation of CRP from <10 to >20 mg/liter was 12.8% (12/94). Only mild clinical courses of acute pancreatitis were observed. PCT significantly increased in subjects with post-ERCP pancreatitis after 24 hr. However, PCT levels did not exceed 0.5 ng/ml in any patient. Interleukin-1 receptor antagonist (IL-1RA) began to differ from baseline 2 hr after ERCP, followed by interleukin-6 (IL-6, 6 hr), solubilized tumor necrosis factor-alpha receptor II (sTNF-alphaRII, 24 hr) and SAA (24 hr). Interleukin 10 (IL-10) showed marked interindividual variations with no obvious peak. Among all parameters evaluated, only peak values of IL-6 and IL-10 showed significant correlations with the reported pain score (r2 = 0.62/0.78), degree of ampullar irritation (r2 = NS/0.87), and the duration of ERCP (r2 = 0.58/0.76). No correlation was found with the volume of the injected contrast agent. We conclude that IL-10 and IL-6 appear to be useful to monitor patients after ERCP. The absence of any PCT elevation in the present study is in accordance with the clinical course of the patients who suffered from mild pancreatic damage without systemic or infectious complications.

Acute Disease↗
PubMed2000

Indications for preoperative ERCP.

The indication for preoperative ERCP is about to be changed after the introduction of MRCP. There are however advantages of ERCP especially if the option of a therapeutic procedure, e.g., extraction of stones or placing of stents is considered. Besides ERCP prior laparoscopic cholecystectomy which is discussed elsewhere in this journal, indications for preoperative ERCP consist in patients after concussion trauma and hyperamylasemia as long as CT or MRI are not able to show pancreatic duct rupture. In this context the possibility of a stent placement is a major advantage of ERCP, since surgery may be avoided by this procedure. Preoperative ERCP may be performed in patients with chronic pancreatitis and refractory pain with the option of endoscopic therapy in cases with limited findings (less than 3 stones located in the pancreatic head). Furthermore, ERCP plays an important role in the preoperative differentiation between cystic neoplasms and pancreatic pseudocysts. Pseudocysts may be cured by endoscopical placement of transpapillary, transgastric or transduodenal stents. But so far no prospective studies have compared surgical with endoscopical drainage of pseudocysts. Finally, ERCP in the primary diagnosis of pancreatic carcinoma plays only a limited role and should be performed only if non-invasive methods are not able to clarify the situation.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1999

Small-bowel perforations related to endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy.

BACKGROUND AND STUDY AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is one of the mainstays in the diagnosis and treatment of hepatobiliary and pancreatic diseases, and is also increasingly used for patients with previous Billroth II gastrectomy. The aim of this study was to review our experience of ERCP in patients with Billroth II gastrectomy, and the complications associated with this procedure. PATIENTS AND METHODS: The records of 110 patients with Billroth II gastrectomy, treated between January 1993 and December 1997, were received retrospectively. Details noted included indications for ERCP, therapeutic interventions, causes of failure, and complications. RESULTS: A total of 110 patients underwent ERCP; the total number of ERCP attempts was 185. The major indications for ERCP were cholangitis (31%), common bile duct stones (22%), and jaundice (15%). The endoscope was successfully passed up to the papilla in 134 examinations (71%), and selective cannulation was successful in 122 of these (66%). There were 63 (34%) failed ERCP attempts. Causes of failure were: difficulty in entering the afferent loop (n = 19, 10%), failure to enter the duodenum (n = 23, 12%), endoscope-related bowel perforation (n = 9, 5%), and failed cannulation (n = 10, 6%). The other two failures were caused by desaturation in the patient, and inability to distend the duodenum. The major complication of the procedure was perforation, which occurred in 11 examinations (6%). Of these perforations, nine occurred in the small bowel while the endoscope was being manipulated through the afferent loop; these patients required laparotomy. Two patients had retroduodenal perforations, one occurring after sphincterotomy and one after cannulation. Both patients were successfully managed conservatively. Three patients suffered bleeding after sphincterotomy (3/185 procedures, 1.6%), and one patient developed acute pancreatitis. These were managed conservatively. The overall complication rate was 8%. There were two deaths among the patients with small-bowel perforations, and consequently an overall mortality rate of 1% (2/185 procedures). CONCLUSIONS: Most complications of ERCP in patients with previous Billroth II gastrectomy were caused by bowel perforation while the endoscope was being manipulated through the afferent limb. Such perforations are intraperitoneal and require surgical intervention.

Adult↗
PubMed1998

Predictors of post-ERCP complications in patients with suspected choledocholithiasis.

BACKGROUND AND STUDY AIMS: Determinants of complications after endoscopic retrograde cholangiopancreatography (ERCP) have not yet been completely characterized. PATIENTS AND METHODS: Data were collected from an endoscopic database. Univariate analysis and multivariate logistic regression analysis were used to generate the best model of independent predictors of post-ERCP pancreatitis. RESULTS: The database included 1239 ERCP examinations carried out to investigate suspected choledocholithiasis over a five-year period. From these, 45 patients who developed post-ERCP complications were compared to a random sample of 486 patients who had undergone an uncomplicated ERCP for suspected choledocholithiasis. Univariate analysis demonstrated significant differences between the two patient groups for the following factors: age, using a cut-off point of 59 years (27% vs. 51%, P = 0.002), pancreatic channel opacification (73% vs. 58%, P = 0.05), and absence of common bile duct stones (41% vs. 24%, P = 0.03). Using multivariate logistic regression, the best model for predicting post-ERCP pancreatitis in patients undergoing sphincterotomy included age under 59 years (P = 0.04), and absence of a common bile duct stone (P = 0.004). The model yielded probabilities of developing post-sphincterotomy pancreatitis that ranged from 2.8% if no predictor was present, to 27% when both predictors were present. Among patients in whom a sphincterotomy was not performed, the only significant independent predictor found was pancreatic channel opacification (P = 0.05). CONCLUSION: Age under 59 years, pancreatic channel opacification, and an absence of common bile duct stones at ERCP are all independent predictors of post-ERCP pancreatitis.

Adolescent↗
PubMed2000

Success of ERCP at a referral center after a previously unsuccessful attempt.

BACKGROUND: The diagnostic and therapeutic success of endoscopic retrograde cholangiopancreatography (ERCP) depends on a number of factors. When an attempt at ERCP fails, the physician must decide whether to repeat the procedure, rely on another imaging procedure (noninvasive or invasive), or refer to another endoscopist/center. Our aim in this prospective study was to determine the role of a second attempt at ERCP at a referral ERCP center. METHODS: Five hundred sixty-two patients were referred for ERCP after having undergone a previous unsuccessful attempt to visualize the clinically relevant duct(s). RESULTS: The overall success in visualizing the desired duct was 96.4% (542 of 562). Advanced techniques for cannulation were used in 41% (229 of 562). Anatomic abnormalities possibly contributing to the previous lack of success were present in 27% of cases. ERCP with or without manometry identified a cause or potential cause for the signs and symptoms in 86% of patients. Sixty complications occurred in 57 patients (10.1%). ERCP was unsuccessful in 20 patients (3.6%). CONCLUSIONS: The cannulation success rate and diagnostic yield of further ERCP with an acceptable complication rate warrant consideration of referral to centers with available resources and expertise.

Biliary Tract Diseases↗
PubMed2001

Serum lipase, C-reactive protein, and interleukin-6 levels in ERCP-induced pancreatitis.

BACKGROUND: C-reactive protein (CRP) and interleukin-6 (IL-6) are elevated in acute pancreatitis. Limited studies have evaluated their role in ERCP-induced pancreatitis. The aim of this study was to assess the role of serum lipase, CRP, and IL-6 in ERCP-induced pancreatitis. METHODS: Eighty-five patients (62 women, 23 men; mean age 43 years; range 16-85 years) who underwent ERCP were entered in a prospective trial. ERCP-induced pancreatitis was classified as mild, moderate, or severe. Serum levels of lipase, CRP, and IL-6 were measured before ERCP and at 12 to 24 hours and 36 to 48 hours after ERCP. RESULTS: Mild, moderate, and severe pancreatitis occurred, respectively, in 9, 7, and 4 patients after ERCP. There were significant differences in levels of CRP and IL-6 but not lipase for patients with mild versus moderate and moderate versus severe pancreatitis. The mean CRP levels (mg/dL) at 12 to 24 hours were 0.98 +/- 0.24 in mild pancreatitis, 3.89 +/- 0.32 in moderate pancreatitis, and 12.0 +/- 1.60 in severe pancreatitis. The levels, respectively, at 36 to 48 hours were 1.60 +/- 0.31, 7.60 +/- 0.74, and 25.0 +/- 2.9. The mean IL-6 levels (pg/mL) at 12 to 24 hours were 16.6 +/- 2.06 in mild pancreatitis, 73.0 +/- 15.60 in moderate pancreatitis, and 235.5 +/- 26.31 in severe pancreatitis. The levels at 36 to 48 hours were, respectively, 18.92 +/- 3.28, 100.17 +/- 11.56, and 438.2 +/- 71.50. CONCLUSIONS: Serum CRP and IL-6 levels may be useful early markers for predicting the severity of ERCP-induced pancreatitis.

Acute Disease↗
PubMed2002

Mechanism of pancreatitis caused by ERCP.

BACKGROUND: Acute pancreatitis can develop after either ERCP or endoscopic sphincterotomy (ES). The pathogenesis of this complication remains poorly understood. METHODS: The frequency and severity of acute pancreatitis were retrospectively evaluated after 17,602 ERCP procedures and 3003 ES procedures. Pancreatitis was diagnosed and evaluated according to the scoring system of Ranson and criteria developed in Japan. RESULTS: Pancreatitis developed after 15 (0.09%) of 17,602 ERCP procedures and 13 (0.43%) of 3003 ES procedures (p = 0.0001, chi-square). The severity of pancreatitis (Ranson score) was less than 3 in 10 cases of ERCP-induced pancreatitis and from 3 to 5 in 5 cases. One (7%) of the 15 patients with ERCP-related pancreatitis died. All 13 patients with ES-induced pancreatitis had a Ranson score of less than 3; none died (p = 0.04, Fisher exact test). The ERCP pancreatitis score (Japanese criteria) beyond 48 hours after the onset of pancreatitis increased in 5 (33%) of the 15 patients with ERCP-induced pancreatitis; the score did not increase in any of the 13 patients with ES-induced pancreatitis (p = 0.04, Fisher exact test). CONCLUSIONS: Although the frequency of ES-induced pancreatitis is significantly higher than that of post-ERCP pancreatitis, the frequency of severe pancreatitis within 48 hours and worsening of pancreatitis after 48 hours is significantly lower with ES-induced pancreatitis. Our hypothesis is that the lowering of pancreatic intraductal pressure after ES mitigates the severity of postprocedure pancreatitis.

Acute Disease↗
PubMed1997

ERCP-induced acute necrotizing pancreatitis: is it a more severe disease?

Acute necrotizing pancreatitis (ANP) is an uncommon but serious complication of endoscopic retrograde cholangiopancreatography (ERCP). This study compares the severity, clinical course, and long-term outcome of ERCP-induced ANP with ANP induced by other causes. A review of 72 consecutive patients with ANP treated surgically at the Mayo Clinic identified ERCP as the cause in 6 patients (8%). Compared to the remaining 66 patients, the post-ERCP group had higher APACHE II scores on admission (mean, 13 vs. 10) and more extensive pancreatic necrosis (mean, 55 vs. 47%). The post-ERCP group had a higher rate of infected necrosis (100 vs. 75%) and required earlier necrosectomy after the onset of pancreatitis (9 vs. 13 days). The rate of postoperative pancreatic and enteric fistulae was also higher (50 vs. 33%). Although the mortality rate in the post-ERCP group was lower (17 vs. 29%), they were significantly younger (50 vs. 62 years; p = 0.02) and all the survivors had residual long-term morbidity. ANP is more severe when ERCP-induced; infection introduced during the ERCP may, in part, account for this severity.

Adult↗
PubMed2001

Evaluation of a rapid urine amylase test using post-ERCP hyperamylasemia as a model.

OBJECTIVE: The initial diagnosis of acute pancreatitis is often based on clinical criteria together with elevations of serum amylase and lipase. A reliable bedside urine test could facilitate the early diagnosis of pancreatitis. We evaluated a rapid urine amylase test (Rapignost) by using post-ERCP hyperamylasemia as a human model of acute development of hyperamylasemia suggestive of pancreatitis. METHODS: Seventy-five patients undergoing ERCP were prospectively evaluated. Patients with renal insufficiency, hyperlipidemia, or hyperglycemia were excluded. Before ERCP, patients had serum amylase and lipase measured, and urine amylase tested with the Rapignost test strip. At 4 and 16-24 h post-ERCP, a serum and urine (test strip) amylase were measured again; the adequacy of urine collection was verified by measuring a 2-h creatinine clearance. Patients were clinically assessed for the development of clinical pancreatitis. The concordance of the strip result with post-ERCP hyperamylasemia was assessed. RESULTS: The sensitivity of the test strip for the detection of hyperamylasemia was greatest at 16-24 h post-ERCP (78%). Specificity was uniformally high (100% specificity at 16-24 h post-procedure). The test strip was positive in all cases of clinical pancreatitis. Of three cases of clinically evident ERCP-induced pancreatitis, only one was urine test strip positive by 4 h post-procedure. CONCLUSIONS: Using post-ERCP hyperamylasemia as a model, the Rapignost rapid urine amylase test strip was only marginally sensitive but highly specific for hyperamylasemia. The urine test strip was positive in all cases of clinical pancreatitis and may be a useful bedside test for the diagnosis of acute pancreatitis.

Adolescent↗