Safety and Efficacy of Endoscopic Sphincterotomy and Bile Duct Clearance in Patients with Acute Cholangitis Due to the Common Bile Duct Stones

Abstract

Safety and Efficacy of Endoscopic Sphincterotomy and Bile Duct Clearance in Patients with Acute Cholangitis Due to the Common Bile Duct Stones Neven Ljubicic, Luka Rotkvic Background: It has been shown that urgent endoscopic drainage is an effective treatment for acute cholangitis and is superior to surgical drainage with a better clinical outcome Because of the risk of post-sphincterotomy bleeding in these patients many endoscopists have advocated endoscopic drainage by using nasobiliary catheter or an indwelling stent without sphincterotomy. The aim of this study was to analyze safety and efficacy of endoscopic sphincterotomy (ES) and urgent stone extraction in patients with acute cholangitis due to the common bile duct stones.Methods: Between January andDecember 2002, one hundred and eleven patients with clinical jaundice and common bile duct stones were enrolled to an ES and urgent stone extraction. ES has been performed in a standard manner, always using the guide-wire. In patients with cholangitis vigorous washing of the common bile duct has been performed after removal of the stones. Forty-six patients fulfilled criteria for acute cholangitis. Prior to the ES all patients received intravenously ciprofloxacin for at least 24 hours. Results: ES has been performed successfully in 102 (92%) patients. Complete duct clearance has been achieved in 90% of patients without cholangitis and in 93% of patients with cholangitis (not significant). Complications occurred in 12% of patients without and in 16% of those with acute cholangitis (Table). In patients with post-sphincterotomy bleeding blood transfusion was not required. The median lengths of time for resolution of jaundice in patients with and without cholangitis were similar. Significant coagulopathy has been observed in two (4.5%) patients with acute cholangitis. In those patients there were no bleeding occurred after ES. Conclusions: ES and bile duct clearance is very effective and safe method even in the patients with acute cholangitis. Mild bleeding was the most common postsphincterotomy complication not required blood transfusion even in the presence of coagulopathy. *T1500 MRCP Vs ERCP: A Comparative Study in Diagnosis of Common Bile Duct Stones Luigi T. Familiari Background: Because it is a noninvasive method, without complications, the magnetic resonance cholangiography (MRCP) is going to reliably replace ERCP in the diagnosis of pancreato-biliary diseases. Althoughmany studies documented a high sensitivity and specificity of MRCP, its ability in detecting microlithiasis ( 270; I-GT > 50 UI/l). Patients underwent upper abdominal ultrasonography (US), thenMRCP and, within 72 h, diagnostic and/or operative ERCP. All patients signed an informed consent. The statistical analysis was based on the report of true positives and negatives, false positives and negatives. Results:106/123 patients completed the study. MRCP diagnosed lithiasis of CBD in 73; did not document stones in 33. ERCP confirmed the presence of lithiasis in 66/73 pts who were submitted to ES. Seven were not found to have stones after ES.Among 33 negative pts, ERCPdocumented stones in 9: in 4 only after ES (it was performed according to clinico-biochemical data and to CBD dilation, though ERCP did not identify stones). The stones were 2-3 mm. In 24/33 patients negative at MRCP, ERCP confirmed this response:10/24 were submitted to ES. ES was not performed in 14/24 subjects, without CBD dilation and/or cholestasis. After a 27.8 months follow-up (range: 4-54), 8/14 remained asymptomatic, 6 underwent laparoscopic cholecystectomy without finding of CBD stones at the intra-operative cholangiography. The sensitivity, specificity, diagnostic accuracy, PPV and NPV of MRCP were: 88%, 77%, 85%, 90%, 73%. Conclusions: asMRCPhas still a limitation in the diagnosis of small stones,missed at US, it leaves unrisolved the question of which patient is candidate to ERCP/ES. The recognition of microlithiasis should refer to other imaging techniques preliminar to ERCP (e.g. EUS) though their limited availability makes until now MRCP a method of choice in the diagnosis of biliary disease.