Cases Of post-ERCP Pancreatitis Research Articles

Risk factors for pancreatitis after endoscopic retrograde cholangiopancreatography in children

To investigate the application of endoscopic retrograde cholangiopancreatography (ERCP) in children and the risk factors for post-ERCP pancreatitis (PEP). A retrospective analysis was conducted on the clinical data of 66 children, aged ≤16 years, who underwent ERCP for pancreaticobiliary diseases at the Gastrointestinal Endoscopy Center of the Second Affiliated Hospital of Kunming Medical University from September 2013 to September 2023. The incidence rate of PEP and the risk factors for the development of PEP were analyzed. A total of 78 ERCP procedures were performed on 66 children, with 5 diagnostic ERCPs, 69 therapeutic ERCPs, and 4 failed procedures. The success rate of ERCP operations was 95% (74/78). There were 17 cases of PEP in total, with an incidence rate of 22%. In the PEP group, the proportion of children with normal preoperative bilirubin and the proportion of guidewire insertion into the pancreatic duct during surgery were higher than in the non-PEP group (P<0.05). The multivariate logistic regression analysis showed that guidewire insertion into the pancreatic duct was an independent risk factor for PEP (P<0.05). With the increasing application of ERCP in children with pancreaticobiliary diseases, it is important to select an appropriate intubation technique during surgery to avoid blindly entering the guidewire into the pancreatic duct and reduce the occurrence of PEP.

A Novel Serum Exosomal miRNA Signature in the Early Prediction of Persistent Organ Failure in Patients with Acute Pancreatitis.

Current study aims to investigate whether serum exosomal microRNAs (miRNAs) could be potential biomarkers in predicting APs with POF at early phase. Novel biomarkers are sorely needed for early prediction of persistent organ failure (POF) in acute pancreatitis (AP) patients. In the discovery stage, exosomal miRNAs were profiled in sera from APs with or without POF (5 vs. 5) using microarrays. POF-associated miRNA signatures then were assessed in training cohort (n=227) and further validated in three independent cohorts (n=516), including one nested case-control cohort. A total of 743 APs were recruited in this large-scale biomarker identification study with a nested case-control study. Data from the discovery cohort demonstrated that 90 exosomal miRNAs were significantly dysregulated in APs with POF compared with controls. One miRNA classifier (Cmi) comprising 3 miRNAs (miR-4265, 1208, 3127-5p) was identified in the training cohort, and was further evaluated in two validation cohorts for their predictive value for POF. AUCs for Cmi ranged from 0.88 to 0.90, which was statistically superior to AUCs of APACHE-II and BISAP, and outperformed BUN and creatinine in POF prediction across all cohorts (P<.05). Higher levels of Cmi indicated increased need for ICU admission, prolonged hospitalization, and elevated mortality rate, thus poor prognosis. In the nested case-control study, Cmi could help identify prediagnostic POF in post-ERCP pancreatitis cases within "golden hours" after ERCP with high efficacy. Serum exosomal Cmi may be an early predictor for POF in AP, even within "golden hours" after AP onset. ClinicalTrials.gov (NCT02602808).

Instant duodenal decompression after endoscopic retrograde cholangiopancreatography can effectively reduce the incidence of post-ERCP pancreatitis and hyperamylasemia.

Post-ERCP pancreatitis (PEP) is significantly influenced by the reflux of duodenal fluid. While gastrointestinal decompression represents a fundamental approach in acute pancreatitis management, the effectiveness of immediate duodenal decompression following ERCP to prevent PEP remains uncertain. This study aimed to investigate the impact of immediate duodenal decompression after ERCP on reducing the incidence of hyperamylasemia and PEP. This retrospective study encompassed patients with native papilla who underwent therapeutic ERCP for choledocholithiasis at the Department of Gastroenterology, Chun'an Branch of Zhejiang Provincial People's Hospital (Zhejiang, China) between January 2020 and June 2023. Based on the immediate placement of a duodenal decompression tube post-ERCP, patients were categorized into two groups: the duodenal decompression group and the conventional procedure group. Primary outcomes included the incidence of PEP and hyperamylasemia. A total of 195 patients were enrolled (94 in the duodenal decompression group and 101 in the conventional procedure group). Baseline clinical and procedural characteristics exhibited no significant differences between the two groups. PEP occurred in 2 patients (2.1%) in the duodenal decompression group, in contrast to 11 patients (10.9%) in the conventional procedure group (Risk difference [RD] 8.8%; 95% confidence interval [CI] 1.7%-16.5%, P = 0.014). Hyperamylasemia was observed in 8 patients (8.5%) in the duodenal decompression group, compared to 20 patients (19.8%) in the conventional procedure group (RD 11.3%; 95% CI 1.4%-21.0%; P = 0.025). Patients with PEP in both groups showed improvement after receiving active treatment. No severe cases of PEP occurred in either group, and no serious adverse events related to duodenal catheter decompression were reported. Immediate duodenal decompression following ERCP demonstrates an effective reduction in the incidence of hyperamylasemia and PEP.

Endoscopic retrograde cholangiopancreatography as a single-modality 'gold-standard' treatment for common bile duct stones in the elderly.

There are more octogenarians presenting with gallstone disease each year. Many are not suitable for surgical intervention. An alternative treatment option for common bile duct stones in the elderly is endoscopic retrograde cholangiopancreatography (ERCP) with or without stent insertion. We conducted a retrospective study using a prospectively collected database, analysing the outcomes of consecutive patients >80 years old who underwent an ERCP in a single centre for the treatment of common bile duct stones. In total, 156 patients, with a median age of 91 years, underwent an ERCP for choledocholithiasis over a 3-year period. ERCP was successful in 90% of patients but a proportion required repeat intervention. Forty-six (29%) patients had a concurrently inserted stent due to incomplete stone extraction. Six (4%) patients required a post-ERCP cholecystectomy due to ongoing symptoms. The overall ERCP complication rate was 7% (4% Clavien-Dindo 1 and 3% Clavien-Dindo 2), with no cases of post-ERCP pancreatitis or death. Patients were followed up over 5 years following index ERCP. There was a 60% 3-year survival and 30% 5-year survival rate following index ERCP. Importantly, of those who did not survive, only four patients (2.6%) had a death attributable to a biliary cause and none were fit for definitive surgery. ERCP can be considered as a possible definitive management option for treating common bile duct stones in the elderly, particularly in the comorbid population. Concurrent stenting is an effective temporizing strategy and mitigator of biliary-related readmission, but routine stent changes should be considered. Key messages What is already known on this topic Current guidelines advocate for laparoscopic cholecystectomy and common bile duct exploration in patients with choledocholithiasis. What this study adds Endoscopic retrograde cholangiopancreatography with or without stent insertion is a safe, alternative single-treatment modality for choledocholithiasis in the elderly comorbid population. How this study might affect research, practice, or policy Studies and guidelines evaluating treatment options for choledocholithiasis may be altered to accommodate patient-specific factors, including age and comorbid status, and the concurrent use of stenting as a either a temporizing or longer-term measure for complex stone disease.

Cooling the papilla with ice water in preventing post-ERCP pancreatitis (ice water challenge study).

The most common adverse event of endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP). The aim of this study was to investigate the efficacy of cooling the papilla with iced water to reduce PEP. Between December 2018 and July 2019, 100 consecutive patients with native papilla undergoing ERCP were prospectively enrolled in this study. In all patients, iced water was injected endoscopically toward the papilla via the working channel at the end of ERCP. The results were compared with 100 previous cases with native papilla that underwent ERCP under the same conditions without papilla cooling. Although the difference was not significant, the incidence of PEP tended to be lower in the study group (4%) than in the control group (11%) (p = 0.060). In addition, the incidence of PEP was significantly reduced in patients who underwent biliary sphincterotomy (p = 0.033). All cases of PEP were mild. Cooling the papilla with iced water injection, which is safe, easy, and cheap might reduce PEP.

Hydration with Lactated Ringer’s solution combined with rectal diclofenac in the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography

Different measures are recommended to reduce pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). We conducted a study in patients with ERCP treated with rectal diclofenac or lactated Ringer’s solution, or both interventions, to assess whether there is a decrease in the number of cases of post-ERCP pancreatitis. A mixed cohort study involving 1896 patients from 2009 to 2018. Up to June 2012 without treatment (Group I). Subsequently, 100 mg of rectal diclofenac (Group II). Since 2016, lactated Ringer’s solution 200 ml/h during the procedure and 4 h after it, in addition to 500 ml over 30 min when the pancreas was cannulated (Group III). Since 2017, lactated Ringer’s solution plus Diclofenac (Group IV). There were 725 patients in group I, and 530, 227 and 414 patients in groups II, III and IV, respectively. Factors predisposing to post-ERCP pancreatitis and post-ERCP pancreatitis cases that were defined by consensus criteria have been collected. There were 65 cases of post-ERCP pancreatitis (3.4%); 2.9%, 3.4%, 3.1% and 4.3% in groups I, II, III and IV, respectively ( p = .640). In group I, there was 4.2% of post-ERCP pancreatitis in naïve papillae and 4%, 4.9% and 6.3% in groups II, III and IV, respectively ( p = .585). The severity of post-ERCP pancreatitis and adverse effects were similar in all groups. 38.4% were high-risk patients. There were also no differences in post-ERCP pancreatitis in this group ( p = .501). In this work, no benefit was obtained with diclofenac plus hydration in reducing the number and severity of cases of post-ERCP pancreatitis nor with the other prophylactic measures. Se aconsejan diferentes medidas para disminuir la pancreatitis post-colangiopancreatografía retrógrada endoscópica (PPCPRE). Efectuamos un estudio en pacientes con CPRE tratados con Diclofenaco rectal o Ringer Lactato o bien ambas intervenciones para valorar si existe una disminución en el número de PPCPRE. Estudio de cohortes mixto con 1.896 pacientes desde 2009 hasta 2018. Hasta junio de 2012 sin tratamiento (grupo I). Posteriormente 100 mg de diclofenaco rectal (grupo II). Desde 2016 Ringer Lactato 200 ml/h durante el procedimiento y 4 h después del mismo, además 500 ml en 30 min cuando se canuló el páncreas (grupo III). Desde 2017 Ringer Lactato más diclofenaco (grupo IV). Hubo 725 pacientes en el grupo i, 530, 227 y 414 pacientes en grupos II, III y IV. Se han recogido factores predisponentes a PPCPRE y los casos de PPCPRE que fue definida por criterios de consenso. Hubo 65 PPCPRE (3,4%); 2,9; 3,4; 3,1 y 4,3% en los grupos I, II, III y IV respectivamente (p = 0,640). En el grupo I hubo un 4,2% de PPCPRE en papilas naïve y un 4; 4,9% y 6,3% en los grupos II, III y IV respectivamente (p = 0,585). La gravedad de PPCPRE y los efectos adversos fueron similares en los grupos. El 38,4% eran pacientes de alto riesgo. Tampoco hubo diferencias de PPCPRE en este grupo (p = 0,501). En este trabajo no se ha obtenido beneficio con diclofenaco más hidratación en la disminución del número y gravedad de la PPCPRE. Tampoco con las otras medidas profilácticas.

Hidratación con Ringer Lactato combinado con diclofenaco rectal en la prevención de pancreatitis poscolangiopancreatografía retrógrada endoscópica

ObjectiveDifferent measures are recommended to reduce pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). We conducted a study in patients with ERCP treated with rectal diclofenac or lactated Ringer's solution, or both interventions, to assess whether there is a decrease in the number of cases of post-ERCP pancreatitis. Material and methodsA mixed cohort study involving 1,896 patients from 2009 to 2018. Up to June 2012 without treatment (Group I). Subsequently, 100mg of rectal diclofenac (Group II). Since 2016, lactated Ringer's solution 200ml/hour during the procedure and 4hours after it, in addition to 500ml over 30minutes when the pancreas was cannulated (Group III). Since 2017, lactated Ringer's solution plus Diclofenac (Group IV). There were 725 patients in group I, and 530, 227 and 414 patients in groups II, III and IV, respectively. Factors predisposing to post-ERCP pancreatitis and post-ERCP pancreatitis cases that were defined by consensus criteria have been collected. ResultsThere were 65 cases of post-ERCP pancreatitis (3.4%); 2.9%, 3.4%, 3.1% and 4.3% in groups I, II, III and IV, respectively (P=.640). In group I, there was 4.2% of post-ERCP pancreatitis in naïve papillae and 4%, 4.9% and 6.3% in groups II, III and IV, respectively (P=.585). The severity of post-ERCP pancreatitis and adverse effects were similar in all groups. 38.4% were high-risk patients. There were also no differences in post-ERCP pancreatitis in this group (P=.501). ConclusionIn this work, no benefit was obtained with diclofenac plus hydration in reducing the number and severity of cases of post-ERCP pancreatitis nor with the other prophylactic measures.

EUS-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography (EDGE): The First Learning Curve.

Endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) is a minimally invasive option for pancreaticobiliary access in patients with Roux-en-Y anatomy. The procedure involves creating a fistulous tract between the remnant stomach or jejunum and the bypassed stomach with the deployment of a lumen-apposing metal stent (LAMS), followed by the advancement of an endoscope through the LAMS to perform an ERCP or EUS. It is a technically challenging procedure, requiring skills in EUS, fluoroscopy, and LAMS deployment. The aim of this study was to determine the learning curve for EDGE. Consecutive patients undergoing EDGE by a single operator were included from a prospective registry over 3 years. Demographics, procedure info, postprocedure follow-up data, and adverse events were collected. Nonlinear regression and cumulative sum analyses were conducted for the learning curve. Technical success was defined as the successful creation of the fistulous tract. Clinical success was defined as successful EUS or ERCP via the LAMS. Nineteen patients were included (21% male, mean age 58.7 y). Indication included symptomatic biliary stricture (n=6, 32%), choledocholithiasis (n=5, 26%), pancreatitis (n=3, 16%). Technical success was 100%. All patients had a 15 mm LAMS placed, 3 (16%) had cautery-enhanced LAMS. Clinical success was achieved in 18/19 (95%) patients. Fourteen patients had an ERCP, 1 patient had a EUS, and 3 patients had both. Adverse events included 2 cases of bleeding, 1 case of post-ERCP pancreatitis, and 1 jejunal perforation during duodenoscope insertion managed endoscopically.Median procedure time was 54.5 minutes (range: 31 to 88 min). Cumulative sum chart shows a 54-minute procedure time was achieved at the ninth procedure hence indicating efficiency. Apart from 2 outliers, the procedure duration further reduced with consequent procedures with the last 3 being under 40 minutes indicating that after 25 to 35 procedures a plateau may be reached indicating mastery (nonlinear regression P<0.0001). Endoscopists experienced in EDGE are expected to achieve a reduction in procedure time over successive cases, with efficiency reached 54.5 minutes and a learning rate of 9 cases. After 25 to 35 procedures, a plateau may be reached indicating mastery.

A270 AMPULLARY MORPHOLOGY PREDICTS SUCCESS AND POST-PROCEDURE COMPLICATIONS IN PRIMARY NEEDLE-KNIFE FISTULOTOMY FOR BILIARY CANNULATION IN ERCP: RESULTS OF A PROSPECTIVE CASE SERIES

Abstract Background Biliary cannulation is often the most challenging component of successful ERCP. Needle-knife fistulotomy (NKF) involves incising directly into the intra-duodenal portion of the bile duct, away from the native orifice, to achieve direct biliary access. This technique is usually performed when standard cannulation is unsuccessful, however recently, has been shown by our group to be a potentially effective and safe method to achieve biliary access as the primary approach. It has also been demonstrated that ampullary morphology influences cannulation success. Aims This study aims to assess the impact of ampullary morphology on the success and complications of NKF. Methods A retrospective visual analysis was performed of the ampullary morphology collected prospectively as part of our original NKF study (NCT03698266). Endoscopic videos and photos were reviewed to classify the ampulla into one of four types, as per a validated classification system. Ampullas were either Type 1 (regular), Type 2 (small), Type 3 (protruding or pendulous) or Type 4 (creased or ridged). Outcomes examined included: time to cannulation, proceduralist-perceived difficulty and complications. Results Of the 71 patients enrolled in the NKF study, 66 had video or photographs of the ampulla to facilitate classification. There were 35 (52%) Type 1 ampullas, 16 (24%) Type 2 and 14 (21%) Type 3 and one (1%) Type 4 ampullas. 65 out of the 66 (98.4%) patients had successful biliary access after primary NKF. The mean time to cannulation in all patients was 5.3 minutes (range 0.25–27 minutes). There were 3 cases of post-ERCP pancreatitis (PEP) (4.5%) and 3 cases of post-ERCP bleeding (4.5%). Compared to Type 1 ampullas, there was a no significant increase in time to cannulation in Type 2 and Type 3 ampullas using NKF (Type 1 4.7 vs. Type 2 7.1 vs. Type 3 6.4 minutes, p = NS). Only one patient with a Type 2 ampulla was rated as ‘low difficulty’ by the proceduralist performing NKF. Nevertheless, successful NKF was achieved in 15 out of 16 Type 2 ampullas (93.8%). There was 100% success rate in biliary access for Type 3 ampullas, previously shown to more challenging using conventional cannulation techniques. All cases of PEP occurred in patients with Type 2 ampullas. Conclusions As with the impact on conventional cannulation, ampullary morphology may influence outcomes of NKF. It appears that small, Type 2 ampullas with a short intra-duodenal segment makes NKF more challenging and may be associated with a higher rate of PEP. Unlike conventional cannulation, Type 3 ampullas are similar to Type 1 ampullas in ease of NKF access. Funding Agencies None

Pancreatic stenting to prevent post-ERCP pancreatitis: a randomized multicenter trial

Background and study aims Acute pancreatitis (AP) is one of the most common gastrointestinal disorders leading to hospitalization and the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Besides pharmaco-prophylaxis, pancreatic stenting has been demonstrated to protect from post-ERCP pancreatitis (PEP). However, it remains unclear which patients benefit from pancreatic stenting. We therefore hypothesized that in an unselected population, inadvertent cannulation of the pancreatic duct during first-time ERCP increases risk of PEP and that this risk can be significantly reduced by pancreatic stenting. Patients and methods This study was a multicenter, prospective, randomized controlled trial conducted at four European centers. A total of 167 patients undergoing first-time ERCP were enrolled in this trial. In the case of inadvertent cannulation of the pancreatic duct, patients were randomly assigned to receive either a 5 French plastic pancreatic stent of various length or no routine prophylactic intervention for PEP. Results A total of 167 patients were included in the final analysis. Prophylactic stent insertion significantly reduced the rate of PEP during first-time ERCP (odds ratio 0.43; 95% confidence interval 0.19 – 0.98; P = 0.04). The number needed to treat to prevent one case of PEP by prophylactic stent insertion after inadvertent cannulation of the pancreatic duct was 8.1 for the intention-to-treat population. Conclusion In an unselected patient population, inadvertent cannulation of the pancreatic duct during first-time ERCP is associated with a high risk for PEP. This risk can be significantly reduced by prophylactic pancreatic stenting, which is a safe and feasible procedure.

Prolonged retention of prophylactic pancreatic stents is not associated with increased complications

ObjectivesThe risk of post-ERCP pancreatitis (PEP) can be reduced effectively by the placement of a self dislodging pancreatic stent. The present study analyzed whether a prolonged interval until stent passage evaluation and removal of retained stents is associated with an increased risk for clinically relevant complications. MethodsIn the retrospective study 182 patients receiving a pancreatic stent for PEP prophylaxis were included and clinical data and complications until documented spontaneous stent dislodgement or removal were analyzed. ResultsThe main indication for ERCP was choledocholithiasis (40.1%) followed by malignant stenosis (30.8%). Stent passage evaluation was performed in 34.1% at day 1–4, 23.6% at day 5–10, 17.6% at day 11–28 and 24.7% at day >28. PEP occurred in 13.1% of patients with no case of severe PEP. No association between PEP and day of stent passage evaluation (p = 0.719), retention of the pancreatic stent at time of evaluation (0.867) or prolonged stent retention >10 days (0.234) was observed. Only the duration of the procedure was associated with risk for PEP (p = 0.037). Besides PEP only one clinically relevant complication was observed in the cohort (0.5%) which was a late possibly stent related pancreatitis at day 9 after the procedure that resolved completely. ConclusionsA prolonged interval for stent passage evaluation and stent retention is not associated with an increase of clinically relevant complications. A later evaluation and extraction of retained stents might be acceptable in selected cases where an additional endoscopic procedure can be saved due to a planned follow-up endoscopy.

The Polymorphisms at PRSS1-PRSS2 and MORC4 Loci and the Risk of Post-ERCP Pancreatitis.

Background and Aim The risks of post-ERCP pancreatitis (PEP) are identified as patient- and procedure-related factors. However, the genetic contribution for PEP is still unclear. Recent data show that the polymorphisms of PRSS1-PRSS2 (rs10273639) and MORC4 (rs12688220) are associated with recurrent acute pancreatitis and chronic pancreatitis. We aim to evaluate the association between these polymorphisms and post-ERCP pancreatitis in order to improve better prognosis and better care for these patients. Methods This is a retrospective, case-control study which includes 49 cases and 97 controls that are age-, procedure-, and risk of PEP-matched with the cases in 1 : 2 fashion. The PEP was diagnosed and graded for severity according to the standard consensus, and the risk factors of PEP were identified according to the ESGE guideline. Polymorphisms at rs10273639 and rs12688220 were evaluated by TaqMan technique and were identified in 133 (40 cases and 93 controls) and 146 patients, respectively. Results The demographic data between 2 groups are not significantly different. The genotype frequencies of PRSS1-PRSS2 (TT, TC, and CC) are 26, 13, and 1 vs. 67, 25, and 1 in cases and controls, respectively (p = 0.642). The genotype frequencies of MORC4 in female (TT, TC, and CC) are 8, 23, and 5 vs. 12, 26, and 21 in cases and controls, respectively (p = 0.071). The genotype frequencies of MORC4 in male (T and C) are 5 and 8 vs. 21 and 17 in cases and controls, respectively (p = 0.468). The allelic frequencies of MORC4 in combination of both genders (T, C) are 44 and 41 vs. 71 and 84 in cases and control, respectively (p = 0.431). In PEP cases, the allelic frequencies of PRSS1-PRSS2 (T and C) are 59 and 13 vs. 6 and 2 in mild and moderate/severe cases, respectively (p = 0.633). The allelic frequencies of MORC4 (T and C) are 38 and 39 vs. 4 and 4 in mild and moderate/severe cases, respectively (p = 0.972). Conclusion Polymorphisms at PRSS1-PRSS2 and MORC4 are not associated with the risk or severity of post-ERCP pancreatitis.

National Trend in Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis in United States: Analysis of the Nationwide Inpatient Sample (NIS) Database, 2004-2014

Introduction: Post-ERCP pancreatitis (PEP) is the most common complication following ERCP with an estimated annual cost burden in excess of $200 million. In recent years, there have been many advances in preventive strategies, including administration of rectal indomethacin to reduce the incidence of PEP. We report population-based trends over a 10-year period in the incidence of PEP in the United States. Methods: The NIS database was queried to identify patients who had an ERCP with or without PEP from 2004 to 2014. We adopted the previously validated definition for PEP from the NIS database. Appropriate International Classification of Diseases, 9th Revision (ICD-9) diagnosis codes were used to isolate PEP cases. The primary outcome was PEP and secondary outcomes were in-hospital death, length of stay and hospital costs. Poisson regression models were used to derive adjusted incidence risk ratios (IRR) of PEP and outcomes over time. Independent predictors of mortality and extended length of stay were determined by multivariate logistic regression. Results: Of 381,288 discharges (60.8% females) for patients who underwent ERCP, we found a total of 37,712 discharges for PEP (9.9%). Among the all the patients, 198,269 (52.0%) were performed in teaching hospitals. The median age was 60 (IQR 46-75) years. The number of in-patient ERCPs performed was 32,346 in 2004, with a peak of 38,394 in 2011, and decreased to 34,730 in 2014. From 2004 to 2014, the rate of PEP increased by 23.6 % (8.9% to 11.0%, p-trendTable 1 summarizes the results of the multivariable analysis.Table: Table. Multivariable Logistic Regression Analysis of predictors of post-ERCP pancreatitisConclusion: Over the past decade, there has been a considerable increase in the incidence of PEP in the US despite a simultaneous decrease in number of ERCPs performed. This trend is likely to continue in the near future and suggest a need for a better understanding of pathogenesis and preventive strategies for PEPFigure: Proportion of discharges with post-ERCP pancreatitis.Figure: Number of ERCPs performed.Figure: Mortality, length of stay and cost.

A case of post-ERCP pancreatitis due to peroral cholangioscopy

A case of post-ERCP pancreatitis due to peroral cholangioscopy

OC-074 Novel Point of Care Test for Detection of Human Phospholipase A2 to Predict Acute Pancreatitis Post Endoscopic Retrograde Cholangiopancreatography (ERCP) and Aid Same Day Discharge

Introduction ERCP is a therapeutic procedure which carries a 5% risk of pancreatitis. Most patients who have undergone ERCP are admitted overnight for observation as it can take up to 12 hours for post-ERCP pancreatitis to manifest. Phospholipase A2 Group IB (PLA2GIB) is a sensitive marker of pancreatitis. A rapid, quantitative, point-of-care (POC) test for PLA2GIB has been developed.1 We aimed to apply this test in a clinical setting, and determine its ability to detect clinically significant episodes of post-ERCP pancreatitis. Methods Ethical approval for the study and informed patient consent were obtained. Patients undergoing ERCP were randomly selected within a tertiary referral HPB centre. Blood amylase levels were obtained before and 3 hrs after ERCP. At the same times, 20µL of blood was taken, added to a running buffer and applied to the POC kit. Movement of the diluent was observed along the lateral flow strip. The lateral flow strip was then read by a micro device, calculating the PLA2GIB concentration from a standard curve. Cases of post ERCP pancreatitis were idenitified on the basis of characteristic pain, examination findings and elevation in serum amylase. Results 46 patients undergoing ERCP were recruited (26 M). Indication for ERCP included biliary stones (21), biliary strictures (12), biliary stent removal (6), pancreatic duct intervention (2) and other (5). The median pre-ERCP amylase level was 52 IU/L (range 19–316). The median post ERCP amylase was 78 IU/L (32–1720). Median pre-ERCP PLA2GIB concentration was 4 ng/mL (0.5–45). Median post-ERCP PLA2GIB was 6 ng/mL (0.6–418). There was a median 0.3 fold (-0.7-29) increase in PLA2GIB concentration after ERCP. 3 patients developed post-ERCP pancreatitis. These patients all had corresponding elevations in PLA2GIB above 70 ng/mL. A further 3 patients had elevation of amylase >3 x the upper limit of normal but without clinical symptoms of pancreatitis and with a PLA2GIB level With a cut off level of 70 ng/mL, PLA2GIB had a sensitivity of 100% and specificity of 98%. The PPV was 75% and NPV 100%. Conclusion This is the first clinical trial of a POC test for PLA2GIB activity. The test appears to be highly sensitive for post-ERCP pancreatitis. In our cohort of 46 patients undergoing ERCP, a negative test at 3 hours would have reliably excluded all cases of post-ERCP pancreatitis. This low cost, easy to use POC test could be used to support same day discharge of patients undergoing ERCP. Reference 1 Chapman R, et al. Multivalent nanoparticle networks enable point-of-care detection of human phospholipase-A2 in serum. ACS Nano 2015;2565–2573. Disclosure of Interest None Declared

PTH-017 Safety of self-expandable metal stents for malignant biliary strictures in a district general hospital setting

Introduction Self-expandable metal stent (SEMS) are widely used as first line palliative therapy for unresectable malignant biliary strictures. We present our experience of use of self-expandable metal stents in malignant biliary strictures in a District General Hospital (DGH) setting. Method We conducted a retrospective review on the data of all patients who had undergone an ERCP with a placement of self-expandable metal stent for inoperable malignant biliary strictures between Jan 2009 and Aug 2014. Comprehensive information was gathered with regards to patient’s demographics, procedural indications and procedure success rates. We assessed the stents efficacy, stent patency rates, complications and patient survival rates Results 50 patients were identified and analysed during this period. 60% were females and the mean age was 72 years (range, 35–93 years). The most common underlying diagnoses were Pancreatic carcinoma (60%) and Cholangiocarcinoma (32%) followed by Ampullary Carcinoma (6%) and Lymphoma (2%). Indications for metal stent placement included malignant bile duct stricture (54%), blockage of old stents (42%) and stent migration (4%). 23/50 (42%) patients had previous stent placement (Plastic 18, Metal 5). Of these, 21 stents failed due to blockage either due to biliary sludge or tumour overgrowth while 2 stents had migrated out (both plastic stents). The mean duration of previous stent patency was; plastic 96 days (7–523 days) and metal 237 days (39–595 days). The types of metal stents used were; Fully Covered (28%), Partially Covered (32%) and Uncovered (40%). The mean duration of all metal stents patency was 122 days (range, 7 – 566 days) and there was no statistical difference in terms of duration of stent patency among fully covered, partially covered and uncovered stents. Overall complication rate was 18%, which included Cholangitis (2%) and Stent Blockage (8/50, 16%) mainly due to biliary sludge (6/8). Of these blocked stents 5 were Fully covered, 3 Partial covered, 1 was Uncovered. There were no cases of post ERCP pancreatitis or migration of metal stent. There were no reported cases of procedure related mortality. The mean survival period after metal stent insertion was 161 days (range 9 to 566). Conclusion Self-expandable metal stents offers safe and effective palliative therapy for inoperable malignant biliary strictures and can be safely performed in a district general hospital with low complication rates. High blockage rate of fully covered stents is in our series is unexpected and the reasons for this were not obvious but this would be the subject of further analysis and study. Disclosure of interest None Declared.

PTU-036 Endoscopic sphincteroplasty in combination with sphincterotomy; is it worth it?

Introduction Endoscopic balloon sphincteroplasty (EBS) is an adjunct and possible alternative to sphincterotomy to remove biliary stones. EBS alone can be associated with complications like pancreatitis but can be safe and effective when combined with sphincterotomy. Reduced pancreatitis rates with a combined technique may relate to the force of dilatation being directed away from the pancreatic orifice. NSAIDs reduce the risk of post-procedure pancreatitis but there is insufficient data on its use specifically with combined technique. Method A retrospective review of patients undergoing EBS in addition to sphincterotomy for management of stones. Objectives were to assess CBD clearance and complication rates, and review the outcome of rectal NSAID use. We identified 93 eligible cases – 10 were excluded due to insufficient data. Results 30 of 41 index cases had successful clearance with EBS. 8 failed cases underwent further ERCP, 5 had upstaged balloon sphincteroplasty with successful clearance. For 32 of 42 repeat cases, this was the first EBS procedure. 22 of these were successful. Reasons for failed clearance were mainly poor tolerance/prolonged procedure/duodenoscope malfunction. Of a total of 22 failed cases, only 4 were due to large stones/difficult anatomy. The addition of EBS achieved higher clearance rates for stones 2 cm led to more complications and reduced clearance rates. No complications were seen when ‘interval’ sphincteroplasty was performed with balloon >15 mm. 15 cases developed complications, 11 were minor bleeds resolved at ERCP. 1 elderly patient had a significant delayed bleed requiring endoscopic haemostasis but developed fatal re-bleeding triggered by anticoagulation. There were 3 cases of post-ERCP biliary sepsis. A total of 39 of 83 cases received rectal diclofenac based on perceived risk of post procedure pancreatitis and risk of NSAID use. No cases of post-ERCP pancreatitis were seen. Conclusion EBS with sphincterotomy appears safe and potentially prevents additional procedures. Complication rates are greater with balloons >15 mm or stones >2 cm at index procedure and suggests alternative modalities should be considered in such cases. ‘Interval’ sphincteroplasty >15 mm appears safer than use at index. Immediate complications encountered were largely minor except 1 patient who required repeat endoscopic haemostasis but had fatal re-bleed due to anticoagulation. The use of adrenaline to control haemostasis and prevent delayed bleeding appears effective. No cases of pancreatitis were seen in our cohort; this may signify a benefit in using NSAIDs post-ERCP where suitable but requires analysis with a larger patient cohort. Disclosure of interest None Declared.

PTH-015 Post-ercp Pancreatitis In Secondary Care: Can We Predict Who Would Benefit From A Prophylactic Pancreatic Stent?

IntroductionPancreatitis is a recognised complication of ERCP. Measures taken to reduce the incidence in high-risk patients include placement of prophylactic pancreatic stents and use of NSAIDs, but current practice varies...

Continued evidence for safety of endoscopic retrograde cholangiopancreatography during pregnancy.

To report the safety of continued use of endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy at various maternal ages. A retrospective chart review of pregnant patients who underwent ERCP at a tertiary academic center was undertaken between 2002 and 2012. Pertinent past medical history and initial presenting laboratory data were collected. Review of the procedure note for each ERCP performed provided documentation of lead shielding, type of sedation, fluoroscopy time, and post-procedure complications. Patients' clinical courses were reviewed until the time of delivery and pregnancy complications with fetal outcomes were examined. Data was stratified based upon the mother's age at the time of ERCP: 18-21, 22-29, and ≥ 30 years of age. Twenty pregnant patients who underwent ERCP between 2002 and 2012 were identified. The mean age at the time of ERCP was 26.4 years (18-38 years) and the average trimester was the second. The indications for ERCP were choledocholithiasis in 17 patients, gallstone pancreatitis in 2 patients, and cholangitis in 1 patient. The mean fluoroscopy time of ERCP was 3.8 min (0.3-23.6 min). Sphincterotomy was performed in 18 patients with therapeutic intent and not as a prophylactic measure to prevent recurrences. Clinical documentation of use of protective shielding was found in only 8 notes (40%). Post procedure complications were limited to two cases of post-ERCP pancreatitis (10%). Elective cholecystectomy was performed shortly after ERCP in 11 of the pregnant patients. Birth records were available for 16 patients, of which 15 had full-term pregnancies. Cesarean sections were performed in 5 (31%) patients. Term birth weight was greater than 2500 g in all cases except one in which the mother had a known hypercoagulable state. ERCP during pregnancy is both safe and efficacious regardless of maternal age or trimester.

Post-ERCP Pancreatic Phlegmon: An Uncommon Presentation of a Common Condition

Introduction: Post-ERCP pancreatitis (PEP) is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), occurring in approximately 3.5% of cases. PEP with phlegmon is rarely observed in current clinical practice. We herein describe a case of severe PEP complicated by phlegmon formation presenting as acute pyelonephritis. Case Presentation: A 31-year-old female with history of cholelithiasis and non-obstructive left kidney stone presented with acute left lower abdominal pain associated with fever, nausea, and vomiting. The patient underwent an uneventful elective ERCP with negative findings 1 day prior to this visit. On examination, she had SIRS with significant CVA tenderness. Labs showed a leukocytosis of 17,600, serum lipase of 1,686 unit/L, and contaminated urine. She developed hypotension shortly after admission. An abdominal CT demonstrated acute pancreatitis with phlegmonous changes and gas in the retroperitoneum. Abscessed fluid was also identified to extend inferiorly into the left pararenal spaces. Exploratory laparotomy was emergently performed and revealed pancreatic tail necrosis complicated by an early abscess formation. The patient went through the multiple sessions of debridement and drainage during 2 months of her hospitalization. Subsequently, the patient was safely discharged home. Discussion: PEP with phlegmon formation is an extremely rare complication. In this case, extension of abscessed fluid to the left pararenal space perplexingly contributed to the typical manifestation of acute pyelonephritis. Early imaging is definitely crucial for appropriate, timely management. Hence, it is imperative for internists to be aware of common complications of ERCP, which could be presented in an uncommon fashion.