Diagnostic Endoscopic Retrograde Cholangiopancreatography 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.

Rise in First-Time ERCP for Benign Indications >1 Year After Cholecystectomy Is Associated With Worse Outcomes

Background & AimsGreater availability of less invasive biliary imaging to rule out choledocholithiasis should reduce the need for diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in patients who have a remote history of cholecystectomy. The primary aims were to determine the incidence, characteristics, and outcomes of individuals who undergo first-time ERCP > 1 year after cholecystectomy (late-ERCP). MethodsData from a commercial insurance claim database (Optum Clinformatics) identified 583,712 adults who underwent cholecystectomy, 4,274 of whom underwent late-ERCP, defined as first-time ERCP for nonmalignant indications > 1 year after cholecystectomy. Outcomes were exposure and temporal trends in late-ERCP, biliary imaging utilization, and post-ERCP outcomes. Multivariable logistic regression was used to examine patient characteristics associated with undergoing late ERCP. ResultsDespite a temporal increase in the use of non-invasive biliary imaging (35.9% in 2004 to 65.6% in 2021, p<0.001), the rate of late-ERCP increased eight-fold: 0.5 to 4.2/1,000 person-years from 2005 to 2021, p<0.001). While only 44% of patients who underwent late-ERCP had gallstone removal, there were high rates of post-ERCP pancreatitis (7.1%), hospitalization (13.1%), and new chronic opioid use (9.7%). Factors associated with late-ERCP included concomitant disorder of gut-brain interaction (OR 6.48, 95%CI:5.88-6.91) and metabolic dysfunction steatotic liver disease (OR 3.27 95%CI:2.79-3.55) along with use of anxiolytic (OR 3.45 95%CI:3.19-3.58), anti-spasmodic (OR 1.60 95%CI:1.53-1.72), and chronic opioids (OR 6.24 95%CI:5.79-6.52). ConclusionThe rate of late-ERCP post-cholecystectomy is increasing significantly, particularly in patients with comorbidities associated with disorder of gut-brain interaction and mimickers of choledocholithiasis. Late-ERCPs are associated with disproportionately higher rates of adverse events, including initiation of chronic opioid use.

Endoscopic Ultrasound in Pancreatic Duct Anomalies.

Embryological development of the pancreas is a complex phenomenon and, therefore, it can have multiple developmental aberrations. Fortunately, the majority of these pancreatic ductal anomalies are asymptomatic with no clinical relevance and are incidentally detected during diagnostic cross-sectional imaging or endoscopic retrograde cholangiopancreatography (ERCP) or autopsy. Occasionally, pancreatic duct anomalies can result in symptoms like abdominal pain or recurrent pancreatitis. Also, an accurate pre-operative diagnosis of ductal anomalies can prevent inadvertent duct injury during surgery. Conventionally, ERCP had been used for an accurate diagnosis of pancreatic duct anomalies. However, because it is invasive and associated with a risk of pancreatitis, it has been replaced with magnetic resonance cholangiopancreatography (MRCP). MRCP has demonstrated high sensitivity and specificity for the diagnosis of ductal anomalies, which can be further improved with the use of secretin-enhanced MRCP. Endoscopic ultrasound (EUS) is a new diagnostic and interventional tool in the armamentarium of endoscopists and has demonstrated promising results in the detection of pancreatic duct variations and anomalies. Along with the visualization of the course and configuration of the pancreatic duct, EUS can also visualize changes in the pancreatic parenchyma, thereby helping with an early diagnosis of any co-existent pancreatic disease. Absence of the stack sign and crossed duct sign are important EUS features to diagnose pancreas divisum. EUS can also help with the diagnosis of other congenital ductal anomalies like annular pancreas, ansa pancreatica, and anomalous pancreaticobiliary union, although the published experience is limited.

The role of magnetic resonance cholangiopancreatography in evaluation of etiological spectrum of obstructive jaundice

Jaundice is a commonly encountered problem in society. Discrimination between obstructive and non-obstructive causes is important to imply surgical intervention in cases of obstructive jaundice whereas medical management in non-obstructive jaundice. Nowadays diagnostic endoscopic retrograde cholangiopancreatography (ERCP) may be replaced by Magnetic resonance cholangiopancreatography (MRCP) as it has high level of resolution and reliability. We studied the role of MRCP in obstructive jaundice to evaluate its etiological spectrums and radiological findings. To evaluate the role of MRCP in the determination of aetiologies in obstructive jaundice, to assess degree and level of biliary obstruction and to correlate MRCP findings with post surgical follow-ups / ERCP/ histopathology. Total sixty-eight patients with a clinical diagnosis of obstructive jaundice referred for MRCP were included in our study. We correlated MRCP findings with the final diagnosis made by post-surgical follow-up / ERCP/ histopathology as a gold standard. For benign lesions, overall sensitivity of MRCP was 97.73%, specificity was 95.83% with an accuracy of 97.06%. MRCP had 94.74% sensitivity, 93.88% specificity, 94.12% accuracy in the diagnosis of choledocholithiasis, and 66.67% sensitivity, 98.39% specificity, and 95.59% accuracy in the diagnosis of benign strictures. For malignant lesions, accuracy, sensitivity, and specificity of MRCP were 97.06%, 95.83%, and 97.73%. MRCP is a highly reliable, accurate, non-invasive imaging technique and has a high sensitivity for the evaluation of aetiologies of obstructive jaundice.

Our experiences in 1000 case single-centre endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) has a very important role in both diagnosis and treatment of pancreaticobiliary pathologies. The aim of this study was to review the indications, technical success complications and results of ERCP procedures performed in our centre. In the study, the data of 1000 patients who were diagnosed with extrahepatic cholestasis, obstructive cholangitis/pancreatitis or bile leakage in clinical, medical and radiological data and who underwent ERCP between May 2019 and November 2021 were evaluated retrospectively. The age distribution was between 14 and 109 years, and the average age was 57.97 years for women (14-109) and 57.48 for men (19-95). Gender distribution was as follows: 552 (55.2%) women and 448 (44.8%) men. ERCP indications in this study were as follows: choledocholithiasis, malignant bile duct obstruction, odysphincter dysfunction (ODS), post-operative bile leakage, hepatic hydatid cyst rupture into the biliary tract and bile duct stenosis. Eight hundred and seventy-one (87.1%) patients had common bile duct stones, 30 (3%) pancreatic head tumour, 22 (2.2%) common bile duct tumour and 20 (2%) cholestasis due to papilla tumour and/or obstructive icterus. Twenty-two (2.2%) patients were treated for sphincter dysfunction (ODS) of Oddi. ERCP was performed in 12 (1.2%) patients with the diagnosis of bile leakage after liver hydatid surgery, 10 (1%) after gall bladder surgery and 8 (0.8%) with the diagnosis of biliary tract stenosis after gall bladder surgery. ERCP was performed in 5 (0.5%) patients due to biliary tract obstruction as a result of rupture of hydatid liver cyst into the biliary tract. Successful cannulation was achieved in 1000 patients listed. Ninety-seven patients who were included in the ERCP procedure but could not be cannulated were not included in the study. Endoscopic sphincterotomy was performed on all patients in the ERCP procedure. In patients with choledochal stones, stone extraction from the common bile duct and/or plastic stent placement in the common bile duct was added. Plastic stent was placed in the common bile duct in patients with pancreatic head tumour, common bile duct tumour, bile duct leakage and common choledochal stenosis. Endoscopic biopsy was taken from all patients with suspected papillary tumour. The processing time varied between 15 and 90 min. The overall complication rate was 17.4%. After ERCP, 93 patients developed amylasaemia that did not require treatment, while 50 patients were diagnosed with clinical and laboratory acute pancreatitis. Intraoperative bleeding, which did not require blood transfusion and could be controlled with adrenaline injection and/or balloon pressure, developed in 10 patients. In one patient, basket and stone were stuck in the papilla during stone extraction. There was no operative mortality. ERCP is a complex procedure that uses special equipment and must be performed by experienced specialists. To increase the reliability of the ERCP procedure, it is necessary to determine the risk factors for ERCP complications very well. Unnecessary ERCP should be avoided. ERCP should not be performed, especially in patients with low probability of stone or stricture, patients with normal bilirubin and patients who do not show other signs of biliary disease. The use of non-invasive imaging methods as much as possible instead of diagnostic ERCP will reduce the complications associated with ERCP.

Primary sclerosing cholangitis-A long night's journey into day.

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Diagnostic value of endoscopic retrograde cholangiopancreatography and therapeutic value of endoscopic sphincterotomy in dogs with suspected hepatobiliary disorders

BackgroundConventional diagnostic methods have some limitations in diagnosing specific causes of canine hepatobiliary disorders. In the evaluation of the hepatobiliary system in dogs, ultrasonography (US) is the first imaging method of choice. Nonetheless, endoscopic retrograde cholangiopancreatography (ERCP) has also been proven to be a practicable technique for evaluating canine hepatobiliary (endoscopic retrograde cholangiography, ERC) and pancreatic duct (endoscopic retrograde pancreatography, ERP) disorders, providing additional therapeutic options by sphincterotomy (EST). To date, the efficacy and safety of diagnostic and therapeutic ERCP has not been evaluated in veterinary medicine literature. The present study sought to report complications and outcomes of dogs undergoing ERCP and EST, and to assess the usefulness of diagnostic ERCP by comparing the findings of US, ERCP and histopathological findings in liver and pancreas.ResultsThis retrospective case series comprises data collected from 15 dogs that underwent successful ERC/ERCP. Nine dogs underwent EST following ERC. US and ERC were best in agreement when assessing the common bile duct. In case of disagreement between the modalities, the ERC findings of the ductal structures were in line with the available pathology findings more often than the US findings, whereas the opposite was noted for the gallbladder. The technical success rates were 88.2% for ERC, 66.7% for ERP, and 81.8% for EST, with no major complications during or immediately after the procedure. Immediate bile flow after EST was recorded in 7/9 dogs but only four showed coinciding clinical and laboratory improvement and four dogs were euthanized within 1-6 days after EST.ConclusionsUS remains a valuable initial diagnostic imaging method for hepatobiliary disorders and allows good assessment of the gallbladder. ERC can serve as a complementary procedure for diagnostic assessment of the hepatobiliary duct disorders. However, in order to improve the outcomes of EST, careful selection of patients for the procedure would require more advanced diagnostic imaging of the hepatobiliary area.

Endoscopic Retrograde Cholangiopancreatography in Pediatric Patients.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic technique used in the diagnosis and treatment of pancreaticobiliary system. ERCP is used less frequently in children than in adults due to the rarity of pancreaticobiliary diseases and technical difficulties. However, ERCP is a safe, effective diagnosis and treatment tool for children. Methods: All patients within the age range of 1-19 years, who underwent ERCP between 2010 and 2021 at our endoscopy unit, were retrospectively examined. Patient demographics, use of imaging methods, indications, type of sedation, interventions, success of ERCP, findings, and complications were evaluated. Results: Overall, 105 ERCPs were performed in 66 children (29 male and 37 female). The indications were choledocholithiasis, cyst hydatic, choledochal cyst, biliary atresia or anomaly, liver transplantation-related disorders, and pancreatic disorders, respectively. ERCP was finished as diagnostic ERCP in 20% and as therapeutic in 80%. Therapeutic procedures were sphincterotomy, stent placement or removal, stone or debris extraction, and balloon sweep or dilatation, respectively. The success rate in the procedures was 75.23%. The overall complication rate was 15.23%. Postprocedure pancreatitis occurred in 11.42%, hemorrhage occurred in 2.85%, and aggravation of cholangitis in 0.95%. All complications were managed conservatively. Conclusion: ERCP in pediatric patients is a safe procedure that can be performed by adult endoscopists with high success rates. Since our region is an endemic region for hydatid cyst disease, the most common ERCP indication after choledocholithiasis is procedures related to liver hydatid cyst disease. The most common complication was pancreatitis, and complications were treated medically.

PREDICTIVE FACTORS FOR PROPHYLAXIS EFFECT OF NAPROXEN IN POST ENDOSCOPIC PANCREATITIS

&nbsp;Endoscopic retrograde cholangiopancreatography (ERCP) can be associated with complications like post-ERCP pancreatitis (PEP). We aimed to examine the possible influence of selective demographic and clinical factors on efficacy of periprocedural 500 mg Naproxen single dose rectal administration in prevention of PEP in patients after diagnostic or therapeutic ERCP. This randomized prospective mono-centric clinical study was implemented during January-April 2022 on 30 patients referred for ERCP at the University Clinical Center of Kosovo-Prishtina. Before ERCP, all patients received periprocedural 500mg Naproxen single dose rectal administration in prevention of PEP. The levels of amylase, lipase, and CRP were measured before ERCP, and 4/24h after. The incidence of PEP was 16,67% (5/ 30) – 2 (11,76%) of the male and 3 (23,08%) of the female (p=0,4101). No significant differences between the patients without/with PEP was found related to age (p=0,8674), BMI (p=0,5591) and duration of procedure (p=0,5590). Pancreatic duct wire cannulation happened in 5 (16,67%) patients, while only 2 (40%) of them developed PEP. Amylases levels 24h after ERCP were significantly higher in patients with PEP (p=0,0005). Between patients without/with PEP there were significant differences in lipase levels before/4h/24h after ERCP for p=0,0451 vs. p=0,0278 vs. p=0,005 respectively. Related to CRP levels, no significant difference was found between the groups at any measurement time. Analyzed potential influencing factors didn’t show significant influence on efficacy of Naproxen in prevention of PEP after ERCP. More extensive controlled trials are underway in Republic of Kosovo to precise the effects of Naproxen in reduction of PEP after ERCP. Key words: Naproxen; nonsteroidal anti-inflammatorydrugs; pancreatic duct cannulation; post-endoscopicretrograde cholangiopancreatography; pancreatitis

Endoscopic retrograde cholangiopancreatography‐related adverse events in Korea: A nationwide assessment

BackgroundAlthough endoscopic retrograde cholangiopancreatography (ERCP) is a pivotal procedure for the diagnosis and treatment of a variety of pancreatobiliary diseases, it has been known that the risk of procedure‐related adverse events (AEs) is significant.ObjectiveWe conducted this nationwide cohort study since there have been few reports on the real‐world data regarding ERCP‐related AEs.MethodsPatients who underwent ERCP were identified between 2012 and 2015 using Health Insurance Review and Assessment database generated by the Korea government. Incidence, annual trends, demographics, characteristics according to the types of procedures, and the risk factors of AEs were assessed.ResultsA total of 114,757 patients with male gender of 54.2% and the mean age of 65.0 ± 15.2 years were included. The most common indication was choledocholithiasis (49.4%) and the second malignant biliary obstruction (22.8%). Biliary drainage (33.9%) was the most commonly performed procedure, followed by endoscopic sphincterotomy (27.4%), and stone removal (22.0%). The overall incidence of ERCP‐related AEs was 4.7% consisting of post‐ERCP pancreatitis (PEP; 4.6%), perforation (0.06%), and hemorrhage (0.02%), which gradually increased from 2012 to 2015. According to the type of procedures, ERCP‐related AEs developed the most commonly after pancreatic stent insertion (11.4%), followed by diagnostic ERCP (5.9%) and endoscopic sphincterotomy (5.7%). Younger age and diagnostic ERCP turned out to be independent risk factors of PEP.ConclusionsERCP‐related AEs developed the most commonly after pancreatic stent insertion, diagnostic ERCP and endoscopic sphincterotomy. Special caution should be used for young patients receiving diagnostic ERCP due to increased risk of PEP.

Endoscopic retrograde cholangiopancreatography using short‐type double‐balloon enteroscope: Experience in Hong Kong

To illustrate the efficacy and safety profile of double-balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) using a short enteroscope in patients with surgically altered anatomy. A retrospective study was performed to review the endoscopic outcomes of patients undergoing DBE-assisted ERCP for biliary diseases in Tuen Mun and Pok Oi hospitals in Hong Kong SAR, China from December 2015 to December 2020. Altogether 46 DBE-assisted ERCP procedures were performed in 37 patients. The enteroscopic success rate, defined as reaching the papilla or bilioenteric anastomosis, was 95.7% (95% confidence interval [CI] 85.2%-99.5%), which was significantly lower in patients with intact stomach than in those who had a previous gastrectomy (67% vs 100%, P=0.014). The diagnostic ERCP success rate, defined as performance in an informative cholangiogram, was 84.1% (95% CI 69.9%-93.4%) in cases where it was attempted. Intended biliary therapeutic interventions were successfully performed in 76.1% (95% CI 61.2%-87.4%) of all procedures. Adverse events were reported in six (13.0%) procedures (95% CI 4.9%-26.3%), including the micro-perforation of the intestine in two (4.3%) patients with prior Roux-en-Y gastrectomy, three (6.5%) of acute cholangitis and one (2.2%) of acute pancreatitis. All adverse events were managed successfully using conservative methods except in one case of micro-perforation, which required a laparotomy. DBE-assisted ERCP using a short enteroscope is a promising technique for managing biliary diseases in patients with surgically altered anatomy. It must be performed to avoid perforation, particularly in patients with a Roux-en-Y reconstruction.

The radiation doses and radiation protection on the endoscopic retrograde cholangiopancreatography procedures.

Although many interventions involving radiation exposure have been replaced to endoscopic procedure in the gastrointestinal and hepatobiliary fields, there remains no alternative for enteroscopy and endoscopic retrograde cholangiopancreatography (ERCP), which requires the use of radiation. In this review, we discuss the radiation doses and protective measures of endoscopic procedures, especially for ERCP. For the patient radiation dose, the average dose area product for diagnostic ERCP was 14-26 Gy.cm², while it increased to as high as 67-89 Gy.cm² for therapeutic ERCP. The corresponding entrance skin doses for diagnostic and therapeutic ERCP were 90 and 250 mGy, respectively. The mean effective doses were 3- 6 mSv for diagnostic ERCP and 12-20 mSv for therapeutic ERCP. For the occupational radiation dose, the typical doses were 94 μGy and 75 μGy for the eye and neck, respectively. However, with an over-couch-type X-ray unit, the eye and neck doses reached as high as 550 and 450 μGy, with maximal doses of up to 2.8 and 2.4 mGy/procedure, respectively.A protective lead shield was effective for an over couch X-ray tube unit. It lowered scattered radiation by up to 89.1% in a phantom study. In actual measurements, the radiation exposure of the endoscopist closest to the unit was reduced to approximately 12%. In conclusion, there is a clear need for raising awareness among medical personnel involved endoscopic procedures to minimise radiation risks to both the patients and staff.

Development of a risk score for choledocholithiasis in pediatric patients.

The prevalence of gallstones in children has increased over the last years. Choledocholithiasis (CD) is present in up to 30% of the cases. There is a scarcity of studies on the management of choledocholithiasis in children. The aim of this study was to develop a score that would allow predicting accurately the risk of CD in children with gallstones and reduce the number of non-therapeutic ERCP. We conducted a retrospective study in children with gallstones and suspected CD seen between January 2010 and December 2019. The main outcome was the presence of CD confirmed by at least one of the following diagnostic tests: magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and/or intraoperative cholangiography (IOC). We developed a risk score based on the presence or absence of the following risk factors: acute biliary pancreatitis, ascending cholangitis, elevated liver function tests (AST, ALT, total bilirubin [TB, ≥ 2mg/dl], conjugated bilirubin, gamma-glutamyl transpeptidase, and alkaline phosphatase), CD on ultrasound (US; this was considered predictive but not confirmatory of CD), and dilation of the common bile duct (> 6mm) by US. The score was divided into three different categories: low risk (no risk factors), intermediate risk (one risk factor present), high risk (≥ 2 risk factors present or ascending cholangitis). Given the main goal of reducing the number of diagnostic ERCPs, a very-high-risk subgroup (3 risk factors present or ascending cholangitis) was identified. We reviewed 133 patients with gallstones and suspected CD. In 56 (42.1%) patients, the presence of CD was confirmed by one or more of the definitive diagnostic tests (MRCP, ERCP, and IOC). The following variables were found to be the strongest predictors of CD: ascending cholangitis, TB ≥ 2mg/dl, common bile duct > 6mm, and the presence of CD by US. The positive predictive value for CD was 7.5% in the low-risk group (OR 0.06, P = < 0.001); 22.9% in the intermediate-risk group (OR 0.31, P = 0.007); 77.6% in the high-risk group (OR 20.14, P = < 0.001); and 95.7% in very-high-risk subgroup (OR 49.18, P = < 0.001). The risk score proposed in this study predicts accurately the presence of CD in children with gallstones. It can serve as a helpful tool to triage the need for costly and complex studies in the workup of CD, particularly in centers with limited resources. Finally, due to its high specificity and positive predictive value (PPV), the use of the very-high-risk criteria would allow for an important decrease in the number of non-therapeutic ERCP.

Imaging of inflammatory disease of the pancreas.

Increasingly acute and chronic pancreatitis (AP and CP) are considered a continuum of a single entity. Nonetheless, if, after flare-up, the pancreas shows no residual inflammation, it is classified as AP. CP is characterised by a long cycle of worsening and waning glandular inflammation without the pancreas ever returning to its baseline structure or function. According to the International Consensus Guidelines on Early Chronic Pancreatitis, pancreatic inflammation must last at least 6 months before it can be labelled CP. The distinction is important because, unlike AP, CP can destroy endocrine and exocrine pancreatic function, emphasising the importance of early diagnosis. As typical AP can be diagnosed by clinical symptoms plus laboratory tests, imaging is usually reserved for those with recurrent, complicated or CP. Imaging typically starts with ultrasound and more frequently with contrast-enhanced computed tomography (CECT). MRI and/or MR cholangiopancreatography can be used as a problem-solving tool to confirm indirect signs of pancreatic mass, differentiate between solid and cystic lesions, and to exclude pancreatic duct anomalies, as may occur with recurrent AP, or to visualise early signs of CP. MR cholangiopancreatography has replaced diagnostic endoscopic retrograde cholangiopancreatography (ERCP). However, ERCP, and/or endoscopic ultrasound (EUS) remain necessary for transpapillary biliary or pancreatic duct stenting and transgastric cystic fluid drainage or pancreatic tissue sampling, respectively. Finally, positron emission tomography-MRI or positron emission tomography-CT are usually reserved for complicated cases and/or to search for extra pancreatic systemic manifestations. In this article, we discuss a broad spectrum of inflammatory pancreatic disorders and the utility of various modalities in diagnosing acute and chronic pancreatitis.

Endoscopic Retrograde Cholangiopancreatography (ERCP) in Patients With Liver Cirrhosis: Analysis of Trends and Outcomes From the National Inpatient Sample Database.

Goals:We aimed to assess outcomes of patients with liver cirrhosis who underwent therapeutic or diagnostic endoscopic retrograde cholangiopancreatography (ERCP) to determine whether these patients had different outcomes relative to patients without cirrhosis.Background:ERCP is an important procedure for treatment of biliary and pancreatic disease. However, ERCP is relatively technically difficult to perform when compared with procedures such as esophagogastroduodenoscopy or colonoscopy. Little is known about how ERCP use affects patients with liver cirrhosis.Study:Using patient records from the National Inpatient Sample (NIS) database, we identified adult patients who underwent ERCP between 2009 and 2014 using International Classification of Disease, Ninth Revision coding and stratified data into 2 groups: patients with liver cirrhosis and those without liver cirrhosis. We compared baseline characteristics and multiple outcomes between groups and compared outcomes of diagnostic versus therapeutic ERCP in patients with cirrhosis. A multivariate regression model was used to estimate the association of cirrhosis with ERCP outcomes.Results:A total of 1,038,258 hospitalizations of patients who underwent ERCP between 2009 and 2014 were identified, of which 31,294 had cirrhosis and 994,681 did not have cirrhosis. Of the patients with cirrhosis, 21,835 (69.8%) received therapeutic ERCP and 9459 (30.2%) received diagnostic ERCP. Patients with cirrhosis had more ERCP-associated hemorrhages (2.5% vs. 1.2%; P<0.0001) compared with noncirrhosis patients but had lower incidence of perforations (0.1% vs. 0.2%; P<0.0001) and post-ERCP pancreatitis (8.6% vs. 7%; P<0.0001). Cholecystitis was the same between groups (2.3% vs. 2.3%; P<0.0001). In patients with cirrhosis, those who received therapeutic ERCP had higher post-ERCP pancreatitis (7.9% vs. 5.1%; P<0.0001) and ERCP-associated hemorrhage (2.7% vs. 2.1%; P<0.0001) but lower incidences of perforation and cholecystitis (0.1% vs. 0.3%; P<0.0001) and cholecystitis (1.9 vs. 3.1%; P<0.0001) compared with those who received diagnostic ERCP.Conclusions:Use of therapeutic ERCP in patients with liver cirrhosis may lead to higher risk of complications such as pancreatitis and postprocedure hemorrhage, whereas diagnostic ERCP may increase the risk of pancreatitis and cholecystitis in patients with cirrhosis. Comorbidities in cirrhosis patients may increase the risk of post-ERCP complications and mortality; therefore, use of ERCP in cirrhosis patients should be carefully considered, and further studies on this patient population are needed.

ID: 3521859 OPTIMAL DIAGNOSTIC IMAGING STRATEGY FOR PATIENTS WITH INTERMEDIATE PROBABILITY FOR CHOLEDOCHOLITHIASIS: A COST-EFFECTIVENESS ANALYSIS

For patients with cholelithiasis with intermediate probability for choledocholithiasis, various confirmatory imaging studies including endoscopic ultrasound (EUS), magnetic resonance cholangiopancreatography (MRCP), and intraoperative cholangiogram (IOC) are advocated by the American Society for Gastrointestinal Endoscopy, instead of diagnostic endoscopic retrograde cholangiopancreatography (ERCP). While local expertise will affect the choice of one confirmatory imaging study over another, there is limited information available regarding the most cost-effective approach.

Chronic pancreatitis : Characterization and differentiation from pancreatic cancer

Klinisches/methodisches ProblemBei der chronischen Pankreatitis (CP) handelt es sich um eine langanhaltende Entzündung der Bauchspeicheldrüse, welche die normale Struktur und Funktion des Organs schädigt. Das breite Spektrum an entzündlichen Pankreaserkrankungen umfasst einzelne Entitäten, wie die fokale Pankreatitis (FP) oder den Pseudotumor („mass-forming pancreatitis“), welche radiomorphologisch ein Adenokarzinom der Bauchspeicheldrüse (PDAC) nachahmen können. In weiterer Folge kann eine Fehldiagnose zu einem vermeidbaren und unnötigen operativen Eingriff oder zu einer Therapieverzögerung führen.Radiologische StandardverfahrenDer Ultraschall (US) ist das primäre bildgebende Verfahren zur Abklärung von Pankreaserkrankungen, gefolgt von kontrastmittelverstärkter Computertomographie (KM-CT), die als meistverwendete Methode bei der diagnostischen Abklärung von Bauchspeicheldrüsenerkrankungen gilt. Die Magnetresonanztomographie (MRT) und/oder die MR-Cholangiopankreatographie (MRCP) können als Problemlöser eingesetzt werden, um zwischen soliden und zystischen Läsionen zu unterscheiden sowie auch Anomalien der Pankreasgänge auszuschließen, welche bei rezidivierender akuter Pankreatitis (AP) vorhanden sein können, oder um frühe Anzeichen einer CP zu visualisieren. Die MRCP hat dabei die diagnostische endoskopische retrograde Cholangiopankreatographie (ERCP) in der Abklärung von therapeutischen Interventionen im Wesentlichen ersetzt.Empfehlung für die PraxisFolgender Übersichtsartikel fasst die relevanten Merkmale in der Computertomographie (CT) und MRT zusammen, um eine akkurate, frühzeitige Diagnose einer CP zu stellen und eine Differenzierung zwischen FP und Pankreaskarzinom zu ermöglichen, um somit – auch in schwierigen Fällen – ein adäquates Therapiemanagement zu gewährleisten.

Recent Update of Accessories for ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) became the standard method of choice for the management of patients with a variety of benign and malignant pancreaticobiliary disorders. A growing range of ERCP accessories has been developed to support the increasing demands and complexity of therapeutic ERCP. Various accessories are needed from selective cannulation to the removal of bile duct stones which involves endoscopic sphincterotomy or endoscopic papillary (large) balloon dilation with a balloon or basket-assisted stone extraction. Detailed knowledge and correct usage of accessories are essential to ensure optimal patient care and safety. This review describes current accessories that are available to use during diagnostic and therapeutic ERCP.

ERCP-Related Bleeding

Clinically significant bleeding is an uncommon complication of diagnostic endoscopic retrograde cholangiopancreatography. But the endoscopists needs to be skilled at prevention and management. Post ERCP bleeding is most often seen following sphincterotomy. The overall risk of bleeding in patients undergoing sphincterotomy is approximately 1-2 percent. Most bleeding episodes are mild to moderate in severity. The risk of bleeding can be minimized by identifying patients at risk, correcting coagulation abnormalities and careful technique by skilled endoscopists in high-volume centers. Post-sphincterotomy bleeding often stops spontaneously and is rarely life-threatening, except in patients with a bleeding diathesis. Most clinically relevant bleedings can be managed with medical treatment and/or endoscopic therapy, which should be performed without delay in patients who have immediate bleeding. Endoscopic therapy options include epinephrine injection, hemostatic clips, thermal therapy and placement of full covered self-expandable metal stents. Angiography or surgery is usually reserved for patients with refractory bleeding and is rarely required.

Intermediate Likelihood of Choledocholithiasis: Do All Need EUS or MRCP?

Abstract Background Recently updated guidelines for choledocholithiasis stratify suspected patients into high, intermediate, and low likelihood, with the aim to reduce risk of diagnostic endoscopic retrograde cholangiopancreatography. This approach has increased proportion of patients in intermediate likelihood making it heterogenous. We aim to substratify intermediate group so that diagnostic tests (endoscopic ultrasound/magnetic resonance cholangiopancreatography) are judicially used. Methods This is a single-center retrospective analysis of prospectively maintained data. We used subset of patients who met intermediate likelihood of American Society of Gastrointestinal Endoscopy (ASGE) criteria from previously published data (PMID:32106321) as derivation cohort. Binominal logistic regression analysis was used to define independent predictors of choledocholithiasis. A composite score was derived by allotting 1 point for presence of each independent predictor. The diagnostic performance of a composite score of ≥ 1 was evaluated in validation cohort. Results A total of 678 (mean age [standard deviation]: 47.0 [15.9] years; 48.1% men) and 162 (mean age 47.8 [14.8] years; 47.4% men) patients in ASGE intermediate-likelihood group were included as derivation cohort and validation cohort, respectively. Binominal logistic regression analysis showed that male gender (p = 0.024; odds ratio [OR] = 1.92), raised bilirubin (p = 0.001; OR = 2.40), and acute calculus cholecystitis (p = 0.010; OR = 2.04) were independent predictors for choledocholithiasis. A composite score was derived by allotting 1 point for presence of independent predictors Using ≥ 1 as cutoff, sensitivity and specificity for detection of choledocholithiasis were 80% (95% confidence interval [CI]: 68.2–88.9) and 36.2% (95% CI: 32.2–40.0), respectively, in derivation cohort. Applying composite score in independent validation cohort showed sensitivity and specificity of 73.3% (95% CI: 44.9–92.2) and 40.1% (95% CI: 30.1–48.5), respectively. Conclusion Substratification of intermediate-likelihood group of ASGE criteria is feasible. It may be useful in deciding in whom confirmatory tests should be performed with priority and in whom watchful waiting may be sufficient.