Early Early Endoscopic Retrograde Cholangiopancreatography Research Articles

Early Endoscopic Retrograde Cholangiopancreatography in Gallstone Pancreatitis Is Safe: Results From A Large Single Center Retrospective Study

Abstract Objectives There is concern that performing early endoscopic retrograde cholangiopancreatography (ERCP) in the setting of gallstone pancreatitis (GSP) with choledocholithiasis can worsen underlying pancreatitis. This study was designed to assess outcomes of early versus delayed ERCP in patients with gallstone pancreatitis with choledocholithiasis in the absence of cholangitis. Methods In this single center retrospective study, we identified 124 patients who underwent ERCP for choledocholithiasis in the setting of GSP without cholangitis between 2012 and 2022. Timing of ERCP was categorized as early (<48 hours after time of diagnosis) versus delayed (>48 hours). Data on patient demographics, complications, length of stay (LOS), and mortality were collected. Results Cannulation success rates were similar for early and delayed ERCP (97% vs. 100%). The adverse event rate for early ERCP was 15% compared to 29% for delayed ERCP. LOS for patients with predicted mild pancreatitis was shorter for early versus delayed ERCP (4.2 vs. 7.1 days, p = 0.007). There were no deaths in either group. Conclusion There was a trend toward fewer adverse events and there was a shorter LOS among patients with GSP with choledocholithiasis undergoing early versus delayed ERCP. Early ERCP should be considered, particularly in patients with predicted mild pancreatitis.

Effect of Antibiotic Resistance of Pathogens on Initial Antibiotic Therapy for Patients With Cholangitis.

ObjectivesConsidering that pathogens resistant to initial antibiotic therapies for cholangitis can affect mortality rates, appropriate initial empiric antibiotic therapy is important. However, evidence regarding the influence of pathogens resistant to initial antibiotics in patients with cholangitis who have undergone early endoscopic retrograde cholangiopancreatography (ERCP) is limited, and the conditions in several cases can improve with early ERCP even when pathogens resistant to initial antibiotics are detected on time. Therefore, this study aimed to assess the influence of pathogens resistant to initial antibiotics on the course of cholangitis in patients undergoing early ERCP.Materials and methodsPatients (n=266) with positive blood or bile culture results treated with early ERCP were divided into those with cultures that were resistant to the initial antibiotics (antibiotic-resistant group; n=66; 24.8%) and those with cultures that were sensitive to the initial antibiotics (antibiotic-sensitive group; n=200; 75.2%). The duration of hospitalization, in-hospital mortality rates due to cholangitis, rates of increased disease severity, and complications during hospitalization were studied.ResultsEnterococcus, Enterobacter, Citrobacter, and Pseudomonas species showed high resistance to several antibiotics. No significant between-group differences were found in the duration of hospitalization, in-hospital mortality rates due to cholangitis, and rates of increased disease severity. However, the rate of post-ERCP cholecystitis was significantly higher in the antibiotic-resistant group than in the antibiotic-sensitive group (p=0.0245).ConclusionsEven if the initial antibiotics were ineffective, the rate of fatal outcomes did not increase among patients with cholangitis who had undergone early ERCP. However, when initial antibiotics were ineffective, the frequency of post-ERCP cholecystitis increased even after early bile duct decompression.

Role of early endoscopic retrograde cholangiopancreatography in the management of acute biliary pancreatitis

Objective The aim was to evaluate the role of early endoscopic retrograde cholangiopancreatography (ERCP) in reducing mortality and morbidity of acute biliary pancreatitis with the consideration of the economic burden of this maneuver. Background A stone that obstructs the ampulla of Vater can cause biliary pancreatitis. ERCP is used to remove the stones that obstruct the ampulla. The risk-to-benefit ratio of this in the setting of acute pancreatitis is a matter of debate. In this research, we intend to overweight one of the both schools (conservative vs early ERCP). Patients and methods This prospective randomized comparative study was done at the Menoufia University Hospital between April 2015 and January 2018 which included 40 patients who were divided into two groups: groups A included 20 patients managed by early ERCP. Group B included 20 patients managed initially conservatively and they will be divided into three subgroups according to the course of jaundice. B1 subgroup: Those who will continue the conservative course due to continuous daily serial declination of their direct serum bilirubin. Group B2: those with continuous daily serial rising of the serum bilirubin (for 2 consecutive days) and they will be subjected to urgent ERCP. Group B3: those with fluctuating levels of serum bilirubin and they will be subjected to elective ERCP. Both group A and B patients will be subjected to laparoscopic cholecystectomy and were compared as regards the complications, mortality, economic burden, and hospital admission time. Results There was only one complication in group A with a percentage of 5% while there were three complications in group B and there were three with a percentage of 15%; thus, there was a significant reduction in complications in group A (P 0=0.05–0.001). Conclusion Early ERCP by a well-trained endoscopist in acute biliary pancreatitis is effective in reducing the complications and hospital admission time though it has more cost.

Feasibility of Temporary Pancreatic Stenting after Early Endoscopic Retrograde Cholangiopancreatography in Patients with Acute Biliary Pancreatitis.

To assess the safety and effectiveness of temporary pancreatic stenting after early endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis regardless of the severity or concomitant cholangitis. Temporary pancreatic stenting was performed in 79 patients with visualized pancreatic duct during ERCP. The outcomes of 64 patients with adequate pancreatic stenting (PS) and 15 patients with inadequate pancreatic stenting (no PS) were compared in this prospective, observational trial. The baseline characteristics were similar. Development of systemic inflammatory response syndrome (7.8% for PS vs. 13.3% for no PS; p=0.50) and mortality (none for both groups; p=0.99) did not differ. However, fewer local complications occurred in PS than in no PS (4.7% for PS vs. 20.0% for no PS; p=0.04) and the difference was most outstanding in necrosis (1.6% for PS vs. 13.3% for no PS; p=0.03). Temporary pancreatic stenting after early ERCP should be considered safe, as complications did not increase even in cases of inadequate stenting. However, if successful, there appears to be a reduction in local complications.

Delayed endoscopic retrograde cholangiopancreatography is associated with persistent organ failure in hospitalised patients with acute cholangitis

Predictors of organ failure and the impact of early endoscopic retrograde cholangiopancreatography (ERCP) on outcomes in patients with acute cholangitis are unclear. To identify factors associated with persistent organ failure and assess the impact of early ERCP on outcomes in hospitalised patients with cholangitis. Consecutive hospitalised patients who received ERCP at two centres for cholangitis from 4/2005-3/2013 were retrospectively reviewed. Delayed ERCP was defined as ERCP ≥ 48 h after hospitalisation. Primary outcome was persistent organ failure at >48 h after hospitalisation (≥ 1.5 times rise in creatinine levels from baseline values to ≥ 1.5 mg/dL or need for dialysis, mechanical ventilation and/or hypotension requiring vasopressor). 203 patients (mean age 59 ± 19 years) had ERCP for cholangitis: 115 with choledocholithiasis, 48 with other benign obstructions and 40 with malignant strictures. Forty-five (22%) patients had persistent organ failure at >48 h and 11 (5%) died. On multivariate analysis, Charlson Comorbidity Index >2 (OR = 4.6, 95% CI = 1.5-13.8), systemic inflammatory response syndrome (SIRS; OR = 3.2, 95% CI = 1.1-9.8), hypoalbuminemia (OR = 3.3, 95% CI = 1.4-7.9), bacteremia (OR = 2.8, 95% CI 1.3-6.2) and delayed ERCP(OR = 3.1, 95% CI: 1.4-7.0) were associated with persistent organ failure. Every 1-day delay in ERCP was associated with a 17% (95% CI = 5-29%) relative risk increase in persistent organ failure after adjusting for significant factors. Delay in ERCP beyond 48 h was associated with persistent organ failure in hospitalised patients with acute cholangitis. Other factors included increased comorbidities, SIRS, hypoalbuminemia and bacteremia. Early ERCP performed within 48 h after presentation in patients with cholangitis may improve outcomes.

Therapeutic step-up strategy for management of hereditary pancreatitis in children

Background/PurposeVarious different regimes exist for the treatment of hereditary pancreatitis in childhood. Here, we propose a therapeutic pathway with emphasis on endoscopic and surgical procedures. MethodsFrom 2006 to 2013, 12 patients with a diagnosis of hereditary pancreatitis were prospectively included in a therapeutic step-up schema. The treatment outcome was evaluated and correlated to aetiological factors and pathoanatomic findings. ResultsAfter diagnostic work-up (laboratory data, ultrasound examination, magnetic resonance cholangiopancreatography and genetic testing), all 12 patients underwent early endoscopic retrograde cholangiopancreatography (ERCP), which was successfully performed in ten children. Obstructive pancreatitis was found in eight children, and required sphincterotomy, dilation and stenting for 12months. In two children with unsuccessful ERCP, open surgical drainage procedures were performed. After a mean follow-up of 32months all children are free of recurrence of pancreatitis without any impairment of everyday activities. ConclusionsFor children with hereditary pancreatitis, a therapeutic step plan with early ERCP and open surgical drainage procedures in case of impossible or insufficient endoscopic treatment prevents recurring pancreatitis and offers a normal quality of life without any major complications.

Predictors of Organ Failure and Role of Early ERCP in Hospitalized Patients with Acute Cholangitis

Purpose: Acute cholangitis is considered a medical emergency and predictors associated with organ failure are not well defined. Furthermore, the impact of early endoscopic retrograde cholangiopancreatography (ERCP) on outcomes in hospitalized patients with cholangitis is unclear. The aim of the study is to examine clinical outcomes and identify predictors associated with persistent organ failure in hospitalized patients with acute cholangitis. Methods: Consecutive hospitalized patients who received ERCP at Loma Linda University Medical Center for suspected cholangitis between 4/2005-3/2013 were identified by reviewing an internal endoscopy database. Cholangitis was defined by radiographic evidence of biliary obstruction and signs of systemic infection (fever, leukocytosis, bacteremia, and/or purulent bile drainage during ERCP). Primary outcome was persistent organ failure at >48 hours from hospitalization (≥1.5 times rise in creatinine levels from baseline values to ≥1.5 mg/dL, or need for dialysis, mechanical ventilation, and/or hypotension requiring vasopressor). Results: A total of 167 patients who underwent ERCP for indication of suspected cholangitis met the inclusion criteria. The mean age was 60±19 years; 70% were male. On presentation, 86 (51%) patients demonstrated Charcot's triad, 58 (35%) had bacteremia, and ERCP was performed at a median of 41 hours (range, 0-927 hours) from hospitalization. The cause of cholangitis included common bile duct stone in 87 (52%) patients, biliary stent dysfunction in 46 (28%), and malignant stricture in 12 (7%). Initial biliary decompression with ERCP was accomplished in all but 11 patients (7%), and 4 (2%) developed ERCP associated complications (pancreatitis in three, post-sphincterotomy bleeding in one). Clinical outcomes of the 167 patients with cholangitis are shown in Table 1. On multivariate analysis, patients with Charlson Comorbidity Index >2 (odds ratio [OR] 14.0; 95% confidence interval [CI] 2.9-69.0; P=0.001) and 1-2 (OR 6.9; 95% CI 1.3-36.9; P=0.02) compared to zero, presence of systemic inflammatory response syndrome (SIRS; OR 3.7; 95% CI 1.6-8.7; P=0.002), and ERCP performed ≥48 hours (OR 3.2; 95% CI 1.4-7.9; P=0.006) compared to <48 hours from presentation were associated with persistent organ failure.TableConclusion: Delayed performance in ERCP was associated with persistent organ failure in hospitalized patients with acute cholangitis after adjusting for medical comorbidity and SIRS. Early ERCP performed <48 hours from presentation in patients with suspected cholangitis may improve outcomes.

Early Endoscopic Retrograde Cholangiopancreatography in Predicted Severe Acute Biliary Pancreatitis

The role of early endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis (ABP) remains controversial. Previous studies have included only a relatively small number of patients with predicted severe ABP. We investigated the clinical effects of early ERCP in these patients. We performed a prospective, observational multicenter study in 8 university medical centers and 7 major teaching hospitals. One hundred fifty-three patients with predicted severe ABP without cholangitis enrolled in a randomized multicenter trial on probiotic prophylaxis in acute pancreatitis were prospectively followed. Conservative treatment or ERCP within 72 hours after symptom onset (at discretion of the treating physician) were compared for complications and mortality. Patients without and with cholestasis (bilirubin: >2.3 mg/dL [40 mumol/L] and/or dilated common bile duct) were analyzed separately. Of the 153 patients, 81 (53%) underwent ERCP and 72 (47%) conservative treatment. Groups were highly comparable at baseline. Seventy-eight patients (51%) had cholestasis. In patients with cholestasis, ERCP (52/78 patients: 67%), as compared with conservative treatment, was associated with fewer complications (25% vs. 54%, P = 0.020, multivariate adjusted odds ratio [OR]: 0.35, 95% confidence interval [CI]: 0.13-0.99, P= 0.049). This included fewer patients with >30% pancreatic necrosis (8% vs. 31%, P = 0.010). Mortality was nonsignificantly lower after ERCP (6% vs. 15%, P = 0.213, multivariate adjusted OR: 0.44, 95% CI: 0.08-2.28, P = 0.330). In patients without cholestasis, ERCP (29/75 patients: 39%) was not associated with reduced complications (45% vs. 41%, P = 0.814, multivariate adjusted OR: 1.36; 95% CI: 0.49-3.76; P = 0.554) or mortality (14% vs. 17%, P = 0.754, multivariate adjusted OR: 0.78; 95% CI: 0.19-3.12, P = 0.734). Early ERCP is associated with fewer complications in predicted severe ABP if cholestasis is present.

Analysis of Risk Factors Predictive of Early Mortality and Urgent ERCP in Acute Cholangitis

Multifactor prognostic scoring systems have been developed for acute pancreatitis to identify those patients with a potentially poor prognosis. A similar system for patients with acute cholangitis is still lacking. To identify common clinical, biochemical, and etiologic variables that can be used to predict mortality and the need for early endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute cholangitis. A retrospective study of 108 patients with acute cholangitis was performed at a single center. Univariate analysis and logistic regression were used to identify variables that were significantly associated and predictive of mortality and need for early ERCP. Univariate analysis identified 18 variables significantly associated with mortality and 15 variables that predicted the need for early ERCP. Through logistic regression total bilirubin (P<0.01), partial prothrombin time (P<0.01), and presence of a liver abscess (P<0.01) were found to be significant in predicting mortality. Alanine aminotransferase (P<0.01) and white blood cell count (P<0.01) were determined to be predictive of a need for early ERCP. The scoring systems for predicting mortality (93.9%, 80.7%) and early ERCP (98%, 91%) were both highly sensitive and specific, respectively. Acute cholangitis is a disease that presents with varying severity. We report a scoring system that can be used to identify patients at high risk of early mortality and those that may benefit from earlier ERCP.

Early Endoscopic Retrograde Cholangiopancreatography Versus Conservative Management in Acute Biliary Pancreatitis Without Cholangitis

Early endoscopic retrograde cholangiopancreatography (ERCP) should be performed in all patients with acute biliary pancreatitis (ABP) and coexisting acute cholangitis. In patients without cholangitis and predicted mild ABP it is generally accepted that early ERCP should not be performed. Nevertheless, there is a controversy regarding the role of early ERCP in the treatment of patients with predicted severe ABP without cholangitis. We reviewed randomized trials on early ERCP versus conservative management in patients with ABP without acute cholangitis. Relevant publications in 3 electronic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) were systematically reviewed and meta-analyzed. Seven randomized trials on ERCP in acute pancreatitis were found, of which 3 including a total of 450 patients (230 in the invasive arm and 220 in the control arm) qualified for a meta-analysis according to predefined criteria. In all patients with ABP (predicted mild and severe), early ERCP was associated with a nonsignificant reduction in overall complications [risk ratio (RR) 0.76; 95% confidence interval (CI) 0.41-1.04; P = 0.38] and a nonsignificant increase in mortality (RR 1.13; 95% CI 0.23-5.63; P = 0.88). Subgroup analysis based on predicted severity did not affect these outcomes (overall complications: predicted mild: RR 0.86; 95% CI 0.62-1.19; P = 0.36; predicted severe: RR 0.82; 95% CI 0.32-2.10; P = 0.68; mortality: predicted mild: RR 1.90; 95% CI 0.25-14.55; P = 0.53; predicted severe: RR 1.28; 95% CI 0.20-8.06; P = 0.80). In this meta-analysis, early ERCP in patients with predicted mild and predicted severe ABP without acute cholangitis did not lead to a significant reduction in the risk of overall complications and mortality.

Early ERCP for Gallstone Pancreatitis: For Whom and When?

The indications for early endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis are unclear, and the examination is often requested or performed without substantial supporting evidence. Several trials have been performed to determine the benefit of early ERCP in pancreatitis, yet the results of these studies are inconsistent. To more closely analyze these studies, we performed an evidence-based review of the outcomes of early ERCP in gallstone pancreatitis. To obtain the best available evidence, a PubMed search using the MeSH terms “gallstones” and “pancreatitis” was performed and further refined to identify appropriate studies. We included five randomized trials, a meta-analysis, and a Cochrane Database Systematic Review in our detailed examination of the pertinent literature. Collectively, these studies suggest that early ERCP does not alter mortality in gallstone pancreatitis. In addition, few patients with mild pancreatitis benefit from the procedure, whereas some studies indicate that patients with severe pancreatitis or documented biliary obstruction may experience fewer complications if ERCP is performed. The data in the studies are confounding because of heterogeneity of the patient population and the inability to confirm gallstones in up to one third of patients. In conclusion, ERCP is not indicated for patients with mild pancreatitis. In select patients with severe disease or biliary obstruction, ERCP may be indicated. A multicenter trial designed to study the effect of early ERCP in severe pancreatitis only may provide additional useful information in patients with documented gallstones.

Early ERCP vs. Conservative Management in Gallstone Pancreatitis

For patients with acute gallstone pancreatitis, whether there is a need for early endoscopic retrograde cholangiopancreatography (ERCP) remains

Early ERCP in biliary pancreatitis?

Background: The role of early endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy in the treatment of patients who have acute biliary pancreatitis without obstructive jaundice is uncertain. Methods: We conducted a prospective, multicenter study in which 126 patients were randomly assigned to early ERCP (within 72 hours after the onset of symptoms) and endoscopic papillotomy for the removal of stones in the common bile duct, when appropriate, and 112 patients were assigned to conservative treatment. In the conservative- treatment group, ERCP was performed within three weeks if signs of biliary obstruction or sepsis developed. Overall mortality, mortality due to pancreatitis, and complications were compared in the two groups. Results: Early ERCP was successful in 121 of the 126 patients in the invasive-treatment group. Endoscopic papillotomy was performed to remove bile-duct stones in 58 patients; stones were successfully extracted in 57. ERCP was performed in 22 of the 112 patients in the conservativetreatment group; papillotomy for stone removal was successful in 13 patients. Fourteen patients in the invasire- treatment group and 7 in the conservative-treatment group died within three months (P =0.10); 10 patients in the invasive-treatment group and 4 in the conservativetreatment group died from acute biliary pancreatitis (P= 0.16). The overall rate of complications was similar in the two groups, but patients in the invasive-treatment group had more severe complications. Respiratory failure was more frequent in the invasive-treatment group, and jaundice was more frequent in the conservative-treatment group. Conclusions: In patients with acute biliary pancreatitis but without obstructive jaundice, early ERCP and papillotomy were not beneficial.