Endoscopic Retrograde Cholangiopancreatography Findings Research Articles

The Frequency, Patterns and Management of Bacterial Cholangitis in Living-Donor Liver Transplant Recipients with Biliary Complications: A Single Center Study

Abstract Background Biliary complications are still frequent after liver transplantation especially living donor liver transplantation (LDLT). Bacterial cholangitis is a potentially life-threatening complication. Management is based on antimicrobial therapy and surgical drainage. Bile cultures can play a role in determining the causative agent and optimizing antibiotic therapy. Aim We aimed to assess the incidence of bacterial cholangitis among recipients of LDLL, identify the most common bacteria and their antibiotic susceptibility, and evaluate the role of bile culture and endoscopic retrograde cholangiopancreatography (ERCP) in the management of potential biliary infection. Methods This study was conducted at Ain Shams Center for Organ Transplantation between February 2019 and April 2022. The study included 39 LDLT recipients who developed post-transplant cholangitis on top of biliary complications. Liver function tests, imaging, ERCP, and blood and bile culture and sensitivity were performed in all patients. Results The incidence of biliary complications was 38.2%. Imaging and ERCP findings were consistent regarding the diagnosis of anastomotic stricture. Stones were detected by ERCP in 12 patients when magnetic resonance cholangiopancreatography detected them in only one patient. The most common organism isolated from both bile and blood cultures was E. coli. Antibiotics that matched bile and blood cultures were linezolid, ceftazidime/avibactam, imipenem + cilastatin, and amoxicillin/clavulanic acid. Three bile cultures showed multidrug resistance for combination therapy. Conclusion Anastomotic strictures and cholangitis are common complications of LDLT. E coli is the most common organism detected in bile and blood cultures. Therefore, antibiotic selection based on concurrent blood and bile culture interpretation can help optimize therapy.

Comparative study of Endoscopic Retrograde Cholangiopancreatography Findings versus Magnetic Resonance Cholangiopancreatography in detection of lesions of the biliary tree in patients with common bile duct dilatation

Comparative study of Endoscopic Retrograde Cholangiopancreatography Findings versus Magnetic Resonance Cholangiopancreatography in detection of lesions of the biliary tree in patients with common bile duct dilatation

Association of short-course antimicrobial therapy and bacterial resistance in acute cholangitis: Retrospective cohort study.

Background and study aims Although the number of resistant bacteria tends to increase with prolonged antimicrobial therapy, no studies have examined the relationship between the duration of antimicrobial therapy and increase in the number of resistant bacteria in acute cholangitis. We hypothesized that the short-term administration of antimicrobial agents in acute cholangitis would suppress bacterial resistance. Patients and methods This was a single-center, retrospective, observational study of patients with acute cholangitis admitted between January 2018 and June 2020 who met the following criteria: successful biliary drainage, positive blood or bile cultures, bacteria identified from cultures sensitive to antimicrobials, and subsequent cholangitis recurrence by January 2022. The patients were divided into two groups: those whose causative organisms at the time of recurrence became resistant to the antimicrobial agents used at the time of initial admission (resistant group) and those who remained susceptible (susceptible group). Multivariate analysis was used to examine risk factors associated with the development of resistant pathogens. Multivariate analysis investigated antibiotics used with the length of 3 days or shorter after endoscopic retrograde cholangiopancreatography (ERCP) and previously reported risk factors for the development of bacterial resistance. Results In total, 89 eligible patients were included in this study. There were no significant differences in patient background or ERCP findings between the groups. The use of antibiotics, completed within 3 days after ERCP, was associated with a lower risk of developing bacterial resistance (odds ratio, 0.17; 95% confidence interval, 0.04-0.65; P =0.01). Conclusions In acute cholangitis, the administration of antimicrobials within 3 days of ERCP may suppress the development of resistant bacteria.

Choledocholithiasis: A Review of Management and Outcomes in a Regional Setting.

Background Choledocholithiasis is a common surgical presentation with an incidence of 8% to 16% in symptomatic cholelithiasis. Treatment often requires a multi-stage approach via endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC), which can prolong the length of stay (LoS) and expose patients to unnecessary risks. A single-stage procedure, such as LC with common bile duct exploration (CBDE), is a safe and effective option that may decrease LoS. This study compares patient outcomes and management in a regional center and aims to identify factors that predict the presence of confirmed choledocholithiasis. Methods A retrospective cross-sectional analysis was performed on all patients admitted to Toowoomba Hospital for management of diagnosed or suspected choledocholithiasis from January 2021 to March 2023. Patient demographics, ERCP findings, and operative data were collated. Results A total of 195 patients were identified, including 136 patients undergoing multi-stage management, 34 patients who had an ERCP alone, and 25 patients who underwent single-stage management. Single-stage procedures had an 80% success rate with an average LoS of 3.6 days. Multi-stage procedures had an average LoS of 8.1 days and an ERCP success rate of 93%. Complication rates between ERCP (11.7%) and LC with CBDE (9.7%) were comparable. Time to index ERCP and serum bilirubin level were found to be significantly lower in those with positive index ERCP findings compared to those without. Conclusion Single-stage procedures are a safe way to manage choledocholithiasis and are associated with a reduced LoS when compared to multi-stage management, with comparable efficacy and morbidity rates.

Ectopic Opening of Common Bile Duct to Duodenal Bulb: A Single Tertiary Center Experience.

The ectopic opening of the common bile duct(CBD) into the duodenal bulb is a rare biliary anomaly. The study aimed to reveal the experience with clinical and endoscopic outcomes in these patients. This study was conducted on 57 consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for ectopic opening of the CBD into the duodenal bulb at our institution between 2010 and 2020. The median age was 59 years (49 males). A total of 146 ERCP procedures were performed (once in 26 patients and 2 or more times in 31 patients). Ten patients had a history of unsuccessful ERCP in an external center. The median follow-up time was 14.6 months. All patients had a slit-like opening of the CBD into the duodenal bulb, apical stenosis, and hook-shaped distal CBD. ERCP findings were CBD stone or dilatation in 55 patients and post-cholecystectomy biliary leakage in 2 patients. Balloon dilatation was performed for apical stenosis in 7 patients and distal CBD stenosis in 26 patients. During the first ERCP session, biliary stent/nasobiliary drainage was placed in 37 patients, and CBD stones were extracted in 19 patients without stenting. Biliodigestive anastomosis was applied to 13 patients, 5 of whom had recurrent cholangitis, 7 required recurrent ERCP, and one was due to the technical difficulty of ERCP. Ectopic biliary opening should be remembered if the papilla cannot be seen in its usual place in a patient with apical stenosis. ERCP should be performed in experienced hands, and surgery should be considered in the need for recurrent ERCP.

ERCP findings provide further justification for a "surgery-first" mindset in choledocholithiasis.

Choledocholithiasis is most often managed in a two-procedure pathway including endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). In contrast, a single-stage, surgery-first approach consisting of LC, cholangiogram, and laparoscopic common bile duct exploration (LCBDE) is associated with reduced hospital stays and equivalent morbidity. Despite this, nationwide referral patterns heavily favor ERCP, obscuring those undergoing ERCP with obstructions amenable to simple intraoperative interventions. We hypothesized that most patients had endoscopic findings consistent with simple sludge or small-to-medium stones, which could have been cleared by basic LCBDE maneuvers. We retrospectively reviewed 294 patients > 18yearsold who underwent preoperative ERCP for the management of suspected choledocholithiasis. Exclusion criteria included: failed ERCP, cholangitis, prior cholecystectomy, patient refusal of surgery, or medical conditions precluding surgical candidacy. Stone size was categorized as small (0-4mm), medium (5-7mm), and large (≥ 8mm). At the time of ERCP, 37 (20.1%) patients had sludge only, 96 (52.2%) had stones only, 42 (22.8%) had sludge and stones, and 9 (4.8%) had no stones. Of the 138 patients with any stones, 37 (26.8%) had small stones, 41 (29.7%) medium, 43 (31.2%) large, and 17 (12.3%) had uncharacterizable stones. Overall, 74.3% of patients had findings of sludge, stones (0-7mm), or negative ERCP. The majority of patients who underwent preoperative ERCP for suspected choledocholithiasis had findings that are amenable to simple intraoperative interventions. In fact, over a quarter of the patients had a negative ERCP, sludge, or small stones which would likely be cleared by flushing/glucagon precluding any further instrumentation. While large stones may require more advanced techniques, this represents a small percentage of patients. Surgery-first management for suspected choledocholithiasis can offer an efficient alternative for the majority of patients.

ADVERSE OUTCOMES OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AT GASTROENTEROLOGY AND HEPATOLOGY CENTERS IN SULAYMANIYAH AND DUHOK CITY

Background 
 Endoscopic retrograde cholangiopancreatography (ERCP) has a significant and managing management of pancreaticobiliary diseases in Iraq and Kurdistan. Evaluating ERCP adverse outcomes is essential in raising the effectiveness and safety of ERCP.
 Objectives 
 To review and measure the rate of ERCP complications in our centre and compare our results with other countries.
 Patients and Methods
 The present study was a prospective cross-sectional study carried out in the Kurdistan Center of Gastroenterology and Hepatology (KCGH) in Sulaimani city and Azadi Gastroenterology and Hepatology Center in Duhok city, Kurdistan region-Iraq through the period of one year from 1st of November 2020, to 31st of October, 2021 on a sample of two hundred patients underwent ERCP; 140 patients from Sulaimani city and 60 patients from Duhok city. The researcher followed up with the patients one month after completing ERCP through direct interviews or by phone calling to observe any ERCP adverse outcomes.
 Results
 The most typical indication for ERCP among studied patients was choledocholithiasis (43.7%), followed by; stent removal with occlusion cholangiography (12%) and biliary malignancy (11.6%). The commonest findings of ERCP among studied patients were bile duct dilation (42.3%), filling defects (33.8%) and bile duct strictures (14.7%). The post-ERCP complications were present in 45 (22.5%) patients, including pancreatitis (12.5%), cholangitis (4.5%), hypoxia (3.5%), bleeding (1.5%), perforation (1.5%) and death (0.5%). 
 Conclusion
 The adverse outcomes of ERCP in KCGH in Sulaimani City and the Gastroenterology and Hepatology centre in Duhok city are increased in the last year.

Incidence and Predictors of Incidental Biochemical and Radiologic Pancreatic Alterations Following Uncomplicated ERCP.

Despite post-ERCP pancreatitis (PEP) being a major focus of outcomes research in endoscopic retrograde cholangiopancreatography (ERCP), little is known regarding the frequency with which asymptomatic biochemical and/or radiologic pancreatic alterations occur in patients following ERCP. Adult inpatients undergoing ERCP were identified from a prospective ERCP registry. Patients with any abdominal pain, confirmed PEP, or pancreatitis or abnormal pancreatic enzymes preceding ERCP were excluded. Primary outcomes were asymptomatic lipase elevation on bloodwork within 24 h of ERCP or asymptomatic cross-sectional imaging findings consistent with acute pancreatitis in the absence of clinical PEP within 14 days. Multinomial logistic regression and multiple logistic regression were used to examine associations between exposures and lipase levels and between PEP or imaging findings, respectively. In total, 646 and 187 patients were analyzed as part of the biochemical and radiologic cohorts, respectively. A total of 26.0% of patients had asymptomatic elevations in lipase above the upper limit of normal (ULN) within 24 h, and 9.4% had elevations >3× ULN. A total of 20.9% of patients had incidental findings of enlargement, inflammation/edema/fat stranding, peri-pancreatic fluid collections, and/or necrosis on cross-sectional imaging within 14 days. Pancreatic contrast injection was associated with higher odds of asymptomatic lipasemia (adjusted odds ratio, AOR, 7.22; 95% confidence intervals, CI, 1.13 to 46.02), as was the use of the double-wire technique (AOR 15.74; 95% 1.15 to 214.74) and placement of a common bile duct stent (AOR 4.19; 95% CI 1.37 to 12.77). Over 10 cannulation attempts were associated with the presence of one or more radiologic finding(s) (AOR 33.95; 95% CI 1.64, to 704.13). Significant rates of incidental biochemical and/or radiologic pancreatic abnormalities are present following ERCP. Clinicians should be aware of our findings to minimize misclassification and better direct healthcare utilization.

Sensitivity and Specificity of Magnetic Resonance Cholangiopancreatography against Endoscopic Retrograde Cholangiopancreatography in Diagnosing Choledocholithiasis

Background: Various imaging modalities including EUS (Endoscopic ultrasound), CT abdomen (Computed tomography), MRCP (Magnetic resonance cholangiopancreatography), and ERCP (Endoscopic retrograde cholangiopancreatography) are used for diagnosis of choledocholithiasis. ERCP allows direct visualization of bile duct through endoscope, and it also helps in retrieval of stones. On the other hand, MRCP is a noninvasive procedure which uses strong magnetic field to visualize hepatobiliary system. In patients with choledocholithiasis calculi appear as dark filling defects within high signal intensity fluid at MRCP. This study compares the diagnostic accuracy of MRCP in comparison to ERCP in patients with choledocholithiasis. This study aims to compare sensitivity and specificity of MRCP in comparison to ERCP in diagnosing choledocholithiasis.
 Methodology: This comparative cross-sectional study included 170 patients with clinical diagnosis of choledocholithiasis who presented in Liver Center, Holy Family Hospital, Rawalpindi, during the year 2017. Non-probability consecutive sampling technique and a set of established inclusion and exclusion criteria was used to enroll patients. Data was collected by a self-structured questionnaire. Information about the demographic details and findings of ERCP and MRCP were noted on that questionnaire. Data analysis was done using SPSS 25.
 Results: Out of 170 patients, 111 (65.29%) were females and 59 (34.71%) were males. The mean of age for study population was 45.68 with standard deviation (SD) of ±12.40. ERCP confirmed stones in 95 patients while in case of MRCP 87 true positives, 55 true negatives, 20 false positives, and 8 false negatives cases were noted. According to these results, the sensitivity and specificity were 91.6% and 73.3% respectively for MRCP against ERCP. Whereas positive predictive value and negative predictive values were 81.3 and 87.3% respectively for MRCP in comparison to ERCP.
 Conclusion: MRCP has 91.6% sensitivity compared to ERCP. Although MRCP is a comparatively noninvasive procedure, but ERCP remains the diagnostic modality of choice for choledocholithiasis. MRCP could be used in diagnosis of choledocholithiasis instead of ERCP when there are contraindications of ERCP or when no therapeutic role of ERCP is required.
 Recommendations: MRCP should be used when only diagnostic role of ERCP is needed. MRCP should be used when there are contraindications of ERCP. Level of expertise should be increased for MRCP and ERCP.

Diagnostic utility of MRCP in obstructive jaundice and comparison with CT & ultrasonography

Introduction: With availability of multiple therapeutic options accessible to patients with obstructive jaundice, it is crucial to convey vital information through radiological investigations to decide further management plan. Apart from confirming presence of obstruction in biliary tract and identifying its cause whether benign or malignant, imaging can provide details about anatomical level of obstruction, extent of the pathology as well as its amenability to interventional procedures. Aim and Objective: To evaluate the diagnostic accuracy of Magnetic Resonance Cholangiopancreatography (MRCP) compared with Ultrasound and Computed Tomography (CT) in patients with obstructive jaundice taking findings of ERCP/ PTC and histopathology as gold standard.Materials and Methods: This prospective study included 36 patients who were referred to the department of radio-diagnosis with clinical features of obstructive jaundice.Initial ultrasonography (USG) was followed by Computed tomography (CT) and Magnetic Resonance Cholangiopancreatography (MRCP), however in cases of benign pathologies where USG findings were unequivocal Computed tomography (CT) was not done to avoid unnecessary radiation exposure. The reporting was done by radiologists blinded to other imaging findings. The characteristic Endoscopic Retrograde Cholangiopancreatography (ERCP) features/ histopathological diagnosis (as applicable) were considered as final.Results: For diagnosing the cause of obstructive jaundice, MRI with MRCP has a greater diagnostic accuracy of 94.4% than CT with accuracy is 91.6% and USG with diagnostic accuracy of 30.56%.Conclusion: Ultrasound is a good screening modality to confirm biliary obstruction and to decide whether MRCP is required as next step or not. MRCP is a highly useful non-invasive imaging study in the pre-operative workup of cases with obstructive jaundice.

Evaluating the accuracy of American Society for Gastrointestinal Endoscopy guidelines in patients with acute gallstone pancreatitis with choledocholithiasis.

BACKGROUNDAcute gallstone pancreatitis (AGP) is the most common cause of acute pancreatitis (AP) in the United States. Patients with AGP may also present with choledocholithiasis. In 2010, the American Society for Gastrointestinal Endoscopy (ASGE) suggested a management algorithm based on probability for choledocholithiasis, recommending additional imaging for patients at intermediate risk and endoscopic retrograde cholangiopancreatography (ERCP) for patients at high risk of choledocholithiasis. In 2019, the ASGE guidelines were updated using more specific criteria to categorize individuals at high risk for choledocholithiasis. Neither ASGE guideline has been studied in AGP to determine the probability of having choledocholithiasis. AIMTo determine compliance with ASGE guidelines, assess outcomes, and compare 2019 vs 2010 ASGE criteria for suspected choledocholithiasis in AGP. METHODSWe conducted a retrospective cohort study of 882 patients admitted with AP to a single tertiary care center from 2008-2018. AP was diagnosed using revised Atlanta criteria and AGP was defined as the presence of gallstones on imaging or with cholestatic pattern of liver injury in the absence of another cause. Patients with chronic pancreatitis and pancreatic malignancy were excluded as were those who went directly to cholecystectomy prior to assessment for choledocholithiasis. Patients were assigned low, intermediate or high risk based on ASGE guidelines. Our primary outcomes of interest were the proportion of patients in the intermediate risk group undergoing magnetic resonance cholangiopancreatography (MRCP) first and the proportion of patients in the high risk group undergoing ERCP directly without preceding imaging. Secondary outcomes of interest included outcome differences based on if guidelines were not adhered to. We then evaluated the diagnostic accuracy of 2019 in comparison to the 2010 ASGE criteria for patients with suspected choledocholithiasis. We performed the t test or Wilcoxon rank sum test, as appropriate, to analyze if there were outcome differences based on if guidelines were not adhered to. Kappa coefficients were calculated to measure the degree of agreement between pairs of variables. RESULTSIn this cohort, we identified 235 patients with AGP of which 79 patients were excluded as they went directly to surgery for cholecystectomy without prior MRCP or ERCP. Of the remaining 156 patients, 79 patients were categorized as intermediate risk and 77 patients were high risk for choledocholithiasis according to the 2010 ASGE guidelines. Among 79 intermediate risk patients, 54 (68%) underwent MRCP first whereas 25 patients (32%) went directly to ERCP. For the 54 patients with intermediate risk who had MRCP first, 36 patients had no choledocholithiasis while 18 patients had evidence of choledocholithiasis prompting ERCP. Of these patients, ERCP confirmed stone disease in 11 patients. Of the 25 intermediate risk patients who directly underwent ERCP, 18 patients had stone disease. One patient with a normal ERCP developed post ERCP pancreatitis. Patients undergoing MRCP in this group had a significantly longer length of stay (5.0 vs 4.0 d, P = 0.02). In the high risk group, 64 patients (83%) had ERCP without preceding imaging, of which, 53 patients had findings consistent with choledocholithiasis, of which 13 patients (17%) underwent MRCP before ERCP, all of which showed evidence of stone disease. Furthermore, all of these patients ultimately had an ERCP, of which 8 patients had evidence of stones and 5 had normal examination.Our cohort also demonstrated that 58% of all 156 patients with AGP had confirmed choledocholithiasis (79% of the high risk group and 37% of the intermediate group when risk was assigned based on the 2010 ASGE guidelines). When the updated 2019 ASGE guidelines were applied instead of the original 2010 guidelines, there was moderate agreement between the 2010 and 2019 guidelines (kappa = 0.46, 95%CI: 0.34-0.58). Forty-two of 77 patients were still deemed to be high risk and 35 patients were downgraded to intermediate risk. Thirty-five patients who were originally assigned high risk were reclassified as intermediate risk. For these 35 patients, 26 patients had ERCP findings consistent with choledocholithiasis and 9 patients had a normal examination. Based on the 2019 criteria, 9/35 patients who were downgraded to intermediate risk had an unnecessary ERCP with normal findings (without a preceding MRCP).CONCLUSIONTwo-thirds in intermediate risk and 83% in high risk group followed ASGE guidelines for choledocholithiasis. One intermediate-group patient with normal ERCP had post-ERCP AP, highlighting the risk of unnecessary procedures.

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 Findings in HIV Cholangiopathy Patients

HIV infection and its related opportunistic infections increasing the risk of having HIV-related cholangiopathy, especially those who had low CD4 counts. In this case series, we assessed the findings of endoscopic retrograde cholangiopancreatography and the interventions required in those patients who underwent this procedure at Tripoli Central Hospital between January 2007 and December 2020, comparing them with previous studies conducted in other centers. Our study concluded that common bile duct strictures are more frequent finding than papillary stenosis, and accordingly most of those patients managed by placing common bile duct stent rather than sphincterotomy only.

ID: 3517428 AUTOIMMUNE PANCREATITIS WITH PANCREATIC CALCULI AND PSEUDOCYST: A CASE REPORT

Autoimmune pancreatitis (AIP) is a unique form of pancreatitis often associated with Immunoglobulin G4 (IgG4) infiltration, swollen pancreas, and diffuse narrowing of pancreatic ducts. Unlike acute pancreatitis, AIP is rarely complicated with pseudocysts. Pancreatic calculi, a feature of ordinary chronic pancreatitis, are unusual during short-term follow-up in AIP. Here, we report a 46-year-old man whom initially presented as submucosal tumor of the stomach. The patient was finally diagnosed with AIP accompanied with a pseudocyst on the tail of the pancreas located on the gastric wall and pancreatic calculi by endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA). He underwent endoscopic retrograde cholangiopancreatography (ERCP), pancreatic duct stent placement, and steroid treatment and achieved good clinical and laboratory responses. Though AIP is a common form of autoimmune disease which responses well to steroids, pseudocyst and pancreatic calculi are rare manifestations of AIP and should be paid attention to especially in patients with disease relapse. EUS and ERCP findings of the patient. (A) EUS shows a gastric abscess with surrounding enhancement after Sulphur Hexafluoride Microbubbles injection. EUS shows (B) calculi and (C) pancreatic duct dilation in pancreatic body. (D) ERCP shows pancreatic duct dilation. (E) Pancreatic duct stent placement was performed. View Large Image Figure Viewer Download Hi-res image

Pancreaticobiliary maljunction in Turkish patients: a multicenter case series.

Pancreaticobiliary maljunction (PBM) is a malformation in which the pancreatic and bile ducts join outside the duodenal wall. It is associated with various biliary and pancreatic diseases. In addition, patients with PBM carry a substantial lifetime risk of developing biliary or gallbladder carcinoma. We aimed to present a multicenter case series of PBM from Turkey. This study was conducted in adult and pediatric PBM patients who were referred to three tertiary reference centers of Turkey for endoscopic retrograde cholangiopancreatography (ERCP) between July 2007 and May 2020. The clinical presentations, types of PBM, ERCP findings, surgical histories, and the postoperative courses, including the development of biliary malignancies, were retrospectively reviewed. The study group included 47 (31 adult and 16 children) patients. Type D PBM was more frequent (13/41: 27.7%) than that reported in Eastern studies. Type A PBM was more common in the adults (51.6% vs. 12.5%, p < 0.05), whereas type C was more common in pediatric patients (31.3% vs. 13.2%, p < 0.05). Although fusiform anatomy was predominant in both of the groups, cystic dilatation was more common (25.8% vs. 12.5%) in adults and the common bile duct diameter was greater [22mm (range 11-58) vs. 12mm (range 5-33)] in adult patients compared to pediatric patients. Resective surgeries were more frequently done in pediatric patients (73.3% vs. 53.6%), whereas cholecystectomy was more frequently performed in adult patients (21.4% vs. 6.7%). Although our findings were compatible with Eastern studies, type D PBM (associated with pancreas divisum) was more frequent in our study population.

Comparative study between endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in diagnosis of biliary obstruction

Introduction Endoscopic ultrasound (EUS) is a diagnostic procedure that continues to have greater clinical applications. EUS performed before endoscopic retrograde cholangiopancreatography (ERCP) in patients with obstructive jaundice can reduce morbidity and mortality. Aim This study aimed to compare the diagnostic accuracy of both EUS and ERCP as combined or individual procedures in 30 patients diagnosed with biliary obstruction. Patients and methods From January 2017 to December 2019 in Al Azhar University Hospitals in Cairo, we recruited 30 patients with obstructive jaundice. All the patients underwent clinical examination, laboratory investigations, and abdominal US followed by EUS and ERCP procedures at the same session, and EUS findings were compared with that of ERCP. Results The diagnostic accuracy of EUS was as follows: choledocholithiasis in 92%, and malignant lesions in 95%. EUS showed pathology in 47.3% of patients who had an unknown pathology in biliary system at initial investigations. The overall diagnostic performance of EUS shows that the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 90.9, 89, 91.7, 95, and 93.5%, respectively. Regarding common bile duct stone (s), by ERCP, it was present in 13 (43.3%) cases, whereas by EUS, it was present in 12 (40%) cases. Regarding malignant lesions (ampullary tumor, cholangiocarcinoma, and pancreatic tumor), by ERCP, they were present in four (13.3%), seven (23.3%), three (10%) cases, respectively, whereas by EUS, they were present in five (16.6), six (20%), and five (16.6) cases, respectively. The complication rate was 3.3%. Conclusions EUS established high diagnostic accuracy in diagnosing the causes of obstructive jaundice, with no statistically significant difference between ERCP and EUS findings. This accurately guided ERCP need and avoided needless ERCP. EUS and ERCP in a single session for treatment of obstructive jaundice is scientifically valuable.

Development of an Online App to Predict Post-Endoscopic Retrograde Cholangiopancreatography Adverse Events Using a Single-Center Retrospective Cohort

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding procedure with a high risk for adverse events (AEs). Aim: evaluate patient- and procedure-related risk factors for ERCP-related AEs and develop an online app to estimate risk of AEs. Methods: retrospective study of 1,491 consecutive patients who underwent 1,991 ERCPs between 2012 and 2017 was conducted. AEs definition and severity were classified according to most recent ESGE guidelines. Each variable was tested for association with occurrence of overall AEs, post-ERCP pancreatitis (PEP) and cholangitis. For each outcome, 2 regression models were built, from which an online Shiny-based app was created. Results: Overall AE rate was 15.3%; in 19 procedures, >1 AE occurred. Main post-ERCP AE was PEP (7.5%), followed by cholangitis (4.9%), bleeding (1.3%), perforation (1%), cardiopulmonary events (0.9%), and cholecystitis (0.3%). Seventy-eight percent of AEs were mild/moderate; of severe (n = 55) and fatal (n = 20) AEs, more than half were related to infection, cardiac/pulmonary AEs, and perforation. AE-related mortality rate was 1%. When testing precannulation, procedural covariates, and ERCP findings, AE occurrence was associated with age (odds ratio [OR] 0.991), previous PEP (OR 2.198), ERCP complexity grade III/IV (OR 1.924), standard bile duct cannulation (OR 0.501), sphincterotomy (OR 1.441), metal biliary stent placement (OR 2.014), periprocedural bleeding (OR 3.024), and biliary duct lithiasis (OR 0.673). Conclusion: Our app may allow an optimization of the patients’ care, by helping in the process of decision-making, not only regarding patient or endoscopist’s selection but also definition of an adequate and tailored surveillance plan after the procedure.

Assessment of the possible risk factors for primary common bile duct stone recurrence after cholecystectomy.

Common bile duct (CBD) stone recurrence is considered an unresolved concern after cholecystectomy and complete extraction of previous CBD stones. This study aimed to investigate the potential risk factors for primary CBD stone recurrence after cholecystectomy and endoscopic treatment. The endoscopic retrograde cholangiopancreatography (ERCP) database of our medical center was retrospectively reviewed between February 2008 and May 2018. A total of 45 patients with CBD stone recurrence with a history of previous cholecystectomy were recruited in the study. Moreover, 104 patients who underwent cholecystectomy at our medical center and who were followed up for more than 1 year without CBD stone recurrence were assigned to the control group. The characteristics of the patients, surgical records during cholecystectomy, and ERCP records obtained immediately before cholecystectomy were analyzed. Univariate analysis, based on the binary logistic regression method, indicated that age (p = 0.01) and the presence of the periampullary diverticulum (PAD; p = 0.006) were significantly different between the non-recurrence and recurrence groups. However, the surgical records during cholecystectomy were not significantly different between the two groups. The CBD stone number (p = 0.039), CBD stone diameter (≥ 10mm; p = 0.05), and CBD diameter (≥ 15 mm; p < 0.001), based on the ERCP findings were significantly different between the two groups. Multivariate analysis revealed that CBD diameter (≥ 15mm; OR, 3.878; 95% CI, 1.406-10.697; p = 0.008) was the independent risk factors for CBD stone recurrence after cholecystectomy. CBD diameter (≥ 15mm) at the time of the initial ERCP is associated with CBD stone recurrence after cholecystectomy.

S1601 Malignant Melanoma of the Gallbladder Masquerading as Cholangitis and Cholecystitis

INTRODUCTION: Metastatic Malignant melanoma is reported in the stomach, intestine and colon. The involvement of the gallbladder and the bile duct are extremely rare. CASE DESCRIPTION/METHODS: A 61-year-old male presented with abdominal pain, nausea, vomiting, fever, chills, and 10lb weight loss. Physical examination was notable for right upper quadrant abdominal tenderness with a positive Murphy’s sign and minimal jaundice. Lab data showed no leukocytosis and normal hemoglobin. Elevated liver tests with Alk Phos 435U/L, ALT 546U/L, AST 474U/L, and Tbili 3.1mg/dl prompted an abdominal ultrasound which showed intrahepatic and extrahepatic bile duct dilatation (common bile duct (CBD) 11mm). A diffusely abnormal thick-walled gall bladder filled with debris was seen. This was concerning for cholecystitis and cholangitis. He was started on piperacillin/tazobactam. An endoscopic ultrasound (EUS) revealed hyperechoic material suggestive of thick sludge versus tissue within gallbladder lumen extending into the CBD (Figure 1a). Endoscopic retrograde cholangio-pancreatography (ERCP) revealed irregular filling defects within CBD close to cystic duct takeoff (Figure 1b). After sphincterotomy, balloon sweeps evacuated pigmented tissue debris (Figure 1c) which was retrieved and sent for pathology. Unusual EUS/ ERCP findings prompted an MRI which showed high T1 signal within periportal nodes and gallbladder suggesting hemorrhage. Surgical consultation was obtained and patient underwent laparoscopic cholecystectomy, but frozen section indicated malignancy, therefore, an open liver resection and lymphadenectomy was completed. The gross pathology showed a 2.5 × 1.6 × 1.5cm mass arising from the gallbladder (Figure 2a) with invasion into the peri muscular connective tissue on the hepatic side but with no direct extension. An immunostain on the tumor and the prior biliary tissue debris showed positive staining for Vimentin, and S100 and a diagnosis of melanoma was confirmed (Figures 2b and 2c). Surgical staging was pT2bN1. Skin and ocular examination did not reveal any lesions. DISCUSSION: Melanoma involving the gastrointestinal tract is usually metastatic from known cutaneous melanoma; however primary melanoma of the GI tract have been reported. Within the GI tract, primary gallbladder melanoma is extremely rare with less than 40 cases reported in the literature. Clinical course is typically aggressive; our patient developed metastatic disease to brain soon after gallbladder resection.Figure 1.: EUS and ERCP image.Figure 2.: Pathology image.

Endoscopic retrograde cholangiopancreatography (ERCP) findings to predict survival in patients with metastatic pancreatic adenocarcinoma.

e16734 Background: Chemotherapy is the primary therapy for patients with metastatic pancreatic ductal adenocarcinoma (PDAC), but response to therapy is variable. Patients with PDAC often develop jaundice and cholangitis and require endoscopic biliary stenting. Here, we investigate the association between ERCP findings, cholangitis, chemotherapy use, and survival in PDAC patients. Methods: We conducted a retrospective chart review of all patients who received metal stents for biliary obstruction with PDAC over a five-year period at the Massachusetts General Hospital. Only patients with metastatic cancer were included. Patients were stratified by whether or not they received chemotherapy, as well as the presence or absence of cholangitis. Associations between chemotherapy use and ERCP findings were investigated. Survival analyses were performed to compare patients by chemotherapy use, presence of cholangitis, and findings at ERCP. Results: A total of 126 patients were included; the average age of patients in our study was 69.9 ± 11.8. The average size of the primary lesion was 38.7 ± 14.4 mm. Sixty-nine percent of patients completed chemotherapy. The average number of stents for all patients was 2.5 ± 2.5, but was significantly higher in patients who experienced cholangitis (3.3 ± 2.8) as expected (p &lt; 0.001). The majority of ERCP reports noted debris or sludge (44%), followed by presence of infiltrating or obstructing tumor (27%), stone (13%), pus or purulence (11%), and blood clot (5%). Patients who did not receive chemotherapy were more likely to have tumor obstruction noted on ERCP compared to those who received chemotherapy (p = 0.024). Patients undergoing chemotherapy were also more likely to have sludge noted on ERCP (p = 0.009) compared to those who did not have chemotherapy. There was no association between chemotherapy use and presence of stones (p = 0.94) or presence of purulence (p = 0.44) noted on ERCP. Among patients who received chemotherapy, those who had sludge or debris noted on their ERCP tended to have better survival compared to those where sludge was not noted on endoscopy (p = 0.038). Conversely, among patients who received chemotherapy, identification of an obstructing tumor on ERCP was prognostic of poorer survival (p = 0.037). Among patients who did not get chemotherapy, there was no survival difference between patients who had sludge or tumor and those who did not. Conclusions: Findings on ERCP may serve as a surrogate for chemotherapy response and be prognostic of survival in metastatic PDAC.