Endoscopic Retrograde Cholangiopancreatography Pancreatitis Research Articles

Multi-step validation of a Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis prediction system integrating multi-modal data: A multi-center study

Background and study aimsThe impact of various categories of information on the prediction of Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis (PEP) remains uncertain. We aimed to comprehensively investigate the risk factors associated with PEP by constructing and validating a model incorporating multi-modal data through multiple steps. Patients and MethodsA total of 1,916 cases underwent ERCP were retrospectively collected from multiple centers for model construction. Through literature research, 49 electronic health record (EHR) features and one image feature related to PEP were identified. The EHR features were categorized into baseline, diagnosis, technique, and prevent strategies, covering pre-ERCP, intra-ERCP, and peri-ERCP phases. We first incrementally constructed models 1-4 incorporating these four feature categories, then added the image feature into models 1-4 and developed models 5-8. All models underwent testing and comparison using both internal and external test sets. Once the optimal model was selected, we conducted comparison among multiple machine learning algorithms. ResultsCompared with model 2 incorporating baseline and diagnosis features, adding technique and prevent strategies (model 4) greatly improved the sensitivity (63.89% vs 83.33%, p<0.05) and specificity (75.00% vs 85.92%, p<0.001). Similar tendency was observed in internal and external tests. In model 4, the top three features ranked by weight were previous pancreatitis, NSAIDS, and difficult cannulation. The image-based feature has the highest weight in model 5-8. Lastly, model 8 employed Random Forest algorithm showed the best performance. ConclusionsWe firstly developed a multi-modal prediction model for identifying PEP with clinical-acceptable performance. The image and technique features are crucial for PEP prediction.

Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis Risk Factors: Is Postsphincterotomy Bleeding Another Risk Factor?

Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis Risk Factors: Is Postsphincterotomy Bleeding Another Risk Factor?

Duodenal papilla radiomics-based prediction model for post–endoscopic retrograde cholangiopancreatography pancreatitis using machine learning: a retrospective multicohort study

Background and AimsThe duodenal papillae are the primary and essential pathway for ERCP, greatly determining its complexity and outcome. We aimed to investigate the association between papilla morphology and post-ERCP pancreatitis (PEP), and to construct a robust model for PEP prediction. MethodsWe enrolled retrospectively patients underwent ERCP in 2 centers from January 2019 and June 2022. Radiomic features of papilla were extracted from endoscopic images with deep learning. Potential predictors and their importance were evaluated with three machine learning algorithms. A predictive model was developed using best subset selection by logistic regression, and its performance was evaluated in terms of discrimination, calibration, and clinical utility based on area under curve (AUC) of receiver operation characteristics (ROC), calibration and clinical decision curve, respectively. ResultsA total of 2038 and 334 ERCP patients from 2 centers were enrolled in this study with PEP rates of 7.9% and 9.6%, respectively. The R-score was significantly associated with PEP and showed great diagnostic value (AUC, 0.755-0.821). Six hub predictors were selected to conduct a predictive model. The radiomics-based model demonstrated excellent discrimination (AUC, 0.825-0.857) and therapeutic benefits in the training, testing, and validation cohorts. The addition of the R-score significantly improved diagnostic accuracy of the predictive model (NRI, 0.151-0.583, p<0.05; IDI, 0.097-0.235, p<0.001). ConclusionsRadiomic signature of papilla is a crucial independent predictor of PEP. The papilla-radiomics-based model performs well for the clinical prediction of PEP.

Endoscopic features of low-phospholipid-associated cholelithiasis syndrome: A retrospective cohort study

Background and objectiveLPAC (low phospholipid-associated cholelithiasis) syndrome is a rare genetic form of cholelithiasis. ERCP (endoscopic retrograde cholangiopancreatography) is often used to remove gallstones in the bile duct. No published data is available on the role of ERCP in LPAC syndrome. Patients and methodsIn this retrospective cohort study, we included patients diagnosed with LPAC syndrome in a single tertiary referral center between 2009 and 2021. Our aim was to assess the frequency, indications, modalities, results, and complications of ERCP, as well as predictive factors for ERCP, in LPAC syndrome. Independent factors associated with ERCP occurrence were identified using a multivariable Cox regression analysis. ResultsERCP was required in 31.2 % of the 269 patients included for analysis. Among patients who required ERCPs, 78.6 % had the procedure before diagnosis (i.e., starting UDCA). Most common indications were choledocholithiasis (53.6 %) and acute cholangitis (29.5 %). Post ERCP pancreatitis, perforation and bleeding rates were 7.2 %, 2.6 %, and 1.3 %, respectively. Age and history of cholelithiasis in first-degree relatives were associated with a higher risk of ERCP (Hazard-ratio [HR]=1.30 [95 %confidence-interval [CI] 1.04–1.62] and HR=1.88 [95 %CI 1.15–3.07] respectively). Female gender and UDCA intake ≥ 1 year were associated with a lower risk of ERCP (HR=0.49 [95 %CI 0.29–0.82] and HR=0.44 [95 %CI 0.22–0.90] respectively). Median follow-up was 10.8 years. ConclusionOne-third of patients with LPAC syndrome undergo sphincterotomy. However, most procedures are performed before diagnosis and UDCA is associated with a lower risk of endoscopic procedure. Earlier diagnosis and treatment with UDCA may further reduce the need for ERCP in patients with LPAC syndrome.

Validity of Predictive Markers for Post ERCP Pancreatitis Patients: A Single Centre Study

Abstract: Endoscopic retrograde cholangiopancreatography (ERCP) is a proprietary procedure, endoscopic modality, and specialized procedure used to diagnose and treat disorders of the pancreatic and biliary systems. The incidence of reported post-ERCP complications varied among several studies including post ERCP pancreatitis (PEP), duodenal perforation, and cholangitis. In this study, the author would like to show certain intra procedural factors related to PEP incidence. This was a retrospective study of secondary data of patients undergoing ERCP procedures from 2017-2022 at Prof. Dr. R. D. Kandou Hospital, Manado. Length of procedure, cannulation on pancreatic duct, pancreatogram, double wire technique, and the use of certain common bile duct (CBD) stone retrieval techniques such as endoscopic papillary balloon dilatation (EPBD) were recorded and analyzed. The results showed that based on the analyzed data, the percentage of pancreas cannulation was 8%, pancreatogram 5%, double-wire technique 3%, and EPBD procedure 10%, Incidence rate of PEP in all ERCP procedures was 19%. Increased amylase/lipase enzymes were found in 13 of 24 patients (54%) who underwent cannulation; 8 of 16 patients (50%) who underwent pancreatogram; 4 of 9 patients (44%) who underwent double wire procedure; and 10 of 30 patients (33%) who underwent EPBD. This PEP could be caused by several risk factors during ERCP including cannulation, pancreatogram, double wire, and EPBD. Number of cannulation attempt could result in trauma to the ampulla. Pancreatogram could result in hydrostatic, chemical, and allergic injury. Any manipulation of the pancreas that caused trauma could trigger the incidence of PEP. Assessment of the occurrence of PEP was based on increases in lipase and amylase enzyme values by four times the normal value and tested 6 hours after procedure. We could reduce the incidence of PEP by providing prophylactic therapy before ERCP. In conclusion, PEP is the most common complication in ERCP procedures and can be risky in patients with high risk factors. In this study, factors that affecting the incidence of PEP are cannulation, pancreatogram, double wire and EPBD. Keywords: endoscopic retrograde cholangiopancreatography; pancreatitis; complications

Indications, success, and adverse event rates of pediatric endoscopic retrograde cholangiopancreatography (ERCP): a systematic review and meta-analysis

BackgroundTo improve knowledge on endoscopic retrograde cholangiopancreatography (ERCP) in children, we aimed to study the proportion of indications, success rate and complication of ERCP.MethodsWe performed a systematic search of all articles published up to December 2022 in the following databases: Cochrane Library, PubMed (MEDLINE) and Scopus. The meta-analysis was performed using a random-effects model. Heterogeneity was determined by the I2 statistics and the Cochrane Q test. The included data were analyzed to identify the proportion of indications, success rate and complications of ERCP in children.ResultsBased on data from 52 studies with a total of 5624 participants, the most common indications for ERCP in children were biliary [48% (95% CI: 0.40 - 0.57; I2 = 98.17%, P < 0.001)] and both biliary and pancreatic [41% (95% CI: 0.33 - 0.49; I2 = 98.27%, P < 0.001)]. The success rate of ERCP was 95% (95% CI: 0.94 - 0.96; I2 = 82.53%, P < 0.001) with the overall complication rate of 7% (95% CI: 0.05 - 0.09; I2 = 82.06%, P < 0.001). The pooled estimate for the incidence of post ERCP pancreatitis was 4% (95% CI: 0.03 - 0.06; I2 = 85.46%, P < 0.001) and the bleeding was 0% (95% CI: 0.0 - 0.0; I2 = 28.21%, P = 0.03).ConclusionsERCP appears to be performed safely in children with a similar success rate as in the adult population.

Efficacy and safety of endoscopic retrograde cholangiopancreatography in recurrent pancreatitis of pediatric asparaginase-associated pancreatitis.

Asparaginase (ASP) is an important drug in combined chemotherapy regimens for pediatric acute lymphoblastic leukemia (ALL); ASP-associated pancreatitis (AAP) is the main adverse reaction of ASP. Recurrent pancreatitis is a complication of AAP, for which medication is ineffective. To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in treating recurrent pancreatitis due to AAP. From May 2018 to August 2021, ten children (five males and five females; age range: 4-13 years) with AAP were treated using ERCP due to recurrent pancreatitis. Clinical data of the ten children were collected, including their sex, age, weight, ALL risk grading, clinical symptoms at the onset of pancreatitis, time from the first pancreatitis onset to ERCP, ERCP operation status, and postoperative complications. The symptomatic relief, weight change, and number of pancreatitis onsets before and after ERCP were compared. The preoperative symptoms were abdominal pain, vomiting, inability to eat, weight loss of 2-7 kg, and 2-9 pancreatitis onsets. After the operation, nine of ten patients did not develop pancreatitis, had no abdominal pain, could eat normally; the remaining patient developed three pancreatitis onsets due to the continuous administration of ASP, but eating was not affected. The postoperative weight gain was 1.5-8 kg. There was one case of post ERCP pancreatitis and two cases of postoperative infections; all recovered after medication. ERCP improved clinical symptoms and reduced the incidence of pancreatitis, and was shown to be a safe and effective method for improving the management of recurrent pancreatitis due to AAP.

Pharmacological and Endoscopic Interventions for Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) represents the most common serious complication after endoscopic retrograde cholangiopancreatography (ERCP). Rectal non-steroidal anti-inflammatory drugs (NSAIDs) and pancreatic duct stenting (PDS) are the prophylactic interventions with more evidence and efficacy; however, PEP still represents a significant source of morbidity, mortality, and economic burden. Chronic statin use has been proposed as a prophylactic method that could be cheap and relatively safe. However, the evidence is conflicting. We aimed to evaluate the impact of endoscopic and pharmacological interventions including chronic statin and aspirin use, on the development of PEP. A retrospective cohort study evaluated consecutive patients undergoing ERCP at John H. Stroger, Jr. Hospital of Cook County in Chicago from January 2015 to March 2018. Univariate and multivariate analyses were performed using logistic regression. A total of 681 ERCPs were included in the study. Twelve (1.76%) developed PEP. Univariate, multivariate, and subgroup analyses did not show any association between chronic statin or aspirin use and PEP. PDS and rectal indomethacin were protective in patients undergoing pancreatic duct injection. Pancreatic duct injection, female sex, and younger age were associated with a higher risk. History of papillotomy was associated with lower risk only in the univariate analysis (all P values < 0.05). Chronic use of statins and aspirin appears to add no additional benefit to prevent ERCP pancreatitis. Rectal NSAIDs, and PDS after appropriate patient selection continue to be the main prophylactic measures. The lower incidence at our center compared with the reported data can be explained by the high rates of rectal indomethacin and PDS, the use of noninvasive diagnostic modalities for patient selection, and the expertise of the endoscopists.

Universal prophylactic rectal nonsteroidal anti-inflammatory drugs with a policy of selective pancreatic duct stenting significantly reduce post-endoscopic retrograde cholangiopancreatography pancreatitis.

Although rectal nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be effective for the prevention of post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis (PEP) in high-risk patients, the benefit in average-risk patients is unclear. We aimed at assessing the benefit of prophylactic rectal NSAIDs in unselected consecutive patients to prevent PEP. All patients undergoing index ERCP procedures from January 2018 until March 2020 were included. All patients received prophylactic rectal diclofenac. A prophylactic pancreatic duct (PD) stent was placed if there was repeated PD cannulation, at the discretion of the endoscopist. The frequency of PEP was compared with historical controls. Of 769 patients who underwent ERCP, 34 (4.4%) developed PEP (mild in 29 [85.3%], moderate in four [11.8%] and severe in one [2.9%]). Female gender, precut sphincterotomy, inadvertent PD cannulation and procedural time of > 30minutes predicted PEP in univariate analysis. Inadvertent PD cannulation (OR 4.6, 95% CI: 1.8-11.7; p < 0.001) and procedural time of > 30minutes (OR 8.5, 95% CI: 3.7-10.1; p < 0.001) were independent risk factors on multivariate analysis. When compared with historical controls, the odds of PEP with prophylactic use of rectal NSAIDs and selective PD stenting was 0.54 (CI: 0.31-0.93, p = 0.027). The number needed to treat (NNT) was 22 to prevent one PEP with prophylactic rectal NSAIDs. Routine use of prophylactic rectal NSAIDs effectively prevents the occurrence of PEP in unselected consecutive patients in a real-world scenario.

Risk Factors for Post Endoscopic Retrograde Cholangio Pancreatography(ERCP) Pancreatitis (PEP) and Efficacy of Octreotide in its Prevention

Background: Pancreatitis is a potentially fatal complication of ERCP, seen in 5-15% procedures. Factors precipitating its risk and effective pharmacological intervention for its prevention need exploration to improve patient safety. Objective: To identify risk factors for post-ERCP pancreatitis (PEP) and to determine efficacy of intravenous octreotide in preventing PEP. Methodology: A quasi-experimental triple blind placebo-based study included patients undergoing ERCP and randomize them in two groups through simple random sampling. Group A to receive intravenous Octreotide 4μg/kg before attempting cannulation during ERCP and 1cc N/S as placebo for group B. Patients were followed for PEP and data were analyzed using chi square (x2) and logistic regression analysis. Results: Of 203 included patients, 101 (49.3%) received octreotide while 102 (50.7%) were in control group. Post ERCP pancreatitis developed in 32 (15.8%) patients, in 8 (7.9%) patients of octreotide group while in 24 (23.8%) patients of control group (p value 0.002 with odds ratio (OR) for octreotide of 0.33 (95% CI 0.15- 0.71). We identified biliary surgery (p value 0.005), serum bilirubin ≥ 3 mg/dl (p value 0.03), cannulation&#x0D; time &gt; 5 minutes (p value 5 minutes, use of needle knife, PD cannulation and procedure time &gt; 30 minutes are associated with increased risk of PEP. Intravenous octreotide before cannulation reduces risk of post ERCP pancreatitis.

Trans-papillary bilio-pancreatic stenting: When how and which stent

Nowadays, stenting malignant biliary stenosis (extrahepatic or hilar), benign biliary stenosis, and pancreatic duct stenosis in chronic pancreatitis as well as stenting for prophylaxis of post- endoscopic retrograde cholangiopancreatography pancreatitis and for failed extraction of biliary stones or endoscopic papillectomy are the many common challenges for a bilio-pancreatic endoscopist. The purpose of this review is to provide a practical approach to bilio-pancreatic stenting indications and techniques. Having a thorough understanding of stenting indications and techniques, for a bilio-pancreatic endoscopist means being able to develop a tailored approach for each clinical scenario depending on the type of stent used. Biliary stents, in fact, vary in diameter, length, and composition, making it possible to give each patient personalized treatment.

Evaluation of direct epinephrine injection into the major papilla in the prevention of post ERCP pancreatitis

Giriş ve Amaç: Akut pankreatit, endoskopik retrograd kolanjiyopankreatografinin en yaygın komplikasyonudur. Dikkate değer morbidite ve mortalite oranlarına sahiptir. Bu çalışmanın amacı, tek başına lokal epinefrin uygulamasının endoskopik retrograd kolanjiyopankreatografi sonrası pankreatit sıklığını ve şiddetini azaltmadaki etkisini araştırmaktır. Gereç ve Yöntem: Endoskopik retrograd kolanjiyopankreatografi yapılan 979 hastanın verileri retrospektif olarak değerlendirildi. Yaş, cinsiyet, endoskopik retrograd kolanjiyopankreatografi endikasyonları, tekniği, endoskopik retrograd kolanjiyopankreatografi sonrası pankreatit riskini artıran durumlar, endoskopik retrograd kolanjiyopankreatografi sonrası pankreatit varlığı ve şiddeti, serum amilaz, lökosit ve C-reaktif protein seviyeleri (öncesi ve sonrası) kaydedildi. Veriler sadece lokal epinefrin profilaksisi alan 473 hasta ve almayan 506 hasta olmak üzere iki grup arasında karşılaştırıldı. Bulgular: Tüm hastalar arasında endoskopik retrograd kolanjiyopankreatografi sonrası pankreatit oranı %6.8, yüksek riskli hasta grubunda ise %13.6 olarak saptandı. Lokal epinefrin profilaksisi alan grupta, almayan gruba göre endoskopik retrograd kolanjiyopankreatografi sonrası pankreatit daha az görüldü (%9.1’e karşı %4.4; p = 0.004). Epinefrin grubunda endoskopik retrograd kolanjiyopankreatografi sonrası amilaz, lökosit ve C-reaktif protein düzeyleri epinefrin almayan gruba göre anlamlı olarak düşük saptandı (p = 0.001, p = 0.004, p = 0.001). Epinefrin grubunda daha az sıklıkla şiddetli ve orta derecede şiddetli pankreatit görüldü (p = 0.003). Yüksek riskli hasta grubunda lokal epinefrin irrigasyonunun endoskopik retrograd kolanjiyopankreatografi sonrası pankreatit oranını düşürdüğü gözlendi (%18.9’a karşı %7.9; p = 0.002). Sonuç: Majör papillaya direkt püskürtme yöntemi ile epinefrin irrigasyonu endoskopik retrograd kolanjiyopankreatografi sonrası pankreatitin önlenmesinde uygulaması kolay, güvenli ve ümit verici bir yöntemdir. Etkinliğini araştırmak için geniş popülasyonlarla daha fazla çalışmaya ihtiyaç vardır.

S61 Opiate Use Is Associated With Increased Risk of Post ERCP Pancreatitis: A National Cohort Study

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) has evolved as a valuable tool in therapeutic management of pancreatobiliary disorders but is associated with a range of significant complications, the most common being post-ERCP pancreatitis (PEP). The aim of this study was to elucidate the impact of opiate use on the development and severity of post-endoscopic retrograde cholangiopancreatography. Pancreatitis (PEP). Methods: We retrospectively analyzed patients who were hospitalized in 2017 using the national inpatient sample (NIS) database who underwent endoscopic retrograde cholangiopancreatography (ERCP) (via ICD-10 procedure codes). Our study group consisted of patients who had a secondary diagnosis of opiate use, and our control group consisted of patients who did not have a secondary diagnosis of opiate use. Our primary end point was to elucidate if the presence of opiate use increased the risk of developing post-ercp pancreatitis. Additionally, we assessed if opiate use worsened outcomes in patients who underwent ERCP. We accomplished this by extracting variables such as length of hospital stay (LOS), total hospital charges and in hospital mortality rates. Categorical variables were compared using the chi-square test, and continuous variables were compared using t-test. Multivariate regressions models and all statistical analysis were performed using STATA 16 software. Results: A total of 172,255 patients who underwent ERCP were identified, of which 2,120 were opiate users. Opiate users were hospitalized at a younger age when compared to opiate non-users (53.7 years vs 60.5 years; p-value: < 0.01), had a longer length of hospital stay (8.3 days vs 6.0 days; p-value: < 0.01), total hospital charges ($102,469 vs $82,191; p-value: < 0.01) and higher incidence of PEP (4% vs 2.7%; p-value: < 0.01). Conclusion: Opiate use is associated with younger age of presentation, increased LOS, total hospital charges, and increased frequency of PEP amongst patients undergoing ERCP. Further investigation is needed to assess the extent to which chronic opiate use may be a risk factor for post-ERCP pancreatitis and worse outcomes. If so, discontinuation of opiates before ERCP may be reasonable when possible. (Table) Table 1. - Hospital outcomes in opiate users vs non-users undergoing ERCP Opiate Use (N=2,120) No Opiate Use (N=170,135) P-value Age of presentation 53.7 60.5 < 0.01 LOS (days) 8.3 6.0 < 0.01 Total charges (USD) $102,469 $82,191 0.087 Died 35 (1.6%) 2,520 (1.4%) 0.525 PEP 85 (4%) 4,740 (2.7%) < 0.01 LOS: Length of hospital stay; USD: United States Dollar; PEP: Post-ERCP Pancreatitis.

S1146 Impact of Frailty on ERCP Outcomes

Introduction: Frailty has been recognized as an important risk factor and predictor of mortality and adverse events in the inpatient setting. It has not been studied as a tool to assess risk among patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP). We aim to determine the association between frailty and risk of adverse events in hospitalized patients undergoing ERCP. Methods: We conducted a cohort study using the 2017 Nation Inpatient Sample database, using International Classification of Diseases (ICD) diagnostic codes to identify adult patients who underwent ERCP and the Hospital Frailty Risk Score (HFRS) to classify patients as Frail or non- Frail. HFRS is a validated algorithm of ICD-10 codes. Multivariable analysis logistic regression was performed for outcomes of frail patients compare to non frail patients Results: 216,775 hospitalizations met inclusion criteria, of which 31.7% (68,555) were identified as frail and 68.3% (148,220) as non-frail. Baseline characteristics of both groups are compared in Table. Frail patients had worse post procedure complications including post ERCP pancreatitis (7.3% vs 3.4%, p < .001), perforation (1.2% vs 0.4%, p < .001), bleeding (0.8% vs 0.3%, p < .001) and peritonitis (1.2% vs 0.3%, p < .001). Frail patients had more cardiovascular (22.2% vs 5.5%, P < .001), pulmonary (22.1% vs 4.7%, P < .001), GI (25.9% vs 19.8%, P < .001) and infectious (39.2% vs 4.6%) adverse events compared with non-frail patients. Frail patients also had higher ICU admission (8.5% vs 0.5%, p < .001), increased length of stay (9.3 days vs 4.3 days, p < .001), more total charges (118,875$ vs 62,386$, p< .001) and higher all-cause inpatient mortality rates (4.2 % vs 0%, P < 0.001 as compared to non-frail. When adjusted for age, gender, race, hospital location, teaching status, insurance, median household income and Charlson co-morbidity index frail patients were had a higher risk of cardiac[OR 2.29 (95% CI 2.12-2.46), p< 0.001], pulmonary[OR 4.9 (95% CI 4.52-5.31), p< 0.001], infectious[OR 12.83 (95% CI 11.85-13.88), p< 0.001], GI [OR 1.68 (95% CI1.58-1.77), p< 0.001] adverse events as well as inpatient mortality[OR 9.93 (95% CI 7.3-13.3), p< 0.001] as compared to non-frail. Conclusion: In hospitalized patients undergoing ERCP, frailty status is associated with increased adverse events including all-cause mortality. The use of frailty assessments can further guide clinical decision-making when considering ERCP and the risk of adverse events in adult patients. Table 1. - Baseline characteristics and outcomes of the frail and non-frail groups undergoing ERCP Variable ERCP + Not Frail n=148,220 ERCP + Frail * n= 68,555 p-value Female, % 59.69 52.61 < 0.001 Age (years), mean ± SD 55.87 ± 18.93 69.37 ± 15.35 < 0.001 Age >=65 years, % 37.20 67.85 < 0.001 Race, % < 0.001 White 65.18 70.06 Black 9.21 10.58 Hispanic 17.38 11.67 Other 8.24 7.70 Charlson co-morbidity index, mean ± SD 1.33 ± 1.98 3.11 ± 2.59 < 0.001 Hospital Frailty Risk Score, mean ± SD 1.71 ± 1.55 8.56 ± 3.14 < 0.001 In-hospital all-cause mortality, % 0.25 4.20 < 0.001 Length of Stay (Days), mean ± SD 4.37 ± 3.80 9.39 ± 10.32 < 0.001 Total Charges ($), mean ± SD 62,386.77 ± 50,903.26 118,875.9 ± 175,602 < 0.001 Post Procedure complications, % Post-ERCP pancreatitis 3.44 7.38 < 0.001 Perforation 0.43 1.28 < 0.001 Bleeding 0.31 0.81 < 0.001 Peritonitis 0.29 1.25 < 0.001 Cardiac complications, % 5.50 22.19 < 0.001 Pulmonary complications, % 4.75 22.11 < 0.001 GI complications, % 19.82 25.95 < 0.001 ID complications, % 4.59 39.23 < 0.001 Anesthesia and drug-related complications, % 0.02 0.08 0.001 Required Intensive Care Unit, % 0.53 8.56 < 0.001 Multivariate Regression for the Outcomes # Outcome Adjusted Odds Ratio (FrailERCP vs NonFrailERCP) 95% CI p-value In-hospital mortality 9.93 [7.38 – 13.35] < 0.001 Length of Stay (Days) 4.53 & [4.28 – 4.77] < 0.001 Total Charges ($) 54,659.9$ & [50,176.52$ – 59,143.28$] < 0.001 Cardiac complications 2.29 [2.12 – 2.46] < 0.001 Pulmonary complications 4.90 [4.52 – 5.31] < 0.001 GI complications 1.68 [1.58 – 1.77] < 0.001 ID complications 12.83 [11.85 – 13.88] < 0.001 Anesthesia and drug-related complications 3.68 [2.13 – 15.13] 0.001 Required Intensive Care Unit 17.19 [13.99 – 21.13] < 0.001 *Frail =Hospital Frailty Risk Score (HFRS)≥5.#Analysis adjusted for age, gender, race, hospital location and teaching status, insurance, median household income and Charlosn co-morbidity index.&Adjusted co-efficient representing the average difference in this outcome between FrailERCP and NonFrailERCP.

Knowledge, attitude, and the practices in prevention of post endoscopic retrograde cholangiopancreatography pancreatitis (PEP) among advanced endoscopists.

Knowledge, attitude, and the practices in prevention of post endoscopic retrograde cholangiopancreatography pancreatitis (PEP) among advanced endoscopists.

Serum Amylase as a Biomarker for Proof-of-Concept Studies in Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis Prevention

Considerable effort and resources have been expended in the last 3 decades on the study of pharmacoprevention for post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), with limited success, in part because of inadequate sample sizes in randomized controlled trials (RCTs). For reference, an adequately powered RCT aiming to detect a 50% reduction in PEP from 10% to 5% requires approximately 950 subjects. 1 Elmunzer B.J. et al. N Engl J Med. 2012; 366: 1414-1422 Crossref PubMed Scopus (460) Google Scholar ,2 Fogel E.L. et al. Lancet Gastroenterol Hepatol. 2020; 5: 132-141 Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Because sample sizes of this magnitude for every potentially effective medication are impractical, a cogent framework for proof-of-concept (POC) studies to screen candidate agents is critical for drug development and repurposing.

Intraductal pressure in experimental models of acute and chronic pancreatitis in mice

Background/ObjectivesPancreatic intraductal pressure is related to the development of pancreatitis, including post-ERCP (endoscopic retrograde cholangiopancreatography) pancreatitis. In this study, we investigate pancreatic intraductal pressure in various mouse models of acute and chronic pancreatitis. MethodsPost-ERCP pancreatitis was induced by retrograde infusion of normal saline or radiocontrast at the constant rate of 10 or 20 μL/min. Obstructive pancreatitis was induced by ligation of the pancreatic duct followed by a single injection of caerulein and the changes of intraductal pressure were recorded in day 3 for obstructive acute pancreatitis and day 14 for obstructive chronic pancreatitis. Non-obstructive pancreatitis was induced by repetitive intraperitoneal injections of caerulein. The changes of intraductal pressure were recorded right after the last caerulein injection for non-obstructive acute pancreatitis and after the completion of 4-week caerulein injections for non-obstructive chronic pancreatitis. ResultsElevated pancreatic intraductal pressure was observed in both normal saline and radiocontrast infusion groups and was furtherly indicated that was positively correlated with the viscosity of solution but not genders. In the models of obstructive pancreatitis, a rise in intraductal pressure was observed in both acute and chronic pancreatitis; whereas in the models of non-obstructive pancreatitis, a rise in intraductal pressure was only observed in chronic, but not acute pancreatitis. ConclusionsDuring ERCP, the elevations in pancreatic intraductal pressure are induced by increasing rate or viscous solution of infusion. During different forms of experimental acute and chronic pancreatitis, obstructive or non-obstructive etiologies of pancreatitis also induces the elevations in pancreatic intraductal pressure.

Predisposing Factors in Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis

Objective: To ascertain the prevalence of risk factors in pancreatitis after endoscopic retrograde cholangiopancreatography at Isra University Hospital in Hyderabad. Methodology: This descriptive case series study was done at the gastroenterology department of Isra University Hospital, Hyderabad, from September 2018 to March 2020. Patients aged 18 to 50 years, both genders, and diagnosed with post-ERCP pancreatitis were included. All the patients were undergoing an ERCP procedure. The procedure was done under conscious sedation or propofol where needed. The serum amylase level was assessed in all patients at 4 hours. Patients had been considered to have post-ERCP pancreatitis if they developed new or worsening pain of abdomen and had a threefold increase in serum amylase. All the cases were assessed regarding risk factors in pancreatitis after endoscopic retrograde cholangiopancreatography. All the data was recorded in the proforma. Results: The mean age of the patients was 42.7 years. The majority of the patients (65.47%) were females and 32.90% were males. The mean duration of pancreatitis was 3.1 days. Sphincter of Oddi dysfunction was found in 17.1% of cases. Precut papillotomy was done in 18(23.7%) cases. Repeated pancreatic duct injury was seen in 10(13.2%) cases. No significant difference was found in the effect of modifiers on predisposing factors in post-endoscopic retrograde cholangiopancreatography pancreatitis, p-values were almost insignificant. Conclusion: Cannulation attempts, Sphincter of Oddi dysfunction, precut papillotomy, repeated pancreatic duct injection, and female gender were observed to be the predisposing factors in post-endoscopic retrograde cholangiopancreatography pancreatitis.

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.

Emergency Endoscopic Retrograde Cholangiopancreatography Did Not Increase the Incidence of Postprocedural Pancreatitis Compared With Elective Cases: A Prospective Multicenter Observational Study.

ObjectiveThe aim of this study was to identify the incidence of and risk factors for post–endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after emergency endoscopic retrograde cholangiopancreatography (ERCP).MethodsWe performed a prospective multicenter observational study of 3914 patients who underwent ERCP. We compared the incidence of PEP after emergency and elective ERCP.ResultsA total of 3410 patients were enrolled in this study. Post-ERCP pancreatitis occurred in 44 of 800 patients (5.5%) and in 190 of 2418 patients (7.9%) in the emergency and elective groups, respectively. No significant difference was noted between the groups (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.52–1.03; P = 0.07). Multivariate analysis showed that the following factors increased the risk for PEP after emergency ERCP: contrast medium injection into the pancreatic duct (OR, 2.56; 95% CI, 1.30–5.03; P = 0.005), >4 cannulation attempts (OR, 5.72; 95% CI, 2.61–12.50; P < 0.001), and endoscopic papillary balloon dilatation (OR, 9.24; 95% CI, 2.13–40.10; P < 0.001).ConclusionsNo significant difference was noted in the incidence of PEP in patients after emergency and elective ERCP. We may prevent PEP even after emergency ERCP by avoiding contrast injection into the pancreatic duct, multiple cannulation attempts, and endoscopic papillary balloon dilatation.