Normal ERCP Research Articles

Predictive Values of Intraoperative Cholangiogram for Choledocholithiasis in Patients with Normal Liver Function Test – A Prospective Study

Introduction: Cholecystectomy is an accepted treatment for cholelithiasis. IOC is not regularly done in patients with normal liver function test (LFT). However, up to 11.6% of cholecystectomies have incidental choledocholithiasis on IOC. In this study, we examine the predictive values of routine IOC in detecting choledocholithiasis with normal LFT. Methodology: This is a prospective study which includes patients with normal LFT who underwent cholecystectomies and IOC between October 2019 to December 2020. Patients with choledocholithiasis had ERCP and stone clearance. Patients with stones on ERCP are true positive whilst patients with normal ERCP are false positive. Patients with normal IOC and LFT at 2 weeks follow-up are true negative whilst patients with normal IOC and abnormal LFT were subjected to ERCP (false negative). Sensitivity, specificity and predictive values were calculated. Results: One hundred and eighty patients were analysed. 25.6 % (n = 46) were found to have filling defect on IOC and were confirmed after ERCP. 74.4% (n = 134) did not have choledocholithiasis. 65.6% (n = 118) had normal IOC and LFT on follow up whilst 8.9% (n=16) of patients had abnormal LFT on follow up and ERCP was done. IOC showed a specificity of 85.5%, NPV of 88.1% and AUC of 73.7%. The PPV and sensitivity was 56.5% and 61.9% respectively. Conclusion: Routine IOC is a specific diagnostic tool with good negative predictive value. Routine IOC is useful to exclude incidental choledocholithiasis when LFT is normal. This will reduce the incidence of undetected retained stones and its complications.

Rectal NSAIDs and selective pancreatic stenting significantly reduces acute pancreatitis in normal risk ERCP

Rectal NSAIDs and selective pancreatic stenting significantly reduces acute pancreatitis in normal risk ERCP

Elevación de las aminotransferasas: una nueva herramienta para el diagnóstico de coledocolitiasis. Un estudio de casos y controles

Introducción: la coledocolitiasis (CDL) afecta al 10 % de los pacientes con cálculos en la vesícula biliar. La obstrucción del colédoco se asocia a pancreatitis, colangitis y ruptura del colédoco. Clásicamente, la obstrucción biliar es considerada cuando se aumentan la fosfatasa alcalina, la γ-glutamil-transpeptidasa (GGTP) y las bilirrubinas. En la última década, se ha encontrado que hasta un 10 % de los pacientes con CDL presentan elevaciones de las aminotransferasas. En Latinoamérica, no se ha estudiado esta alteración. El objetivo del presente trabajo fue determinar la prevalencia de la elevación de transaminasas y su evolución. Metodología: estudio de casos y controles. Se determinó la alanina aminotransferasa (ALT) al ingreso, a las 48 h y a las 72 h. Si la ecografía era normal, se realizó una colangiorresonancia o una ecoendoscopia, así como una colangiopancreatografía retrógrada endoscópica (CPRE) cuando fue necesario. Resultados: se incluyeron 72 pacientes con CDL (casos) y 128 con colecistitis, sin CDL (controles). En los casos, el 83 % tuvo un aumento de ALT, mientras que el 56,9 % presentó una elevación de 2-9 veces, el 16 %, de 10-20 veces, y el 8,3 % mostró una elevación >20 veces. En contraste, a las 48 h, las ALT descendieron al 30 % y a las 72 h al 56 %. Entre tanto, en los controles hubo un aumento de ALT en el 27,3 %, mientras que en el 15,6 % se observó una elevación de 2-9 veces, en el 7,8 %, de 10-20 veces, y >20 veces en el 2,9 %. La combinación de cólico biliar y la elevación de ALT tuvo un valor predictivo positivo (VPP) para CDL del 72 %, así como un valor predictivo negativo (VPN) del 87,7 %. Conclusión: cuando hay un cólico biliar y una elevación de ALT es imperativo descartar una CDL, y si la ecografía es normal, es necesario realizar una colangiorresonancia o una ecoendoscopia biliopancreática.

Magnetic resonance imaging features of small-duct primary sclerosing cholangitis.

To evaluate the biliary tree and hepatic parenchymal findings on magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) in small-duct primary sclerosing cholangitis (SD-PSC). Thirty-nine patients with biopsy-proven primary sclerosing cholangitis (PSC) without any bile duct abnormality on MRCP (n = 15) or ERCP (n = 24) at the time of diagnosis were identified. Follow-up MRCP was available in 36/39 patients (12/15 Baseline MRCP group and 24 Baseline ERCP group). Two radiologists in consensus assessed the MRI/MRCP findings. The baseline MRI/MRCP of 15 SD-PSC patients was compared with MRI/MRCP of 15 normal healthy potential liver donors (Control group). Comparisons were made between SD-PSC patients and the Control group, and between baseline and follow-up MRI/MRCP findings in the SD-PSC patients. In the 15 Baseline MRCP SD-PSC subjects, the biliary tree was normal with a trend of larger bile ducts compared to the Control group. Periductal enhancement (arterial phase: 70%, 7/10; delayed phase: 90%, 9/10), heterogeneous parenchymal signal on T2-weighted (53%, 8/15) and post contrast-enhanced images (70%, 7/10), and enlarged periportal lymph nodes (73%, 11/15) were frequently present in patients with SD-PSC. Eight (33%) of 24 SD-PSC patients who had normal MRCP at baseline MRCP or initial follow-up MRCP after normal baseline ERCP showed large-duct PSC (LD-PSC) features on follow-up and the 10-year cumulative incidence for progression to LD-PSC rate was 8.5%. SD-PSC patients have a normal biliary tree but frequently have peribiliary enhancement, abnormal parenchymal signal intensity, and periportal lymphadenopathy. One-third shows progression to LD-PSC on follow-up.

41 Rectal nsaids and selective pancreatic stenting significantly reduces acute pancreatitis in normal risk ercp

Background In high-risk cases a combination of non-steroidal anti-inflammatory drugs (NSAIDs) and selective pancreatic stenting may reduce the risk of post ERCP pancreatitis (PEP). However, studies on whether this practice reduces PEP in normal risk ERCPs have shown conflicting results. Aim To compare the rate of PEP for normal risk ERCP, where patients are administered rectal NSAIDs immediately following the procedure with selective pancreatic stenting (N/S), against the previous practice, which did not incorporate N/S. Method Consecutive ERCPs from 2009–2016 were analysed pre and post N/S. In the post N/S group rectal NSAIDS were administered immediately following the procedure. Pancreatic stents were used if the pancreatic duct was cannulated more than three times during the procedure. PEP was defined as post ERCP abdominal pain and a rise in amylase to at least twice the upper limit of normal. Statistical analysis was by paired t and McNemars tests. Results 574 ERCP procedures were performed, of which 509 were successful (89%). 335 (58%) were female, with an average age of 67.7 (range16–94 years). 488 were therapeutic (96%). There were no statistically significant differences in the demographics of each group. 23 of 375 (6.1%) in the Pre N/S group developed PEP compared with 4 of 199 (2%) in the Post N/S group, p=0.02. Conclusions This study shows a further significant reduction of PEP in normal risk ERCP in a cohort of patients with a historically low PEP rate following the introduction of rectal NSAIDs and selective pancreatic stenting.

Evaluation of patients with abnormalities on intraoperative cholangiogram: time to abandon endoscopic retrograde cholangiopancreatography as the initial follow-up study

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is currently the method of choice for the postoperative evaluation of suspected bile duct stones seen on intraoperative cholangiogram (IOC); however, the sensitivity of IOC for...

PTH-011 Changing Trends Of Ercp, A Decade Apart

IntroductionERCP has become a well established therapeutic intervention. Indications and practice of ERCP have changed over the years due to advent of new imaging modalities. Our aim was to evaluate...

The Role of Multiple Parallel Stents in the Management of Post-Orthotopic Liver Transplantation (OLT) Biliary Anastomotic Strictures (AS)

Background: Efficacy of multiple parallel biliary stents for post-OLT AS has not been reported. Methods: We conducted a retrospective study of ERCP post-OLT to characterize biliary strictures and outcome of endoscopic therapy. Initial management of strictures was single stent placement. If the stricture persisted at the time of stent removal, parallel stents were placed, generally after balloon dilation. The number of parallel stents was increased every 4-8 weeks until the maximum number felt to be safely accommodated by the duct was reached. Biliary reconstruction (BR) was undertaken for endoscopic failures or progressive liver dysfunction. Results: From 3/01 to 11/06, OLT was performed in 301 patients of whom 75 (25%) underwent 194 ERCPs (mean 2.6 ERCP per patient). Bile duct cannulation at initial ERCP was successful in 72 (96%). There were no cases of post-ERCP pancreatitis or major complications. Biliary strictures were seen in 48 of 72 patients (67%), of which 21 (44%) were early (<90 days) and 27 (55%) were late. 45 patients had AS. Associated findings were intra-hepatic strictures (IHS) in 5, filling defects in 18 and bile leak in 2. 3 had only IHS. 6 AS were diagnosed after an initial normal ERCP with a mean interval from initial to diagnostic ERCP of 581 days. Initial management of AS was single stent in 41 (91%), conservative management in 1 (2%) which resolved, and direct surgery in 3 (7%): 1 re-OLT, 2 BR for high-grade eccentric strictures precluding guide wire passage. Outcome of single stent was resolution in 23 (56%), parallel stenting in 12 (29%) and surgery in 6 (15%, 4 re-OLT, 2 BR for large stones proximal to high-grade strictures). 68% of early strictures resolved with single stent versus 39% of late strictures. Parallel stents were generally 10 Fr and the mean maximum number of stents was 3.25 (range 3-5). Outcome of parallel stents was resolution in 6 (50%), currently ongoing stenting in 3 (25%) and surgery in 3 (25%; 2 re-OLT, 1 BR for persistent AS and IHS). Overall, 12/45 (27%) patients had surgery: 7 (16%) re-OLT and 5 (11%) BR. In no case was failure of multiple parallel stents the indication for surgery. All 8 patients with IHS (5 with and 3 without AS) required re-OLT. Conclusions: 1. ERCP is a safe and effective approach to diagnosis and management of post-OLT biliary AS; 2. An initial normal ERCP does not exclude a subsequent stricture development; 3. Early AS may be primarily related to edema and frequently resolve with single stent; 4. Parallel stent placement is an effective therapeutic option in patients with persistent AS; 5. Patients with IHS likely representing ischemic bile duct injury frequently require re-OLT.

The role of ERCP in patients with pancreatico-biliary problems in the setting of hematopoietic stem cell transplant

Patients undergoing hematopoietic stem cell transplant may develop pancreatico-biliary complications that may require ERCP. Due to their immunocompromised state, these patients may be at higher risk of procedure-related complications. To determine the role of ERCP in the diagnosis and treatment of patients who have undergone hematopoietic stem cell transplant and the patients' clinical outcomes. Retrospective analysis of patients with hematopoietic stem cell transplant who underwent ERCP from 1997 to 2004 evaluating ERCP indications, diagnosis, therapeutic interventions, and complications. Tertiary referral center. Of the 16 patients identified, 9 were female, 15 had had allogeneic hematopoietic stem cell transplant, and 1 had an autologous hematopoietic stem cell transplant. Twenty-six ERCP procedures were performed in the 16 patients. Index ERCP findings included: extra hepatic bile duct obstruction in 12 patients, of which 7 had biliary lithiasis. Ampullary obstruction due to infiltration from graft versus host disease was seen in 3 of 12 patients, benign bile duct stricture in 1 of 12, and ampullary obstruction in the setting of a peri-ampullary diverticulum in 1 of 12. Index ERCP findings in the remaining 4 patients included: intrahepatic bile duct compression due to metastatic disease in 1 of 16 patients, bile duct leak in 1 of 16, pancreatic duct stone in 1 of 16, and normal ERCP in 1 of 16. Complications occurred in 4 patients: mild pancreatitis (1), mild bleeding (1), cholangitis due to late stent occlusion (1), and intermittent bradycardia (1). There were no ERCP-related deaths. Single-center study. In patients with hematopoietic stem cell transplant, bile duct lithiasis was the most common finding at ERCP, followed by obstructive ampullary tissue infiltration due to graft versus host disease. ERCP yielded clinically relevant information in this particular group of patients.

Endoscopic management of post-laparoscopic cholecystectomy biliary strictures: Long-term outcome in a multicenter study

The aim of this retrospective study was to assess the long term results of long-lasting endoscopic stenting for benign biliary strictures related to laparoscopic cholecystectomy. Additional biological and morphological data were collected from these patients during follow-up. Patients undergoing ERCP for post-laparoscopic cholecystectomy biliary stricture in one of the three participating centers between 1990 and December 2001 were identified. Only patients with successful endoscopic stenting were subsequently included and analyzed. Follow-up data were obtained from referring centers, general practitioners and patients or relatives. Hepatic blood tests and abdominal ultrasound were proposed to all the patients who had not undergone further treatments after stent removal. Eight-eight patients had undergone ERCP for benign biliary stricture related to laparoscopic cholecystectomy. Stenting failed in 19 patients. Balloon dilatation alone was used in four patients. Strictures were successfully stented in 65 patients. The mean number of stents inserted at the same time was 1.6. The mean duration of stenting was 14 months (range 1-120 months). Eighteen patients (28%) developed biliary or pancreatic symptoms during stenting. ERCP was considered satisfactory at the end of stenting (i.e. no remaining stricture or minor remaining change on ERCP) in 45 patients (69%). Twenty-two patients were lost to follow-up. Twenty-nine out of forty-three patients (67%) remained symptom-free with normal updated blood tests and abdominal ultrasound during a mean follow-up of 28 months (range 12-117 months) after stent removal. None of the patients with a normal ERCP at the end of stenting developed stricture recurrence during follow-up. Eleven patients were operated (8 with persistence of stricture, 2 for stricture recurrence up to 63 months after stent removal, 1 for pancreatitis). Based on clinical, morphological and biological criteria, a long-term success was obtained in 70% of patients with post-laparoscopic cholecystectomy benign biliary strictures, after several months of endoscopic stenting.

High Prevalence of Sphincter of Oddi Dysfunction in Patients with Biliary-Pancreatic Disease Referred to Endoscopic Retrograde Cholangiopancreatography

Sphincter of Oddi Manometry (SOM) is the gold standard method for diagnosis of Sphincter of Oddi Dysfunction (SOD). The prevalence of SOD among patients referred to ERCP is largely unknown. The aims of this study are to evaluate the prevalence of SOD among patients with biliary-pancreatic diseases referred to ERCP and to study the safety of SOM in this setting. SOM was tried prospectively in patients referred to ERCP for any indication. Anticholinergic and meperidine were not administered during SOM. The number of attempts of deep cannulation of the papilla was recorded and divided into two groups: easy (up to 5 attempts) and difficult cannulation(>5 attempts). Overall 110 patients were included. SOM was successful in 73 (66,4%) - biliary SOM in 71 and pancreatic in 2, with a median age of 51 ± 18 years, 32 male. SOD was found in 18/73 patients (24,7%) - 11/41 women (26,8%) and 7/32 men (21,8%). The patients were grouped according to ERCP findings: normal ERCP in 19, biliary lithiasis in 38, biliary neoplasm in 9 and benign biliary strictures in 7. SOD was found in 5/19 with normal ERCP, 7/38 with biliary lithiasis, 3/9 with biliary neoplasm and 3/7 with benign biliary stenosis (p=0,487). SOD was found in 12/49 patients with easy and in 6/24 patients with difficult cannulation (p=0,962). ERCP related complications were observed in 8/55 with normal sphincter and in 3/18 with SOD (p=0,827). ERCP related complications have occured in 5/49 patients with easy and in 6/24 with difficult cannulation (p=0,097). Only 2/73 (2,7%) patients developed post-procedure mild pancreatitis. We have found a 24,7% prevalence of SOD in patients referred to ERCP. Among these patients the prevalence of SOD was not influenced by gender, nature of the disease or the number of cannulation attempts. SOM is a safe procedure for the evaluation of SOD in patients referred to ERCP.

Detection of Small Bile Duct Stones by Intraductal US in Patients with Highly Suspected Choledocholithiasis Showing No Filling Defect on ERCP

BACKGROUND/AIM: ERCP has been considered an accurate means in the diagnosis of choledocholithiasis. However, small bile duct stone can be difficult to diagnose during ERCP. The aim of this study was to prospectively evaluate the ability of intraductal US for detecting small choledocholithiasis in patients with highly suspected bile duct stones demonstrating no filling defect on ERC. METHODS: Fifty nine consecutive patients who underwent ERCP within 48 hours after admission for highly suspected choledocholithiasis with negative results were evaluated with intraductal US (20 MHz) for the presence of stones or sludge. Patients showing any filling defect on biliary tree on ERCP excluded. Reference standard for choledocholithiasis was endoscopic extraction of stone or sludge. RESULTS: 1) Of 59 patients, IDUS found evidence of bile duct stone in 11(18.6%) patients. IDUS findings were confirmed by endoscopic extraction of stone in 10 of 11 (16.9%) patients. The sensitivity and specificity of IDUS in detecting choledocholithiasis were 100% and 97.9%. 2) IDUS showed evidence of biliary sludge in 10 patients and confirmed by extraction of sludge in 7 patients. 3) Mean diameter of CBD stones diagnosed by IDUS was 2.3 mm (range: 1-4 mm). 4) In dilated bile ducts, detection rate of bile duct stone/sludge missing on ERC were significantly higher than that of nondilated bile duct (p<0.05). CONCLUSION: Intraductal US is highly accurate in the detection of small bile duct stones that missed on ERCP. In patients with suspicion of bile duct stones but normal ERCP, intraductal US could be performed as a useful adjunct to ERCP.

Determination of Sphincter of Oddi Dysfunction in Patients with Prior Normal Manometry

Background: Assessment of sphincter of Oddi motility by manometry is limited to a finite time period, and the presence of a motor disorder that is intermittent may not be documented. This study evaluated the frequency of sphincter of Oddi dysfunction in persistently symptomatic patients with previously normal sphincter of Oddi manometry studies. Methods: A total of 177 patients underwent ERCP for suspected sphincter of Oddi dysfunction and had a normal sphincter of Oddi manometry study (both biliary and pancreatic) over a 5-year period (1996-2001). All patients referred for a second ERCP with sphincter of Oddi manometry for evaluation of persistent symptoms were included in this study. Results: Of the 177 patients, 12 (mean age 37.6 years, range 19-59 years) met criteria for inclusion. The mean time interval between the first and second ERCP was 337 days (range 43-792 days). Sphincter of Oddi dysfunction was diagnosed at a second sphincter of Oddi manometry in 5 (42%) patients; 4 had pancreatic sphincter hypertension; one had elevation of both pancreatic and biliary sphincter pressures. All 5 patients underwent endoscopic sphincter ablation therapy; 4 were symptom-free on follow-up at, respectively, 26, 40, 48, and 72 months; one patient had persistent symptoms from pancreatic sphincter restenosis and required multiple endoscopic interventions. Five of the 12 (42%) patients with normal manometric studies were found to have pancreatographic changes of chronic pancreatitis; the two remaining patients had a normal ERCP and manometry. Conclusions: A single negative manometry study does not rule out sphincter of Oddi dysfunction. Repeat ERCP with manometry may be warranted for patients with persistent symptoms in whom the clinical suspicion for sphincter of Oddi dysfunction remains high.

ERCP in the diagnosis and management of complications after surgery for hepatic echinococcosis

Surgery for liver hydatidosis can result in serious morbidity and mortality. The role and efficacy of ERCP in the management of these complications was reviewed. Retrospective analysis of 79 patients with liver hydatidosis who underwent ERCP for postoperative complications. All patients with biliary fistulas (n = 50) were managed by endoscopic sphincterotomy, although 9 (18%) also required a biliary endoprosthesis. Surgical reintervention was avoided in 46 (92%) patients with subsequent surgery required in only in 4 (8%). The mean time to fistula closure was 13.3 days. Patients with daughter cysts in the bile ducts (n = 7) were also treated by endoscopic sphincterotomy and evacuation of obstructing cyst material. Seven patients with elevated liver enzymes or biliopancreatic symptoms but normal ERCP findings also underwent endoscopic sphincterotomy with normalization of biochemical tests. ERCP is valuable for detecting and treating postoperative biliary complications after surgery for hepatic echinococcal disease. In the majority of patients, endoscopic sphincterotomy allows healing of postoperative external biliary fistulas, and should be performed as early as possible. In some cases, a biliary prosthesis may be required. Endoscopic sphincterotomy also enables clearing of the bile ducts of hydatid remnants.

Usefulness of endoscopic observation of the main duodenal papilla in the diagnosis of sclerosing pancreatitis

Background: There are no descriptions of the appearance of the main duodenal papilla in sclerosing pancreatitis. The intent of the present study was to clarify the characteristics of the main duodenal papilla in patients with sclerosing pancreatitis. Methods: Macroscopic findings at ERCP with reference to the main duodenal papilla of 17 patients with sclerosing pancreatitis were compared with those of 24 patients with normal ERCP findings, 11 with chronic pancreatitis, 13 with primary sclerosing cholangitis, 21 with pancreatic cancer, and 18 with bile duct cancer. Endoscopic photographs of the papilla were reviewed retrospectively by 3 observers blinded to the underlying pancreaticobiliary pathology. Degree of swelling was scored in all patients. Biopsy specimens from swollen papillae were assessed histopathologically in 3 patients with sclerosing pancreatitis. Results: Severe swelling of the main duodenal papilla was observed in 7 (41%) of 17 patients with sclerosing pancreatitis. The total score for the degree of swelling in patients with sclerosing pancreatitis was significantly higher than that for patients with a normal ERCP, chronic pancreatitis, primary sclerosing cholangitis, pancreatic cancer, and bile duct cancer ( p < 0.01). T-lymphocyte infiltration of the papilla was evident in the biopsies from 3 patients with sclerosing pancreatitis. Conclusions: A swollen main duodenal papilla was a characteristic finding in patients with sclerosing pancreatitis. T-lymphocyte infiltration is present in the swollen main duodenal papilla. These features may be useful in the diagnosis of sclerosing pancreatitis. (Gastrointest Endosc 2002;56:880-4.)

Usefulness of endoscopic observation of the main duodenal papilla in the diagnosis of sclerosing pancreatitis.

There are no descriptions of the appearance of the main duodenal papilla in sclerosing pancreatitis. The intent of the present study was to clarify the characteristics of the main duodenal papilla in patients with sclerosing pancreatitis. Macroscopic findings at ERCP with reference to the main duodenal papilla of 17 patients with sclerosing pancreatitis were compared with those of 24 patients with normal ERCP findings, 11 with chronic pancreatitis, 13 with primary sclerosing cholangitis, 21 with pancreatic cancer, and 18 with bile duct cancer. Endoscopic photographs of the papilla were reviewed retrospectively by 3 observers blinded to the underlying pancreaticobiliary pathology. Degree of swelling was scored in all patients. Biopsy specimens from swollen papillae were assessed histopathologically in 3 patients with sclerosing pancreatitis. Severe swelling of the main duodenal papilla was observed in 7 (41%) of 17 patients with sclerosing pancreatitis. The total score for the degree of swelling in patients with sclerosing pancreatitis was significantly higher than that for patients with a normal ERCP, chronic pancreatitis, primary sclerosing cholangitis, pancreatic cancer, and bile duct cancer (p < 0.01). T-lymphocyte infiltration of the papilla was evident in the biopsies from 3 patients with sclerosing pancreatitis. A swollen main duodenal papilla was a characteristic finding in patients with sclerosing pancreatitis. T-lymphocyte infiltration is present in the swollen main duodenal papilla. These features may be useful in the diagnosis of sclerosing pancreatitis.

Reply to Dr. Mosca

Dear Sir,the comments raised by Professor Mosca are provocative and reflect many of our opinions with regard to ”who should perform ERCP“. With the decreasing number of diagnostic procedures and increasing number of options for biliary tract imaging, it is of critical importance that physicians performing ERCP are not only fully equipped technically, but also possess a full breadth of knowledge regarding the advantages and disadvantages of various alternatives available. As demonstrated by Freeman et al. [1], the number of cases one performs does appear to be reflected in outcomes. Physicians who routinely performed fewer than one sphincterotomy per week had a greater complication rate than those performing more procedures. For these reasons, most large centers have created specialized biliary services in an effort to ensure that a few physicians maintain a high level of skill in this advancing field. Our study [2] was designed to assess risk factors for perforation. In any effort to do this, comparator groups would be required. As described in the methods section, we performed a case-control study in an attempt to identify risk factors for perforations related to ERCP. The baseline group consisted of patients with normal ERCP and the other comparative group comprised patients with pancreatitis. The study group was that group of patients with perforation. The patients were randomly selected. This is the basis for performing a case-control study to assess risk factors related to a certain procedure. Although there were 10 000 ERCPs in the database, most were not normal, and there were only 33 perforations. For the purpose of a case-control study, a comparison group was required. Although there are always limitations whatever group one selects as a comparison, we felt that a group with pancreatitis (i. e., a group, which suffered another complication, selected at random) might give us insights into risk factors. The ideal setting would be that of a controlled trial; however, since perforations are not common, any type of controlled trial would be an enormous undertaking; if not an impossible one. Therefore, we used a case-control study to evaluate this issue as well as possible. Although there were limitations in this approach, we reported on the largest group of perforation patients (even though they were somewhat diverse) that has been evaluated in an in-depth approach, in an attempt to further elucidate the risk factors for their complication. We concentrated only on perforations, unlike other studies, which have often concentrated on pancreatitis or a range of complications occurring during ERCP. We have successfully performed many procedures on Billroth II patients; however, the data with regard to the percentage of patients who suffered perforation or other complications have not been analysed. Logically, as noted by Dr. Mosca, it does appear that altered anatomy (i. e., Billroth II gastrectomy, duodenal stricture) probably slightly increases the risk of perforation. Unfortunately, these are rare conditions and caution is recommended in drawing conclusions from complications occurring in only one or two patients. In our evaluation we did include patients who we classified as having ”guide wire“ perforations. These perforations occurred with varying types of guide wires, during difficult cannulations or manipulation through distal strictures. They were usually diagnosed at ERCP when contrast was noted to extravasate, in patients who had not had a sphincterotomy. We do agree that one of the inferences from the paper (as supported by previous published reports) is that ERCP is safe, in expert hands. We believe that adequately trained endoscopists, who perform ERCP on a regular basis, will have the best therapeutic results with the lowest complication rates.

ERCP, biliary crystal analysis, and sphincter of Oddi manometry in idiopathic recurrent pancreatitis

Background: This study investigated the role of ERCP, analysis of bile for microcrystals, and sphincter of Oddi manometry in idiopathic recurrent pancreatitis. Methods: One hundred twenty-six patients met criteria for idiopathic recurrent pancreatitis. Patients with a normal ERCP underwent sphincter of Oddi manometry and analysis of bile. Bile was also collected in patients with papillary stenosis (defined as ductal dilation with delayed drainage of contrast, sphincter basal pressures greater than 40 mm Hg, and positive analysis for cholesterol and/or calcium bilirubinate crystals). Results: ERCP alone identified a cause of idiopathic recurrent pancreatitis in 47 (37%) patients: papillary stenosis in 26 (21%), pancreas divisum in 9 (7%), and choledocholithiasis in 6 (5%). Among patients with a gallbladder, microcrystals were found in 27 (50%) and sphincter dysfunction in 17 (31%). Among patients who have undergone cholecystectomy, sphincter dysfunction was identified in 24 (47%). Minor papilla sphincterotomy was performed in 8 patients (89%) with pancreas divisum. Biliary sphincterotomy was performed in 85 patients and included all patients with choledocholithiasis, choledochocele, microcrystals, papillary stenosis, and sphincter dysfunction except 2 patients with microcrystals who underwent cholecystectomy. Additionally, pancreatic sphincterotomy was performed in 32 (78%) patients with pancreatic sphincter hypertension and in 6 (23%) of 26 patients with papillary stenosis with dilated pancreatic ducts. Thus, among the 126 patients, 93 of the 100 patients with a detected abnormality underwent endoscopic sphincterotomy. Response rates varied from 67% to 100% during follow-up (mean 29.6 months, range 18 to 33 months). Conclusion: ERCP techniques including minor papilla cannulation, analysis of bile for microcrystals, and sphincter of Oddi manometry identified a cause of idiopathic recurrent pancreatitis in 79% (endoscopically treatable in 75%) of patients, with or without prior cholecystectomy. (Gastrointest Endosc 2002;55:157-62.)

Modalities of testing Helicobacter pylori in patients with nonmalignant bile duct diseases.

This paper describes the procedure of detection of Helicobacter pylori (H. pylori) in bile specimens in patients suffering from benign diseases of biliary ducts (lithiasis with/without nonspecific cholangitis). The group of 72 patients entering the study consisted of 32 male and 40 female (45% and 55%, respectively). Bile was obtained during ERCP in 68 patients, and during cholecystectomy in 4 patients. A fast urease test (FUT) to determine the existence of H. pylori in gastric mucosa was carried out for all the patients during the endoscopic examination. The existence of genetic material of H. pylori was determined by detection of ureA gene by the method of nested PCR. The results of this reaction were shown by electrophoresis on 10g.L(-1) agarose gel in a band of 256bp. The majority of the patients included in our study had biliary lithiasis without signs of cholangitis (48 patients, 67%), whereas other patients were complicated by cholangitis (17 patients, 24%). Seven patients (9%) had normal ERCP, forming thus the control group. In the group of patients with lithiasis 26 patients (54.2%) had positive PCR of H. pylori in bile and among the patients with associated cholangitis positive PCR was detected in 9 patients (52.9%). Among the seven patients with normal ERCP only one (14%) had positive PCR of H. pylori. A high percentage of H. pylori infection of gastric mucosa was observed (57 patients, 79%). It was also observed that its slightly higher positivity was in the patients with distinct bile pathology: 81% FUT positive patients in the group with choledocholithiasis alone and 76% in the group with choledocholithiasis associated with cholangitis. Seventy-one percent of the patients with regular findings had positive FUT. The prevalence of H. pylori infection both in bile and in gastric mucosa in patients with benign diseases of biliary ducts does not show a statistically significant difference in relation to the prevalence of the same with the patients with normal ERCP. The existence of H. pylori infection possibly does not play a role in pathogenesis of benign biliary diseases.

Pancreatic Mass caused by Mycobacterium tuberculosis with Reduced Drug Sensitivity

Pancreatic tuberculosis is a rare condition which should be considered in patients with a pancreatic mass, particularly if the patient is young, not jaundiced, from an area of high TB prevalence with a normal ERCP. We report a case of pancreatic tuberculosis due to Mycobacterium tuberculosis with reduced sensitivity to rifampicin and isoniazid, that was treated with rifabutin, ciprofloxacin, ethambutol and pyrazinamide following clinical failure of first-line therapy. The case presented illustrates the importance of obtaining material for culture and sensitivity testing in cases of suspected TB.