Post ERCP Research Articles

Success and Limitations of ERCP in the Management of Obstructive Jaundice

Background: Obstructive jaundice can be caused by malignant or benign lesions. The treatment for these conditions is biliary decompression either by surgery or by endoscopic methods.Objectives: The aim of this study was to evaluate the diagnostic and therapeutic role of ERCP with its success and limitations in the management of obstructive jaundice.Methods: This study was carried out in the depertment of General Surgery & hepato-biliary surgery in Bangabandhu Sheikh Mujib Medical University during 1st January, 2012 to 30th June,2012.Results: The study included 60 patients (male, 38, female,22), mean age 45 years(range, 21-70 years). Commonest malignant cause of obstructive jaundice was Carcinoma of the pancreas 27% followed by, cholangiocarcinoma 15%, and periampullary carcinoma 8%. Bile duct stone 32% was the commonest benign cause followed by papillary stenosis 13% and round warm in biliary tree 5%. Stenting were done in 42% of patients and success rate was 92%. Biopsy were taken for diagnosis in 8% for papillary tumours. Stone extraction were done in 32% of patients for CBD stone and success rate was >94%. Warm extraction were done in 5% and sphincterotomy in 11% of patients for papillary stenosis where success rate was 100%. ERCP could not be performed due to stenosis of duodenum in 1.66% of patients, complete papillary obstruction in 3.33%, papillary position abnormality in 3.33% and endoscopically ampulla not found in 5% of patients. The commonest post ERCP complication was acute pancreatitis that was 5%. Other complications include bleeding in 3.33%, perforation in 1.66% and acute cholangitis in 3.33% cases.Conclusion: Despite its associated limitations and complication, ERCP is a reliable method in treating obstructive jaundice for most of the benign conditions and stenting as a palliative measure & tissue diagnosis in malignant obstruction. In this study the success rate is acceptable for ERCP in the management of obstructive jaundice.KYAMC Journal Vol. 8, No.-1, Jul 2017, Page 38-42

Comparison of Safety Profile of ERCP in Patients With Cirrhotic and Non-cirrhotic Portal Hypertension

Background and Aim: Reports suggest that patients with cirrhosis may be prone for adverse events following ERCP due to underlying coagulopathy, hepatic dysfunction, portal hypertension and other systemic derangements. Methods: We performed a retrospective study of ERCP in 34 patients (32 males, 2 females) with liver cirrhosis (11 Child A, 12 Child B, 11 Child C) and compared the profile with 11 patients with portal cavernoma cholangiopathy (7 males, 4 females) who underwent ERCP between July 2014 and June 2016 out a total of 843 patients who underwent ERCP in this 2 year period. Results: The mean age of patients with liver cirrhosis was 60.4 ± 2.4 years while that of portal cavernoma cholangiopathy was 51.3 ± 4.2 years. The most common indication for ERCP was choledocholithiasis. Biliary sphincterotomy was performed in 38 patients and needle-knife papillotomy in 6 patients. Biliary brushings were taken in 1 patient while SpyGlass cholangioscopy was performed in 1 patient. There was no post-procedure mortality or severe adverse event. Adverse events were seen in 9/34 (26.4%) patients with liver cirrhosis and in 4/11 (36.3%) patients with portal cavernoma cholangiopathy. There was no significant procedure related bleeding in both groups. Mild post ERCP pancreatitis and cholangitis were equally common complications in both groups. Adverse events were more common in patients with advanced Child class (C > B > A). Conclusions: Mild cholangitis was the most common complication in addition to pancreatitis in patients with cirrhotic and non-cirrhotic portal hypertension. Post-procedure bleeding was not found to be a significant adverse event in patients who underwent ERCP. The authors have none to declare.

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.

Comparison of Endoscopic Papillary Large Balloon Dilation and Endoscopic Sphincterotomy for Retrieval of Choledocholithiasis

Background: Endoscopic sphincterotomy (EST) combined with balloon catheters and/or baskets are the routine endoscopic techniques for stone extraction in the great majority of patients. Whereas large common bile duct (CBD) stones are treated conventionally with mechanical lithotripsy, large balloon papillary dilation after endoscopic sphincterotomy (ELPBD) represents the onset of an era in large CBD stone extraction and the management of “impaction”. That is because it seems effective, inexpensive, less traumatic, safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists. Studies comparing the efficacy and safety of EPLBD with EST have reported mixed outcomes. The aim of the study to compare the success and complications rates between endoscopic papillary balloon dilation and endoscopic sphincterotomy for enlargement of papillary opening during endoscopic removal of common bile duct stones. Methods: Randomized prospective comparative study was conducted on seventy four patients with CBD stone(s), subjective to therapeutic ERCP procedures for endoscopic extraction of common CBD(s). The enrolled patients were randomly divided into two groups according to the maneuver for dilate the papillary orifice into: Group I: Thirty one patients underwent EPLBD technique combined with balloon catheters and/or baskets for stone extraction. Group II: Forty three patients underwent EST combined with balloon catheters and/or baskets, which is considered as conventional endoscopic technique for stone extraction in the great majority of patients. Results: Complete extraction CBD stones among the patients of group1; EPLBD was effective for clearance of (92.5%) of CBD stones in patients with the stone sized 1cm, (overall clearance rate=87%). Overall adverse effects of patients of group1 was (29%) as mild self-limiting post ERCP pain occurred in (9.6%) and mild intra- procedure bleeding occurred in (9.6%), whereas more serious complication as melena which occurred in (3.2%), and mild pancreatitis occurred in (6.4%). Whereas complete CBD stones clearance among the patients of group 2; EST was effective in (96%) of patients with the stone sized 1cm, (overall clearance rate=79%). Overall adverse effects of patients of group 2 was (18.5%) as mild self-limiting post ERCP pain occurred in (7%) and mild intra-procedure bleeding occurred in (4.6%), whereas more serious complications as mild pancreatitis developed in (4.6%), and post ERCP cholangitis in (2.3%). The comparison between the two groups regarding the extraction of CBD stones revealed combination of papillary large balloon dilation after EST is not required in patients whose the CBD stone size 1cm among the group 1 was (83%) which better than among the group 2 which was (56%) with nearly statistical difference (P value=0.07). Conclusion: Conventional EST is an effective method for removal of common bile duct stones 1cm which is difficult to be extracted by conventional sphincterotomy and extraction devices. Endoscopic papillary large balloon dilation is an adjunctive tool to endoscopic sphincterotomy for removing large or difficult CBD stones.

Endoscopic Balloon Dilatation vs. Sphincterotomy in Cases of Calcular Obstructive Jaundice during Endoscopic Retrograde Cholangio Pancreatography

Background: Compared to Endoscopic sphincterotomy (ES), endoscopic balloon dilation (EBD) has been reported to have a lower risk of bleeding but an increased risk of post-ERCP pancreatitis. Additionally, removal of large stones may be challenging when using EBD alone. Patients and methods: 50 patients with calculary obstructive jaundice was enrolled in our randomized comparative study, ES was done for have of them and EBD for the rest. During ERCP, stone removal was declared as complete if the final cholangiogram showed no residual stones. Clinical evaluation for post ERCP pancreatitis was performed on the following day by symptoms and serum amylase. Results: There is no statistical significant difference between the two groups, as regard, procedure duration, cannulation trials and time. Success rate was 88% and 80 after ES and EBD respectively. Significant higher rates of endoscopic bleeding were detected with ES. Apart from significant higher rates of post-ERCP bleeding after ES, no difference was detected between the 2 groups at regard post-ERCP complications. Conclusion: The efficacy of EBD is similar to ES regarding, removal of common bile duct stones, and it can be safely applied particularly in patients with systemic coagulopathy as it carries a lower rate of bleeding. Further study evaluating the combined ES and EBD is highly recommended.

Comparative study between magnesium sulphate and L-hyoscyamine on duodenal motility during ERCP under general anaesthesia: A prospective randomized study

ObjectiveEndoscopic retrograde cholangiopancreatography (ERCP) is a relatively complex procedure as compared with other endoscopy which needs longer duration, duodenal relaxation and good sedation. The aim of this study was to evaluate the efficacy and safety of magnesium sulphate as spasmolytic agent during ERCP under general anaesthesia.DesignA prospective randomized study.SettingDelivery room, operating room and postoperative recovery area.Patients and methodPatients, who were treated for calcular obstructive jaundice by ERCP were randomized into two groups. The patients were randomized into two groups: G I, patients received 500 mg magnesium sulphate in 100 ml saline 15 min before induction and G II, patients received 0.5 mg L-hyoscyamine sulphate before induction of anaesthesia.MeasurementThe primary outcome was duodenal relaxation during ERCP under general anaesthesia. Secondary outcomes include changes of heart rate, changes in oxygen saturation, time needed for cannulation, procedure difficulty, duration of the procedure, post-procedure complications, and the need of post-procedure analgesia.ResultsDuodenal motility score was found to be 0.85 ± 1.47 in GI and 2.2 ± 3.08 in GII (P = 0.0001). The number of patients who had no duodenal contraction was significantly more in GI. The success rate of biliary cannulation is significantly higher in GI than in GII (58 (100%) vs 54 (93.1%), P = 0.04). The duration of cannulation was significantly shorter in GI. The number of patients who developed pancreatitis, nausea and vomiting was significantly less in GI. The pulse rate was found to be statistically less in GI at different time follow-ups.ConclusionMagnesium sulphate is a safe spasmolytic agent during general anaesthesia that improves the success rate of ERCP and it allows easy completion of the procedure by decreasing the duodenal motility. It decreases the duration of the procedure, subsequently shortens the period of anaesthesia and improves post procedure recovery. It reduces post ERCP pancreatitis, nausea and vomiting.

Relationship between duodenal diverticula and cannulation time during ERCP procedures and post ERCP complications

Objective To investigate the influence of duodenal diverticula on cannulation time and complication in patients undergoing ERCP. Methods Data of 3 265 patients undergoing ERCP in Drum Tower Hospital affiliated to Nanjing Medical University between January 1, 2008 and December 31, 2014 were enrolled. The patients′ information and endoscopic pictures/videos were collected. The duodenal diverticula, cannulation time, postoperative complications were analyzed. Results There were 2 599(79.6%) cases of non-diverticula, 445(13.6%) cases of one-diverticula, 122(3.7%) patients with two or more diverticula, and 99 (3.0%) intradiverticular papilla. Patients with duodenal diverticula accounted for 20.4% (666/3 265) of all patients who received ERCP procedure. The mean cannulation time was 6.62 minutes in all cases, 6.30 minutes in non-diverticula group, 7.63 minutes in one-diverticula group, 8.07 minutes in two-or-more group, 8.58 minutes in intradiverticular papilla group, respectively. There were significant differences in cannulation time and complication rate between the groups. Conclusion Duodenal diverticula may be one of the factors that affect the cannulation time. It may enhance the cannulation complications and prolong the cannulation time, especially in those with intradiverticular papilla. Key words: Cholangiopancreatography, endoscopic retrograde; Postoperative complications; Selective biliary cannulation; Duodenal diverticula

The frequency of post ERCP pancreatitis with wire-guided cannulation using early pancreatic guidewire placement without precut sphincterotomy

The frequency of post ERCP pancreatitis with wire-guided cannulation using early pancreatic guidewire placement without precut sphincterotomy

What is the factor of post ERCP pancreatitis for cannulation by trainees in naïve papilla

Access to the pancreatic or the bile duct is paramount to the success of diagnostic and therapeutic ERCP. Selective cannulation may be difficult because of the small size of the papilla and anatomic factors such as peripapillary diverticulum and gastrectomy with Billroth-II anastomosis. Currently, one of the techniques for gaining access in such cases is the pre-cut technique with a catheter that has a thin wire at the tip (needle knife). A less well-described pre-cut technique involves initial cannulation of the pancreatic duct with a “traction-type” papillotome and then incision through the “septum” toward the bile duct. The aim of this randomized trial was to compare the success and the complication rates of needle-knife sphincterotomy and transpancreatic sphincterotomy in achieving cannulation of an otherwise inaccessible bile duct.Sixty-three consecutive patients with inaccessible bile ducts underwent pre-cut sphincterotomy either by needle-knife sphincterotomy (n = 34) or transpancreatic septotomy (n = 29). In patients with an accessible pancreatic duct who undergo needle-knife sphincterotomy, a short (2-3 cm) stent (5F-7F) was placed in the pancreatic duct to act as a guide and to reduce the risk of post-procedure pancreatitis. All patients were hospitalized overnight for observation after pre-cut sphincterotomy. The outcomes measured were success rate and complications. Indications for pre-cut sphincterotomy were the following: suspected choledocholithiasis, 11 patients (17.5%); obstructive jaundice with negative CT findings, 19 patients (29.2%), or with positive CT findings, 13 patients (20.6%); abdominal pain with elevated biochemical tests of liver function, 15 patients (23.8%); and miscellaneous, 5 patients (7.9%).In 55 of 63 (87%) patients, the bile duct was selectively cannulated after pre-cut sphincterotomy. On a pre-protocol basis, the bile duct was cannulated in 29 of 29 (100%) patients randomized to transpancreatic septotomy sphincterotomy and 26 of 34 (77%) patients who underwent needle-knife sphincterotomy (p = 0.01). There were 7 complications, including bleeding (n = 2) and acute pancreatitis (n = 5). Complications were less frequent in the transpancreatic septotomy sphincterotomy group (1/29; 3.5%) compared with the needle-knife sphincterotomy group (6/34; 17.7%).Transpancreatic pre-cut sphincterotomy can be performed with a high degree of success in patients with inaccessible obstructed bile ducts. Compared with standard needle-knife sphincterotomy, transpancreatic septotomy sphincterotomy has a significantly higher rate of bile duct cannulation and a lower complication rate.

PTH-019 Does Rectal Diclofenac Reduce Post ERCP Pancreatitis in The UK?

Introduction Post ERCP pancreatitis(PEP) occurs in up to 10% of unselected cases and carries significant morbidity. PEP is significantly higher in certain patient groups, for example females, young age, Sphincter of Oddi dysfunction, previous pancreatitis and following pancreatic duct cannulation. There is a growing body of evidence that NSAIDS should be used in PEP prophylaxis but use is still uncommon in the UK. The 2010 European Society for Gastrointestinal Endoscopy Guidelines on PEP recommends routine use of rectal NSAIDs in all patients. There is only one published RCT from the UK demonstrating the efficacy of NSAIDS in reducing PEP. Rectal diclofenac was introduced into ERCP practice at the RUH in two phases. Firstly, a selective use in patients determined to be at high risk as determined by criteria above. Secondly diclofenac was used routinely in all patients without contraindication. Methods A retrospective analysis of 5 years ERCP data was performed using readmission data, blood results, radiology reports and discharge summaries to identify patients with PEP from August 2010 – December 2015. The administration of rectal diclofenac post procedure was recorded from the endoscopy reporting system. Fisher’s exact test was used to statistically analyse categorical data. Results 1318 ERCPs were performed by 4 endoscopists during the study period with 66 (5.0%) cases of pancreatitis. 445 ERCPs were performed prior to the introduction of NSAID use during which time there were 35 (7.9%) episodes of PEP. During the selective period of NSAID use (only used if patient deemed high risk by endoscopist) 539 ERCPs were performed and 72 (13.4%) patients received NSAIDS. 17 (3.2%) developed PEP. 334 ERCPs were performed when NSAIDS were given to all patients without contraindication. 289 (86.5%) of patients received rectal diclofenac and 13 (3.9%) developed pancreatitis. There is a statistically significant decrease in PEP comparing the groups of patients receiving NSAIDS selectively (p = 0.0009) or routinely (p = 0.0172) when compared with none. There is no difference between the selective and routine group (p = 0.571). Conclusion The use of rectal diclofenac post ERCP decreases the rate of PEP when used in a selective or routine protocol. Despite a growing body of evidence for NSAIDS use routine administration is used by the minority of endoscopists in the UK. The evidence for use of NSAIDS in PEP is heterogeneous a number of factors including diagnostic criteria for pancreatitis, type and route of NSAID and selective high risk or routine use. We believe that this heterogeneity and lack of UK evidence accounts for the slow uptake of NSAIDS for PEP. Our data demonstrates that the introduction of a selective or routine use of NSAIDS for PEP in a DGH significantly decreases the risk of pancreatitis (RR 43.7%). Disclosure of Interest None Declared

Changing pattern of laparoscopic internal drainage of pancreatic pseudocyst in the era of endoscopy: Experience from a tertiary centre in South India

Background: Management of symptomatic pancreatic pseudocyst (PPC) underwent major changes from open to laparoscopic and then to endoscopic internal drainage. PPC which are amenable for cystogastrostomy are being managed in increasing numbers by endoscopic methods and those in other locations are still managed by surgical methods mainly by jejunal drainage. Methods: Patients who underwent laparoscopic internal drainage for PPC at our centre from May 2007 until August 2015 were analysed from a prospectively maintained data base. Results: There were 56 patients (50 males and 6 females), average age of 41 years and associated co-morbidity in 28.5%. Alcohol pancreatitis was seen in 20 cases (35.7%), biliary pancreatitis in 16 cases (28.5%), 1 case each of auto immune pancreatitis, traumatic and post ERCP induced pancreatitis. Laparoscopic cystogastrostomy (LCG) was done in 42 cases (75%), laparoscopic cystojejunostomy (LCJ) in 14 cases (25%).The mean operating time was 140 minutes. Mean hospital stay was 6.5 days. Two patients in LCG were re-operated for stomal bleeding and leak from gastrostomy wound. We had no mortality and nil recurrence. During this period, we had 14 cases of PPC done by Endoscopic CG which were excluded from this study. In our previous series, between 1994–2006, of the total 108 cases, LCG was done in 90 cases (83.4%) and LCJ was done in 8 cases (7.4%). Conclusion: Our experience in two different time period shows that there is increasing proportion of LCJ being done compared to LCG due to growing role of endoscopy in management of PPC.

A study to assess the outcome of patients undergoing laparoscopic cholecystectomy post ERCP

Background: Choledocholithiasis is prevalent in 8 to 20 percent of patients with cholelithiasis. Of all the treatment options available, laparoscopic cholecystectomy post ERCP is one of the most commonly used modality. Surgeons have always experienced difficulties while performing a laparoscopic cholecystectomy post ERCP due to adhesions induced by ERCP. This study was to investigate this modality further to assess the difficulty during the procedure and the possible factors influencing this. Methods: Patients post ERCP who underwent interval laparoscopic cholecystectomy was studied in a tertiary care centre in the urban setting. Results: Out of the 40 patients studied over the 18 month period, 14 (35%) underwent conversion to open cholecystectomy. Calot’s triangle adhesions were the most common cause of conversion. Multiple ERCP sessions positively influenced the chance of conversion (P-value 0.014). Intraoperative bleeding was directly related to the Calot’s triangle adhesions which subsequently increased the chance of post-operative bile leak (P-value 0.022). No mortalities were encountered during the course of the study. Conclusions: Laparoscopic cholecystectomy in post ERCP patients is difficult but safe.

Hepatic subcapsular hematoma: a rare late complication after ERCP

We present a clinical case of a 83 years old man, who consulted to the Emergency Department by continuous pain in right upper quadrant, having been discharged a week ago after ERCP for choledocholithiasis. TAC was performed showing a subcapsular hematoma without active bleeding. This complication post ERCP has been described on few occasions.

Endoscopic Management of Common Bile Duct Stones

Gallstone disease is one of the most common reasons for hospital admission. CBD stones are classified in primary and secondary stone on the basis of the site of origin. Clinical presentation varies from asymptomatic to life threatening conditions such as acute biliary pancreatitis and cholangitis. Patients are categorized in low, intermediate and high risk of choledocholithiasis using clinical, biochemical and imaging factors. Patients with low risk of choledocholithiasis should receive cholecystectomy without further evaluation whileit has been recognized the importance of sequential use of EUS-ERCPin patients with intermediate risk of choledocholithiasis to triage patients in need of treatment. Patients with high risk of choledocholithiasis should receive ERCP before performing cholecystectomy although randomized clinical trial showed no benefit for preoperative ERCP over operative cholangiography and common duct exploration. Patients should be received an informed consent and antiplatelet and anticoagulation treatment should discontinued for the appropriate drug-specific interval in according to the recent guideline. Routine administration to all patients undergoing to ERCP is considered unnecessary unless cholangitis or immunosoppression is present or biliary drainage is predicted to be incomplete. All patients undergoing to ERCP should be administered prophylactic drugs such as rectal indomethacin or diclofenac because of consistently reduced risk of post ERCP pancreatitis according to several meta-analysis and ESGE guideline. Endoscopic treatment is based on selective incannulation of the CBD and performing adequate endoscopic sphincterotomy. In case of failed biliary access several reasonable options could be chosen. CBD stone can be removed with either a basket or a balloon catheter in 85-90% of cases and the choice of the better device depends on common bile duct and stone size. Approximately 10-15% of biliary stone are difficult to extract and several technique, such as EPBD, PBSD and ML can be used. Alternative modality for the fragmentation of refractory CBD stone are intraductal lithotripsy (eg. Laser or Electrohydraulic lithotripsy) and ESWL. Mirizzi syndrome is usually treated by surgery although although there have been case reports of endoscopic removal.Intrahepatic stones are treated by dormia basket on guidewire after balloon dilation if stricture is present or cholangioscopy with intraductal lithotripsy, per-oral cholangioscopic lithotripsy (POCSL) or percutaneous transhepatic cholangioscopy lithotripsy (PTCSL) and surgical resection (Hepatectomy). POCSL and PTCSL are hindered by high rates of stone recurrence. Biliary stenting as definitive treatment of difficult bile duct stone should be reserved for patients with short life expectancy.A review of case series suggest that BS is a safe and effective treatment for common bile duct stone in the pregnant patient but may be associated with higher risk of post ERCP pancreatitis than in the general population.

Epidemiology, aetiology and outcomes of acute pancreatitis: A retrospective cohort study

BackgroundAcute pancreatitis is a common acute surgical presentation in Western Society. The causes and pattern of pancreatitis has not been previously documented for Western Sydney. As Western Sydney contains many areas of low socio-economic status with an expected high level of alcohol abuse, it was hypothesised that alcoholic pancreatitis would be more prevalent in this population. The aims of this study were to determine the epidemiology, aetiology and outcomes of acute pancreatitis. MethodsA retrospective analysis of patients presenting with acute pancreatitis to four tertiary hospitals over a four-year period was undertaken. Results932 patients presented with acute pancreatitis with a median age of 50 years (range 16–95); 470 (50.4%) were female. Almost half had gallstones (40%), 25.6% idiopathic, 22% alcohol induced and 3.9% post ERCP. 69 (7.4%) of patients were admitted to ICU/HDU, with a median length of stay in ICU was 6 days (range 1–106). 85 (11.1%) patients had severe pancreatitis (score ≥ 3). Mortality in this study was 1% (9). ConclusionThe majority of patients with acute pancreatitis in Western Sydney present with mild disease and have a low risk of morbidity or mortality. The ratio of gallstone to alcohol aetiology was 2:1. Idiopathic pancreatitis is responsible for more cases than expected.

PTU-017 An audit of post ercp pancreatitis (pep) over four years in a uk tertiary centre

Introduction The incidence of complications post ERCP is roughly 10%, with a reported mortality of around 1%. Pancreatitis (PEP) is the most common serious complication and although most are self-limiting, 10% develop severe pancreatitis resulting in considerable morbidity and occasional mortality. Determining incidence is difficult due to patient variation in selection for ERCP. This audit cycle over a four year period compares the incidence at a UK tertiary centre with the standard derived from guidance issued by the European Society of Gastrointestinal Endoscopy (ESGE). Method Data was collected retrospectively using clinical coding to identify patients with post ERCP pancreatitis between 01/04/2010 and 31/03/2014. Electronic hospital records were analysed using set criteria to select those undergoing ERCP and developing subsequent pancreatitis. Results 572 ERCPs were performed over this four year period. Nineteen patients undergoing ERCP in this time interval developed pancreatitis, with an incidence of 3.32%. Thirteen patients were female, and the median age at ERCP was 64 years. Most patients underwent ERCP due to gallstones however two patients had cholangiocarcinoma. Of the nineteen patients with PEP, five patients had been previously investigated with MRCP, and fourteen had received an upper abdominal ultrasound scan (USS). Three of the nineteen patients with PEP had an amylase level less than three times the upper limit of normal, however when compared with their baseline serum amylase, their post ERCP result was three times greater than their baseline level. Conclusion Incidence of PEP at the UK tertiary centre was within the standard set by ESGE guidelines. There are no recommendations for improvement however re-audit should occur after April 2014 and should be carried out prospectively with additional outcome measures such as 30-day mortality, haemorrhage, perforation, cholangitis and cardiorespiratory complications. Disclosure of interest None Declared.

PWE-218 Risk factors predicting recurrent hospital admission acute pancreatitis

Introduction Acute pancreatitis is a relatively common condition and is associated with significant morbidity and mortality. Patients with acute pancreatitis do experience repeated hospital visits and admission due to recurrent symptoms. The aim of the study was to evaluate the factors that may predispose to recurrent pancreatitis requiring repeated hospital admission. Method Demographic and clinical data of all patients admitted to our hospital with acute pancreatitis between January 2011 and December 2014 were retrospectively reviewed. We collected data relating to the severity using modified Glasgow scoring tool, length of hospital stay and outcomes including intensive care admission, presence of complications and acute pancreatitis specific mortality. Patients with recurrent hospital admission were identified and factors predicting repeat presentation were evaluated. Results 569 patients with acute pancreatitis were admitted during the 4 year study period. There were 264 males and 305 females with the mean age of 60 (13–100) years. The aetiology factors included 290 gallstones, 91 alcohol induced, 142 idiopathic, 12 drug related, 9 hyperlipidaemia, 8 post ERCP, 8 pancreatic malignancy, 4 pancreatic divisum, 3 hypercalcaemia, 1 trauma and 1 autoimmune disease. 44.5% of the patients had at least one associated co-morbidity. There were 449, 44 and 76 patients with mild, moderate and severe pancreatitis according to the modified Glasgow criteria. Majority of the patients (83%) were managed on the ward while 71 and 35 were admitted to the high dependency and intensive care units respectively. 105/569 (18.5%) patients developed complications and we recorded pancreatitis specific mortality rate of 4.7%. 35% (199/569) of the patients required repeated admissions ranging from 2–4 episodes. Factors such as the aetiology of pancreatitis and the presence of comorbidity are predictors of recurrent symptoms and repeated hospital admission. Patients with gallstone pancreatitis (p-value 0.002) and comorbidity (p-value 0.008) have more likelihood of representation. Patients older than 70 years were more likely to present with recurrent symptoms but the difference did not reach a statistically significant level (p-value (0.060). Factors such as gender, severity of pancreatitis and the presence of complications at the first presentation have no significant influence on recurrent presentation. Conclusion Significant proportion of the patients with acute pancreatitis present with recurrent symptoms particularly those with gallstone induced with associated comorbidity. Early surgical and endoscopic treatment of the gallstones may prevent recurrent presentation. Disclosure of interest None Declared.

PWE-196 Factors predicting mortality in acute severe gallstone pancreatitis

Introduction The British Society of Gastroenterology (BSG) guidelines state that “Urgent therapeutic ERCP should be performed in patients with acute pancreatitis of suspected or proven gall stone aetiology who satisfy the criteria for predicted or actual severe pancreatitis”. The Cochrane review in 2012 suggested that ERCP does not affect morbidity and mortality and some patients with gallstones in the CBD will pass spontaneously. Aim The aim of this study was to assess predictive factors of mortality and the need for ERCP in severe gallstone pancreatitis. Method Data for patients who presented with acute severe biliary pancreatitis between January 2012 and April 2014 was collected. Data collected included predicted severity (Modified Glasgow score), liver function tests, white cell count, USS, ERCP and MRCP reports. Overall 90 day mortality was also recorded. Results 123 patients had predicted severe pancreatitis. On US 21 patients had a dilated CBD and 16 had CBD stone. 51% of patients (n = 63) had MRCP of which 22 patients had CBD stones. 60 patients had ERCP. In 17% (n = 21) no stone was found. 2 patients (3%) developed post ERCP pancreatitis.11% (n = 14)of the patients admitted with predicted severe acute pancreatitis died. On univariate analysis albumin (p = 0.003), alanine transaminase (ALT) (p= Conclusion Low serum albumin and ALT predicts mortality in severe GSP but ERCP does not and may precipitate further attacks of pancreatitis. Patients who have severe gallstone pancreatitis without deteriorating LFTs or cholangitis should have an MRCP to confirm stones in the CBD prior to ERCP. Disclosure of interest None Declared.

PWE-250 Clinical usefulness and safety of performing manometric guided sphincterotomy in patients with suspected type ii sphincter of oddi dysfunction: Abstract PWE-250 Table 1

Introduction Persistent biliary pain following cholecystectomy can be a challenging symptom to manage and the role of sphinterotomy has been questioned. Manometry during ERCP has been available in our unit since 2013 for patients with suspected type II sphincter of Oddi dysfunction (SOD). The aim of this study was to assess the response to sphincterotomy following manometric confirmation of a hypertensive sphincter and to assess the safety of this procedure. Method Patients fulfilling criteria for type II SOD underwent ERCP and manometry with the Cook long nose catheter. Pressure was zeroed in the duodenum prior to insertion into the common bile duct and a minimum of 2 pull-throughs performed. A persistent trough pressure ≥40 mmHg was considered hypertensive and an indication to perform sphincterotomy. All patients had rectal Diclofenac and an attempt at insertion of a prophylactic stent. Primary outcomes were reduction in abdominal pain and post-procedural complication rate. Coexistent anxiety, depression and functional disorders were also noted. Results 20 patients (mean age 42yrs and 18 females) were included (shown in Table 1). 4/20 did not receive a stent due to concomitant pancreas divisum (PD) and there were no complications during the procedure. 4/20 had acute pancreatitis post ERCP (3 mild, 1 moderate). Patients were followed-up at a mean of 10.9 weeks with the majority of patients finding benefit post sphincterotomy. 3/9 responders v 2/4 non-responders had a history of anxiety/depression and 6/10 responders v 2/4 non-responders had other functional disorders. 6 patients are awaiting follow-up. Conclusion Manometry is helpful in predicting response to sphincterotomy in patients with type II SOD with 71% having significantly improved or abolished pain at early follow up. Pancreatitis occurred in 20%, consistent with previous reports in the literature of up to 24%. 1 There was a higher proportion of anxiety/depression in non-responders but no difference in the proportion with functional disorders between groups. However, study numbers are too small to assess these parameters accurately. Disclosure of interest None Declared. Reference Toouli et al . Functional Gallbladder and Sphincter of Oddi Disorders. Gastroenterology 2006;130:1498–1509

PTH-017 Safety of self-expandable metal stents for malignant biliary strictures in a district general hospital setting

Introduction Self-expandable metal stent (SEMS) are widely used as first line palliative therapy for unresectable malignant biliary strictures. We present our experience of use of self-expandable metal stents in malignant biliary strictures in a District General Hospital (DGH) setting. Method We conducted a retrospective review on the data of all patients who had undergone an ERCP with a placement of self-expandable metal stent for inoperable malignant biliary strictures between Jan 2009 and Aug 2014. Comprehensive information was gathered with regards to patient’s demographics, procedural indications and procedure success rates. We assessed the stents efficacy, stent patency rates, complications and patient survival rates Results 50 patients were identified and analysed during this period. 60% were females and the mean age was 72 years (range, 35–93 years). The most common underlying diagnoses were Pancreatic carcinoma (60%) and Cholangiocarcinoma (32%) followed by Ampullary Carcinoma (6%) and Lymphoma (2%). Indications for metal stent placement included malignant bile duct stricture (54%), blockage of old stents (42%) and stent migration (4%). 23/50 (42%) patients had previous stent placement (Plastic 18, Metal 5). Of these, 21 stents failed due to blockage either due to biliary sludge or tumour overgrowth while 2 stents had migrated out (both plastic stents). The mean duration of previous stent patency was; plastic 96 days (7–523 days) and metal 237 days (39–595 days). The types of metal stents used were; Fully Covered (28%), Partially Covered (32%) and Uncovered (40%). The mean duration of all metal stents patency was 122 days (range, 7 – 566 days) and there was no statistical difference in terms of duration of stent patency among fully covered, partially covered and uncovered stents. Overall complication rate was 18%, which included Cholangitis (2%) and Stent Blockage (8/50, 16%) mainly due to biliary sludge (6/8). Of these blocked stents 5 were Fully covered, 3 Partial covered, 1 was Uncovered. There were no cases of post ERCP pancreatitis or migration of metal stent. There were no reported cases of procedure related mortality. The mean survival period after metal stent insertion was 161 days (range 9 to 566). Conclusion Self-expandable metal stents offers safe and effective palliative therapy for inoperable malignant biliary strictures and can be safely performed in a district general hospital with low complication rates. High blockage rate of fully covered stents is in our series is unexpected and the reasons for this were not obvious but this would be the subject of further analysis and study. Disclosure of interest None Declared.