Repeat ERCP Research Articles

A294 CHOLESTASIS SECONDARY TO XANTHOGRANULOMATOUS CHOLANGITIS: A CASE REPORT

Abstract Background An 86-year-old female presented with four weeks of intermittent abdominal pain, postprandial nausea with an associated 10 lbs weight loss. Initial labs demonstrated a predominantly cholestatic liver enzyme elevation. Imaging revealed a thickened gallbladder with dilated CBD up to 15mm with no calculi, obstruction or pancreatic mass. EUS demonstrated a prominent ampulla with an area of hyperechogenicity, and ERCP was completed with sphincterotomy and biopsy of the ampulla. A cholangiogram showed a prominent common bile duct and a smooth distal taper without filling defects. Tumor markers, ampullary biopsy, and cytology of CBD brushings were negative for malignancy. Repeat ERCP for non-resolving symptoms with an extension of the sphincterotomy, brushings and insertion of a metal stent was completed without improvement in liver enzymes and a standard hepatitis workup returned negative. Her clinical course was further complicated by recurrent gram-negative bacteremia with CT findings of innumerable abscesses or metastasis in the liver. A US-guided targeted liver biopsy revealed large duct periductal tissue expansion by foamy macrophages with admixed neutrophils, eosinophils, plasma cells, and lymphocytes. These features were consistent with xanthogranulomatous cholangitis. We were planning to start ursodiol given the small duct disease however the patient succumbed to recurrent bacteremia and passed away. Aims Review of methods to attain diagnosis of xanthogranulomatous cholangitis. Methods Case Report. Results Diagnosis of xanthogranulomatous cholangitis can be attained from targetted US-guided biopsy, surgical excision, or EUS-guided CBD biopsy. Conclusions Xanthogranulomatous cholangitis is an extremely rare entity described in limited case reports, frequently mimicking neoplastic disease. Pathology is difficult to attain and historically case reports required surgical resections. One recent case reported diagnosis confirmed via EUS-guided FNA of the CBD. In our case, we attained the diagnosis through a targeted liver biopsy. Pathology of xanthogranulomatous cholangitis typically demonstrates foamy histiocytes, lipid-laden macrophages, eosinophils, lymphocytes, plasma cells, and fibrosis indicating xathogranulomas. The pathogenesis is thought to be an extension of xanthogranulomatous cholecystitis in which bile is extravasated into the gallbladder wall through Rokitansky-Aschoff sinuses or ulceration of the mucosa resulting in an inflammation caused by fibroblasts and macrophages as they phagocytose the lipids in bile, resulting in the formation of xanthoma cells. Given the rarity of the disease, there is no guideline on management and a majority of patients reported underwent surgical excision. This case demonstrates the utility of liver biopsy to establish this rare diagnosis, allowing for better detection and subsequently better-studied management. Funding Agencies None

Biliary drainage in hilar and perihilar cholangiocarcinoma: 25-year experience at a tertiary cancer center

This study analyzed the optimal biliary stenting strategy for palliation in cholangiocarcinoma (CCA). This was a retrospective study of patients with CCA who underwent biliary drainage from 1997 to 2023. A per-patient analysis of percutaneous transhepatic biliary drainage (PTBD) rates, the median number of ERCPs, and overall survival (OS) and a per-procedure analysis of clinical success (CS), stent-specific adverse events (AEs), and mean time to repeat ERCP by stent type and laterality (unilateral and bilateral) are presented. A total of 333 patients underwent 1050 ERCPs, 85% with plastic stents (PSs). PTBD was eventually done in 23% of PS patients, 35% of whom had their PS removed before PTBD. ERCPs with the use of self-expandable metal stents (SEMSs)/unilateral SEMSs had higher CS (89%/91%) versus PSs/unilateral plastic stents (uPSs) (85% both) and PSs within SEMSs (PS-SEMSs)/uPS-SEMSs (71%/74%; P= .013/P= .054). Compared with PSs, SEMSs and PS-SEMSs were associated with higher stent-specific AEs (odds ratios [ORs]: SEMSs 4.85 [95% confidence interval (CI), 3.23-7.27], PS-SEMSs 9.99 [95% CI, 5.33-18.71]; P< .001). Straight PSs were associated with more stent-specific AEs compared with double-pigtail stents (OR 6.74 [95% CI, 3.95-11.45]; P< .001). More 7F stents were used in cases with balloon dilation (BD) (109 with BD vs 88 without BD; P< .001). BD had a 79% CS rate versus 87% without BD (P< .001). Cases with pus on ERCP and those with BD had a shorter mean time to repeat ERCP. On regression analyses, higher Bismuth class, PS use, and PS-SEMS use were associated with a shorter mean time to repeat ERCP. Fifty-two percent of patients in the bilateral SEMS arm died from cholangitis (P= .005). The relatively higher CS rate of SEMSs is countered by the higher stent-specific AE rate. PSs can be removed and may better facilitate PTBD. Within PS types, double-pigtail stents may have fewer stent-specific AEs. Cases requiring BD and with endoscopic evidence of pus may benefit from earlier reintervention.

1121 Evaluating the Practice and Post-Procedural Outcomes of Endoscopic Retrograde Cholangiopancreatography in United Lincolnshire Hospitals Trust in 2019

Abstract Aim To evaluate the performance of ERCPs within our trust through exploring the rates of post-procedural complications and outcomes. Method Data was collected from multiple databases including EndoWeb, which had all the reports of ERCPs performed, including indications, diagnosis and whether there were any complications during the procedure. We used WebV to look at post-procedural blood results and any tests from readmission that could be consistent with a complication. We also used CarePortal to look at clinic and discharge letters post-ERCP to identify whether readmission was necessary. The data collected was entered in an Excel Spreadsheet and analysis was performed in Microsoft Excel. Results We collected data for 248 ERCP procedures and there were 37 patients with repeat ERCPs in the same year. The most common indications were gallstones (34%) and jaundice with dilated ducts (36%). 81% ERCPs were successful, diagnostically and therapeutically and the complication rate was 6% with acute pancreatitis and bleeding being the most common complications. Finally, we noted a 30-day mortality rate of 2.8% but none of the deaths were related to ERCPs and were mostly due to co-morbidities. Conclusions The British Society of Gastroenterologists published a standards framework in 2014 concluding that the UK requires a national system to check ERCP practice similar to that of the US, the ERCP Quality Framework. Our post-ERCP pancreatitis rate is within the standards set by the BSG. This audit is a step in developing a national standardising system, however, there is a requirement of 100% engagement from all centres within the UK.

HPB P07 A propensity matched retrospective study of metal vs plastic stents in the preoperative biliary drainage of patients with resectable perihilar cholangiocarcinoma

Abstract Background Preoperative biliary drainage is required in the majority of patients with resectable perihilar cholangiocarcinoma (pCCA). Most centres use plastic stents rather than uncovered self-expanding metal stents (uSEMS) because of the potential difficulties associated in removing uSEMS. In the palliative setting, however, uSEMS are associated with superior patency and even improved survival. The aim of this study is to compare the utility of uSEMS versus plastic stents in the pre-operative drainage of patients with resectable pCCA. Methods In this retrospective, multicentre, international cohort study, all consecutive patients with a high suspicion of resectable pCCA who underwent an initial endoscopic biliary drainage with uSEMS or plastic stent between 2010–2020 were included. Analyses were stratified by groups according to initial stent type. The primary outcome was stent failure, which was a composite endpoint of cholangitis and/or re-intervention due to biliary complications or inadequate biliary drainage. Propensity score matching (1:1) was performed to adjust for age, gender, primary sclerosing cholangitis, Bismuth classification, WHO performance status and ASA classification. Results A total of 474 patients with successful initial stent placement were included. Of these patients 61 received uSEMS and 413 plastic stents. Matching resulted in two groups of 59 patients. Stent failure occurred significantly less in the uncovered uSEMS group (31% vs 64%, P&amp;lt;0.001) and resulted in a significant reduction in the number of repeat ERCP procedures (14% vs 54%, P&amp;lt;0.001). Despite this the number of patients eventually required percutaneous transhepatic biliary drainage was similar (9% vs 7%, P=1). uSEMS placement was also associated with a reduction in episodes of cholangitis (15% vs 31%, P=0.012), although other ERCP and stent related complications did not differ. The number of patients ultimately undergoing surgical resection was not significantly different (81% vs 90%, P=0.19) between groups with uSEMS removal during surgery successful in all patients. The median overall survival after initial stent placement was 482 days [95% CI, 338–787] in the uSEMS group and 429 [95% CI, 263–881] in the plastic stent group (log-rank P=0.81). Survival after surgical resection was similar and post-operative outcomes also comparable: R1 resections (58% vs 59%, P=0.569), complications according to Clavien-Dindo (P=0.227), and hepatico-jejunostomy associated complications (leak: 4% vs 14%, P=0.393, stricture: 15% vs 21%, P=0.822). Conclusions Stent failure occurred significantly less often in uSEMS group resulting in fewer drainage procedures and reduced episodes of cholangitis. Removal of uSEMS during surgery was feasible and surgical outcomes were comparable. Although preoperative biliary drainage by uSEMS shows promising results further study is warranted and multicentre randomized controlled trials with a clear treatment strategy should be performed.

S1886 A Case Report of Iatrogenic Common Bile Duct Stricture

Introduction: Iatrogenic bile duct injuries (IBDIs) are common postsurgical complications following cholecystectomy. IBDI vary from a minor bile leakage to biliary stricture or a complete occlusion of the common bile duct. The authors report a case of a common bile duct stricture caused by suture material after an open cholecystectomy. Case Description/Methods: A 57-year-old male with history of NAFLD presented with acute onset of severe epigastric abdominal pain, nausea and vomiting. Lipase was elevated. CT scan of the abdomen/pelvis revealed gallbladder wall thickening and dilated extrahepatic bile ducts consistent with cholecystitis and biliary obstruction. The patient underwent an open partial fenestrated cholecystectomy which was complicated by injury of the gastric antrum requiring primary two-layered repair and omental patching. ERCP was not performed due to gastric injury. His symptoms improved and he was discharged home. One month later he returned with severe epigastric pain. Initial work-up revealed elevated lipase and transaminases. CT of the abdomen/pelvis showed peripancreatic fluid and fat stranding with persistent mild biliary dilatation. MRCP identified three choledocholiths at the level of the ampulla. ERCP was performed with sphincterotomy, balloon extraction of several stones and sludge, and placement of a plastic biliary stent. There was an area of resistance felt during balloon sweep. He was discharged after symptom resolution with recommendations to repeat ERCP in 6 weeks for stent removal. A repeat ERCP revealed persistent area of resistance with filling defect on fluoroscopy. (Figure). A spyglass revealed a suture material and mild inflammation in the CBD at the cystic duct takeoff (Figure). Stone formation induced by suture material is thought to be the culprit of the recurrent acute pancreatitis. Discussion: IBDIs account for the majority of postsurgical complications after cholecystectomy. The incidence of IBDIs is higher in laparoscopic cholecystectomy when compared to open cholecystectomy. IBDIs are associated with significant perioperative morbidity, mortality, and prolonged hospital stay. If left untreated, they can result in life-threatening complications such as cholangitis, secondary biliary cirrhosis, and portal hypertension. One of the uncommon postoperative complications is stone formation induced by suture material used in cystic duct ligature. Surgical sutures can function as a nidus for crystallization leading to obstruction and development of large choledocholiths.Figure 1.: Top. ERCP shows filling defect in the common bile duct. Bottom: Spyglass shows suture material and adjacent mild imflammation of the CBD at the systic duct takeoff.

S1818 Rare Sequelae of Obstructive Jaundice: Hyperferritinemia and Bile Cast Nephropathy

Introduction: Obstructive jaundice occurs due to a physical blockage in the biliary outflow tract or external compression. While jaundice and scleral icterus are common symptoms initially, long term sequelae include severe systemic manifestations from the buildup of various compounds normally excreted in bile such as bilirubin. Case Description/Methods: A 67-year-old male smoker presented with 3 weeks of pruritus, acholic stools, dark urine, nausea, vomiting, and 20-pound weight loss. Physical exam was notable for jaundice and scleral icterus, LUQ and epigastric tenderness to palpation, but lacked hepatosplenomegaly, ascites or other stigmata of cirrhosis. Liver function tests showed AST 486 IU/L, Alk Phos 1419 IU/L, Alt 600 IU/L, and total bilirubin >30.0 mg/dL with direct bilirubin >10.0 mg/dL. Ferritin was >7500 ng/mL with decreased transferrin of 159 mcg/dL. Hepatitis panel and malignancy/autoimmune markers were negative. CMP showed BUN 74 mg/dL, and creatinine 5.1 mg/dL with 2+bilirubin on urinalysis and microscopic analysis showing pigmented renal tubular cells, bilirubin crystals, and waxy casts suggestive of ATN due to bilirubin damage and possible CKD given waxy casts (Table). CT abdomen reported severe intra and extra hepatic biliary duct dilation with CBD of 17 mm and abrupt tapering with pancreatic head fullness confirmed with MRCP. On day 2, ERCP showed a tight 15mm distal biliary stricture. A small sphincterotomy followed by balloon dilation allowed for placement of a CBD stent with excellent drainage of dark green bile. Following ERCP, patient had a drop of liver function tests and ferritin levels, gradual improvement in BUN and creatinine, and was discharged in stable condition on hospital day 6. On day 16, EUS revealed a hypoechoic area within the periampullary area with atypical cells in brushings collected during repeat ERCP (Figure). Discussion: Iron and iron binding proteins have been shown to be excreted in bile, primarily in iron excess. Our patient showed a large increase in ferritin signifying the potential role of biliary excretion of excess ferritin, with unknown ramifications. Additionally, severe biliary tree obstruction led to markedly elevated bilirubin, overwhelming renal clearance leading to severe tubular damage. With alleviation of obstruction, there was a steady decrease in ferritin and return to normal baseline renal function. Further research is needed to clarify both the consequences of excess ferritin in biliary obstruction and the significance of excess bilirubin in renal injury.Figure 1.: a) Ampulla prior to ERCP on day 2 shows no periampullary abnormality. b) Day 16 - Endoscopic Ultrasound showing narrowing of distal common bile duct with hypoechoic intraductal area. c) Bile casts and bilirubin crystals seen on microscopy. Table 1. - Patient’s Laboratory test results on and post admission Laboratory Values Reference Range Day 1 Day 5 (3 days post-ERCP) Day 21 AST 13 – 39 IU/L 486 187 18 ALT 7 – 52 IU/L 600 315 27 Alkaline Phosphatase 34 – 104 IU/L 1419 886 160 Total Bilirubin 0.3 - 1.2 mg/dL >30.0 13.0 4.4 Albumin 3.5 - 5.2 g/ 3.0 2.9 3.4 BUN 7 – 25 mg/dL 74 64 18 Creatinine 0.5 - 1.2 mg/dL 5.1 2.90 1.01 WBC 4 – 11 K/cmm 13.8 17.7 10.1 Hgb 13.7 - 17.5 g/dL 11.9 9.4 8.5 Ferritin 24 – 336 >7500 4677 976 Transferrin 300 to 360 mcg/dL 159 233 Iron 50 - 182 ug/dL 126 61 Iron Saturation 57% 19% TIBC 250 – 450 ug/dl 233 326 Urine Bilirubin Negative 2+ Negative Urobilinogen 0.0 - 2.0 EU/dL 4.0 < 2.0 PT 9.1 - 13.2 sec 26.6 12.8 PTT 23.3 - 36.6 SEC 42.0 33.0 INR 0.8 - 1.2 2.3 1.1 Alpha-1-Antitrypsin (ATT) 83 – 199 mg/dL 256 Ceruloplasmin 18– 36 mg/dL 51 Carcinoembryonic Antigen (CEA) 0.0 - 3.0 ng/mL 3.9

S1724 Eosinophilic Cholangitis: A Great Mimic

Introduction: Eosinophilic Cholangitis (EC) is a rare infiltrative disorder of the biliary tree and a diagnostic dilemma. The initial presentation mimics malignancy and is distinguished by histopathology. Steroid response supports the diagnosis. This case elucidates the diagnostic and therapeutic approach to EC in a patient with acute jaundice. Case Description/Methods: A 44-year-old female with a history of SLE and marginal cell lymphoma in remission presented with fevers, leukocytosis, abdominal pain, and hyperbilirubinemia. She underwent an ERCP that showed a common bile duct (CBD) stricture with stent placement that was removed 6 weeks later (Figure). She then underwent a cholecystectomy for chronic cholecystitis with an intraoperative liver biopsy for persistently elevated LFTs (AST 512 U/L, ALT 500 U/L). Surgical specimens showed dense eosinophils at the cystic duct margin with mild non-specific lobular inflammation involving 15% of liver parenchyma. Six months later, she presented to our hospital with worsening abdominal pain and jaundice. Pertinent labs included a total bilirubin of 16.9 mg/dL, AST 321 U/L, ALT 335 U/L, and alkaline phosphatase 2700 U/L. MRCP showed CBD narrowing at the hilum with intrahepatic ductal dilation She underwent an ERCP which identified a Bismuth IV hilar stricture and a ductal polypoid mass on cholangioscopy. Two biliary stents were placed across the stricture into the right and left intrahepatic ducts. A direct biopsy, while negative for malignancy, revealed marked eosinophilia. Labs included peripheral eosinophilia of 0.78 x109/L. IgG4 and Anti-mitochondrial antibody were normal. A month later, repeat ERCP with stents exchange and ductal mass re-biopsy was performed given high concern for malignancy, however again demonstrated sheets of eosinophils. After multidisciplinary discussion, she was presumptively diagnosed with EC and started on 40mg of prednisone. Seven weeks later, repeat ERCP showed complete resolution of the stricture. LFTs and bilirubin normalized. Her symptoms resolved and she was transitioned to azathioprine for maintenance. Discussion: EC is a rare, benign process affecting the biliary system and poses a significant diagnostic challenge. Our case supports proposed diagnostic criteria for EC, including biliary stricture, eosinophilic infiltration on histopathology, and steroid responsiveness. Our case is unique in our demonstration of the direct cholangioscopy view of this benign entity and the utility of cholangioscopy in achieving the diagnosis.Figure 1.: a) Ductal polypoid mass near common hepatic duct identified via endoscopic retrograde cholangiopancreatography with cholangioscopy. b) Intrahepatic biliary ductal dilatation seen on magnetic resonance cholangiopancreatography. c) Occlusion cholangiogram during endoscopic retrograde cholangiopancreatography showing a Bismuth Type IV common bile duct stricture. d) Occlusion cholangiogram during endoscopic retrograde cholangiopancreatography showing resolution of the common bile duct stricture after steroid treatment. e) Biliary stricture biopsies showing fragments of bile duct mucosa with acute and chronic inflammation with marked eosinophilia. f) Ductal mass/biliary stricture biopsy demonstrating inflammation and eosinophilia on Hematoxylin-eosin stain.

S372 Cystic Artery Pseudoaneurysm: A Rare Case of Upper Gastrointestinal Bleeding

Introduction: Cystic artery pseudoaneurysm (CAP) is a rare complication of acute cholecystitis and cholecystectomy. We present an unusual case of upper GI bleed due to CAP. Case Description/Methods: An elderly female presented with one month history of lethargy and unintentional weight loss. Clinical exam was unremarkable apart from pallor. Blood tests revealed severe iron deficiency anaemia and bland cholestasis. CT scan showed a common bile duct (CBD) mass and a gallbladder (GB) neck lesion with prominent regional lymph nodes, which was worrying for biliary malignancy. MRI scan showed a 3cm CBD stone with acute emphysematous cholecystitis and possible CAP at the GB neck. An urgent OGD and ERCP was done on the same day as she developed hematemesis and cholangitis. On endoscopy, there was active bleeding from possible enteric fistula at first part of duodenum (D1), this was treated with metal clips. During ERCP, haemobilia was noted on CBD cannulation. On cholangiogram, the endoclips were adjacent to distal CBD stone. A plastic stent was inserted into the CBD and she was referred to the surgeons. Cholecystectomy and CBD exploration was performed for definitive treatment. Intra-operatively, there was active bleeding into the GB from CAP. D1 was thinned out with adhesions to the GB. There was stale blood in the bile duct but no biliary-enteric fistula seen. CAP was sutured, adhesiolysis, subtotal cholecystectomy, omental patch repair of D1 and CBD stone was retrieved. Repeat OGD and ERCP with CBD stent removal done 2 months later showed healed D1 mucosa. Discussion: The clinical features of CAP include right upper quadrant pain, upper GI bleed due to haemobilia and abnormal liver enzymes. It is diagnosed on arterial phase of CT scan, angiography, MRI or during surgery. It is treated with surgery or angioembolization. This is a challenging case with delayed diagnosis of CAP as she lacks the typical presentation of CAP. A plain contrasted CT without arterial phase was done initially, which have mistaken the CAP as soft tissue lesion in GB. Endoscopic findings raises possibility of choledocho-duodenal fistula; this was excluded during surgery. The final diagnosis is acute calculous cholecystitis complicated by CAP with direct pressure on D1 leading to upper GI bleed. To our knowledge, this is the first case of CAP with such entity. In conclusion, CAP should be considered in patients with symptomatic gallstone disease and upper GI bleed in order to select appropriate imaging modality and guide therapy. Watch the video at https://tinyurl.com/ACGAbstractS372

S1787 Steroid-refractory IgG4-Related Disease Presenting as Sclerosing Cholangitis

Introduction: IgG4-related disease (IgG4-RD) is characterized by tumefactive infiltration of IgG4-bearing plasmablasts and other lymphocytes, along with storiform fibrosis, into one or multiple organs, with resultant organ enlargement, fibrosis, and dysfunction. Although initial reports of IgG4-RD concerned involvement of the pancreas, other organs such as the biliary tract can be involved. We present a case of steroid refractory IgG4- RD sclerosing cholangitis (IgG4-SC). Case Description/Methods: A 67-year-old man with hypertension presented with a 2-week history of unintentional weight loss, painless jaundice, and pruritus. Exam showed jaundice and scleral icterus. Laboratory revealed elevated liver tests with an obstructive pattern, with ALP, GGT, & Bilirubin of 431 U/L, 438 IU/L, 17.6mg/dL, respectively. MRCP, ERCP, and subsequent EUS demonstrated diffuse pancreatic parenchymal hypo-echogenicity, long segment strictures at the distal common bile duct with proximal duct dilation, dilated common hepatic duct, and multiple segmental intrahepatic biliary duct strictures. Biliary sphincterotomy and stent placement resolved symptoms. Biopsy of the Ampulla of Vater revealed chronic inflammation with ulceration. Further work-up uncovered an elevated serum IgG4 of 266 mg/dL with a negative ANA, SMA, AMA, and tumor markers. He was then diagnosed with IgG4-SC and completed a course of prednisone. Relapse of symptoms prompted a repeat ERCP which uncovered biliary tree pruning and irregularity, necessitating biliary stent replacement. Due to poor tolerance with rituximab infusion, he was treated with Mycophenolate Mofetil which accomplished a year of disease quiescence. Discussion: The prime gastrointestinal manifestations of IgG4-RD include type 1 Autoimmune Pancreatitis and less commonly, IgG4-SC. Management involves high dose steroids for 4 weeks with a slow taper over years to prevent permanent fibrosis. Patients are at highest risk of relapse during steroid taper or within 6 months of completion, with a relapse rate of 15-60%. Although our patient did not have the classic predictive factors of relapse, such as proximal strictures or serum IgG4 >280 mg/dL, he had a suboptimal response to steroids which prolonged his clinical course and exposed him to repeated procedures. There is still a need for further studies regarding the role for possible combination therapy (steroids & immunosuppressive therapy) to prevent relapse in high-risk individuals.

S358 Endoscopic Ultrasound-Directed Transgastric ERCP for Pancreatic Duct Stent Placement to Treat Pancreatic Ascites

Introduction: Endoscopic ultrasound (EUS)-Directed transGastric ERCP (EDGE) is an advanced procedure utilized to enable pancreaticobiliary access in patients with Roux-en-Y gastric bypass anatomy. We hereby present a case of refractory pancreatic ascites from a persistent pancreatic duct (PD) leak treated with EDGE and transpapillary PD stenting. Case Description/Methods: A 62-year-old White female with history of morbid obesity with Roux-en-Y gastric bypass and biliary pancreatitis with prior cholecystectomy was referred for refractory pancreatic ascites causing significant abdominal pain, poor oral intake and weight loss necessitating total parenteral nutrition. MRCP showed a PD leak in the body as cause for ascites (Fig. 1). After multidisciplinary team discussion, a staged EDGE for PD stenting was pursued. The gastric remnant was identified endosonographically through the jejunum, a 19G needle was advanced into it and 500 ml of saline was instilled to dilate the remnant. A 0.025 guidewire was coiled in the remnant and a 15mm by 10 mm cautery enhanced lumen apposing metal stent (LAMS) delivery system was used to create a jejunogastrostomy followed by LAMS deployment. LAMS was post dilated to 15 mm and ERCP was pursued after 10 days. During ERCP, PD leak at the body was confirmed on the pancreaticogram. A 5 Fr by 15 cm single pigtailed stent was deployed to bridge this leak. A large biliary sphincterotomy was also performed for a subjectively stenotic major papilla. Follow up CT scan after 1 month showed resolution of pancreatic ascites and repeat ERCP confirmed resolution of the PD leak. The biliary and pancreatic stents were removed. The jejunogastrostomy stent was removed after three months. She continues to remain asymptomatic and is tolerating a regular diet. Discussion: This case demonstrates the successful use of EDGE procedure for management of refractory pancreatic ascites from a pancreatic duct leak. EDGE for pancreatic endotherapy in Roux-en-Y gastric bypass anatomy is a safe and effective alternative to more invasive laparoscopy or percutaneous gastrostomy access to the gastric remnant and should be considered in cases with ascites. Watch the video at https://tinyurl.com/ACGAbstractS358Figure 1.: MRCP With Pancreatic Duct Leak.

S1891 A Diagnostic Dilemma: Primary Sclerosing Cholangitis With High IgG4 vs IgG4-Related Sclerosing Cholangitis

Introduction: Two etiologies of sclerosing cholangitis with overlapping features are Type 2 IgG4-Related Sclerosing Cholangitis (IgG4-SC) and Primary Sclerosing Cholangitis with high IgG4 (PSC). Here, we present a complex case of a young patient with features of both diseases. Case Description/Methods: A 25-year-old Caucasian female with a medical history of diabetes and no previous pancreatic disease was incidentally found to have an AST and ALT in the low 200s, total bilirubin 2.6, and alkaline phosphatase of 1130 concerning for cholestatic obstruction. She was asymptomatic and not jaundiced at the time. Subsequent MRCP revealed a dilated common bile duct. The patient underwent ERCP/EUS demonstrating a common bile duct stricture. A plastic stent was placed, and cells for cytology/FISH analysis were unyielding for malignancy. Repeat ERCP/EUS was performed a few months later for stent exchange. Biopsies to evaluate the indeterminate stricture yielded IgG4+ plasma cells up to 14/HPF. Based on the findings suspicious for IgG4-SC, she started prednisone therapy for one month. Subsequent labs demonstrated mild improvement in alkaline phosphatase to 450, total bilirubin 0.2, and a normal IgG4 level but with persistent elevation of total IgG 1.5 times the upper limit of normal. Repeat ERCP demonstrated resolution of the distal biliary stricture. She never developed abdominal pain, jaundice, weight changes or loss of appetite. Six months later, LFTs began to uptrend and a third ERCP/EUS demonstrated new distal biliary stricture. Biliary biopsies showed dense lymphoplasmacytic infiltrates and fibrosis with an average of 10 IgG4 positive plasma cells/HPF. Liver biopsies showed periductal fibrosis and a fibro-obliterative duct lesion. Given the concern for PSC, colonoscopy was performed with biopsies showing mild crypt distortion, mild eosinophilia, and rare neutrophils in the lamina propria. The patient remained asymptomatic throughout the disease course but had persistent biochemical hepatitis despite being on steroid therapy. A shared provider-patient decision was made to withhold immunosuppressive or biologic therapy. Discussion: In this case, the patient’s epidemiologic, clinical, and histological factors were more consistent with PSC. Conversely, the mild biochemical and stricture steroid-responsiveness were initially more suggestive of IgG4-SC. It is imperative to delineate between the two, as prognosis, treatment-responsiveness, and anticipated comorbidities differ.

S2949 Case of Cholangiogram-Induced Acute Liver Injury Disease

Introduction: We present a female who had prolonged acute hepatocellular liver injury after undergoing a cholangiogram using Omnipaque contrast. About 10 cases of cholestatic liver injury have been reported after ERCP, however our case is unique being predominantly hepatocellular injury. Case Description/Methods: Initially presenting with abdominal pain then diagnosed with cholecystitis, she underwent cholecystectomy with cholangiogram. She subsequently underwent ERCP due to a retained stone and discharged home the next day without notable complications. She presented to the hospital two days later with pruritus. After ruling out infectious cause and further mechanical hepatobiliary pathology, she was discharged home due to improved symptoms with symptomatic management. Transaminases gradually resolved with close outpatient follow-up at two weeks and two months. Discussion: The exact mechanism remains unclear, liver injury due to idiosyncratic reaction from contrast was postulated. This is possibly due to local hepatic injury from the contrast agent in the biliary system. The contrast material being infused under high pressure, can have a toxic effect on the liver with disruption of canalicular plasma membranes. Systemic distribution of the contrast medium from the bile duct and the spreading of the agent extracellularly to the nearby tissues might be responsible for direct toxic liver injury. Awareness of this reaction is helpful in preventing unnecessary repeat ERCP to confirm bile duct clearance as well as liver biopsies. Prednisone may be considered if persistently elevated liver enzymes.Figure 1.: Title: Liver Function Tests during clinical course Caption: Patient's liver function test over the hospitalization, readmission, two-week outpatient follow-up, and two-month outpatient follow-up revealing fluctuating elevation in transaminases after cholangiogram performed on day of admission while total bilirubin remains within normal limits. Gradual resolution of elevated transaminases over two-week and two-month follow-up. ERCP occurred on hospital day 1. Legend: HD- Hospital day RD- Readmission day ALP- alkaline phosphatase AST- Aspartate transaminase ALT- Alanine Transaminase.

S3033 HIV-AIDS: A Rare Cause of Cholestatic Cholangiopathy

Introduction: HIV/AIDS has been shown to affect hepatic parenchyma and biliary tree leading to inflammation and biliary strictures. With the advent of highly active antiretroviral therapy (HAART), it is rarely encountered, except in cases of resistance or medication non-compliance. Case Description/Methods: A 48-year-old man with history of HIV and poor compliance with HAART presented with abdominal pain, nausea and diarrhea. Physical exam showed scleral icterus and mild abdominal tenderness, with labs showing a T.bili. 16.9, AST 212, ALT 133, and ALP 3885. MRCP revealed intrahepatic biliary ductal dilatation of both lobes of liver and mild dilatation of the proximal extrahepatic CBD (9 mm) without cholelithiasis, biliary sludge or ductal stone suggesting nonspecific cholestasis. ERCP was performed which revealed papillary stenosis and moderately enlarged CBD (12 mm). Irregularities were noted in bilateral intrahepatic branches but not in ducts. A pancreatic and biliary sphincterotomy was performed. With minimal decrease in T.bili. and ALP, repeat MRCP was performed 3 months later showing persistent intrahepatic biliary ductal dilatation with normal CBD. Repeat ERCP showed patent prior sphincterotomy and the biliary tree was swept with nothing found. Further workup revealed a CD4 count of 17 and serology positive for cryptosporidium antigen. A diagnosis of HIV-cholangiopathy was made and the patient was restarted on HAART and nitazoxanide with gradual decline in T.bili and ALP. (Figure) Discussion: HIV/AIDS-cholangiopathy is a rarely encountered biliary syndrome, usually manifesting in severely immunosuppressed AIDS patients. Several opportunistic pathogens have been implicated in its pathogenesis with Cryptosporidium parvum being the most commonly associated pathogen. C. parvum predominantly affecting the biliary tract leading to apoptotic cell death of the cholangiocytes. Biliary involvement has been described in four cholangiographic patterns – papillary stenosis, extrahepatic strictures, intra and extrahepatic sclerosing lesions, and acalculous cholecystitis. Diagnosis can be established usually by MRCP or ERCP which shows papillary stenosis with intrahepatic ductal dilatation. Alternating multifocal intrahepatic strictures can also be seen giving a beaded appearance. The cornerstone of management involves the management of opportunistic infections with the initiation of HAART. The prognosis is usually poor due to advanced stages of immunosuppression and multiple opportunistic infections.Figure 1.: CT Abdomen pelvis showing intrahepatic biliary ductal dilation.

A205 IS REPEAT ERCP REQUIRED AFTER INITIAL ENDOSCOPIC MANAGEMENT OF POST-SURGICAL BILE LEAKS? MULTI-CENTER VALIDATION OF THE CALGARY BILE LEAK RULE

BackgroundThe Calgary Bile Leak Rule was developed to identify patients in whom biliary stent removal via gastroscopy could be safely performed in lieu of ERCP for post-surgical bile leaks.AimsThis study aimed to evaluate a Modified Calgary Bile Leak Rule (MCBLR) for a cohort of patients who underwent laparoscopic cholecystectomy complicated by bile leak.MethodsThis retrospective cohort study included patients who underwent ERCP for management of laparoscopic cholecystectomy-induced bile leaks between 2005 and 2017. The primary outcome was defined as the absence of persisting bile leak or other pathology on follow-up ERCP. The MCBLR includes a) normal post-surgical serum alkaline phosphatase, b) small or absent leak with no other biliary pathology on initial ERCP, and c) time between initial and follow-up ERCP was 4–8 weeks. Test performance of the prediction rule was analyzed by calculating sensitivity, specificity, positive predictive value and negative predictive value.Results124 cases met inclusion criteria, of which 116 (94%) of bile leak cases had no leak identified during the follow-up ERCP. 8 (6.4%) had a persisting bile leak on follow-up ERCP. Bivariate analysis found no factors significantly associated with the primary outcome. The MCBLR demonstrated a sensitivity of 100% (95% CI 63% - 100%), a specificity of 35% (95% CI 26% - 44%), a positive predictive value of 10% (95% CI 4% - 18%), and a negative predictive value of 100.0% (91% to 100%).ConclusionsThe MCBLR demonstrated high sensitivity and negative predictive value for determining the need for repeat ERCP following endoscopic management of laparoscopic cholecystectomy-induced bile leaks.Funding AgenciesNone

Predictors of Early Repeat Endoscopic Retrograde Cholangiopancreatography After Liver Transplantation by Organ Donor Type

Background and AimsEndoscopic retrograde cholangiopancreatography (ERCP) is the first-line therapy for management of post-transplant biliary complications. We assess ERCP frequency and rate of early repeat ERCP and anastomotic stricture development across, living donor (LD), donation after cardiac death (DCD) and donation after brain death (DBD) liver transplant (LT) donor types. MethodsWe performed a single-center retrospective study of patients who underwent LT from January 2014 to December 2019. Proportion of patients requiring ERCP and number of ERCPs per patient were compared across donor types using analysis of variance and chi-squared methods. Logistic regression was used to assess the risk of early repeat ERCP, defined as ERCP within 28 days of preceding ERCP and anastomotic stricture development. ResultsA total of 509 LTs, 352 (69.2%) DBD, 101 (19.8%) DCD, and 56 (11.0%) LD were performed during the study period. A greater proportion of LD (51.8%) recipients required ERCP compared with DBD (28.7%) recipients (P ≤ 0.01). LD and DCD recipients required significantly greater number of median (interquartile range [IQR]) ERCPs compared with DBD recipients (8 [4, 12] vs 3 [2, 5], P < 0.01 and 4 [2, 6] vs 3 [2, 5], P = 0.05). Risk of early repeat ERCP was significantly higher in LD (odds ratio 9.2; 95% confidence interval 4.6-18.5) and DCD (OR 2.3; 95% confidence interval 1.2-4.5) recipients compared with DBD recipients. ConclusionLD and DCD recipients experience higher ERCP frequency and greater risk of early repeat ERCP compared with DBD recipients. Our results suggest the need to tailor ERCP management protocols for post-LT biliary complications based on donor type.

S3374 Plastic vs Metal Stents for Anastomotic Biliary Strictures After Orthotopic Liver Transplant (OLT)

Introduction: Biliary anastomotic stricture is the most common complication of orthotopic liver transplantation (OLT) occurring in about 20% of cases. Endoscopic stent placement across the stricture with plastic or metal stents is the first-line treatment strategy. The aim of this study is to investigate the difference between plastic and metal stents in terms of anastomotic biliary stricture resolution and adverse events. Methods: This is a retrospective study of post OLT patients who underwent ERCP over a 3-year period between 2018-2020. Out of 178 post OLT patients who underwent ERCP, 108 were excluded because of only one ERCP performed and repeat ERCP was not indicated or because ERCP was performed for indications other than anastomotic biliary strictures. Data was collected up to 3 consecutive ERCP procedures during the studied period. Results: A total of 70 patients with anastomotic biliary strictures were included in the study. ERCP was performed on a native papilla in 32 (45.7%), advanced cannulation techniques were performed in 5 (7.1%), and prophylactic pancreatic stents were placed in 6 (8.6%) cases. Plastic stents (PS) were used in 53 (75.7%) of which multiple plastic stents were used in 27 cases, whereas 17 (24.3%) cases were treated with fully covered self-expanding metal stents (FCSEMS). Average follow up duration was 2.2 (1-3) months for PS and 3.7 (2-5) months for FCSEMS (P < 0.01). Biliary strictures resolved in 21 (30.0%) patients on repeat ERCP most of which from the FCSEMS group (58.8% vs 20.8%) (P = 0.009). Plastic stents were exchanged to FCSEMS in 11 (20.8%) patients during the second ERCP follow-up. On the third ERCP during the studied period, biliary strictures resolved in 71.4% of the FCSEMS group vs 33.3% of the PS group (P = 0.03). Using multiple plastic stents instead of a single plastic stent didn’t seem to improve biliary stricture resolution rate. Two patients (2.4%) developed post-ERCP pancreatitis, both patients had a native papilla and underwent FCSEMS placement with sphincterotomy and without pancreatic duct manipulation (P = 0.06). There was no difference between the stents used in terms of post-procedural cholangitis or stent migration rates. Conclusion: FCSEMS outperformed PS with respect to the anastomotic biliary stricture resolution rate over 3 endo-therapy sessions. Post-ERCP pancreatitis, although uncommon, occurred exclusively in the FCSEMS group.

S3208 The Use of ERCP in the Diagnosis of Indeterminate Biliary Strictures: Experience From a Large Tertiary Care Center

Introduction: The diagnosis of indeterminate biliary strictures remains a challenge for the endoscopist and the sensitivity of ERCP based diagnostic methods such as brush cytology is relatively low, usually not exceeding 60%. The aim of this study is to look at the diagnostic performance of ERCP and ancillary techniques in the diagnosis of indeterminate biliary strictures. Methods: we have identified a retrospective cohort of patients who had ERCP for the diagnosis of indeterminate biliary strictures, excluding pancreatic malignancy or metastases from 1/2010 to 8/2020. Data was collected including demographics, type of diagnostic procedure, procedural details, cytology/pathology results from the specimen and need for repeat interventions. Results: A total of 116 patients were identified and 169 ERCP procedures were performed. 42 (36%) patients were male, 82 (71%) were white and the median age was 69 (IQR: 54-69). 59 (51%) patients had brushings alone, 33 (28%) brushings and forceps biopsy combined, 9 (8%) forceps biopsy alone and 15 (13%) had cholangioscopy and direct biopsies. The results of the pathology/cytology after the first ERCP were benign in 55 (46%), atypia in 32 (28%) and malignant in 29 (25%). DNA and FISH analysis of was done in 10 (9%). In 37 (32 %) patients a repeat ERCP was required and the median number of repeat ERCPs was 3 (IQR: 2-3). After a repeat ERCP, 8 (22%) lesions were reported to be malignant. The final diagnosis as malignant cholangiocarcinoma by ERCP was done on 37 (32%) of the patients. The accuracy of detection malignancy during the first ERCP was 54 % by brushings, 51 % by brushings and biopsy and 56 % by cholangioscopy (Table 1). Conclusion: ERCP with the different ancillary techniques are essential for the diagnosis of indeterminate biliary strictures. The combination of these methods with reintervention can increase cancer detection rates on indeterminate biliary strictures with or without FISH and DNA analysis. As described in other publications, we could reproduce a very high sensitivity and overall accuracy for the diagnosis of malignant strictures.Table 1.: Outcomes.

S1284 Expanding the Use of ERCP in Pediatrics: A National Database Analysis of Demographics and Complication Rates

Introduction: Despite increasing ERCP usage, there remains a paucity of information regarding demographic differences and complication rates in pediatric populations, with published evidence only encompassing small sample sizes or lacking head-to-head comparisons. This study aims to aid in risk assessment in pediatric ERCP candidates by utilizing a national pediatric database with a large sample to assess how ERCP demographics affect complication rates. Methods: The KID is a sample of pediatric discharges from community hospitals in states participating in the Healthcare Cost and Utilization Project (HCUP). Demographic information, hospital region, hospitalization duration, and mortality information were provided by the database for individual hospitalizations. ICD-10 codes were also used to determine the hospitalization indication, and subsequently coded ERCP indicated a repeat ERCP within the hospitalization. ERCP complication rate was ascertained via complication codes (K91.89, K91.81). All statistical analysis was performed using SAS 9.4. Results: This analysis captured a large Hispanic population, specifically in the South and West regions (Table 1). Procedure complications were seen in 5.4% of hospitalizations with mortality observed in less than 0.2%. Of pediatric patients with documented ERCP during the hospitalization, 30.0% required a repeat ERCP during the same hospitalization. Repeat ERCP was not associated with increased rate of complication. Calculus of the gallbladder, acute, and chronic cholecystitis were more likely to occur in the female group (Figure 1), though there was no difference in complication between genders (p = 0.3). A higher percentage of hospitalized patients in the age 10-17 age group were female (52.7% vs 72.2%, p < 0.01) and Hispanic (22.7% vs 33.4%, p < 0.01) compared to the age 0-9 group. Age 0-5 was associated with a lower routine home discharge rate and a longer length of stay (Table 2). Complications also occurred at a higher rate in this age group, though the difference was not statistically significant. Conclusion: ERCP is a safe procedure for pediatric populations with relatively low complication rates and exceedingly rare associated mortality. We found significant differences in the procedure indications between pediatric age groups, races, and genders. Though no statistical difference was found in complication rates between groups, age < 5 yo and male gender were associated with longer lengths of stay and decreased likelihood of routine home discharge.Figure: Table 1.: Over 6 million hospitalizations were included in the overall sample, and we restricted to live births with at least one ERCP, giving n=4484 for ages 0 to 20 and n=1934 for ages 0 to 17. A large percentage of the captured patients came from the older age groups, indicating that this is an uncommon procedure in patients age < 10. A high percentage of hospitalized patients in the age 10-17 age group were female (52.7% vs 72.2%, p < 0.001) and Hispanic (22.7% vs 33.4%, p < 0.001) compared to the age 0-9 group. Differences in admission primary diagnosis between genders are also depicted. Females had statistically higher rates of calculus of the gallbladder/bile duct (p = 0.03) and chronic cholecystitis (p = 0.02). Males had higher rates of traumatic injury (p < 0.001), obstruction of the bile duct (p < 0.001), cholangitis (p = 0.002), and primary sclerosing cholangitis (p = 0.02).Table 2.: ERCP Age Group Comparison. A large percentage of the dataset if comprised of patients age >10, indicating that this is an uncommonly performed procedure in younger age groups. The common primary diagnoses for age 10 were more often Hispanic. There was no statistical difference in rates of repeat procedure or complication between age groups. The HCUP database prohibits reporting patient counts < 10.

S2141 Endoscopic Resection of Intraductal Papillary Neoplasm of the Bile Duct

Introduction: Intraductal papillary neoplasm of the bile duct (IPNB) is a neoplasia variant considered the biliary equivalent of IPMN of the pancreas. Characterized by a papillary growth with or without mucin hypersecretion, it can progress to invasive cholangiocarcinoma and develops along both the intra and extrahepatic bile ducts (BD). Case Description/Methods: A 79-year-old male with a PMH of anemia, CVA, CHF, CAD, CKD, Afib on anticoagulation was assessed for chronic anemia with CT of the abdomen. A 13mm CBD dilation was found, and this was further assessed with MRI which revealed choledocholithiasis and nodular enhancement of the ampulla. With these findings an ERCP was performed, stones were removed from the CBD and a polypoid mass was seen distally in the CBD and a plastic stent was placed, biopsy from the mass showed IPNB with low grade dysplasia. Another ERCP (Figure 1-B, 1-C) was performed for further assessment, during cholangioscopy the lesion was seen on the distal CBD. Since the patient was deemed a poor surgical candidate, attempts to endoscopically resect the lesion was made. Prior sphincterotomy was extended and the polypoid mass spontaneously extruded into the intestinal lumen (Fig 1-D), then the tumor was resected in a piecemeal fashion with a cold snare, followed by a repeat cholangioscopy, with no apparent tissue remaining (Fig 1-E). A fully covered metal stent was placed in attempts to cause pressure necrosis of any remaining tissue (Fig 1-F). Repeat ERCP with cholangioscopy for surveillance is pending. Discussion: IPNB is a rare tumor that presents most commonly with abdominal pain, jaundice, and/or cholangitis, or as an asymptomatic intraductal mass with BD dilation. Commonly affecting ages 50-70 with a marginal male predominance, the highest incidence is reported in Eastern countries where risk factors such as hepatolithiasis, choledocholithiasis, and parasitic infections of the BD are common. The WHO classification differentiates IPNB as low, intermediate, or high-grade intraepithelial neoplasia and IPNB associated with invasive carcinoma. IPNB mandates treatment irrespective of the presence of malignancy, otherwise the tumor growth can provoke obstructive jaundice which can lead to further morbidity. Surgical resection is considered for tumors without metastasis. Tumors without carcinoma and limited superficial spread can have limited surgical resection aimed to preserve organ function. We describe a case of a distal IPNB with limited superficial spread treated endoscopically.Figure 1.: A) Polypoid mass and plastic stent in the distal CBD during MRCP. B) Polypoid mass in the distal CBD during cholangiogram. C) Ampullary region showing previously placed plastic stent. D) Distal IPNB better visualized after extended sphincterotomy. E) Cholangioscopy after piecemeal resection of IPNB F) Stent placement after resection.

S3463 Obvious or Elusive? Pancreatic Adenocarcinoma

Introduction: Pancreatic cancer is the fourth leading cause of cancer-related deaths in the United States over the pastthree decades. Many experts postulate that the poor prognosis of pancreatic cancer is related to its delayed diagnosis and lack of symptoms early in disease course. Here, we present a case of pancreatic adenocarcinoma with an aim of focusing on early diagnostic challenges. Case Description/Methods: A 43-year-old male presented to gastroenterology clinic with complaints of fifteen-pound unintentionalweight loss and yellowing of the skin for one month duration. He denied current alcohol, tobacco or illicit drug use. Physical examination was pertinent for scleral icterus and jaundiced skin. Labs were significant for elevated transaminases, elevated CA 19-9 and carcinoembryonic antigen. CT abdomen/pelvis revealed proximal dilatation of the common bile duct (CBD) up to 1cm with a questionable incomplete annular pancreas and a tubular density noted in the 3 rd portion of the duodenum. ERCP revealed an abrupt cut-off above the pancreaticobilliary junction; stent placement was attempted unsuccessful. Consequently, interventional radiology inserted a cholecystectomy tube for decompression. A week later, a repeat ERCP was performed with successful placement of a plastic stent (IMAGE). Biliary brushings were unremarkable; however, clinical suspicion remained high for malignancy. A multidisciplinary team meeting was held and the decision was made to pursue a Whipple procedure. The findings were consistent with a distal CBD tumor with portal vein invasion but no gross evidence of metastasis. Histopathology reported invasive adenocarcinoma well-to-moderately differentiated with negative surgical margins. Currently, the patient is receiving adjuvant chemotherapy with FOLFIRINOX and following in GI clinic. Discussion: Pancreatic cancer is associated with very poor prognosis and resection is the only curative option. Earlydiagnosis can improve prognosis. This case highlights the notion that timely diagnosis for appropriate surgical candidates leads to survival benefit. Endoscopic ultrasound has evolved to play an integral role in determining whether a tumor meets resectability criteria. To date, despite advances in technology, mortality for pancreatic cancer has only marginally improved. This case highlights the need for further research on enhancing imaging techniques and developing sensitive bio-markers for earlier detection ofpancreatic malignancy.Figure 1.: Fluoroscopic image showing guidewire passing beyond distal CBD stricture. Cholecystectomy tube appropriately positioned within gallbladder for decompression.