Acute biliary pancreatitis: The roles of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography

Radial EUS Examination Can be Helpful in Predicting the Severity of Acute Biliary Pancreatitis

We investigated the utility of noncontrast enhanced endosonography (EUS) in predicting the severity of acute pancreatitis (AP) during the first 72 to 96 h of admission.In total, 187 patients with acute biliary pancreatitis were included. The patients were classified into 2 groups as having severe and mild AP according to the Modified Glasgow scoring and computerized tomography severity index (SI). The 158 cases with mild and 29 cases with severe AP had a similar age and sex distribution.Although none of the cases with mild AP developed morbidity and death, of the cases with severe AP, 16 developed serious morbidities and 5 died. On EUS examination, we looked for parenchymal findings, peripancreatic inflammatory signs, free or loculated fluid collections, and abnormalities of the common bile duct and the pancreatic channel. Statistical analysis indicated a significant relationship between the severity of AP with diffuse parenchymal edema, periparenchymal plastering, and/or diffuse retroperitoneal free fluid accumulation, and peri-pancreatic edema. We also defined an EUSSI and found that the EUSSI had sensitivity of 89.7%, specificity of 84.2%, positive predictivity value (PPV) of 88.9%, negative predictivity value (NPV) of 91.2%, and an accuracy of 87.9% in the differentiation of mild and severe AP. We found that the EUSSI had an accuracy of 72.4%, sensitivity of 75.4%, specificity of 65.1%, PPV of 69.3%, and NPV of 73.1% for determining mortality.Our data suggest that EUS allowed us to accurately predict the severity and mortality in nearly 90% of cases with AP.

EUS finding of geographic hyperechoic area is an early predictor for severe acute pancreatitis

BACKGROUND/OBJECTIVES

Endoscopic ultrasonography (EUS) is an accurate imaging modality for delineating pancreatobiliary structures, however, its clinical application of acute pancreatitis (AP) is limited. Therefore, we sought to characterize the typical EUS features of AP and to determine whether early EUS findings may have prognostic significance.

METHODS

Between March 2008 and October 2010, 90 patients with AP and 90 patients without pancreatic disease who underwent EUS were enrolled. An EUS examination was performed within 48 h of admission in AP, and all EUS findings were retrospectively analyzed.

RESULTS

Among 90 patients, 27 (30%) were diagnosed with severe AP. Multivariate analysis revealed the presence of peripancreatic fluid (OR 13.9, 95%, CI: 1.6-123.6), heterogenous (OR 7.2, 95% CI: 1.7-30.4) and hypoechoic parenchymal echogenicity (OR 10.0, 95% CI: 3.9-25.8) were significant EUS features in AP, as compared to those in the control group. Comparison between mild and severe AP showed that geographic hyperechoic area (GHA) of pancreas was a predictive factor (OR 2.9, 95% CI: 1.1-8.2, p = 0.04) for the severe form, and that AP patients with GHA had significantly longer duration of fever, abdominal pain and hospital stay than those without GHA (5.5 vs. 1 day (s), p = 0.002; 4 vs. 3 days, p = 0.023; 11 vs. 8 days, p = 0.021, respectively).

CONCLUSIONS

Typical EUS features of AP are a heterogenous hypoechoic parenchymal changes with peripancreatic fluid collection. The novel EUS variable of GHA in the early phase of AP seems to have prognostic value and could be correlated with a worse clinical outcome.

Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis

BACKGROUND

The role and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute gallstone pancreatitis remains controversial. A number of clinical trials and meta-analyses have provided conflicting evidence.

OBJECTIVES

To systematically review evidence from randomized controlled trials (RCTs) assessing the clinical effectiveness and safety of the early routine ERCP strategy compared to the early conservative management with or without selective use of ERCP strategy, based on all important, clinically relevant and standardized outcomes including mortality, local and systemic complications as defined by the Atlanta Classification (Bradley 1993) and by authors of the primary study, and ERCP-related complications in unselected patients with acute gallstone pancreatitis.

SEARCH METHODS

We searched the CENTRAL (The Cochrane Library), MEDLINE, EMBASE, and LILACS databases and major conference proceedings up to January 2012, using the Cochrane Upper Gastrointestinal and Pancreatic Diseases model with no language restrictions.

SELECTION CRITERIA

RCTs comparing the early routine ERCP strategy versus the early conservative management with or without selective use of ERCP strategy in patients with suspected acute gallstone pancreatitis. We included studies in which the population with acute gallstone pancreatitis was a subgroup within a larger group of patients. We only included studies involving only a selected subgroup of patients with acute gallstone pancreatitis (actual severe pancreatitis) in subgroup analyses.

DATA COLLECTION AND ANALYSIS

Two review authors conducted study selection, data extraction, and methodological quality assessment independently. Using intention-to-treat analysis with random-effects models, we combined dichotomous data to obtain risk ratios (RR) with 95% confidence intervals (CI). We assessed heterogeneity using the Chi² test and I² statistic. To explore sources of heterogeneity, we conducted a priori subgroup analyses according to predicted severity of pancreatitis, cholangitis, biliary obstruction, time to ERCP in routine ERCP strategy, use of selective ERCP in conservative management strategy, and risk of bias. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR versus odds ratio (OR)) and meta-analytic models (fixed versus random-effects), and per-protocol analysis. We performed influence analysis by exclusion of each study.

MAIN RESULTS

Five RCTs comprising 644 participants were included in the main analyses. Two additional RCTs, comprising only patients with actual severe acute gallstone pancreatitis, were included only in subgroup analyses. There was statistical heterogeneity among trials for mortality, but not for other outcomes. In unselected patients with acute gallstone pancreatitis, there were no statistically significant differences between the two strategies in mortality (RR 0.74, 95% CI 0.18 to 3.03), local and systemic complications as defined by the Atlanta Classification (RR 0.86, 95% CI 0.52 to 1.43; and RR 0.59, 95% CI 0.31 to 1.11 respectively) and by authors of the primary study (RR 0.80, 95% CI 0.51 to 1.26; and RR 0.76, 95% CI 0.53 to 1.09 respectively). The results were robust to sensitivity and influence analyses except for systemic complications as defined by the Atlanta Classification. There was no evidence to suggest that the results were dependent on predicted severity of pancreatitis. Among trials that included patients with cholangitis, the early routine ERCP strategy significantly reduced mortality (RR 0.20, 95% CI 0.06 to 0.68), local and systemic complications as defined by the Atlanta Classification (RR 0.45, 95% CI 0.20 to 0.99; and RR 0.37, 95% CI 0.18 to 0.78 respectively) and by authors of the primary study (RR 0.50, 95% CI 0.29 to 0.87; and RR 0.41, 95% CI 0.21 to 0.82 respectively). Among trials that included patients with biliary obstruction, the early routine ERCP strategy was associated with a significant reduction in local complications as defined by authors of the primary study (RR 0.54, 95% CI 0.32 to 0.91), and a non-significant trend towards reduction of local and systemic complications as defined by the Atlanta Classification (RR 0.53, 95% CI 0.26 to 1.07; and RR 0.56, 95% CI 0.30 to 1.02 respectively) and systemic complications as defined by authors of the primary study (RR 0.59, 95% CI 0.35 to 1.01). ERCP complications were infrequent.

AUTHORS' CONCLUSIONS

In patients with acute gallstone pancreatitis, there is no evidence that early routine ERCP significantly affects mortality, and local or systemic complications of pancreatitis, regardless of predicted severity. Our results, however, provide support for current recommendations that early ERCP should be considered in patients with co-existing cholangitis or biliary obstruction.

EUS in exploring the etiology of mild acute biliary pancreatitis with a negative finding of biliary origin by conventional radiological methods

BACKGROUND AND AIM

Conventional radiological methods, including transcutaneous ultrasonography (US), computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP) are non-invasive and recommended for the detection of etiologies of acute biliary pancreatitis (ABP). There are still, however, a number of patients whose etiologies cannot be found by these methods. The value of endoscopic ultrasound (EUS) for this population is still unknown. The aim of the present study was to evaluate the role of EUS in exploring the unknown etiology of mild ABP.

METHODS

The data from patients with mild ABP admitted to Changhai Hospital, Shanghai, China, from June 2006 to December 2009 were retrospectively collected, and the results of the imaging methods in detecting biliary disorders were analyzed.

RESULTS

A total of 223 patients with mild ABP underwent both US and CT. Of these, 106 underwent additional MRCP. There were still 37 patients with unknown biliary etiologies, even after the use of the conventional methods mentioned earlier. EUS was conducted in 33 of these patients. Abnormalities associated with the etiology of mild ABP were found in 14 cases (42.4%) confirmed by subsequent endoscopic retrograde cholangiopancreatography, with biliary stones in 11 cases, biliary sludge in two cases, and ampullary adenocarcinoma in one case.

CONCLUSION

The results suggest that EUS is helpful in the identification of the etiology of mild biliary pancreatitis when conventional radiological imaging is negative or equivocal.

Etiology and diagnosis of acute biliary pancreatitis

Establishing a biliary etiology in acute pancreatitis is clinically important because of the potential need for invasive treatment, such as endoscopic retrograde cholangiopancreatography. The etiology of acute biliary pancreatitis (ABP) is multifactorial and complex. Passage of small gallbladder stones or biliary sludge through the ampulla of Vater seems to be important in the pathogenesis of ABP. Other factors, such as anatomical variations associated with an increased biliopancreatic reflux, bile and pancreatic juice exclusion from the duodenum, and genetic factors might contribute to the development of ABP. A diagnosis of a biliary etiology in acute pancreatitis is supported by both laboratory and imaging investigations. An increased serum level of alanine aminotransferase (>1.0 microkat/l) is associated with a high probability of gallstone pancreatitis (positive predictive value 80-90%). Confirmation of choledocholithiasis is most accurately obtained using endoscopic ultrasonography or magnetic resonance cholangiopancreatography. This Review discusses the pathogenesis of ABP and the clinical techniques used to predict and establish a biliary origin in patients with suspected ABP.

Endoscopic ultrasound in pancreatic disease--its influence on surgical decision-making. An update 2008

Endoscopic ultrasonography (EUS) was introduced about 25 years ago with the primary aim of better visualization of the pancreas as compared to transabdominal ultrasonography. This review discusses the current evidence in 2008 concerning the role of EUS in the clinical management of patients, with a special emphasis on its impact on surgical therapy. According to the literature, good indications are detection of common bile duct stones (e.g. in acute pancreatitis), the detection of small exo- and endocrine pancreatic tumors, the performance of fine-needle aspiration in pancreatic masses depending on therapeutic consequences. In other areas such as diagnosis of chronic pancreatitis and cystic pancreatic lesions, the contribution of EUS seems limited. Pancreatic cancer staging is discussed controversially due to conflicting evidence and certainly has lost grounds due to improvements in CT technology. Therapeutic EUS is, however, more widely accepted and may replace other techniques, e.g. in pancreatic cyst drainage and celiac plexus neurolysis; further techniques of interest are being developed.

Acute biliary pancreatitis: detection of common bile duct stones with endoscopic ultrasound

OBJECTIVES

To determine prospectively the sensitivity and specificity of endoscopic ultrasound (EUS) for detecting common bile duct stones (CBS) in patients with acute biliary pancreatitis in whom transabdominal ultrasound was negative for CBS.

METHODS

In 38 consecutive patients with acute biliary pancreatitis who were negative for CBS by transabdominal ultrasound, EUS was performed before endoscopic retrograde cholangiopancreatography (ERCP). The endoscopist performing ERCP was blind to the results of EUS. The primary goal of EUS and ERCP was to confirm or exclude CBS. The reference standard for CBS was endoscopic extraction of bile duct stones after endoscopic sphincterotomy. When both procedures, EUS and ERCP excluded CBS, it was assumed that there were no CBS and endoscopic sphincterotomy was not performed. The results EUS and ERCP were compared with the McNemar test.

RESULTS

Twenty-five of the 38 patients (66%) had CBS. EUS and ERCP were false negative in one patient each, EUS was false positive in two patients and ERCP in one patient. The sensitivity of both EUS and ERCP was 96%. The specificity of EUS and ERCP was 85 and 92%, respectively. The difference between EUS and ERCP was not significant (P=0.9).

CONCLUSION

EUS proved to be as sensitive as ERCP for detection of CBS in patients with acute biliary pancreatitis. Therefore, EUS could be used as the first-line procedure in patients with acute biliary pancreatitis when therapeutic ERCP is not needed. By this approach a substantial number of unnecessary diagnostic ERCP procedures could be avoided.

Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study

BACKGROUND

EUS may be used to reduce the need of diagnostic ERCP.

OBJECTIVE

Our purpose was to investigate the benefits and safety of an EUS-guided versus an ERCP-guided approach in the management of suspected biliary obstructive diseases caused by choledocholithiasis, in whom a US study is not diagnostic.

DESIGN

A randomized study.

SETTING

A university medical unit.

PATIENTS

Patients with clinical, biochemical, or radiologic suspicion of biliary obstruction.

INTERVENTIONS

In the EUS group, therapeutic ERCP was performed at the same EUS session if a lesion was found. In the ERCP group, therapeutic treatment was carried out at the discretion of the endoscopist.

MAIN OUTCOME MEASUREMENTS

The number of ERCPs avoided, procedure-related complications, and recurrent biliary symptoms on follow-up at 1 year.

RESULTS

Thirty-three patients were randomized to EUS and 32 to ERCP. Three patients (9.4%) had failed ERCPs, whereas all EUS procedures were successful. Nine (27.3%) patients in the EUS group were found to have biliary lesions that were all treated by ERCP. In the ERCP group, 7 (22%) patients had biliary lesions detected that were treated in the same session. More patients had serious complications (bleeding, acute pancreatitis, and umbilical abscess) in the ERCP group. One patient in each group had recurrent biliary symptoms during follow-up. With EUS used as a triage tool, diagnostic ERCP and its related complications could be spared in 49 (75.4%) patients.

CONCLUSIONS

In patients suspected to have biliary obstructive disease, EUS is a safe and accurate test to select patients for therapeutic ERCP.

Endoscopic ultrasonography for evaluating patients with recurrent pancreatitis

Acute recurrent pancreatitis (ARP) is still a complex diagnostic and therapeutic challenge in clinical practice. In up to 30% of cases of ARP, it is not possible to establish the etiology of the disease. In the other 70%, many factors play an etiological role in ARP: microlithiasis, sphincter of Oddi dysfunction (SOD), pancreas divisum, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatic tumors or chronic pancreatitis are diagnosed. EUS should be useful in ARP as it is sensitive for diagnosing bile duct stones, gallbladder sludge, pancreatic lesions, ductal abnormalities and chronic pancreatitis. Endoscopic ultrasound (EUS) appears to be diagnostic in the majority of patients with previously unexplained pancreatitis, and offers an alternative to endoscopic retrograde cholangiopancreatography (ERCP) as the initial diagnostic test in patients with ARP.

EUS: a meta-analysis of test performance in suspected choledocholithiasis

BACKGROUND

EUS has been proposed as a less invasive means of diagnosing choledocholithiasis and may eliminate the need for ERCP and its associated risks. The literature pertaining to EUS for the diagnosis of choledocholithiasis reports widely varying sensitivities and specificities.

OBJECTIVE

To more precisely estimate the diagnostic accuracy of EUS in suspected choledocholithiasis.

DESIGN

MEDLINE and EMBASE databases were used to identify prospective cohort studies in which the results of EUS were compared with the results of an acceptable criterion standard, including ERCP, intraoperative cholangiography, or surgical exploration. Two independent reviewers extracted standardized data and assessed trial quality. A random effects model was used to estimate the sensitivity, specificity, likelihood, and diagnostic odds ratio (DOR), and a summary receiver operating characteristic curve was constructed. All predefined potential sources of heterogeneity were explored by subgroup analysis and meta-regression.

PATIENTS

A total of 2673 patients with suspected choledocholithiasis were reported in 27 studies that satisfied the inclusion criteria.

RESULTS

EUS had a high overall pooled sensitivity of 0.94 (95% CI, 0.93-0.96), a specificity of 0.95 (95% CI, 0.94-0.96), and an area under the curve of 0.98. Three variables appeared to yield a higher DOR: a higher disease prevalence, an adequate time interval between index test and criterion standards, and the presence of verification bias.

LIMITATIONS

Misclassification of patients by imperfect criterion standards could potentially underestimate the performance of an EUS.

CONCLUSIONS

An EUS is a noninvasive test, with excellent overall sensitivity and specificity for diagnosing choledocholithiasis. An EUS should, therefore, be used to select patients for a therapeutic ERCP to minimize the risk of complications associated with unnecessary diagnostic ERCP.

When is pancreatitis considered to be of biliary origin and what are the implications for management?

Acute pancreatitis is a disease caused by gallstones in 40-60% of patients. Identification of these patients is extremely important, since there are specific therapeutic interventions by endoscopic sphincterotomy and/or cholecystectomy. The combination of trans-abdominal ultrasound (stones in the gallbladder and/or main bile duct) and elevated serum alanine transaminase (circa >60 IU/l within 48 h of presentation) indicates gallstones as the cause in the majority of patients with acute pancreatitis. In the presence of a severe attack this is a strong indication for intervention by endoscopic sphincterotomy. The presence of a significant main bile duct dilatation is also strongly indicative of gallstones and should prompt the use of endoluminal ultrasonography: >8 mm diameter with gallbladder in situ, or >10 mm following cholecystectomy if aged <70 years and >12 mm, respectively, if > or = 70 years. In mild pancreatitis surgically fit patients should be treated by cholecystectomy, and intra-operative cholangiography, as pre-operative biliary imaging is not efficient in this setting. Patients who are not fit for cholecystectomy should undergo prophylactic endoscopic sphincterotomy to prevent further attacks. In the post-acute-phase, pancreatitis patients in whom the aetiology is uncertain should undergo endoluminal ultrasonography. Thisis the most sensitive method for the detection of cholelithiasis and choledocholithiasis and may reveal alternative aetiological factors such as a small ampullary or pancreatic cancer. A number of recent studies have shown that bile crystal analysis, a marker for microlithiasis, increases the yield of positive results over and above endoluminal ultrasonography, and should be considered as part of the modern investigative algorithm.

Echo-endoscopy versus endoscopic retrograde cholangiography for the diagnosis of choledocholithiasis: the influence of the size of the stone and diameter of the common bile duct

BACKGROUND

Endoscopic retrograde cholangiography is highly accurate in diagnosing choledocholithiasis, but it is the most invasive of the available methods. Endoscopic ultrasonography is a very accurate test for the diagnosis of choledocholithiasis with a risk of complications similar to that of upper gastrointestinal endoscopy.

AIM

To compare the accuracy of endoscopic ultrasonography and endoscopic retrograde cholangiography in the diagnosis of common bile duct stones before laparoscopic cholecystectomy and to analyze endoscopic ultrasound results according to stone size and common bile duct diameter.

PATIENTS AND METHODS

Two hundred and fifteen patients with symptomatic gallstones were admitted for laparoscopic cholecystectomy. Sixty-eight of them (31.7%) had a dilated common bile duct and/or hepatic biochemical parameter abnormalities. They were submitted to endoscopic ultrasonography and endoscopic retrograde cholangiography. Sphincterotomy and sweeping of the common bile duct were performed if endoscopic ultrasonography or endoscopic retrograde cholangiography were considered positive for choledocholithiasis. After sphincterotomy and common bile duct clearance the largest stone was retrieved for measurement. Endoscopic or surgical explorations of the common bile duct were considered the gold-standard methods for the diagnosis of choledocholithiasis.

RESULTS

All 68 patients were submitted to laparoscopic cholecystectomy with intraoperative cholangiography with confirmation of the presence of gallstones. Endoscopic ultrasonography was a more sensitivity test than endoscopic retrograde cholangiography (97% vs. 67%) for the detection of choledocholithiasis. When stones >4.0 mm were analyzed, endoscopic ultrasonography and endoscopic retrograde cholangiography presented similar results (96% vs. 90%). Neither the size of the stone nor the common bile duct diameter had influence on endoscopic ultrasonographic performance.

CONCLUSIONS

For a group of patients with an intermediate or moderate risk with respect to the likelihood of having common bile duct stones, endoscopic ultrasonography is a better test for the diagnosis of choledocholithiasis when compared to endoscopic retrograde cholangiography mainly for small-sized calculi.

Comparison of early endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the management of acute biliary pancreatitis: a prospective randomized study

BACKGROUND & AIMS

The role and potential benefits of endoscopic ultrasonography (EUS) in the management of acute biliary pancreatitis have not been documented. We report a large prospective randomized study comparing early EUS and endoscopic retrograde cholangiopancreatography (ERCP) in the management of these patients.

METHODS

A prospective randomized study was performed on 140 patients with acute pancreatitis suspected to have a biliary cause. The patients were randomized to have EUS (n = 70) or ERCP (n = 70) within 24 hours from admission. In the EUS group, when EUS detected choledocholithiasis, therapeutic ERCP was performed during the same endoscopy session. In the ERCP group, diagnostic ERCP was performed, followed by therapeutic endoscopy when choledocholithiasis was detected.

RESULTS

Examination of the biliary tree by EUS was successful in all patients in the EUS group, whereas cannulation of the common duct during ERCP was unsuccessful in 10 patients (14%) in the ERCP group (P = .001). Combined percutaneous ultrasonography and ERCP missed detection of cholelithiasis in 6 patients in the ERCP group. The overall morbidity rate was 7% in the EUS group, and that in the ERCP group was 14% (P = .172). The hospital stay and mortality rates were comparable in both groups.

CONCLUSIONS

In selected patients with acute biliary pancreatitis, EUS could safely replace diagnostic ERCP in the management for selecting patients with choledocholithiasis for therapeutic ERCP with a higher successful examination rate, a higher sensitivity in the detection of cholelithiasis, and a comparable morbidity rate.

[Endoscopic therapy of acute and chronic pancreatitis]

Endoscopic therapy is valuable for both acute and chronic pancreatitis. Early endoscopic papillotomy appears, in the case of a severe course of acute biliary pancreatitis, to be advantageous. Endoscopic drainage can be considered in cases of acute fluid retention and necrosis as well as subacute, non-healing pancreatitis or cyst development. By acute chronic pancreatitis with strictures or bile duct stones, papillotomy, dilation and stent insertion can lead to an improvement in pain symptoms. An improvement in endo- or exocrine function, however, is not expected. Studies on the endoscopic therapy of pancreatitis are still very limited, and recommendations can usually only be made based on retrospective case series.

Biliary stones: including acute biliary pancreatitis

The widespread availability of endoscopic ultrasound has facilitated the evaluation of the pancreas and extrahepatic biliary system. Endosonography has been shown to be highly sensitive in the detection of choledocholithiasis (especially in patients with small stones and nondilated bile ducts) and gallbladder microlithiasis; however, the use of this technique in relation to endoscopic retrograde cholangiography and laparoscopic surgery in gallstone disease remains confusing. This article highlights the clinical performance and results of endoscopic ultrasound in this context and proposes strategies in relation to its use in association with endoscopic retrograde cholangiopancreatography and surgery in common clinical practice. Endosonography allows the correct identification of patients with acute biliary pancreatitis and proves an important adjunct in eliminating other causes of undetermined pancreatitis.

N/A

N/A

Endoscopic ultrasonography in detection of cholelithiasis in patients with biliary pain and negative transabdominal ultrasonography

BACKGROUND

The aim of the study was to evaluate endoscopic ultrasonography (EUS) as a single method for diagnosing cholecystolithiasis in patients with a clinical suspicion of cholecystolithiasis, but with a normal transabdominal ultrasonography (TUS).

METHODS

A prospective study was performed on patients with biliary type of colic and normal US of the gallbladder. All patients had at least one normal TUS examination (mean 2.1, range 1-5) performed by an experienced radiologist. All patients were subsequently examined with EUS. EUS examination was performed with either a mechanical radial scanning echo-endoscope (Olympus GF-UM20) or a linear echo-endoscope (Pentax FG32-UA or FG34-UA). Patients in whom EUS demonstrated cholecystolithiasis were offered laparoscopic cholecystectomy within 2 weeks.

RESULTS

A total of 35 patients (31 F and 4 M) were included. In 18 out of 35 (52.4%) patients cholecystolithiasis was diagnosed by EUS. In 15 out of 17 patients the EUS diagnosis was verified by surgery. At follow-up after 12 months, 13 of the 15 patients (87%) with verified gallbladder stones had no abdominal discomfort, whereas 2 patients (13%) complained of persistent and unchanged abdominal pain.

CONCLUSION

EUS seems to be a promising imaging method in the detection of microlithiasis in the gallbladder in patients with clear biliary colic and normal transabdominal US.

Role of ERCP in the management of predicted mild acute biliary pancreatitis

OBJECTIVE

The role of endoscopic retrograde cholangiopancreatography (ERCP) in mild acute biliary pancreatitis is controversial. This study examined the results of ERCP in patients with predicted mild disease and analysed biochemical and imaging findings in relation to the occurrence of choledocholithiasis.

PATIENTS AND METHODS

There were 172 consecutive patients, admitted between January 1998 and December 2000, with the diagnosis of acute pancreatitis. All patients were investigated using transcutaneous ultrasonography and ERCP if biliary aetiology was suspected. Serum bilirubin and alkaline phosphatase were measured, together with abdominal ultrasonographic findings, as potential predictors for choledocholithiasis.

RESULTS

Biliary calculus was the aetiology in 62.8% of patients (108/172). Among these 108 patients, 79.6% (86/108) suffered from mild disease. There were only 80 patients who underwent ERCP, and the incidence of choledocholithiasis was 45% (36/80). Although significant correlation was shown between all three measured parameters (bilirubin, alkaline phosphatase and ultrasonographic abnormalities) and choledocholithiasis, their individual sensitivities, specificities and predictive values were low. Nonetheless, if all three tests were normal, the incidence of ductal stones was significantly lower than that in cases with abnormalities in any one of these parameters (4.8% vs 59.3%).

CONCLUSION

Routine ERCP is not recommended for patients with mild, acute biliary pancreatitis when there is no biochemical derangement or ultrasonographic evidence of a dilated biliary system.

Making cost-effectiveness analyses clinically relevant: the effect of provider expertise and biliary disease prevalence on the economic comparison of alternative diagnostic strategies

RATIONALE AND OBJECTIVES

This study was performed to assess the incremental cost-effectiveness of initial magnetic resonance cholangiopancreatography (MRCP) and initial endoscopic ultrasonography (EUS) compared with initial endoscopic retrograde cholangiopancreatography (ERCP) and to evaluate the effect of MRCP provider expertise on the relative cost-effectiveness of the three methods.

MATERIALS AND METHODS

Thirty patients with suspected biliary disease and referred for ERCP were prospectively evaluated with EUS, MRCP, or ERCP within 24 hours of referral, according to institutional review board-approved protocol. Performance characteristics were measured for EUS and MRCP, with ERCP as the reference standard. A decision analysis compared the clinical and economic effects of three diagnostic strategies (ERCP, EUS followed by ERCP [EUS-ERCP], and MRCP followed by ERCP [MRCP-ERCP]) using prospective EUS and MRCP test characteristics and Medicare reimbursements. The added costs per additional correct diagnosis and per additional false-positive finding averted and the rates and costs of ERCP-related complications were calculated for EUS-ERCP and MRCP-ERCP. Two additional MRCP readers reviewed MRCP data to evaluate interobserver variability and estimate provider expertise. Additional economic analyses incorporated these estimates.

RESULTS

Compared with initial ERCP, EUS-ERCP demonstrated 72% of biliary abnormalities and reduced ERCP-related complications by 60%; the corresponding percentages for MRCP-ERCP were 48% and 40%. Initial EUS and initial MRCP decreased the number of ERCP procedures performed by 69% and 49%, respectively. Each correct diagnosis made with ERCP that would not have been made with initial EUS or initial MRCP cost an additional 4,875 dollars or 2,580 dollars, respectively. Each false-positive diagnosis averted with initial ERCP that would have been made with EUS-ERCP or MRCP-ERCP cost an additional 9,750 dollars or 1,548 dollars, respectively. The decision model was most sensitive to disease prevalence. As provider expertise increased, the additional cost of an additional correct diagnosis increased for ERCP compared with MRCP-ERCP, with disease prevalence accentuating provider effects.

CONCLUSION

Initial EUS and initial MRCP are less costly than initial ERCP, but provider expertise, biliary disease prevalence, and procedural costs influence incremental cost-effectiveness.

Management of severe acute pancreatitis

BACKGROUND

Acute pancreatitis is still associated with significant morbidity and mortality. Current management guidelines are sometimes equivocal, particularly in relation to the surgical treatment of severe disease. This review assesses available investigative and treatment strategies to allow the development of a formalized management approach.

METHODS

A literature review of diagnosis, staging and management of acute pancreatitis was performed.

RESULTS AND CONCLUSION

Recent evidence has helped to clarify the roles of computed tomography, endoscopic retrograde cholangiopancreatography, prophylactic antibiotics, enteral feeding and fine-needle aspiration for bacteriology in the management of acute pancreatitis. Despite a relative shortage of prospective randomized trials there has been a significant change in the surgical management of acute pancreatitis over the past 20 years. This change has been away from early aggressive surgical intervention towards more conservative management, except when infected necrosis is confirmed. A formalized approach, with appropriate use of the various non-surgical and surgical options, is feasible in the management of severe acute pancreatitis.

The role of ultrasound in biliary and pancreatic diseases

The possibilities and the limits of transabdominal ultrasonography (US) in the diagnosis of bilio-pancreatic diseases are reviewed here in the light of the last 10 years' research. US remains the method of choice for the diagnosis of gallstones and is generally accepted as an initial imaging technique in gallstone complications, such as acute cholecystitis. Moreover the method can be useful for the detection of the biliary complications after laparoscopic cholecystectomy and after liver transplantation. US is still considered the first diagnostic procedure when stones are suspected in the common bile duct. The use of color Doppler can provide a differential diagnosis of gallbladder cancer with respect to other benign inflammatory or polypoid lesions. Color Doppler US allows to detect vascular complications of acute pancreatitis such as pseudoaneurysms. US is still considered useful for the initial screening of the pancreatic cancer. However, for staging other imaging techniques must be employed. With US useful informations are obtained in the diagnosis of cystic tumors of the pancreas and of pancreatic metastases. US is generally of little use for the diagnosis of endocrine tumors.

Endoscopic ultrasound

Indications and the clinical utility of endosonography have evolved as new technology, such as linear array echoendoscopes and EUS-guided fine needle aspiration, has emerged. The most noteworthy of the EUS applications are for cancer staging; including rectal, pancreatic, lung, and esophageal malignancies. There is little doubt that EUS is a powerful tool for cancer imaging, but its clinical impact in patient care and management has yet to be validated in prospective outcome studies. Other imaging modalities such as positron emission tomography (PET), dual-phased helical CT, and MR imaging technology will undoubtedly provide increasingly accurate diagnostic and staging information for gastrointestinal diseases. EUS imaging alone may assume a less significant role in relation to these noninvasive modalities in the future. EUS-guided FNA, as well as therapeutic EUS applications, will likely continue to expand in scope and play an important role in clinical medicine for many years to come.

[Endoscopic, percutaneous and laparoscopic treatment for acute biliary pancreatitis]

AIM OF THE STUDY

The aim of this study is to evaluate the results of acute gallstone pancreatitis treatment and to discuss indications in relation with the different forms of the disease.

MATERIAL AND METHOD

From january 1992 to june 2001, 137 patients have been treated for an acute gallstone pancreatitis. Diagnostic criteria were given by the history, clinical examination, biochemical and radiological findings. After exclusion of patients with a systemic disease, a group of 129 patients have been enrolled in a treatment regimen with an endoscopic retrograde cholangiopancreatography (ERCP) and eventual sphincterotomy, a percutaneous US-guided cholecystostomy (PC) when necessary and an elective laparoscopic cholecystectomy.

RESULTS

ERCP has been successfully performed in 121/129 patients. A PC has been performed in 5/8 patients of the failed endoscopic procedure and in 14 with acute cholecystitis. Retrograde and percutaneous cholangiographies showed main bile duct stones in 89 patients, a dilatation of the main bile duct without stones in 26 patients and a negative finding in 6 patients. An endoscopic sphincterotomy has been performed in 117 patients. A laparoscopic cholecystectomy has been performed in 118 patients. Mortality and morbidity rates were 1.6 and 10.3%, respectively.

CONCLUSION

ERCP and sphincterotomy seem to be indicated in all patients observed during the first 72 hours. Endoscopic treatment and percutaneous procedure make it possible to reduce at a very low rate the cases with an unfavourable course of the disease. A definitive treatment may then be performed by the way of a laparoscopic cholecystectomy.

Early EUS of the bile duct before endoscopic sphincterotomy for acute biliary pancreatitis

BACKGROUND

Endoscopic sphincterotomy can benefit patients with suspected biliary pancreatitis, although there are procedure-related complications. EUS can be used to select patients for endoscopic sphincterotomy. The results of this strategy were assessed.

METHODS

Information on patients referred for EUS were recorded in a database. One hundred twenty-three patients with suspected biliary pancreatitis (57 men, 66 women; median age 55 years) were included and followed. All underwent EUS followed by endoscopic sphincterotomy during the same procedure if choledocholithiasis was identified. Outcomes were studied in relation to the initial severity of biliary pancreatitis (Ranson and Balthazar scores), presence of stones, and time span between onset of biliary pancreatitis and EUS plus endoscopic sphincterotomy.

RESULTS

Thirty-five patients (28%) had a Ranson score greater than 3 on admission and 38 (31%) were Balthazar D-E. The median time from admission to EUS was 3 days. EUS imaging of the bile duct was complete in all but 3 patients. Thirty-three patients (27%) had choledocholithiasis on EUS and underwent endoscopic sphincterotomy. Stones were more frequent in patients with jaundice (p < 0.005) and when EUS was performed less than 3 days after admission (p < 0.05). One hundred patients (81%) recovered without complication. Two patients (1.6%) died, 1 had recurrent BP develop, 6 (5%) had further biliary symptoms, and 16 (13%) had complications of pancreatitis develop (9 pseudocysts). There were 3 mild endoscopic sphincterotomy-related complications (complication rate 6.5%).

CONCLUSIONS

In this series in which endoscopic sphincterotomy was performed selectively depending on the endosonographic presence or absence of ductal stones early in the course of the pancreatitis, and not according to its predicted severity, mortality and complications of endoscopic sphincterotomy were low and unrelated to the predicted severity of biliary pancreatitis or the presence of choledocholithiasis. Controlled trials are needed to confirm the superiority of this strategy compared with ERCP alone for the management of biliary pancreatitis.

Endoscopic retrograde cholangiopancreatography in the diagnosis and management of pancreatic diseases

Endoscopic retrograde cholangiopancreatography (ERCP) has been used for diagnosis and treatment of pancreatic diseases for over 20 years. ERCP has been most intensely investigated for acute biliary pancreatitis. Randomized trials have proven that its use will decrease morbidity and have suggested a decrease in mortality for patients with severe gallstone pancreatitis. ERCP is also valuable in detecting and treating main pancreatic duct leaks with transpapillary stenting. Symptomatic pseudocysts, which may be seen in either acute or chronic pancreatitis, can be drained via the papilla or through creation of a cystogastrostomy or cystoduodenostomy with a needle-knife sphincterotome. Endoscopic treatment of patients with recurrent acute pancreatitis presumed due to pancreas divisum and sphincter of Oddi dysfunction remains controversial. Dominant pancreatic strictures or calculi in the setting of chronic pancreatitis may be treated with stenting and removal of calculi to improve abdominal pain. Finally, diagnosis of pancreatic cancer by brush cytology and palliative management of biliary obstruction with various plastic and expandable metal sents have simplified management of this difficult problem.

Endoscopic management of biliary tract disease

Endoscopic management of biliary tract disease continues to be influenced by new advances in technology and shaped by further examination of old controversies. This review covers and highlights recent world literature concerning biliary endoscopy and its effect on the management of biliary disorders. In particular, we examine the role and consequence of the endoscopic management of choledocholithiasis and the continuing controversy over endoscopic treatment of pancreatic disease. The increasing impact of endoscopic ultrasound in the biliary tree is explored, as well as the latest developments in biliary stent technology.