Outcome of endoscopic retrograde cholangiopancreatography in patients with clinically defined decompensated liver cirrhosis

A Study on the Bacteriological Profile of Ascitic Fluids and Their Antibiotic Susceptibility Pattern in a Tertiary Care Hospital

Background Ascitic fluid culture remains an essential step in the management of all patients with ascites, regardless of their presenting complaints. Diagnostic paracentesis should not be delayed or prevent timely administration of antibiotics, particularly in unstable patients. Hence, it is an essential part of the surveillance system of every hospital to perform ascitic fluid culture and assess the antibiotic susceptibility patterns of bacterial isolates. In view of this perspective, the present study was conducted at Chengalpattu Medical College Hospital, Tamil Nadu, India. Objective The aim of the study is to determine the bacterial isolates of ascitic fluid samples and study their antibiotic susceptibility patterns. Materials and methods Ascitic fluids received in the central laboratory at the Department of Microbiology from various departments were included in this study. Preliminary identification of isolates was performed by direct Gram staining, acid-fast staining, and motility testing by the hanging drop method. Within one hour of receiving the samples, they were plated onto blood agar and MacConkey agar media and incubated for 18-24 hours at 37°C for isolation. Growth was checked, and species identification was done based on conventional methods. Antibiotic susceptibility testing was performed using the Kirby-Bauer disk diffusion method. Results In this study, a total of 100 ascitic fluid samples were collected, of which only eight (8%) showed growth. Among the eight isolates, six (75%) were Gram-negative bacilli (GNB). Four (66.66%) of the six GNB were Klebsiella spp., while the remaining two (33.33%) were Escherichia coli. Both Gram-positive cocci were Staphylococcus aureus. All the GNB isolates were susceptible to meropenem, piperacillin-tazobactam, and ceftriaxone, with varying susceptibilities to other drugs. Both Gram-positive isolates were found to be methicillin-sensitive Staphylococcus aureus. Conclusion GNB were the predominant organisms in cases of ascitic fluid infection, and they showed 100% susceptibility to carbapenem drugs (especially meropenem), piperacillin-tazobactam, and ceftriaxone. All these drugs can be kept in reserve for serious infections. Amikacin and gentamicin showed promising susceptibility. These drugs can be started empirically with patients on admission before performing culture. Drug adjustments may be later made based on culture reports.

Safety of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhosis compared to non-cirrhosis and effect of Child-Pugh score on post-ERCP complications: a systematic review and meta-analysis

BACKGROUND/AIMS

The safety of endoscopic retrograde cholangiopancreatography (ERCP) in hepatic cirrhosis and the impact of Child-Pugh class on post-ERCP complications need to be better studied. We investigated the post-ERCP complication rates in patients with cirrhosis compared with those without cirrhosis.

METHODS

We conducted a literature search of relevant databases to identify studies that reported post-ERCP complications in patients with hepatic cirrhosis.

RESULTS

Twenty-four studies comprising 28,201 patients were included. The pooled incidence of post-ERCP complications in cirrhosis was 15.5% (95% confidence interval [CI], 11.8%-19.2%; I2=96.2%), with an individual pooled incidence of pancreatitis 5.1% (95% CI, 3.1%-7.2%; I2=91.5%), bleeding 3.6% (95% CI, 2.8%-4.5%; I2=67.5%), cholangitis 2.9% (95% CI, 1.9%-3.8%; I2=83.4%), and perforation 0.3% (95% CI, 0.1%-0.5%; I2=3.7%). Patients with cirrhosis had a greater risk of post-ERCP complications (risk ratio [RR], 1.41; 95% CI, 1.16-1.71; I2=56.3%). The risk of individual odds of adverse events between cirrhosis and non-cirrhosis was as follows: pancreatitis (RR, 1.25; 95% CI, 1.06-1.48; I2=24.8%), bleeding (RR, 1.94; 95% CI, 1.59-2.37; I2=0%), cholangitis (RR, 1.15; 95% CI, 0.77-1.70; I2=12%), and perforation (RR, 1.20; 95% CI, 0.59-2.43; I2=0%).

CONCLUSION

Cirrhosis is associated with an increased risk of post-ERCP pancreatitis, bleeding, and cholangitis.

Incidence and Cross-Continents Differences in Endoscopic Retrograde Cholangiopancreatography Outcomes Among Patients With Cirrhosis: A Systematic Review and Meta-Analysis

Background

There are conflicting data on the frequency and variability of endoscopic retrograde cholangiopancreatography (ERCP) outcomes in patients with cirrhosis. Our aim was to systematically review the literature on the incidence of post-ERCP adverse events in cirrhotic patients and to examine the differences across continents.

Methods

We searched PubMed/MEDLINE, EMBASE, Scopus, and Cochrane databases to identify studies reporting adverse events after ERCP in patients with cirrhosis from conception to September 30, 2022. The random effects model was used to calculate odds ratios (ORs), mean differences (MDs), and confidence intervals (CIs). A P value < 0.05 was considered statistically significant. Heterogeneity was assessed using the Cochrane Q-statistic (I²).

Results

Twenty-one studies that included 2,576 cirrhotic patients and 3,729 individual ERCPs were analyzed. The pooled overall rate of adverse events after ERCP in patients with cirrhosis was 16.98% (95% CI: 13.06-21.29%, P < 0.001, I² = 86.55%). ERCPs performed in Asia had the highest ERCP adverse events with an overall complication rate of 19.90%, while the lowest overall adverse events were in North America at 13.04%. The pooled post-ERCP bleeding, pancreatitis, cholangitis and perforation were 5.10% (95% CI: 3.33-7.19%, P < 0.001, I² = 76.79%), 3.21% (95% CI: 2.20-5.36%, P = 0.03, I² = 42.25%), 3.02% (95% CI: 1.19-5.52%, P < 0.001, I² = 87.11%), and 0.12% (95% CI: 0.00 - 0.45, P = 0.26, I² = 15.76%), respectively. The pooled post-ERCP mortality rate was 0.22% (95% CI: 0.00-0.85%, P = 0.01, I² = 51.86%).

Conclusions

This meta-analysis shows that the overall complication rates after ERCP, bleeding, pancreatitis, and cholangitis are high in patients with cirrhosis. Because cirrhotic patients are more likely to have post-ERCP complications, with significant cross-continent variations, the risks and benefits of ERCP in this patient population should be carefully considered.

Analysis of risk factors associated with endoscopic retrograde cholangiopancreatography for patients with liver cirrhosis: a multicenter, retrospective, clinical study

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the endoscopic modality of choice for the treatment of biliary and pancreatic diseases. However, patients with cirrhosis, particularly those with decompensated cirrhosis, are believed to be at increased risk for complications associated with ERCP. There is a paucity of literature describing the outcomes of ERCP for patients with cirrhosis. This study aimed to investigate the outcomes of ERCP for cirrhosis patients, especially adverse events, and evaluated its safety and efficacy.

METHODS

We performed a multicenter, retrospective study of all patients at Beijing Friendship Hospital affiliated to Capital Medical University, Xijing Hospital affiliated to Air Force Military Medical University, Beijing Youan Hospital affiliated to Capital Medical University, and the Fifth Medical Center of the People's Liberation Army General Hospital from June 2003 to August 2019. The adverse events of inpatient ERCP for patients with ( n  = 182) and without liver cirrhosis (controls; n  = 385) were compared.

RESULTS

A total of 567 patients underwent ERCP between January 2003 and December 2019 were enrolled in this study. Compared to patients without cirrhosis, patients with cirrhosis were at higher risk for postoperative complications (odds ratio [OR], 4.172; 95% confidence interval [CI], 1.232-7.031; P  < 0.001) such as postoperative pancreatitis (OR, 2.026; 95% CI, 1.002-4.378; P  = 0.001) and cholangitis (OR, 3.903; 95% CI, 1.001-10.038; P  = 0.036). The main indications for ERCP for patients with cirrhosis in this study included choledocholithiasis (101 cases; 55.5%), benign bile duct strictures (46 cases; 25.3%), and malignant bile duct strictures (28 cases; 15.4%). Among them, 23 patients (12.6%) underwent balloon dilation and 79 patients (43.4%) underwent sphincterotomy. Of the patients with cirrhosis, delayed bleeding occurred in ten patients (5.5%), postoperative pancreatitis occurred in 80 patients (44.0%), and postoperative cholangitis occurred in 25 patients (13.7%). An additional multivariate analysis showed that the total bilirubin (TBIL) level (OR, 4.58; 95% CI, 2.37-6.70) and Child-Pugh score of C (OR, 3.11; 95% CI, 1.04-5.37) were risk factors for postoperative complications in patients with cirrhosis.

CONCLUSIONS

Compared with the general population of patients undergoing ERCP, patients with cirrhosis were more prone to postoperative pancreatitis and cholangitis. TBIL levels and Child-Pugh scores were risk factors for postoperative complications in patients with cirrhosis.

Safety and efficacy of common endoscopic treatments in patients with decompensated liver cirrhosis

INTRODUCTION

The safety and efficacy have always been a concern, when patients with decompensated liver cirrhosis (DLC) receive endoscopic treatments.

METHODS

To evaluate the safety and efficacy of common endoscopic treatments including endoscopic resection (ER) and endoscopic retrograde cholangiopancreatography (ERCP) applying to patients with DLC, we performed a retrospective study finally including 81 patients receiving ER (43 endoscopic mucosal resection (EMR) and 38 endoscopic submucosal dissection (ESD)) and 131 patients treated by ERCP.

RESULTS

There were no significant differences in the rate of degeneration and invariability of Child-Pugh (CP) class and the overall rate of adverse events between two groups (93.8%/8.6% ER vs. 96.2%/15.3% ERCP). Both the degeneration rate of CP class (35.4%) and the rate of adverse events (27.1%) in subgroup CP class C of ERCP group were significantly higher (P=0). The rate of poor outcomes was higher in ERCP group (12.2%) than that in ER group (2.5%) (P=0.02). And subgroup CP class C of ERCP group had a higher poor outcome rate (27.1%) (P=0).

CONCLUSION

ER and ERCP could remove focal lesions or relieve symptoms induced by targeted diseases without significant changes of CP class. Significant benefits and risks coexisted in CP class C patients with DLC when receiving ERCP.