Risk Factors for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: Evidence from 1786 Cases

Evaluation of Development of Nonalcoholic Fatty Pancreas Disease After Post-Endoscopic Retrograde Cholangiop ancreatography Pancreatitis in Liver Transplant Patients: Computerized Tomography Versus Ultrasound

BACKGROUND/AIMS

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common serious adverse event in liver transplant patients The average incidence has been reported as 1.3%-15.1% in prospective series. In our study, we have prospectively evaluated the prevalence of nonalcoholic fatty pancreatic disease (NAFPD) after PEP via computerized tomography (CT) and determined the ratio of fatty pancreas by ultrasound imaging in liver transplant patients.

MATERIALS AND METHODS

We have retrospectively analyzed 2922 patient files, and 146 patients were indicated for ERCP. PEP was observed in 32 patients. After presenting the significant association between the NAFPD and PEP, we prospectively reached 32 patients included in the study. Ten out of those patients have been performed ultrasound with regard to NAFPD.

RESULTS

PEP was defined in 32 patients in whom CT was performed to investigate NAFPD. When the patients were contacted, it was observed that 12% were deceased, 71% were alive, but 15% of them were untraceable. Ultrasound has been performed on 10 of 32 patients to determine NAFPD. There was a significant reduction in post-PEP pancreas/spleen rate compared to pre-PEP pancreas/ spleen rate (P = .001). Both the pre-PEP and post-PEP pancreas-spleen difference dropped significantly (P = .002).

CONCLUSION

Ultrasound imaging could be utilized as a scanning test and an alternative to evaluate and diagnose NAFPD, particularly in risky patients.

Safety and indications for endoscopic retrograde cholangiopancreatography in liver transplant patients: an analysis of the United States' National Inpatient Sample database

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is performed to treat biliary complications after a liver transplantation; however, the previously available literature on the safety of ERCP in liver transplant patients is limited. We aimed to study the safety of ERCP in liver transplant patients.

Methods

We used a National Inpatient Sample database from 2016-2019 to identify patients who underwent ERCP and had a history of a liver transplantation, using the international classification of diseases, 10th revision. Multivariate logistic regression analysis was conducted to determine the odds of post-ERCP complications in liver transplant recipients.

Results

Liver transplant patients who underwent ERCP had a higher rate of post-ERCP pancreatitis and bleeding compared to the general adult population (11.39% vs. 9.19%, 0.83% vs. 0.53%, respectively). However, the adjusted odds of post-ERCP pancreatitis (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 0.86-1.49; P=0.36) and bleeding (aOR 1.41, 95%CI 0.58-3.46; P=0.45) were similar in both the liver transplant and no-transplant groups. There was no difference in the odds of post-ERCP cholangitis (aOR 1.26, 95%CI 0.80-2.01; P=0.32), and sepsis (aOR 0.94, 95%CI 0.66-1.34; P=0.76) between liver transplant and no transplant groups. Biliary stricture was the most common indication for ERCP in the liver transplant group, whereas choledocholithiasis was the main reason for ERCP in the general adult population.

Conclusions

ERCP is a safe procedure for treating biliary complications in liver transplant patients. The odds of post-ERCP complications (pancreatitis, bleeding, sepsis, cholangitis) in liver transplant patients are comparable to those in patients with no transplantation.

The Incidence of Endoscopic Retrograde Cholangiopancreatography-Related Complications in Patients With Liver Transplant: A Meta-Analysis and Systematic Review

Background

Existing literature on post-endoscopic retrograde cholangiopancreatography (ERCP) complications in patients with liver transplant remains scarce and largely inconsistent. We therefore aimed to systematically review and analyze the literature on complication rates associated with ERCP in patients with liver transplant.

Methods

We performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through March 2020 to identify all the studies that evaluated post-ERCP complications in patients with liver transplant. Effect estimates from the individual studies were extracted and combined using the random effect, generic inverse variance method of DerSimonian and Laird, and a pooled odds ratio (OR) and event rates were calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques.

Results

Fourteen studies with a total of 1,787 patients were analyzed. In total, 3,192 ERCPs were performed on these patients. The pooled all-complication rate was 5.2% (95% confidence interval (CI): 0.035 - 0.075). Procedural complications analyzed included post-ERCP pancreatitis 3.4% (95% CI: 0.025 - 0.047), bleeding 1.1% (95% CI: 0.006 - 0.020), infections 0.2% (95% CI: 0.025 - 0.047), and cholangitis 0.8% (95% CI: 0.004 - 0.020). No cases of periprocedural death were reported. The pooled OR for post-ERCP pancreatitis in patients with liver transplant compared to patients without liver transplant was 1.289 (95% CI: 0.455 - 3.653, P = 0.633, I² = 72.88%).

Conclusion

Post-ERCP complication rates in liver transplant patients are comparable to the general population and hence, peri-procedural evaluation and management may follow the current standards of care in this patient population.

The Effect of Preoperative Biliary Drainage with or without Pancreatic Stenting on Complications after Pancreatoduodenectomy: A Retrospective Cohort Study

Background

The necessity of preoperative biliary drainage (PBD) prior to pancreaticoduodenectomy (PD) is still controversial. However, in some settings, PBD with endoscopic retrograde cholangiopancreatography (ERCP) procedure is recommended as a preferred management. Meanwhile, pancreatic duct stenting in the drainage procedure is rarely performed for selected indications, and its associated complications after PD remain quite unknown.

Methods

A retrospective observational longitudinal cohort study was performed on patients who underwent PBD and PD from a prospectively maintained database at the National Cancer Center from March of 2015 to July of 2019. Patients who underwent biliary stenting alone, biliary and pancreatic stenting, were distributed into two study cohort groups, and their records were scrutinized for the incidence of postoperative complications.

Results

A total of 83 patients who underwent successful PD after biliary drainage were identified. 29 patients underwent nasobiliary drainage (ENBD)/plastic or metal bile duct stenting (BS) and pancreatic duct stenting (PS group), and 54 patients underwent only ENBD/BS, without pancreatic duct stenting (NPS group). No differences were found between the two groups with respect to in-hospital time, overall complication rate, respective rate of serious (grade 3 or higher) complication rate, bile anastomotic leakage, bleeding, abdominal infection, surgical wound infection, organ dysfunction, and pancreatic anastomotic leakage. Postoperative gastrointestinal dysfunction rates differed significantly, which occurred in 3 (5.56%) cases in the NPS group, compared with 6 (20.7%) cases in the PS group (P = 0.06). In the univariate and multivariate regression model analysis, pancreatic duct stenting was correlated with higher rates of gastrointestinal dysfunction [odds ratio (OR) = 4.25, P = 0.0472].

Conclusion

Our data suggested that PBD and pancreatic duct stenting prior to pancreatoduodenectomy would increase the risk of postoperative delayed gastric emptying, while the overall incidence of postoperative complications and other complications, such as pancreatic leakage and bile duct leakage, showed no statistical difference.

Severe complications of chronic cholelithiasis treatment

BACKGROUND

Gallstone disease is a burden affecting about 15% percent of the population around the world. The complications of gallstone disease are numerous and many require emergency care. Severe complications are not uncommon and require special attention, as lethal outcome is possible.

CASE PRESENTATION

We present a retrospective analysis of eight cases describing severe complications of gallstones in patients undergoing endoscopic treatment of chronic gallstones conditions. All patients were admitted to our emergency care department following symptoms onset. The diagnostic difficulties, treatment strategies and outcomes are presented. The associated risk factors and preventative measures are discussed. Two patients developed profuse bleeding, two developed acute pancreatitis, two patients had perforation related complications. One rare case of bilioma and one case of iatrogenic injury are presented. All patients had severe condition, in two cases lethal outcome was a result of co-morbidity and difficulties in management.

CONCLUSION

Special care should be taken in patients with risk factors of severe complications in order to improve outcome and prevent the development of life-threatening conditions.

Sex-Related Differences of Acute and Chronic Pancreatitis in Adults

The incidence of acute and chronic pancreatitis is increasing in the United States. Rates of acute pancreatitis (AP) are similar in both sexes, but chronic pancreatitis (CP) is more common in males. When stratified by etiology, women have higher rates of gallstone AP, while men have higher rates of alcohol- and tobacco-related AP and CP, hypercalcemic AP, hypertriglyceridemic AP, malignancy-related AP, and type 1 autoimmune pancreatitis (AIP). No significant sex-related differences have been reported in medication-induced AP or type 2 AIP. Whether post-endoscopic retrograde cholangiopancreatography pancreatitis is sex-associated remains controversial. Animal models have demonstrated sex-related differences in the rates of induction and severity of AP, CP, and AIP. Animal and human studies have suggested that a combination of risk factor profiles, as well as genes, may be responsible for the observed differences. More investigation into the sex-related differences of AP and CP is desired in order to improve clinical management by developing effective prevention strategies, diagnostics, and therapeutics.

Increased Use of Prophylactic Measures in Preventing Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs), pancreatic duct stenting, and intensive intravenous hydration have been proven to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Trial participation and guideline changes demanded an assessment of the clinical practice of post-ERCP pancreatitis prophylaxis.

AIMS

The surveys aim to identify points of improvement to inform and educate ERCPists about current evidence-based practice.

METHODS

Two anonymous surveys were conducted among Dutch gastroenterologists in 2013 (n = 408) and 2020 (n = 575) for longitudinal views and attitudes pertaining to post-ERCP pancreatitis prophylaxis and recognition of post-ERCP pancreatitis risk factors.

RESULTS

In 2013 and 2020, respectively, 121 and 109 ERCPists responded. In the 2013 survey, 98% of them utilized NSAID prophylaxis and 62% pancreatic duct stent prophylaxis in specific cases. In the 2020 survey, the use of NSAIDs (100%), pancreatic duct stents (78%), and intensive intravenous hydration (33%) increased among ERCPists. NSAID prophylaxis was the preferred prophylactic measure for all risk factors in the 2020 survey, except for ampullectomy, pancreatic duct contrast injection, and pancreatic duct cannulation, for which NSAID prophylaxis and pancreatic duct stent combined was equally favored or preferred.

CONCLUSION

Rectal NSAIDs are the most applied post-ERCP pancreatitis prophylaxis in the Netherlands, followed by pancreatic duct stents and intensive intravenous hydration. Additionally, there is reason to believe that recent guideline updates and active research participation have led to increased prophylaxis implementation.

A grey zone of hyperamylasemia following endoscopic retrograde cholangiopancreatography: follow-up and differential diagnosis from acute pancreatitis

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a tool often used for treating and diagnosing pancreaticobiliary diseases. One of the important complications of ERCP is pancreatitis. Even though transient hyperamylasemia is a more common and benign situation, it must be distinguished from post-ERCP pancreatitis.

Aim

To define the risk factors associated with post-ERCP pancreatitis (PEP) and tried to identify a cutoff about laboratory findings for positive or negative prediction.

Material and methods

We reviewed the medical files of patients who underwent ERCP for choledocholithiasis in a retrospective cohort study. The primary outcome is the risk factors associated with PEP. Receiver operator characteristics analysis was carried out for determination of cut-offs for laboratory parameters.

Results

The presence of cholangitis (p = 0.018), Wirsung cannulation (p = 0.008), presence of abdominal pain at 12^th and 24^th h (p < 0.001), amylase level at 12^th h (p < 0.001), C-reactive protein (CRP) levels at 6^th and 12^th h (p = 0.001 and p < 0.001), white blood cells (WBC) levels at 6^th and 12^th h (p = 0.001 and p < 0.001) were significant for development of PEP. CRP levels above 8 mg/l and WBC above 10 × 10³ had negative predictive values over 70% and 90% respectively.

Conclusions

Physical examination and inflammatory parameters are important in diagnosis of PEP. CRP and WBC have high negative predictivity and sensitivity. Amylase level increase was most apparent 12 h after ERCP and significantly higher (p < 0.001) for the development of PEP. The first abdominal pain evaluation is meaningful at the 12^th h timepoint because insufflation during the procedure and other causes of abdominal pain may result in misinterpretation.

Complicaciones y factores de riesgo en pacientes sometidos a colagiopancreatografía retrógrada endoscópica en una clínica de tercer nivel de Medellín desde el 2014 hasta el 2017

Introducción. La colangiopancreatografía retrógrada endoscópica es la herramienta de elección para el manejo de una gran cantidad de enfermedades pancreáticas y biliares. Al ser un procedimiento invasivo, trae consigo riesgos que aumentan la morbimortalidad en los pacientes en quienes se practica. El objetivo de este estudio fue analizar las complicaciones más prevalentes relacionadas con el procedimiento, de los pacientes de una institución de tercer nivel de Medellín entre los años 2014 y 2017. Métodos. Se presenta un estudio observacional, retrospectivo y analítico. Se analizaron las historias clínicas de los pacientes sometidos a colangiopancreatografía retrógrada endoscópica con diagnóstico de enfermedades biliares y pancreáticas. La información fue analizada usando estadística descriptiva e inferencial, mediante análisis univariado y multivariado, y se calculó la razón de momios (odds ratio, OR) con un intervalo de confianza del 95 %; se tomó como significativo un valor de p inferior a 0,25 en los análisis bivariados. Resultados. En los 1.546 pacientes sometidos a colangiopancreatografía retrógrada endoscópica, la edad promedio fue de 57,6 ± 19.3 años y el 59,1 % eran mujeres. Las complicaciones identificadas fueron: pancreatitis en 57 pacientes (3,7 %), sangrado en 28 (1,8 %), perforación en 8 (0,5 %) y mortalidad no discriminada de 42 pacientes (2,7 %). Como factores de riesgo con significancia estadística, se encontraron la papilotomía y el contraste del conducto de Wirsung (OR=3 y OR=3,55, respectivamente). Discusión. Los resultados obtenidos se encuentran en concordancia con los de la literatura mundial, con tasas de complicaciones y mortalidad similares. Por otra parte, el perfil sociodemográfico de la población de estudio difiere de las cifras internacionales, con predominancia de la enfermedad estudiada en edades mayores y con mayor cantidad de comorbilidades.

Post-ERCP Pancreatitis: Risk factors and role of NSAIDs in primary prophylaxis

Objective:

To determine efficacy of diclofenac suppository in reducing post-ERCP pancreatitis (PEP) and identify risk factors for PEP.

Methods:

This is a placebo-based prospective study at Department of Medicine & Gastroenterology, Services Institute of Medical Sciences / Services Hospital, Lahore performed from January 2018 to June 2019. Patients were randomized to receive diclofenac suppository or glycerine suppository before ERCP. Both groups were compared for PEP using chi square x² test while risk factors for PEP were determined using binary logistic regression.

Results:

Total of 165 patients with mean age 49.1(±15.2) and male to female ratio 1/1.6 (63/102) were included. Among 82 (49.7%) patients in diclofenac group, 8 (9.7%) developed pancreatitis while 19(22.9%) of 83(50.3%) in placebo group had PEP (p value 0.02). After multivariate analysis, age>45 years (p value 0.014, OR 3.2), Bilirubin >3 mg/dl (p value 0.004 OR 3.58), time to cannulation> 5 minutes (p value<0.000 OR 9.2), use of precut (p value< 0.000 OR 4.9), pancreatic duct cannulation (p value 0.000 OR 5.46) and total procedure time >30 minutes (p value 0.01 OR 3.92) were risk factors for PEP.

Conclusion:

Pre-procedure Diclofenac suppository reduces post-ERCP pancreatitis. Age > 45 years, serum bilirubin > 3 mg/dl, cannulation time > 5 minutes, use of precut, pancreatic duct cannulation and procedure time > 30 minutes are risk factors for post-ERCP pancreatitis.

The synergistic impact of NSAIDs and aggressive hydration therapy on the rate of post-ERCP pancreatitis in high -risk and low -risk patients

AIM

The main complication of Endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP).

BACKGROUND

Based on demographic characteristics and underlying issues and ERCP indication, patients are categorized as high risk or low risk. There have been no studies on the synergistic effects of NSAIDS and hydration therapy, separately sorted by the risk assessment of PEP in different groups of patients.

METHODS

This study included 281 eligible participants after exclusion. According to demographic characteristics and co-morbidities, the patients were divided to high risk and low risk. The high-risk group was divided randomly into two subgroups and both of them received NSAIDs (100 mg rectal Diclofenac). One group received standard hydration (1.5mg/kg/hr), another the other received aggressive hydration (3mg/kg/h). The low-risk group received standard hydration. One of its subgroups received NSAIDs, while others did not. The efficacy of these preventions was compared across 4 subgroups.

RESULTS

The mean age was 59.85±17.17. Eight hours after ERCP, the amylase and lipase were significantly higher in the high-risk group with standard hydration (P=0.00). Amylase, lipase 8 hours, between two low risk subgroups, NSAIDs had no significant effect (P=0.38, P=0.95, respectively). After adjustment based on cannulation, manipulation and duration of time, the results had no change (P=0.64, P=0.19, P=0.61).

CONCLUSION

The aggressive hydration could significantly decrease the risk of PEP. However, the low-risk group was exposed to the lowest risk of PEP. NSAIDs could not help to decrease the rate PEP in the low-risk groups alone. Overall, it seems hydration and NSAIDs therapy had synergistic outcome in high-risk patients.

The Effects of Lycium Barbarum Polysaccharide (LBP) in a Mouse Model of Cerulein-Induced Acute Pancreatitis

BACKGROUND Acute pancreatitis is an inflammatory disease of the pancreas associated with high patient morbidity. Lycium barbarum polysaccharide (LBP), a traditional Chinese medicine with an active component extracted from the goji berry, has previously been reported to have anti-inflammatory effects. This study aimed to investigate the effects of LBP in a mouse model of cerulein-induced acute pancreatitis. MATERIAL AND METHODS Acute pancreatitis was induced by intraperitoneal injection of cerulein in C57BL/6 wild-type mice or nuclear factor erythroid-2-related factor 2 (NRF2) gene knockout mice. LBP or normal saline was administrated by gavage once daily for one week before the induction of acute pancreatitis. At 12 hours after the first intraperitoneal injection of cerulein, the mice were euthanized. Blood and pancreatic tissue were sampled for histology and for the measurement of pro-inflammatory cytokines, serum amylase, and lipase. RESULTS In the untreated mouse model of cerulein-induced acute pancreatitis, amylase and lipase levels were increased, and these levels were reduced by LBP treatment when compared with vehicle treatment. In the untreated mouse model, histology of the pancreas showed edema and inflammation, which were reduced in the LBP-treated mice. In the untreated mouse model, increased levels of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) were found, which were reduced in the LBP-treated mice. NRF2 gene knockout mice with cerulein-induced acute pancreatitis showed reduced anti-inflammatory effects of LBP treatment. LBP increased the expression of NRF2 and heme oxygenase-1 (HO-1). CONCLUSIONS In a mouse model of cerulein-induced acute pancreatitis, LBP reduced inflammation by upregulating NRF2 and HO-1.