Endoscopic drainage of obstructed biliary system in altered gastrointestinal anatomy: An experience from a tertiary center in India

INTRODUCTION

With the advances in imaging and endoscopic technology, scope of endoscopic interventions in biliary obstruction associated with altered gastrointestinal (GI) anatomy has increased. We analyzed our experience on single-balloon enteroscopy and endoscopic ultrasound (EUS)-guided ERCP (SBE-ERCP) and EUS-guided hepatogastrostomy (EUS-HG) in the presence of altered GI anatomy.

METHODS

Data of 15 patients (SBE-ERCP in 12, and EUS-HG in 3) over a period of 1 year (April 2016-March 2017) and followed up for 90 to 270 days were retrospectively analyzed. Inclusion criteria were (a) age 18-80 years, (b) fit for anesthesia, (c) intact primary confluence, (d) failed percutaneous transhepatic biliary drainage (PTBD) or difficult EUS-HG (due to poor visualization of intrahepatic ducts due to pneumobilia after PTBD; SBE-ERCP was undertaken in them), and (e) cholangitis without shock. Exclusion criteria were (a) involved or separated primary biliary confluence, (b) shock, (c) unfit for anesthesia, and (d) liver metastasis in the left lobe (EUS-HG).

RESULTS

All were symptomatic with pain, jaundice, and cholangitis. The median serum bilirubin and serum alkaline phosphatase (SAP) were 2.8 mg/dL and 273 IU/mL, respectively. SBE-ERCP in 12 and EUS-HG in 3 cases were  done successfully with observed success rate of 91.6% and 100% (3/3), respectively. Three patients had minor complications (post-procedure pain, fever, and pneumoperitoneum), which were managed conservatively.

CONCLUSION

Endoscopic interventions in patients with altered GI anatomy are safe.

Development of predisposition, injury, response, organ failure model for predicting acute kidney injury in acute on chronic liver failure

BACKGROUND AND AIM

There is limited data on predictors of acute kidney injury in acute on chronic liver failure. We developed a PIRO model (Predisposition, Injury, Response, Organ failure) for predicting acute kidney injury in a multicentric cohort of acute on chronic liver failure patients.

PATIENTS AND METHODS

Data of 2360 patients from APASL-ACLF Research Consortium (AARC) was analysed. Multivariate logistic regression model (PIRO score) was developed from a derivation cohort (n=1363) which was validated in another prospective multicentric cohort of acute on chronic liver failure patients (n=997).

RESULTS

Factors significant for P component were serum creatinine[(≥2 mg/dL)OR 4.52, 95% CI (3.67-5.30)], bilirubin [(<12 mg/dL,OR 1) vs (12-30 mg/dL,OR 1.45, 95% 1.1-2.63) vs (≥30 mg/dL,OR 2.6, 95% CI 1.3-5.2)], serum potassium [(<3 mmol/LOR-1) vs (3-4.9 mmol/L,OR 2.7, 95% CI 1.05-1.97) vs (≥5 mmol/L,OR 4.34, 95% CI 1.67-11.3)] and blood urea (OR 3.73, 95% CI 2.5-5.5); for I component nephrotoxic medications (OR-9.86, 95% CI 3.2-30.8); for R component,Systemic Inflammatory Response Syndrome,(OR-2.14, 95% CI 1.4-3.3); for O component, Circulatory failure (OR-3.5, 95% CI 2.2-5.5). The PIRO score predicted acute kidney injury with C-index of 0.95 and 0.96 in the derivation and validation cohort. The increasing PIRO score was also associated with mortality (P<.001) in both the derivation and validation cohorts.

CONCLUSIONS

The PIRO model identifies and stratifies acute on chronic liver failure patients at risk of developing acute kidney injury. It reliably predicts mortality in these patients, underscoring the prognostic significance of acute kidney injury in patients with acute on chronic liver failure.