Repeat endoscopic biliary sphincterotomy: indications and complications

Endoscopic biliary sphincterotomy [EBS] carries a substantial risk of recurrent choledocholithiasis but retreatment with endoscopic retrograde cholangiopancreatography [ERCP] and repeat EBS is safe and feasible. However, long term results of repeat ERCP and EBS and risk factors for late complications are largely unknown. The aim of this study was to investigate indications and early complications after repeat EBS compared to patients with initial EBS, as well as the long term outcome of repeat ERCP with or without EBS for recurrent bile duct stones. Risk factors predicting late choledochal complications will be identified. Two groups of patients were included. The first group included 28 patients underwent repeat ERCP combined with EBS in 24 for post-EBS recurrent choledocholithiasis. The second group included 25 patients with symptoms of biliary obstruction and underwent ERCP and initial EBS. Early complications were compared for both groups. Patients in group I were followed for long term outcomes of repeat ERCP and EBS were assessed by multivariate analysis. Complete stone clearance was achieved in all patients in both groups. 16 patients in group 1 had no visible evidence of prior sphincterotomy. Early complications occurred in 3 patients in group I and 4 patients in group II. During a follow up period of 0.9 - 2.3 years [mean 1.4 yrs.] for patients in group I, 8 of them [28.5%] developed late complications including stone recurrence [5 patients], acute acalculous cholangitis [2 patients], and acute cholecystitis [1 patient]. There were no deaths attributable to biliary disease. Multivariate analysis identified three independent risk factors for choledochal complications: interval between initial EBS and repeat ERCP and EBS /= 15 mm., and periampullary diverticulum. Choledochal complications were successfully treated with repeat ERCP with or without EBS in 4 patients. Repeat EBS is a safe and effective procedure to manage recurrent biliary and pancreatic complications after initial EBS. The commonest early indications in our study included bleeding at the time of initial EBS, small length of EBS and failure to continue the procedure due to cholangitis, and multiple stones with variable sizes with inability to clear the bile ducts through the initial EBS. Late indications were mainly due to suspected recurrent bile duct stones as indicated by upper right quadrant abdominal pain with elevation of cholestatic enzymes or jaundice, cholangitis, and bile duct lithiasis and dilation proved by ultrasonography. Tight stenosis of biliary orifice which is one of the indications of repeat EBS was not found in our patients. Early complications of repeat EBS are less than initial one. However late choledochal complications after repeat EBS are relatively frequent but are endoscopically manageable. Careful follow up is necessary, particularly for patients with dilated bile ducts, periampullary diverticulum, or early recurrence. Repeat ERCP with or without EBS is a reasonable treatment even for recurrent choledocholithiasis after initial EBS

Hepatitis C virus-associated hypobetalipoproteinemia is correlated with plasma viral load, steatosis, and liver fibrosis

Aim: A relationship between chronic hepatitis C virus [HCV] infection and lipid metabolism has recently been suggested. The aim of this study was to determine the correlation between lipid profile and virology, and histologic lesions in noncirrhotic, londiabetic patients with hepatitis C. Subjects and Thirty patients with untreated chronic hepatitis C were studied to assess the effects of HCV viral load, steatosis, hepatic fibrosis, and body mass ndex [BMI] on lipid profile. The control group showed a significantly higher apolipoprotein B [apo B] concentration compared with patients with chronic hepatitis C. Hypobetalipoproteinemia [apo B <0.7 g/l] was found in 8 [26.6%] chronic HCV patients and in 1 [10%] control subjects [P=0.0002]. Levels of apo B were negatively correlated with steatosis and HCV viral ioad [r= -0.22, P=0.03]. In multivariate analysis, low apo B concentration was significantly associated with fibrosis grade 2 or 3 versus grade 0 or 1 [P< 0001], stetosis > 5% [P<0.001], low body mass index [P<0.001], and high HCV viral load [P< 0.014]. Conclusions: In chronic HCV patients, hypobetalipoproteinemia occurs already in the early stages of HCV infection before the development of liver cirrhosis. The correlation between apo B levels and HCV viral load seems to confirm the interaction between hepatitis C infection and Beta-lipoprotein metabolism

Correlation between biochemical markers of liver fibrosis and histopathological features in patients with chronic hepatitis C

Aim: Liver fibrosis in chronic hepatitis C is related to sex and age at infection. Several biochemical markers are highly predictive for the discrimination of significant fibrosis. The aims of this study were to compare an index of five-biochemical markers with histological features and to determine the utility of combining historical features [age and sex] with the five-marker index for the prediction of significant fibrosis. Subjects and Thirty untreated patients with chronic hepatitis C and a known duration of infection had a liver biopsy and serum tested for markers of fibrosis. The discriminative values of the markers and an index of historical features for the diagnosis of clinically significant fibrosis [F2-F4, by the Metavir scoring system] were compared using areas under receiving operating characteristic [ROC] curves. A modified index was constructed combining the five-marker index and historical features. Of the 30 patients included 70% were males. The median age at infection was 28 +/- 13 and the median duration of infection was 17 +/- 8 years. By multivariate logistic regression analysis, sex [P=0.003], age at biopsy [P-0.004] were independently predictive of F2-F4 fibrosis. For the discrimination of F2-F4 fibrosis, the areas under ROC curves were 0.796 +/- 0.033 for the five-marker index versus 0.709 +/- 0.037 for the historical index [P=0.079]. For diagnosis of advanced fibrosis [F3, F4] the areas under the curves were 0.920 +/- 0.032 and 0.762'0.049 [P=0.007], respectively. The discriminative value of the combined biochemical and historical index was not statistically significantly different from that of the five-marker index alone [P=ns]. Conclusions: A simple index including age, sex, and five biochemical markers accurately predicts significant hepatitis C related fibrosis