Epidemiological profile, referral routes and diagnostic accuracy of cases of acute cholangitis among individuals with obstructive jaundice admitted to a tertiary-level university hospital: a cross-sectional study

ABSTRACT BACKGROUND: Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available. OBJECTIVE: To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit. DESIGN AND SETTING: Cross-sectional study at a tertiary-level university hospital. METHODS: Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria. RESULTS: Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01). CONCLUSIONS: There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.

Morbilidad postoperatoria por colangiografía endoscópica retrógrada con o sin papilotomía ulterior: serie de casos / Postoperative morbidity by endoscopic retrograde cholangiography with or without ulterior papillotomy: series of cases

La patología biliar litiásica es frecuente en nuestro país, con prevalencias entre 30% y 50%; y la ictericia obstructiva secundaria a coledocolitiasis (IOC), constituye un motivo de consulta frecuente en los servicios de urgencia. Por otra parte, la papilotomía endoscópica (PE) post colangiografía retrógrada endoscópica (CRE), constituye el tratamiento de elección en estos casos; sin embargo, es un procedimiento no exento de complicaciones. El objetivo de este estudio, es describir la MPO e identificar posibles factores de riesgo (FR) asociados a MPO, en pacientes con IOC, sometidos a PE. Serie de casos retrospectiva, de pacientes con IOC, a quienes se les realizó CRE y ulterior PE. La variable resultado fue desarrollo de MPO (hemorragia, perforación y pancreatitis). Otras variables de interés fueron canulación, dificultad de ésta, desarrollo de PE, uso de pre corte y mortalidad. La recolección de datos se realizó mediante una pauta ad-hoc, en la que se registraron las variables extraídas desde el protocolo operatorio y la ficha clínica. Se aplicó estadística descriptiva y analítica (Chi2 de Pearson y exacto de Fisher) para estimar fuerza de asociación. Se intervinieron 200 pacientes. La Media de edad fue de 60±18 años; 62% eran mujeres (n= 124). Se registró MPO en 32 casos (16,0%): Perforación (0,5%), pancreatitis (2,0%) y hemorragia (13,5%). La serie no registró mortalidad. No se logró objetivar asociación entre la variable "canulación difícil" y las variables hemorragia (p= 0,214); pancreatitis (p= 0,519); ni perforación (p= 1). Sin embargo, se verificó asociación entre el desarrollo de hemorragia y la realización de PE (p= 0,017). La hemorragia es la MPO más frecuente en esta serie; y la PE es un FR para el desarrollo de hemorragia.

Bileduct stones is prevalent in our country, with prevalences between 30% and 50%; and obstructive jaundice secondary to choledocholithiasis (OJC), is a frequent reason of consultation in emergency services. Furthermore, endoscopic papillotomy (EP) post ERCP is the treatment of choice in these cases; however, it is not free of complications (POM). The aim of this study is to describe POM and identify potential risk factors (RF) associated with POM in patients with OJC, underwent PE. Retrospective case series of patients with OJC, who underwent ERCP and subsequent PE. Outcome variable was the development of POM (bleeding, perforation, and pancreatitis). Other variables of interest were cannulation, difficulty of this, developing PE, using precut and mortality. Data collection was performed by an ad-hoc pattern in which the variables extracted from surgical protocols and clinical data were recorded. Descriptive and analytical statistics (Pearson Chi2 and Fisher's exact test) were applied to assess strength of association. 200 patients were operated. The mean age was 60±18 years; 62% were women (n = 124). MPO was recorded in 32 cases (16.0%): perforation (0.5%), pancreatitis (2.0%) and bleeding (13.5%). The series does not record mortality. It was not possible to objectify association between "difficult cannulation" and the variables bleeding (p= 0.214); pancreatitis (p= 0.519); and perforation (p= 1). However, association between bleeding and performing PE (p= 0.017) was observed. Hemorrhage is the most common cause of MPO in this series; and PE is a RF for the development of bleeding.

Experiencia en colangiografía endoscópica retrógrada en el Hospital Regional de Temuco: serie de casos con seguimiento / Experience with endoscopic retrograde colangiopancreatography in a regional hospital

Introducción: La Colangiopancreatografía endoscópica retrógrada (CPER) es un procedimiento terapéutico para diversas patologías del árbol biliopancreático. Nuestro objetivo es describir algunos aspectos técnicos, la morbilidad y mortalidad de CPER realizadas de enero de 2005 a diciembre de 2006. Material y método: Estudio de serie de casos con seguimiento. Se incluyeron sujetos que fueron sometidos a CPER por cualquier diagnóstico por el equipo de cirugía hepatopancreática y biliar (HPB) en el período enero de 2005 a diciembre de 2006. Se midieron variables clínicas, farmacológicas, técnicas y de evolución clínica. Se utilizó estadística descriptiva, con cálculo de medidas de tendencia central, dispersión y tendencia extrema. Resultados: La serie está compuesta por 209 pacientes que fueron sometidos a CPER, con un promedio de edad de 60 + 16 años, una mediana de 63 años y edades extremas de 15 y 98 años. La distribución por género muestra 75 por ciento de pacientes de género femenino y 25 por ciento de género masculino. 94 por ciento de los procedimientos se realizaron en el servicio de radiología y 6 por ciento en pabellón. Midazolam fue el fármaco más utilizado para la sedación (93 por ciento), seguido por Propofol (4 por ciento) y anestesia general con intubación orotraqueal en 2 por ciento. Se logró canular la vía biliar en el 76 por ciento de los procedimientos. Se realizó precorte en 16 por ciento y papilotomía en 51 por ciento de la serie. La morbilidad asociada fue de 3 por ciento, y no hubo mortalidad asociada al procedimiento. La complicación más frecuente fue la hemorragia digestiva en 3 pacientes (1,4 por ciento) y la prevalencia de pancreatitis fue de 0,5 por ciento. Conclusiones: La morbilidad y mortalidad asociada a CPER en nuestro centro es comparable con cifras nacionales e internacionales.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic procedure for biliary and pancreatic diseases. Aim: To describe technical issues, morbidity and mortality associated to ERCP, performed in a regional hospital from January 2005 to December 2006. Material and Methods: Review of 209 patients aged 15 to 98 years (157 women) subjected to ERCP for any diagnosis. Clinical, pharmacological, technical variables and clinical evolution were recorded. Results: Ninety four percent of procedures were performed in radiological facilities and 6 percent in operating room. Midazolam was the drug most commonly used for sedation in 93 percent of patients , followed by propofol in 4 percent and general anesthesia in 2 percent. The biliary tree was cannulated in 76 percent of the procedures. A precut was performed in 16 percent and a papillotomy in 51 percent of patients. Six patients had complications (bleeding in three, pancreatitis in one, retention of the Dormia basket and subcutaneous injection of contrast media in one). Conclusions: The rate of complications and mortality of these patients are comparable with national and international series.

Etiological spectrum of obstructive Jaundice

The objective of this study was to determine the etiological spectrum of obstructive jaundice in this part of the world. This prospective study was carried out at Liaquat National Hospital, Karachi from March 1997 to February 2001 and later at Isra University Hospital, Hyderabad from January 2003 to December 2006. Sixty five patients with obstructive jaundice were included in this study. The data was collected with respect to patient's identity, age, gender and cause of the obstructive jaundice. Fifty seven percent of patient had malignant obstructive jaundice and carcinoma of head of pancreas being the leading cause of malignant obstructive jaundice. Forty three percent patients had benign causes of obstructive jaundice, choledocholithiasis being the most common benign cause. Choledocholithiasis and malignancy are the two major causes of obstructive jaundice

Experience on endoscopic retrograde cholangiopancreatography at tertiary referral center in Thailand: risks and complications.

BACKGROUND: Several complications from ERCP have been described, including pancreatitis, hemorrhage, perforation, and cholangitis. The actual incidences and risk factors in Thailand have never been analyzed. MATERIAL AND METHOD: The authors retrospectively reviewed the outcome of ERCP at Chulalongkorn University Hospital between September 2000 and December 2002. Potential risk factors were statistically assessed. RESULTS: The incidence of post-ERCP pancreatitis, hemorrhage, perforation and cholangitis was 3.6%, 2.1%, 1.2% and 6%, respectively. Risk factors of pancreatitis were the suspected diagnosis of sphincter of Oddi dysfunction and pancreatic interventions, especially through minor papilla. Prophylactic pancreatic duct stent prior to precut sphincterotomy may reduce the incidence of pancreatitis. Hemorrhage was associated with duodenal diverticulum. The incidence of cholangitis was higher in biliary duct dilation and cholangiocarcinoma, especially hilar involvement. CONCLUSION: Incidence of these complications was comparable to international series with similar risk factors. Cholangitis developed more frequently probably due to a higher incidence of cholangiocarcinoma.

Endoscopic retrograde cholangiopancreatography use at the University Hospital of the West Indies

All patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) at the University Hospital of the West Indies (UHWI) were entered into a prospective database. Parameters included demographics, indication for the procedure, success of the ERCP and any immediate complications noted. Retrospectively, the patients' case notes were analyzed for complications developing after 24 hours, and outcome. During the period March 1999 to December 2002, a total of 120 consecutive patients were subjected to 123 ERCPs, all being performed by a single gastroenterologist. Of these 120 patients, eight had ERCP as outpatients and were transferred back to their referring hospitals. These patients were excluded from further analysis. Of the 115 UHWI patients, the case notes of 96 were available for analysis and this group formed the basis of this review. ERCP had successful cannulation in 95 of patients. There were 70 females and 26 males with a female to male ratio of 2.7:1. Age ranged from 13 to 85 years (mean +/- SD, 43 +/- 17), males being an average six years older than females. The most common indication for ERCP was a patient with cholelithiasis and abnormal liver function tests scheduled for laparoscopic cholecystectomy. This made up 33 of patients and in this subgroup, sickle cell disease accounted for 50 of cases. Patients with common bile duct stones preoperatively and post-cholecystectomy accounted for 13 and 17 respectively while gallstones pancreatitis accounted for 13 of cases, including three patients with severe pancreatitis. While 64 of the patients had normal cholangiogram, 66 of them had sphincterotomy. Common bile duct stones were seen in 23 cases and complete removal was successful in 48. There were ten cases (10) of ERCP pancreatitis and this was severe in three patients and the direct cause of death in one. One patient had ascending cholangitis post ERCP and there were no cases of post-sphincterotomy bleeding or duodenal perforation. Endoscopic retrograde cholangiopancreatography at the UHWI has high diagnostic yield but its therapeutic use needs further development

Análise das complicações após realização de colangiopancreatografias retrógradas endoscópicas (CPRE) / Analysis of complications after performing of endoscopic retrograde cholangiopancreatography (ERCP)

Objetivo: Descrever a experiência dos autores na realização de CPRE, verificando a ocorrência de complicações associadas ao procedimento.Materiais e métodos: Trata-se de um estudo prospectivo. Foram incluídos no estudo todos os pacientes que realizaram CPRE entre janeiro de 1996 e setembro de 2003 em dois hospitais de Caxias do Sul. As variáveis analisadas foram sexo, idade, complicações relacionadas ao procedimento e mortalidade. Resultados: Foram realizadas 311 CPRE;55,7 por cento dos pacientes eram do sexo feminino e 44,3 por cento do masculino. Ocorreram complicações em 8,4 por cento dos exames realizados, sendo pancreatite a mais freqüente, verificada em 5,1 por cento dos casos.Ocorreu um óbito relacionado à CPRE no presente estudo. Conclusão: A freqüência e a etiologia das complicações verificadas assemelham-se às de outros estudos. Seu conhecimento é de extrema importância para aumentar a possibilidade de prevenção e de diagnóstico precoce de tais complicações

Endoscopic retrograde cholangiopancreatographic evaluation of patients with obstructive jaundice

To evaluate the role of endoscopic retrograde cholangiopancreatography [ERCP] in patients with obstructive jaundice. Design: A retrospective, observational study. Place and Duration of Study: The study was carried out at Valley Clinic, Rawalpindi, from January 1999 to January 2002. Subjects and Two-hundred and twenty-six patients, who underwent ERCP for evaluation of obstructive jaundice were included. ERCP in each case was performed with standard technique and the findings were recorded. Therapeutic procedures like sphincterotomy, Dormia extraction for stone, and stent placements were performed whenever indicated. Of the 226 patients, 117 [51.8%] were males, and 109 [48.2%] females, their mean age being 51.8 ' 16.6 years. Common bile and pancreatic ducts were visualized in 81.8% and 68.1% patients respectively. Growth/masses and stones were commonest causes of obstructive jaundice. Choledocholithias was common in males, while biliary channel related growth/masses were common in females [p-value = 0.03]. Common bile duct stone clearance rate was 88%, stenting was highly successful in patients with growth and strictures. ERCP related complications were noted in 11 [4.8%] patients. ERCP is an important diagnostic and therapeutic modality for evaluation of patients with obstructive jaundice. Growth/masses and stones are common causes of obstructive jaundice which can be diagnosed and treated with ERCP

Terapéutica combinada de la litiasis intrahepática y coledociana / Combined treatment of interhepatic and choledocian lithiasis

Objetivo y diseño: Analizar retrospectivamente la experiencia de un grupo multidisciplinario en el diagnóstico y tratamiento de la litiasis coledociana. Lugar de aplicación: Hospital de Comunidad. Método: Se realizaron 909 CPRE entre junio de 1988 y junio de 1997. Población: Con una edad promedio de 57,6 presentando el sexo femenino una prevalencia de 3:1. Resultados: El estudio resultó positivo para litiasis coledociana en 427 casos, siendo 7 de ellas de localización intrahepática. El 86,85 por ciento de los casos fue resuelto por vía endoscópica. En 93 oportunidades la solución del problema se logró por litroticia extracorpórea (LEC) o mediante métodos combinados de LEC, ursoterapia, métodos endoscópicos y percutáneos. Conclusión: Dada la alta eficacia de la endoscopia, dejamos reservados estos últimos para casos particulares antes de enfrentar una nueva cirugía

Colangiopancreatografía retrógrada endoscópica (CPRE) terapéutica: Experiencia de cinco años en el Hospital Central Militar / Endoscopy retrograde cholangiopancreatography therapeutic use: A five years experience in the Hospital Central Militar

Se presenta la experiencia de cinco años en la realización de colangiopancreatografía Retrógrada Endoscópica (CPRE) de tipo terapéutico en el Servicio de Endoscopia del Hospital Central Militar. De mayo de 1992 a mayo de 1997, se llevaron a cabo 725 CPRE, de las cuales 285 (39 por ciento) se complementaron con algún procedimiento terapéutico endoscópico. De estos pacientes, 216 fueron del sexo femenino y 69 del sexo masculino (relación 3:1). El promedio de edad fue de 61 años con un rango de 16 a 95 años. De los 285 casos, se logró realizar el procedimiento planeado en 269 (94 por ciento). En todos se realizó CPRE diagnóstica y esfinterotomía. Se realizó CPRE diagnóstica y esfinterotomía. Se empleó técnica de precorte en 47 casos (16.5 por ciento). La mayor parte de los casos se realizaron bajo sedación con diazepam, empleando además butilhioscina y lidocaína local en faringe; en ocho casos se empleó anestesia endovenosa y dos pacientes se intubaron. En 184 el diagnóstico fue colédocolitiasis. En 168 (91 por ciento) se extrajeron todos los litos: 160 en una sola sesión, cinco casos en dos sesiones y tres pacientes requirieron más de tres sesiones. Dos casos se realizaron en mujeres embarazadas. En 16 pacientes no se pudieron extraer todos los litos y fueron enviados a cirugía. Se realizaron 52 esfinterotomías por diagnóstico de disfunción del esfínter de Oddi. Se colocaron 11 endoprótesis plásticas para drenaje de la vía biliar por obstrucción maligna y dos para manejo de escape de bilis postcolecistectomía laparoscópica, se colocaron dos prótesis en el conducto pancreático. Se presentaron las siguientes complicaciones: sangrado 21 casos (7 por ciento), perforación dos casos (0.7 por ciento), hiperamilasemia 101 casos (35.4 por ciento), pancreatitis seis casos (2 por ciento). Hubo dos defunciones asociadas al procedimiento (0.7 por ciento)

Análisis de endoscopías en las vías biliares efectuadas en el Hospital Santo Tomás / An analysis of the endoscopies of the biliary tract performed at the Hospital Santo Tomás

Endoscopic Retrograde Cholangiopancreatography (ERCP) was performed in 146 patients, 93 female and 53 male from 10 to 90 years of age. The patients were referred because it was deemed that it was necessary to perform the procedure to establish or confirm the clinical diagnosis (suspected choledocholithiasis, icterus or abdominal pain of undetermined etiology, pancreatitis or obstruction of prosthesis) and to perform cholangiography and pancreatography, papillotomy, extraction of calculi and placement of biliary prosthesis, as indicated. It was shown that the clinical picture was due to choledocholithiasis in the majority of patients. Stenosis due to inflammatory changes or to tumor were much less frequent. In few patients, there was biliary external fistula, distortion of intrahepatic ducts, cancer of the pancreas or sclerosing cholangitis. Chronic pancreatitis, choledochal granuloma or adenoma, or displacement of a T tube were found occasionally. There were few complications (cholangitis, pancreatitis and hyperamylasemia) and no mortality associated with the procedure

El intervencionismo precoz no operatorio en la pancreatitis biliar: nuevo enfoque fundamentado en un clasico planteamiento suramericano / Early non surgical interventionism in biliary pancreatitis: new approach based on a classic south american statement

Human acute pancreatitis associated with gallstones is due to obstruction of the ampulla of Vater caused by migrating gallstones. The degree and duration of the obstruction determine the severity of the inflamatory reaction of the ampulla and the severity of the pancreatic damage. Even though its is recognized that impacted or migrating stones arte the cause of acute pancreatitis, and that therefore the inmediate removal of stones and the opening of the ampullary obstruction is the logical approach, it is commonly favores initial nonoperative therapy and the operation is only undertaken when the acute pancreatitis has subsided. As an innovative approach endoscopic sphincterotomy apears as an alternative for the early removal of stones from the bile duct and the opening and relief of the pathologically altered ampullary region. Perhaps this approach of early endoscopic interventionism, if supported by prospective studies, represents a breakthrough. Will surgical procedures for gallstone associated pancreatitis become a thing of the past?

Radiologia intervencionista en la colangitis esclerosante / Interventionist radiology in sclerosing cholangitis

Se describen e ilustran procedimientos de cateterismo percutaneo de la via biliar para el tratamiento no operatorio de dos pacientes con estenosis de los canales biliares extrahepaticos por colangitis esclerosante