Performance of biliary stents in malignant biliary strictures.

INTRODUCTION: Endoscopic stenting is a commonly applied method of treatment in patients with malignant biliary strictures. It involves the use of self­expandable metal stents (SEMSs) or plastic stents (PSs). OBJECTIVES: The aim of the study was to compare the effectiveness of SEMSs and PSs in the endoscopic drainage of malignant strictures of the biliary tree and its sequels for future optimalization of this treatment method. PATIENTS AND METHODS: Data on 618 consecutive patients with malignant biliary stricture, in whom 1271endoscopic retrograde cholangiopancreatography procedures with biliary stenting have been performed in the years 2012-2017 with at least 3­year follow­up,  were retrospectively derived from a hospital database. RESULTS: The main indications for stenting were pancreatic cancer (37%) and cholangiocarcinoma (34%). The use of SEMSs resulted in a greater decline of serum bilirubin as compared with PSs (37% vs 32% of baseline concentration; P = 0.01). Consequently, hospital stay was shorter by more than 2 days (mean [SD], 9.5 [5.6] vs 11.8 [7.9] days; P <0.001). The median (interquartile range) patency time of SEMSs was more than 2 times longer than for PSs (118 [56-232] days vs 46 [18-97] days; P <0.001), and procedure­related complications were less frequent (19.3% vs 12.9%, respectively in the SEMS and PS group; P = 0.001). SEMSs proved also to be more cost­effective; the hospital profit was 1375 USD for a single hospitalization with SEMS insertion. CONCLUSIONS: In patients with malignant strictures of the biliary tree SEMSs outperform PSs. SEMSs should be used as a treatment of choice for biliary drainage in that group of patients.

Diagnostic and therapeutic management in gastroesophageal reflux disease: consensus of the Polish Society of Gastroenterology.

The paper was prepared by an expert group appointed by the Polish Society of Gastroenterology with an aim to update and systematize the knowledge about diagnosis and treatment of gastroesophageal reflux disease (GERD). Based on the previously published guidelines of international societies, expert consensuses, and recently published good quality data, we formulated 74 statements regarding the definition, diagnosis and treatment of GERD and assessed the level of acceptance of these statements and the reliability of the data. We discussed in details the possibilities and limitations of the available diagnostic methods and therapies, with particular emphasis on the diversity of gastroesophageal reflux symptoms and complications including Barrett's esophagus. Practical principles regarding interpretation of the diagnostic tests are presented. In addition, we discussed the indications for surgical treatment as well as the situations in which surgical treatment is not indicated with emphasis on the importance of preoperative diagnostics. The role of add-on therapy and indications for maintenance treatment are defined.

Scoring system assessing mucosal visibility of upper gastrointestinal tract: The POLPREP scale.

BACKGROUND AND AIM: The proper visibility of mucosa during esophagogastroduodenoscopy (EGD) is crucial for the detection of early upper gastrointestinal tract lesions. In contrast to colonoscopy, no validated scoring system for the assessment of upper gastrointestinal mucosal cleanliness has been developed so far. The aim of the study was to create and validate standardized grading system (POLPREP) to assess the mucosal cleanliness during EGD. METHODS: To assess the visibility of mucosa during EGD, 4-point scale was developed (0-3). Twelve operators assessed 18 images of esophagus, stomach, and duodenum twice (in 2 weeks interval). In validation round, the images and endoscopy reports of 443 EGDs performed in six centers were assessed. RESULTS: The inter-observer accordance of POLPREP was 0.8 (intra-class correlation coefficient; 0.79 consultants, 0.85 trainees). The intra-observer repeatability was 0.64 (Fleiss kappa value; 0.64 consultants, 0.64 trainees). The lesions detection rate was significantly higher in clean (scores 2 and 3; 19.7%) than in "unclean" segments (score 1; 7.7%, P = 0.049). Score 3 was associated with over three-fold higher lesion detection than score 1 (odds ratio 3.2, 95% confidence interval 1.1-9; P = 0.03). CONCLUSIONS: The proposed POLPREP scale allows for unified assessment of upper gastrointestinal tract mucosal cleanliness. The higher cleanliness scores are related with greater upper gastrointestinal pathologies detection.

Performance of plastic stents used for benign and malignant biliary strictures: experience of a single high­volume endoscopy unit.

INTRODUCTION: Endoscopic plastic biliary stenting has been used for more than 30 years as a temporary or definitive treatment of benign and malignant neoplasms. These stents are commonly available, inexpensive, and easy to implant. OBJECTIVES: We aimed to evaluate the duration of plastic stent patency, to assess complications associated with stent use, and to determine the optimal timing of stent replacement depending on the indication for biliary stenting. PATIENTS AND METHODS: This was a retrospective cohort study with a 5­year follow­up including patients who underwent plastic biliary stent implantation between 2012 and 2013 in a tertiary referral gastroenterological center. The performance of stents was assessed on the basis of medical records, direct contact with patients or their family members, and information derived from the national death registry. RESULTS: We assessed 830 biliary stenting procedures performed in 346 patients. The indications for biliary stenting included choledocholithiasis in 120 patients (34.7%), benign stricture in 70 patients (20.2%), and malignant stricture in 156 patients (45.1%). The mean duration of stent patency for these conditions was 110, 106, and 55 days, respectively (P <0.001). Stents implanted for malignant perihilar strictures had a shorter duration of patency than those used for distal strictures (40 days vs 76 days, P = 0.002). CONCLUSIONS: The patency of plastic stents depends on the underlying disease. In patients with benign biliary disease, stent replacement is recommended after about 3.5 months. In patients with cancer, the timing of stent replacement should be guided by survival prognosis and location of stricture.

Composite detection rate as an upper gastrointestinal endoscopy quality measure correlating with detection of neoplasia.

BACKGROUND: Esophagogastroduodenoscopy (EGD) is commonly used diagnostic method with no widely accepted quality measure. We assessed quality indicator-composite detection rate (CDR)-consisting of detection of at least one of the following: cervical inlet patch, gastric polyp and post-ulcer duodenal bulb deformation. The aim of the study was to validate CDR according to detection rate of upper gastrointestinal neoplasms (UGN). METHODS: It was a multicenter, prospective, observational study conducted from January 2019 to October 2019. The endoscopic reports from 2896 symptomatic patients who underwent diagnostic EGD were analyzed. The EGDs were performed in three endoscopy units located in tertiary university hospital, private outpatient clinic and local hospital. RESULTS: 64 UGNs were detected. The mean CDR was 21.9%. The CDR correlated with UGN detection rate (R = 0.49, p = 0.045). Based on CDR quartiles, operators were divided into group 1 with CDR < 10%, group 2 with CDR 10-17%, group 3 with CDR 17.1-26%, and group 4 with CDR > 26%. Detection rate of UGN was significantly higher in the group 4 in comparison to group 1 (OR 4.4; 95% CI 2.2 - 9.0). In the multivariate regression model, patient age, male gender and operator's CDR > 26% were independent risk factors of UGN detection (OR 1.03; 95% CI 1.01 - 1.05, OR 2; 95% CI 1.2 - 3.5, and OR 5.7 95% CI 1.5 - 22.3, respectively). CONCLUSIONS: The CDR is associated with the detection of upper gastrointestinal neoplasms. This parameter may be a useful quality measure of EGD to be applied in general setting.

Diagnostic and therapeutic recommendations in pancreatic ductal adenocarcinoma. Recommendations of the Working Group of the Polish Pancreatic Club.

These recommendations refer to the current management in pancreatic ductal adenocarcinoma (PDAC), a neoplasia characterised by an aggressive course and extremely poor prognosis. The recommendations regard diagnosis, surgical, adjuvant and palliative treatment, with consideration given to endoscopic and surgical methods. A vast majority of the statements are based on data obtained in clinical studies and experts' recommendations on PDAC management, including the following guidelines: International Association of Pancreatology/European Pancreatic Club (IAP/EPC), American Society of Clinical Oncology (ASCO), European Society for Medical Oncology (ESMO), National Comprehensive Cancer Network (NCCN) and Polish Society of Gastroenterology (PSG) and The National Institute for Health and Care Excellence (NICE). All recommendations were voted on by members of the Working Group of the Polish Pancreatic Club. Results of the voting and brief comments are provided with each recommendation.

Mucosal miR-3677 is over-expressed in cirrhotic patients with gastric antral vascular ectasia (GAVE).

INTRODUCTION: Gastric antral vascular ectasia (GAVE) is a rare vasculopathy that associates several diseases, most commonly liver cirrhosis. It usually presents as an occult gastrointestinal bleeding leading to profound iron deficiency anemia. We hypothesized that GAVE is local mucosal pathology dependent on genetic mechanisms, and the purpose of the study was to characterize miRNAs expression in gastric tissue of patients with cirrhosis and GAVE. MATERIALS AND METHODS: Thirteen patients with GAVE and cirrhosis and 35 healthy subjects were recruited. Microarray analysis and comparative microRNA study was done by quantitative polymerase chain reaction (qPCR). The microarray scores were grouped with use of the hierarchical clusterization analysis and miRNA target prediction was done with TargetScan 6.2 algorithm and Gene Ontology analysis (DIANA-miRPath). RESULTS: Concentration of miR-3677 in GAVE-affected mucosa was higher by 72% in comparison with GAVE-free mucosa of patients with cirrhosis (33.7 vs. 35.6 PCR cycles; p < .001) and by 45% in comparison with normal mucosa (33.7 vs. 34.9 PCR cycles; p < .05). According to Gene Ontology analysis miR-3677 was related to angiopoietin-like protein 4 (ANGPTL4) gene. CONCLUSION: GAVE in liver cirrhosis is associated with increased expression of miR-3667 that may be linked with ANGPTL4 gene.

Comparison of patency and cost-effectiveness of self-expandable metal and plastic stents used for malignant biliary strictures: a Polish single-center study.

INTRODUCTION: Most patients with malignant biliary obstruction are suited only for palliation by endoscopic drainage with plastic stents (PS) or self-expandable metal stents (SEMS). OBJECTIVE: To compare the clinical outcome and costs of biliary stenting with SEMS and PS in patients with malignant biliary strictures. PATIENTS AND METHODS: A total of 114 patients with malignant jaundice who underwent 376 endoscopic retrograde biliary drainage (ERBD) were studied. RESULTS: ERBD with the placement of PS was performed in 80 patients, with one-step SEMS in 20 patients and two-step SEMS in 14 patients. Significantly fewer ERBD interventions were performed in patients with one-step SEMS than PS or the two-step SEMS technique (2.0±1.12 vs. 3.1±1.7 or 5.7±2.1, respectively, P<0.0001). The median hospitalization duration per procedure was similar for the three groups of patients. The patients' survival time was the longest in the two-step SEMS group in comparison with the one-step SEMS and PS groups (596±270 vs. 276±141 or 208±219 days, P<0.001). Overall median time to recurrent biliary obstruction was 89.3±159 days for PS and 120.6±101 days for SEMS (P=0.01). The total cost of hospitalization with ERBD was higher for two-step SEMS than for one-step SEMS or PS (1448±312, 1152±135 and 977±156&OV0556;, P<0.0001). However, the estimated annual cost of medical care for one-step SEMS was higher than that for the two-step SEMS or PS groups (4618, 4079, and 3995&OV0556;, respectively). CONCLUSION: Biliary decompression by SEMS is associated with longer patency and reduced number of auxiliary procedures; however, repeated PS insertions still remain the most cost-effective strategy.

Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - updated June 2014.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the prophylaxis of post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis. Main recommendations 1 ESGE recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP in all patients without contraindication. In addition to this, in the case of high risk for post-ERCP pancreatitis (PEP), the placement of a 5-Fr prophylactic pancreatic stent should be strongly considered. Sublingually administered glyceryl trinitrate or 250 µg somatostatin given in bolus injection might be considered as an option in high risk cases if nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated and if prophylactic pancreatic stenting is not possible or successful. 2 ESGE recommends keeping the number of cannulation attempts as low as possible. 3 ESGE suggests restricting the use of a pancreatic guidewire as a backup technique for biliary cannulation to cases with repeated inadvertent cannulation of the pancreatic duct; if this method is used, deep biliary cannulation should be attempted using a guidewire rather than the contrast-assisted method and a prophylactic pancreatic stent should be placed. 4 ESGE suggests that needle-knife fistulotomy should be the preferred precut technique in patients with a bile duct dilated down to the papilla. Conventional precut and transpancreatic sphincterotomy present similar success and complication rates; if conventional precut is selected and pancreatic cannulation is easily obtained, ESGE suggests attempting to place a small-diameter (3-Fr or 5-Fr) pancreatic stent to guide the cut and leaving the pancreatic stent in place at the end of ERCP for a minimum of 12 - 24 hours. 4 ESGE does not recommend endoscopic papillary balloon dilation as an alternative to sphincterotomy in routine ERCP, but it may be advantageous in selected patients; if this technique is used, the duration of dilation should be longer than 1 minute.

Therapeutic and prophylactic management of bleeding from oesophageal and gastric varices - recommendations of the Working Group of the National Consultant for Gastroenterology.

Gastroesophageal varices are one of the most serious consequences of portal hypertension. One-third of patients with varices will develop variceal haemorrhage. Despite significant improvements in the outcomes of treatment, mortality due to bleeding from gastro-oesophageal varices still remains very high. These recommendations present optimal management of patients with non-bleeding and bleeding varices.

Imported cases of dengue in Poland and their diagnosis.

Infections with dengue virus are transmitted by mosquitoes. In tropical areas, it is mainly spread by Aedes aegypti while in countries with lower temperatures by Aedes albopictus. Since 2010, autochthonous cases of dengue are also reported in Europe. There are 4 serotypes of dengue virus (DENV). No correlation between clinical presentation of disease and virus type, however, were determined. Nevertheless, reinfection with different type of DENV may lead to a serious, life-threatening condition. An estimated 100 million persons are infected with dengue virus per year. Of them, approximately a half (mainly children) develop the symptoms of dengue fever (DF), dengue haemorrhagic fever (DHF) or dengue shock syndrome (DSS). Fatality is high in case of severe dengue. Dengue is a serious condition provided there is a presence of IgG antibodies directed against antigens of particular DENV serotypes, associated with primary infection caused by different serotype or transferred from infected mother to her child. For adequate dengue laboratory diagnosis, it is required to apply a set of various diagnostic methods. Within the family Flaviviridae, cross-reactivity is reported, which may lead to the occurrence of false-positive results. In Poland, differential diagnosis with different Flavivirus species is of special importance as it is an endemic area for tick-borne encephalitis (TBE). Thus, data regarding history of patient's immunization against TBE or yellow fever should be also taken into consideration as important in interpretation of results of serological examination.

The frequency of human papillomavirus infection in polish patients with vulvar squamous cell carcinoma.

INTRODUCTION: Vulvar cancer is a rare condition representing about 4% of all female genital tract tumors. In contrast to the established relationship of virtually all cervical cancer cases with the human papillomavirus (HPV) infection, the reported HPV positivity in vulvar carcinoma ranges widely. METHODS: Using the Linear Array HPV Genotyping Test, we investigated the HPV incidence in a group of 46 Polish patients with vulvar squamous cell carcinoma (age range, 37-93 years; median age, 70.2 years) in clinical stages T1-2, N0-2, and M0. RESULTS: The presence of HPV DNA was confirmed in 7 of 46 (15%) primary tumor samples. HPV 16 was found in 5 tumors (71%). HPVs 6 and 58 were detected in the remaining 2 cases of virus-associated tumors. CONCLUSIONS: We conclude that a fraction of cancers of vulva associated with HPV is insignificant, given the HPV prevalence of 8.6% in the Polish population aged 55 to 59 years (the oldest cohort of Polish women studied to date).

Composite neuroendocrine and adenomatous carcinoma of the papilla of Vater.

Malignant tumors of papilla are usually adenocarcinomas. We present a 67-year-old female who became icteric as result of a malignant tumor infiltrating the papilla of Vater. Histopathological assessment of surgically excised tumor showed both neuroendocrine and adenocarcinomatous features. To our knowledge, this is the seventh report of this rare neoplastic association in the duodenal periampullary region.

The dynamics of the oxidant-antioxidant balance in the early phase of human acute biliary pancreatitis.

BACKGROUND/AIM: Reactive oxygen species play an important role in the pathogenesis of acute pancreatitis (AP) in animal models. Data on the oxidant-antioxidant balance in humans are scanty. The present study was undertaken to evaluate the dynamics of changes in the oxidant-antioxidant balance in the early phase of human AP. METHODS: 74 consecutive patients with acute biliary pancreatitis (16 with severe, 58 with mild pancreatitis), treated endoscopically, were included in the study. Serum concentrations of sulfhydryl groups (SH; main nonenzymatic antioxidant; 73 patients) and thiobarbituric acid reactive substances (TBARS; markers of reactive oxygen species-mediated tissue damage; 56 patients) were determined on admission and on each of 10 successive days. The analysis comprised the comparison of results in patients with mild and severe outcome of pancreatitis. RESULTS: Serum SH dropped by 27%, reaching the trough level on day 4 of hospitalization, whereas serum TBARS rose by 28%, reaching a peak 1 day later. Neither SH nor TBARS returned to initial values at the end of observation. The most dynamic changes in both SH and TBARS concentrations occurred in the first 3 days of hospitalization. The changes were significantly greater in patients with complicated pancreatitis in comparison to patients with mild disease, and were most pronounced in patients who developed infected pancreatic necrosis and who subsequently died. CONCLUSIONS: The oxidant-antioxidant balance changes rapidly in the early phase of human AP, confirming the role of oxidative stress in the pathogenesis of AP. The degree of changes correlates with the clinical severity of pancreatitis.

[Evaluation of probability of bile duct stone presence by using of non-invasive procedures]. / Ocena prawdopodobienstwa wystepowania kamicy zólciowej przewodowej oparta na badaniach nieinwazyjnych.

Precise evaluation of bile duct stones presence in particular moment, performed using the most non-invasive method, is important for the planning of optimal treatment. Not only simple imaging procedures (like conventional transabdominal ultrasound--US) but also more sophisticated imaging methods (CT or MRI) are frequently useless. The "gold standards" of bile duct stones diagnosis are still endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy and surgical choledochotomy. However, the ERCP expose the patients to the risk of some serious complications. The aim of the study was to evaluate the diagnostic capabilities of patients case history data and non-invasive tests (such as biochemistry, ultrasound data) in order to establish a risk scale in cases suspected for common bile duct stones. The investigated group comprised of 135 patients treated from January 1996 through March 1997 in the Department of Gastroenterology Silesian Medical Academy. In patients prospectively enrolled to the study case history and a set of blood biochemical examinations were completed. In following, US was performed. The verification of the biliary tree (done with ERCP with endoscopic sphincterotomy or surgical choledochotomy) was performed. Examiners (US, ERCP) were blind to the other results of a patient. Case history data, laboratory blood tests and US results were used to select parameters significantly differing between patients with and without bile duct stones. Thirteen parameters were tested using Mann-Whitney's and chi 2 tests and four parameters were finally selected. For every selected parameter cut off values (i.e. values best differentiating patients with and without stones) were chosen on the basis of the chi 2 value, 95% confidence interval of risk ratio and Youden's index (gamma-GTP, alanine transaminase, enlarged bile ducts on US, bile duct stones on US). In the next step a set of different combinations of selected parameters was tested to find out the best waged scale for bile duct stones risk diagnosis. Finally, diagnostic efficacy of the best constructed scales and US alone were compared. Constructed risk scales can not be employed in the primary selection of patients, as their positive predictive value is quite high, but negative predictive value is low. US is also not valuable in evaluation of patients suspected for common bile duct stones.

[Digestive tract hemorrhage and recurrent ileus. Peutz-Jeghers syndrome-case report]. / Krwawienie z przewodu pokarmowego i nawrotowa niedroznosc--opis przypadku zespolu Peutz-Jeghersa.

Authors describe a case of 24 years old woman with recurrent lower GI bleeding and mechanical obstruction. Crohn's disease was diagnosed at the beginning. It was impossible to treat the patient's profound anemia with blood transfusions due to her religion believes. The diagnosis of Peutz-Jeghers syndrome was made postoperatively. During operation mechanical obstruction (invagination of terminal ileum into ascending colon) was released. The invagination was caused by 3 cm large polyp localized in terminal ileum. Subsequently, 8 polyps (varying in size between 0.5 and 3 cm) in the small intestine were localized using intraoperative upper GI endoscopy and enteroscopy and finally surgically removed. Typical hamartomas were found on histopathological examination of removed polyps. Authors present modern attitude to Peutz-Jeghers syndrome--its diagnostics, treatment and follow-up.

Multivariate analysis of risk factors for development of duodenal ulcer in Helicobacter pylori-infected patients.

BACKGROUND: Although Helicobacter pylori is a significant etiologic factor of peptic ulcer disease, it remains unknown why ulcers develop only in the minority of infected individuals. AIM: The aim of this cross-sectional study was to evaluate the association between the presence of duodenal ulcer in H. pylori-infected patients and different risk factors. METHODS: A total of 122 H. pylori-infected patients were enrolled; 79 had duodenal ulcer and 43 gastritis. Univariate analysis was conducted using either Fisher's exact test or exact Cochrane-Armitage trend test. In multivariate analysis the logistic model was used. RESULTS: Univariate analysis indicated six factors (male sex, smoking, antral H. pylori density, CAGA presence in antrum, and VACA s1a presence in antrum and corpus). Four factors (sex, smoking-alcohol index, H. pylori density index, and CAGA index) were found to be significant in multivariate analysis. The best model predicting duodenal ulcer included male sex, smoking, presence of H. PYLORI on histopathology in antrum and CAGA presence in corpus. CONCLUSION: Although several risk factors were significantly associated with duodenal ulcer, we failed in the identification of either a single risk factor or a set of factors that can unequivocally differentiate patients with ulcer from those with gastritis.

Endosonography with linear array instead of endoscopic retrograde cholangiography as the diagnostic tool in patients with moderate suspicion of common bile duct stones.

AIM: To evaluate the diagnostic efficiency of endoscopic ultrasound (EUS) as the main imaging modality in patients with moderate suspicion of common bile duct stones (CBDS). METHODS: 55 patients with moderate clinical suspicion of CBDS were prospectively included to the study and evaluated with EUS. This study was done in single blind method in the clinical and biochemical data of patients. EUS was done with echo-endoscope Pentax FG 32-UA (f=5-7.5 MHz) and Hitachi EUB 405 ultrasound machine. Patients diagnosed with CBDS by EUS were excluded from this study and treated with ERC. All the other patients were included to the follow up study obtained by mail every 6 months for clinical evaluation (need of ERC or surgery). RESULTS: CBDS was found in 4 patients by EUS. Diagnosis was confirmed in all cases on ERC. The remaining 51 patients without CBDS on EUS were followed up for 6-26 months (meanly 13 months) There were: 40 women, 42 cholecystectomized patients, aged: 55 (mean). Biochemical values (mean values) were as follows: bilirubin: 14.9 micromol/L, alkaline phosphatase: 95 IU/L(-1), gamma-GTP: 131 IU/L(-1), ALT: 50 IU/L(-1), AST: 49 IU/L(-1)(-1). Only 1 patient was lost for follow up. In the remaining 50 patients with follow up, there was only 1 (2 %) patient with persistent biliary symptoms in whom CBDS was finally diagnosed by ERC with ES. All other patients remained symptoms free on follow up and did not require ERC or biliary surgery. CONCLUSION: Vast majority of patients with moderate suspicion of CBDS and no stones on EUS with linear array can avoid invasive evaluation of biliary tree with ERC.

Presence and density of common bile duct microlithiasis in acute biliary pancreatitis.

AIM: Common bile duct microlithiasis (CBDM) is found in majority of patients with acute biliary pancreatitis (ABP) and no CBD stones in fluoroscopy during urgent ERCP. It is unclear, however, weather CBDM is a cause or the result of the disease. This prospective study was done to investigate the presence and density of CBDM in patients with ABP, when endoscopic retrograde cholangiopancreatography (ERCP) was done in different periods from the onset of the disease. METHODS: One hundred fifty one consecutive patients with ABP and no CBDS on ERCP, performed as an urgent (< 24h of admission) procedure, (101 - with gallbladder stones, 50 post-cholecystectomy patients), treated during last 4 years were prospectively included to the study. The presence and density of CBDM (cholesterol monohydrate crystals-CMCs and calcium bilirubinate granules-CBGs) in bile collected directly from common bile duct during ERCP was prospectively calculated according to Juniper and Burson criteria. High density of crystals was considered,when we found >10CMCs and/or >25 clusters of CBGs on 1 slide. RESULTS: CBD microlithiasis was present in given number of patients: on d1-30/34 (88.2%), on d2 41/49 (83.7%), on d3-23/33 (69.6%), on d4-7-24/35 (68.6%) ( P for trend=0.018). In patients with CBD microlithiasis the high density of crystals was observed in given number of patients:on d1-27/30 (90%), on d2-34/41 (82.9%), on d3-18/23 (78.3%), on d4-7-16/24 (66.7%)( P for trend=0.039). CONCLUSION: In patients with ABP and no CBDS on ERCP, CBD microlithiasis is observed in the majority of patients, especially during the first day of the disease. Density of CBD microlithiasis is the highest in the first day of the disease. This suggests that CBD microlithiasis can be the cause and not the result of ABP.