The impact of post-procedure interpretation of ERCP X-ray films by radiologists on patient care: should it be routine or selective?

BACKGROUND: Review of ERCP x-ray films by radiologists is routine, but the utility of this practice is unproven. The aim of this study was to assess whether the routine post-procedural interpretation of ERCP films by radiologists alters patient management. METHODS: A retrospective analysis of 212 ERCPs followed by a prospective analysis of 112 ERCPs was performed. Comparative ductogram interpretations were categorized as: I, complete agreement; II, minor findings reported only by the radiologist; III, findings reported only by the endoscopist; and IV, major findings reported only by the radiologist that altered or should have altered management. RESULTS: In the retrospective analysis, 289 ductograms were identified, and interpretations were classified as: category I, 73%; category II, 16%; category III, 10.7%; and category IV, 0.3%. In the prospective study, interpretations of 167 ductograms were analyzed and classified as follows: category I, 84%; category II, 11%; category III, 5%; category IV, none. CONCLUSIONS: Post-procedure interpretation of ERCP spot x-ray films by radiologists adds little to patient management. Selective consultation with radiologists would appear to be more appropriate than review by radiologists of ERCP spot x-ray films on a routine basis.

Ampullary carcinoid tumors: rationale for an aggressive surgical approach.

Two cases of ampullary carcinoid tumor are reported. These tumors are among the most rare of GI tract carcinoids and appear to have a distinct presentation and biological behavior from carcinoids arising in the duodenum. The existing literature is reviewed with attention to the implications for surgical management of this rare disease.

Prevalence and predictors of severity as defined by atlanta criteria among patients presenting with acute pancreatitis.

INTRODUCTION: Effective triage of patients with acute pancreatitis is dependent on the ability to accurately predict a severe course. Predictors (e.g., APACHE II score of >8) have been tested against wide-ranging definitions of severity (prevalence, 15%-40%). To ensure uniformity in defining a severe course of acute pancreatitis, the Atlanta symposium of 1992 adopted all-encompassing criteria (local complications, systemic complications, need for surgery, or death). AIMS: To assess the prevalence of each Atlanta criteria for severe acute pancreatitis and to determine the sensitivity, specificity, and positive and negative predictive values of the APACHE II score as a predictor of these criteria for severe acute pancreatitis. METHODOLOGY: We reviewed records of patients admitted to the University of Cincinnati Medical Center (Cincinnati, OH, U.S.A.) between 1994 and 1998 with acute pancreatitis. Exclusion criteria included referral from an outside hospital, immunocompromised state, and chronic pancreatitis. RESULTS: Seventy-four consecutive patients met our inclusion criteria. Ten patients (13.5%) had a severe course. Seven patients developed only local complications. Three patients had systemic complications. Pancreatic surgical intervention was required in four patients. No deaths occurred. An APACHE II score of >8 exhibited 50% sensitivity and 69% specificity (positive predictive value, 20%; negative predictive value, 89%). All patients with systemic complications and two of seven patients with only local complications had an APACHE II score of >8. CONCLUSIONS: The prevalence of severity among our nonreferred patients with acute pancreatitis was less than previously reported. The APACHE II scoring system exhibited reasonable sensitivity in predicting systemic complications and/or the need for surgery, with a low positive predictive value. This most certainly is a function of the low pretest probability of severe pancreatitis. Future studies attempting to identify predictive systems that triage patients in a more cost-effective manner should restrict their analysis to Atlanta criteria other than local complications.

Recurrent Acute Pancreatitis.

Patients with recurrent acute pancreatitis should be treated with the same supportive and symptom-oriented measures as those with acute pancreatitis. The need for specific treatment depends on the cause of the pancreatitis. Patients should discontinue alcohol use, putative causative medications, and exposure to toxins or helminths in endemic areas. Metabolic abnormalities need to be corrected, and appropriate treatment should be initiated for associated infections, autoimmune diseases, vasculitis, and hypercoagulable states. For patients with gallstone pancreatitis, endoscopic retrograde cholangiopancreatography is indicated if biliary obstruction persists or if cholangitis is present. Elective cholecystectomy may be performed in appropriate patients; otherwise, consider biliary sphincterotomy and ursodeoxycholic acid for prevention of recurrent attacks. Transpapillary stenting or sphincterotomy of the minor papilla benefits some patients with pancreas divisum and no other explanation for recurrent pancreatitis. Surgical sphincteroplasty is reserved for those failing endoscopic treatment. Biliary sphincterotomy benefits more than 50% of patients with sphincter of Oddi dysfunction and recurrent acute pancreatitis. Some authors advocate pancreatic sphincter manometry and sphincterotomy for persistent pancreatic segment hypertension in patients who have recurrent pancreatitis after biliary sphincterotomy. In patients with pancreatic duct strictures, transpapillary stent placement serves as a short-term measure; most patients ultimately require surgery.