Is ESR Important for Predicting Post-ERCP Pancreatitis?

BACKGROUND: Pancreatitis remains the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), resulting in substantial morbidity and occasional mortality. There are notable controversies and conflicting reports about risk factors of post-ERCP pancreatitis (PEP). AIM: To evaluate the potential risk factors for PEP at a referral tertiary center, as a sample of the Iranian population. MATERIALS AND METHODS: Baseline characteristics and clinical as well as paraclinical information of 780 patients undergoing diagnostic and therapeutic ERCP at Taleghani hospital in Tehran between 2008 and 2012 were reviewed. Data were collected prior to the ERCP, at the time of the procedure, and 24-72 hours after discharge. PEP was diagnosed according to consensus criteria. RESULTS: Of the 780 patients who underwent diagnostic ERCP, pancreatitis developed in 26 patients (3.3%). In the multivariable risk model, significant risk factors with adjusted odds ratios (ORs) were age <65 years (OR = 10.647, P = 0.023) and erythrocyte sedimentation rate (ESR) >30 (OR = 6.414, P < 0.001). Female gender, history of recurrent pancreatitis, pre-ERCP hyperamylasemia, and difficult or failed cannulation could not predict PEP. There was no significant difference in the rate of PEP in wire-guided cannulation versus biliary cannulation using a sphincterotome and contrast injection as the conventional method. CONCLUSIONS: Performing ERCP may be safer in the elderly. Patients with high ESR may be at greater risk of PEP, which warrants close observation of these patients for signs of pancreatitis after ERCP.

Relationship between continuous use of low-dose enteric-coated aspirin and gastrointestinal injuries in patients with gastrointestinal hemorrhage.

BACKGROUND/AIMS: Gastrointestinal disorders are important side effects of aspirin therapy, even if the low-dose enteric-coated form is administered. The aim of the current study was to present the upper and lower endoscopic features of patients with gastrointestinal hemorrhage using low-dose enteric-coated aspirin. MATERIALS AND METHODS: This prospective study was conducted among 633 consecutive patients with gastrointestinal hemorrhage who admitted to our tertiary referral hospital for endoscopy assessment. Patients were divided into two groups as low-dose aspirin users (n=168) and non-aspirin users (n=495). Aspirin users included those who were taking 80-100 mg of enteric-coated aspirin per day. RESULTS: Ulcer lesions were found in 78 patients in the aspirin user group and in 113 patients in the control group. Prevalence of duodenal ulcer was statistically similar between the two groups; however, gastric ulcer was seen more in the aspirin-user group. The use of low-dose aspirin could strongly predict gastric ulcers in the patients examined by endoscopy (p<0.001). Overall prevalence of peptic ulcer disease in those with confirmed Helicobacter pylori infection was significantly higher than in non-infected ones (p<0.001). The presence of this infection was strongly associated with peptic ulcer disease in the aspirin-user group (p<0.001). Multivariable analysis also demonstrated that the use of aspirin had a main triggering effect on short-term mortality following gastrointestinal endoscopy (p=0.003). CONCLUSIONS: Low-dose enteric-coated aspirin causes significant gastric endoscopic lesions and even predicts mortality due to progression of gastrointestinal disorders.

ERCP features and outcome in patients with periampullary duodenal diverticulum.

Background. Although periampullary diverticulum is usually asymptomatic and discovered incidentally in patients during endoscopic retrograde cholangiopancreatography (ERCP), it may lead to post-ERCP morbidity. We compared baseline characteristics and clinical data as well as ERCP results in patients with and without periampullary diverticulum. Methods. Clinical, laboratory, and ERCP data of 780 patients referred to the Taleghani Hospital, as a great referral endoscopy center, in Iran were prospectively analyzed. Results. The periampullary diverticulum was identified in 44 patients (5.6%). Cannulation of common bile duct was more failed in patients with diverticulum compared to others (35.5% versus 11.5, P < 0.001). Patients with diverticulum had eight times more often common bile duct stone compared to patients without diverticulum (54.5% versus 12.2%, P < 0.001). Post-ERCP complications were observed in 2.3% and 4.2% of patients with and without diverticulum, respectively, which did not significantly differ in both groups. Conclusion. Because of more failure cannulation in the presence of periampullary diverticulum, ERCP requires more skills in these patients. Prevalence of common bile duct stone was notably higher in patients with diverticulum; therefore, more assessment of bile stone and its complications in these patients is persistently recommended.

Preventive role of wire-guided cannulation to reduce hyperamylasemia and pancreatitis following endoscopic retrograde cholangiopancreatography.

Background and Study Aims. The usefulness of wire-guided cannulation for avoiding hyperamylasemia and pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) is conflicting, and therefore we designed this study to determine whether wire-guided cannulation reduces the rate of post-ERCP hyperamylasemia and pancreatitis and compare its efficacy to conventional method. Patients and Methods. Seven hundred and forty-eight patients with hepatobiliary diseases consecutively underwent diagnostic or therapeutic ERCP at the unit of Taleghani referral hospital in Tehran. Among them, 546 patients were eligible for wire-guided cannulation and underwent this procedure and others underwent sphincterotome biliary cannulation using contrast injection as the conventional method. Results. Patients in the two groups were comparable in terms of gender and age. Successful biliary cannulation was achieved similary in the guidewire and conventional group (89.2% versus 86.4%) that in 5.4% and 14.1% of them it was difficultly performed, respectively (P = 0.003). The main pancreatic duct was more visualized in 99.0% of patients in conventional group in comparison with 79.0% in another group (P < 0.001). Multivariate regression analysis showed that wire-guided cannulation had a protective role for post-ERCP hyperamylasemia (OR: 0.336, 95% CI: 0.181-0.623, P < 0.001). However, there were no significant differences between the two groups in rates of other procedure-related complications, such as, pancreatitis, bleeding, and perforation. Conclusion. The use of guidewire cannulation in comparison with conventional method can be accompanied with lower post-ERCP hyperamylasemia, and therefore selection of this cannulation technique especially in high-risk group is recommended.

Risk factors for post-ERCP cholangitis in patients with pancreatic cancer from a single referral center in Iran.

Cholangitis is relatively uncommon but associated mortality is high due to the predisposition in people with underlying disease. For this recognition of contributing risk factors is necessary. Therefore, the present descriptive- analytical cross-sectional survey was designed to determine contributing risk factors for post-ERCP cholangitis in patients with pancreatic cancer. From 2005 to 2010, 110 consecutive cases of pancreatic cancer attending to a tertiary referral centre (Taleghani Hospital), Tehran, Iran were recruited. The patients all underwent stenting via endoscopic retrograde cholangiopancreatography (ERCP). On univariate analysis, a metallic stent type (95% confidence interval (CI) 1.025-11.34, P=0.037), having no jaundice (1.44-2.22, P=0.009), having no pain (1.32-1.91, P=0.026), a history of prior ERCP (1.16-10.37, P=0.020), and having a proximal biliary stone (1.002- 5.93, P=0.046) were related to cholangitis. However on multivariate analysis, none of these factors were found to be contributing risk factors. Cholangitis is avoidable with adequate biliary drainage. Because success rates are higher and complication rates lower for endoscopists performing large volumes of ERCP, performance of the procedure should be concentrated as much as possible in institutions with endoscopists having adequate experience. Patients with a high risk for complications may be best served by referral to an advanced center.

Predictive value and main determinants of abnormal features of intraoperative cholangiography during cholecystectomy.

BACKGROUND: The major issue with intraoperative cholangiography (IOC) is whether its diagnostic accuracy for common bile duct (CBD) stones matches that of other diagnostic procedures, and thus, whether it will become a routine diagnostic procedure. The current study aimed to address the main determinants of CBD stone diagnosis in IOC among an Iranian population. METHODS: In a retrospective review database-based study conducted in Taleghani Hospital in Tehran between 2006 and 2008, baseline data and perioperative information of 2060 patients (male to female ratio 542:1518, mean age 53.7 years) who were candidates for cholecystectomy and underwent concomitant IOC for confirming CBD stones were reviewed. The predictive power of this procedure for diagnosis of abnormal biliary ducts with the focus on biliary stones was determined. RESULTS: Overall mortality and morbidity following cholecystectomy in the study population were 0.6% and 2.6%, respectively. Both early mortality and morbidity due to cholecystectomy were higher in male than female. The prevalence of CBD stones in IOC was 3.4% (5.2% in male and 2.8% in female, P=0.008). Among those without gallstones, 8.7% had CBD stones and only 3.1% had concomitant gallstones and CBD stones. The main predictors of stone appearance as an abnormal feature of IOC during cholecystectomy were: advanced age (OR=1.022, P=0.001), male gender (OR=1.498, P=0.050), history of abdominal surgery (OR=1.543, P=0.040) and preoperative endoscopic retrograde cholangiopancreatography (OR=5.400, P<0.001). CONCLUSIONS: IOC is a safe and accurate method for the assessment of bile duct anatomy and stones. Therefore, the routine use of IOC within cholecystectomy seems reasonable and is recommended.

Biliary brush cytology in the assessment of biliary strictures at a tertiary center in Iran.

BACKGROUND: Confirmation of cholangiocarcinoma and other malignant bile duct stenosis is challenging. The aim of the current study was to assess the accuracy of brush cytology for diagnosis of malignant biliary strictures. METHODS: 105 patients with hepatic biliary strictures undergoing ERCP were included in this study. Prospectively collected data included symptoms, results of biochemical testing and imaging procedures, as well as details of ERCP. Exclusion criteria were: 1) strictures that would not permit passage of guidewire and brush accession; and 2) post-operative strictures. Brushings of the bile duct strictures were performed. All patients were followed for at least 6 months. The final diagnosis was confirmed following surgery, histopathological diagnosis of the lesion, radiological infiltration of adjacent organs or metastases, or after at least a 6-month follow-up. RESULTS: 88 brush samples from 88 patients were of appropriate quality. The overall diagnostic sensitivity and specificity for malignant nature of biliary strictures were 40.7% and 100%, respectively. The sensitivity was 66.6 % for ampullary carcinomas, 36.3% for pancreatic cancer and 32.5% for cholangiocarcinomas. CONCLUSIONS: Despite the low sensitivity, due to the relative ease and safety, brush cytology should remain the first choice for diagnosis of causes of biliary strictures.

Endoscopic retrograde cholangiopancreatography outcome from a single referral center in Iran.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is the first choice for diagnostic evaluation of the pancreatic and biliary tree and can be accompanied by a high diagnostic sensitivity and a poor therapeutic outcome. In the current study, we described our experiences in the indications, findings, and technical success of ERCP in a sample of the Iranian population admitted to a referral center in Iran. METHODS: In a retrospective review database-based study, 780 patients (393 males and 387 females; mean age 57.5 years) who had undergone diagnostic and therapeutic ERCP with the primary diagnosis of hepatobiliary disorder between 2006 and 2008 at Taleghani Hospital in Tehran were reviewed. The key data were demographic characteristics, clinical information, laboratory parameters, as well as post-ERCP complications. RESULTS: A history of cholecystectomy was found in about one-third (36.3%) of participants and 80 (10.3%) out of 780 patients had a previous history of biliary stone. A minority (1.4%) of the patients suffered from hepatobiliary carcinomas, and 11 patients had cirrhosis. The most common clinical manifestations in the patients undergoing diagnostic ERCP were icterus (47.3%), weight loss (31.2%), and dark urine (26.9%). Selective biliary cannulation was technically successful in 87.0% of the patients; however, cannulation failed in 13.0%. The most frequent final diagnosis of ERCP was common bile duct stone that was detected in 40.1% of the patients. The ERCP results in 11.0% of the patients were normal. Regarding appropriate treatment, successful stenting was performed in 43 patients (15.2%). Among post-ERCP complications, pancreatitis was the most adverse event with an incidence rate of 3.3%. Other complications including local bleeding, cholangitis and gastrointestinal perforation, rarely occurred. Post-ERCP pancreatitis was reported in 1.8% of men and 3.6% of women (P=0.120). Pancreatitis was more common in women below 70 years than in those who were older than 70 years (3.6% versus 0.5%; OR: 8.216, P=0.015). This might be due to the more functionally active pancreas in younger women than in the older ones. However, other complications were similar in the two age groups. CONCLUSIONS: Based on our experience, ERCP indications, final diagnosis and related complications are comparatively consistent with those reported in other countries. The most common post-ERCP complication is pancreatitis that is more often observed in younger patients.