Predictive model of persistent choledocholithiasis in patients with acute biliary pancreatitis / Modelo predictivo de coledocolitiasis persistente en pacientes con pancreatitis aguda biliar

Background: Choledocholithiasis causing acute biliary pancreatitis (ABP) may migrate to the duodenum or persist in the common bile duct (CBD). We developed a model for predicting persistent choledocholithiasis (PC) in patients with ABP. Methods: This retrospective cohort study included 204 patients, age ≥18 years (mean age: 73 years, 65.7% women), admitted for ABP in 2013–2018, with at least a magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasonography (EUS), and/or endoscopic retrograde cholangiopancreatography (ERCP). Epidemiological, analytical, imaging, and endoscopic variables were compared between patients with and without PC. Multivariate logistic regression analyses were performed to develop a predictive model of PC. Results: Patients underwent MRCP (n=145, 71.1), MRCP and ERCP (n=44, 21.56%), EUS and ERCP (n=1, 0.49%), or ERCP (n=14, 6.86%). PC was detected in 49 patients (24%). PC was strongly associated with CBD dilation, detected in the emergency ultrasound (p<0.001; OR=27; 95% CI: 5.8–185.5), increased blood levels of gamma glutamyl transpeptidase, detected at 72h (p=0.008; OR=3.4; 95% CI: 1.5–8.9); and biliary sludge in the gallbladder (p=0.008; OR=0.03; 95% CI: 0.001–0.3). Conclusions: The predictive model showed a validated area under the curve (AUC) of 0.858 for detecting PC in patients with ABP. A nomogram was developed based on model results. Conclusions: The predictive model was highly effective in detecting PC in patients with ABP. Therefore, this model could be useful in clinical practice.(AU)

Antecedentes: La coledocolitiasis que provoca una pancreatitis aguda biliar (PAB) puede migrar al duodeno o persistir en el conducto biliar común (CBC). Desarrollamos un modelo para predecir la coledocolitiasis persistente (CP) en pacientes con PAB. Métodos: Este estudio de cohortes retrospectivo incluyó a 204 pacientes, edad ≥ 18 años (edad media: 73 años, 65,7% mujeres), ingresados por PAB entre los años 2013 y 2018, a los que se les realizó al menos una colangiopancreatografía por resonancia magnética (CPRM), una ultrasonografía endoscópica (USE) o una colangiopancreatografía retrógrada endoscópica (CPRE). Se compararon variables epidemiológicas, analíticas, de imagen y endoscópicas entre pacientes con y sin CP. Se realizaron análisis de regresión logística multivariante para desarrollar un modelo predictivo de CP. Resultados: Los pacientes se sometieron a CPRM (n=145, 71,1%), CPRM y CPRE (n=44, 21,56%), USE y CPRE (n=1, 0,49%) o CPRE (n=14, 6,86%). Se detectó CP en 49 pacientes (24%). La CP se asoció fuertemente con la dilatación del colédoco, detectada en la ecografía de urgencias (p <0,001; OR=27; IC del 95%: 5,8-185,5), aumento de los niveles sanguíneos de gamma glutamil transpeptidasa, detectados a las 72h (p=0,008; OR=3,4, IC del 95%: 1,5-8,9), y barro biliar en la vesícula (p=0,008; OR=0,03; IC del 95%: 0,001-0,3). El modelo predictivo alcanzó un área bajo la curva validada de 0,858 para la detección de CP en pacientes con PAB. Se desarrolló un nomograma basado en los resultados del modelo. Conclusiones: El modelo predictivo fue altamente efectivo en la detección de CP en pacientes con PAB. Por lo tanto, este modelo podría ser útil en la práctica clínica.(AU)

Predictive model of persistent choledocholithiasis in patients with acute biliary pancreatitis.

BACKGROUND: Choledocholithiasis causing acute biliary pancreatitis (ABP) may migrate to the duodenum or persist in the common bile duct (CBD). We developed a model for predicting persistent choledocholithiasis (PC) in patients with ABP. METHODS: This retrospective cohort study included 204 patients, age ≥18 years (mean age: 73 years, 65.7% women), admitted for ABP in 2013-2018, with at least a magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasonography (EUS), and/or endoscopic retrograde cholangiopancreatography (ERCP). Epidemiological, analytical, imaging, and endoscopic variables were compared between patients with and without PC. Multivariate logistic regression analyses were performed to develop a predictive model of PC. RESULTS: Patients underwent MRCP (n=145, 71.1), MRCP and ERCP (n=44, 21.56%), EUS and ERCP (n=1, 0.49%), or ERCP (n=14, 6.86%). PC was detected in 49 patients (24%). PC was strongly associated with CBD dilation, detected in the emergency ultrasound (p<0.001; OR=27; 95% CI: 5.8-185.5), increased blood levels of gamma glutamyl transpeptidase, detected at 72h (p=0.008; OR=3.4; 95% CI: 1.5-8.9); and biliary sludge in the gallbladder (p=0.008; OR=0.03; 95% CI: 0.001-0.3). CONCLUSIONS: The predictive model showed a validated area under the curve (AUC) of 0.858 for detecting PC in patients with ABP. A nomogram was developed based on model results. CONCLUSIONS: The predictive model was highly effective in detecting PC in patients with ABP. Therefore, this model could be useful in clinical practice.

Innovación en técnica quirúrgica: Dos técnicas no convencionales para el tratamiento de la coledocolitiasis / Innovative surgical techniques. Two non-conventional techniques for the treatment of choledocholithiasis

RESUMEN La litiasis vesicular asociada a coledocolitiasis puede tener distintos tratamientos, endoscópicos o quirúrgicos, dependiendo del paciente, el entrenamiento del personal médico y de la disponibilidad de instrumental. Ninguno ha demostrado estar exento de complicaciones. Presentamos dos técnicas tendientes a mejorar los resultados del tratamiento quirúrgico de la coledocolitiasis. Una es la extracción transcística de coledocolitiasis y stent, en pacientes que fueron tratados endoscópicamente por colangitis, tendiente a resolver el problema (la litiasis vesicular, la coledocolitiasis y el stent) en un solo tiempo por cirugía laparoscópica. La segunda es una nueva indicación de una técnica ya descripta, la dilatación papilar anterógrada con balón, utilizada en este caso para disminuir las fugas biliares tras un cierre primario de colédoco.

ABSTRACT Cholelithiasis associated with choledocholithiasis may have different treatments, either by endoscopy or surgery, depending on the patient, level of training of the medical staff and availability of instruments. None of them is free of complications. We report two non-conventional techniques aimed at improving the results of the management of choledocholithiasis. Transcystic removal of common bile duct stones and stent in patients who underwent endoscopic treatment for cholangitis is one of these new techniques to manage cholelithiasis, choledocholithiasis and stent removal in a single procedure through laparoscopy. The second technique is a new indication of a previously described procedure, antegrade balloon papillary dilation to reduce biliary leaks after primary closure of the common bile duct.

Acute cholangitis in an old patient with Crigler-Najjar syndrome type II - a case report.

BACKGROUND: Crigler-Najjar syndrome (CN) is a very rare genetic disorder characterized by an inability to conjugate bilirubin. Contrary to CN type I, patients with CN II exhibit residual capacity to conjugate bilirubin and may present a normal life expectancy. CASE PRESENTATION: We report an unusual late diagnosis of CN type II in an 80-year-old female admitted with severe acute cholangitis. While the patient present typical clinical and radiologic signs of bile duct obstruction and cholangitis, her blood analysis showed severe unconjugated hyperbilirubinemia. Endoscopic retrograde cholangiopancreatography confirmed the diagnosis and allowed therapeutic intervention. The anatomopathologic examination of her gallbladder following cholecystectomy showed signs of chronic cholecystitis. CONCLUSION: The risk of gallstone disease may be increased in patients with CN syndrome. While unusual, we alert to this curious and potential life-threatening presentation.

Colangiopancreatografía retrógrada endoscópica, esfinterotomía endoscópica y colecistectomía laparoscópica en un paciente con coledocolitiasis y colelitiasis / Endoscopic retrograde cholangiopancreatography, endoscopic esphinterotomy and laparoscopic cholecystectomy in a patient with choledocolitiasis and cholelitiasis

Se presenta el caso clínico de una paciente de 30 años de edad, presumiblemente saludable, quien acudió a la consulta de Gastroenterología del Hospital General Docente "Dr. Juan Bruno Zayas Alfonso" de Santiago de Cuba por presentar cólico biliar, íctero, coluria, náuseas, vómitos e inapetencia. Los exámenes complementarios efectuados confirmaron el diagnóstico de coledocolitiasis y colelitiasis, por lo cual fue preciso realizarle colangiopancreatografía retrógrada endoscópica, esfinterotomía endoscópica y colecistectomía laparoscópica en un tiempo anestésico. La evolución posoperatoria resultó favorable y fue dada de alta sin complicaciones antes de las 24 horas de haber sido intervenida.

The case report of a 30 year-old presumably healthy patient, who attended the Gastroenterology Department from "Dr Juan Bruno Zayas Alfonso" Teaching General Hospital in Santiago de Cuba, and suffering from biliary cholic, ictero, choluria, nausea, vomit and inappetence is presented. The complementary examinations confirmed the choledocolitiasis and cholelitiasis diagnosis, reason why it was necessary to carry out a endoscopic retrograde cholangiopancreatography, endoscopic esphinterotomy and ambulatory laparoscopic cholecystectomy, in a single anesthetic injection. The posoperative clinical course was favorable and she was discharged without complications 24 hours before the intervention.