Jason Bill

A comparison between endoscopic ultrasound-guided rendezvous and percutaneous biliary drainage after failed ERCP for malignant distal biliary obstruction

Background and study Aims: Selective biliary cannulation is unsuccessful in 5 % to 10 % of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for malignant distal biliary obstruction (MDBO). Percutaneous biliary drainage (PBD) has been the gold standard, but endoscopic ultrasound guided rendezvous (EUSr) have been increasingly used for biliary decompression in this patient population. Our aim was to compare the initial success rate, long-term efficacy, and safety of PBD and EUSr in relieving MDBO after failed ERC Patients and methods: A retrospective study involving 50 consecutive patients who had an initial failed ERCP for MDBO. Twenty-five patients undergoing EUSr between 2008 – 2014 were compared to 25 patients who underwent PBD immediately prior to the introduction of EUSr at our center (2002 – 2008). Comparisons were made between the two groups with regard to technical success, duration of hospital stay and adverse event rates after biliary decompression. Results: The mean age at presentation was 66.5 (± 12.6 years), 28 patients (54.9 %) were female. The etiology of MDBO was pancreaticobiliary malignancy in 44 (88 %) and metastatic disease in 6 (12 %) cases. Biliary drainage was technically successful by EUSr in 19 (76 %) cases and by PBD in 25 (100 %) (P = 0.002). Median length of hospital stay after initial drainage was 1 day in the EUSr group vs 5 days in PBD group (P = 0.02). Repeat biliary intervention was required for 4 patients in the EUSr group and 15 in the PBD group (P = 0.001). Conclusions: Initial technical success with EUSr was significantly lower than with PBD, however when EUSr was successful, patients had a significantly shorter post-procedure hospital stay and required fewer follow-up biliary interventions. Meeting presentations: Annual Digestive Diseases Week 2015

Presentation of a Rare Cystic Mass

Question: A 32-year-old woman with no past medical history presented to our medical center with 2 months of intermittent right upper quadrant pain. The pain started gradually, hurting primarily when lying on her right side. She had limited past medical history and denied any current medications. Examination revealed mild tenderness to her right upper quadrant without palpable masses. Laboratory data were within reference values. Cross-sectional imaging (Figure A, B) demonstrated a cystic mass arising in the right retroperitoneum measuring 6.0 8.1 cm. The mass was abutting the right hemidiaphragm with some loculation and abutting the caudate lobe of the liver and inferior vena cava. Given the location and complexity of the mass subsequent endoscopic ultrasound-guided fine needle aspiration biopsy was performed (Figure C) demonstrating a large, 6.5 8.7 cm cyst adjacent to the left lobe of the liver. The cyst was anechoic. There were a few internal septations. The outer wall of the lesion was thin and irregular, with a few areas of thickening. There seemed to be a moderate amount of debris within the cyst cavity. Diagnostic needle aspiration for fluid was performed. The fluid was clear and viscous. The amylase was 35 and carcinoembryonic antigen 19,344; the cytology demonstrated no evidence of malignancy. Given her ongoing symptoms, the size of the lesion, and premalignant nature of mucinous cysts, the decision was made to pursue surgical resection. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Do Consultants Follow-Up on Tests They Recommend? Insights From an Academic Inpatient Gastrointestinal Consult Service

Background Inpatient care is a fundamental part of gastroenterology training and involves the recommendation, performance, and interpretation of diagnostic tests. However, test results are not always communicated to patients or treating providers. We determined the process of communication of test results and recommendations in our inpatient gastroenterology (GI) consult service.

Evaluation of patients with abnormalities on intraoperative cholangiogram: time to abandon endoscopic retrograde cholangiopancreatography as the initial follow-up study

Background Endoscopic retrograde cholangiopancreatography (ERCP) is currently the method of choice for the postoperative evaluation of suspected bile duct stones seen on intraoperative cholangiogram (IOC); however, the sensitivity of IOC for identifying biliary pathology is unclear, with studies reporting false positive rates between 30% and 60%. Objective Evaluate the sensitivity of IOC for biliary pathology, using ERCP with sphincterotomy and balloon sweep as gold standard. Design Retrospective cohort study. Setting Tertiary medical centre. Patients 130 consecutive patients (age 51.3±1.7 years, 69.2% women) who underwent ERCP for the evaluation of abnormalities identified on IOC between 2005 and 2013. Interventions Endoscopic retrograde cholangiopancreatography Main outcome measurements Sensitivity of IOC, identify predictors of positive postoperative ERCP and ERCP-related complications. Results ERCP was successful in all 130 subjects. ERCP-related adverse events occurred in six (4.3%) patients, including self-limited post-sphincterotomy bleeding in three (2.3%) and mild post-ERCP pancreatitis in three (2.3%). Overall, 41 (31.5%) patients had normal cholangiogram at time of ERCP. Finding of a filling defect on IOC was the only predictor for the presence of common bile duct stones on postoperative ERCP (OR 3.3, 95% CI 1.0 to 10.8, p=0.05). Limitations Retrospective study design. Conclusions Nearly one-third of patients with abnormal IOC had a normal postoperative ERCP. Significant pathology could have been missed in 1/130 patients. Based on these findings, we believe the use of less-invasive diagnostic modalities may be used in place of ERCP in patients with suspected choledocholithiasis on IOC.