Tony Tham

Risk factors for complications after performance of ERCP

BACKGROUND ERCP has become widely available for the diagnosis and treatment of benign and malignant pancreaticobiliary diseases. In this prospective study, the overall complication rate and risk factors for diagnostic and therapeutic ERCP were identified. METHODS Data were collected prospectively on patient characteristics and endoscopic techniques from 1223 ERCPs performed at a single referral center and entered into a database. Univariate and multivariate analyses were used to identify risk factors for ERCP-associated complications. RESULTS Of 1223 ERCPs performed, 554 (45.3%) were diagnostic and 667 (54.7%) therapeutic. The overall complication rate was 11.2%. Post-ERCP pancreatitis was the most common (7.2%) and in 93% of cases was self-limiting, requiring only conservative treatment. Bleeding occurred in 10 patients (0.8%) and was related to a therapeutic procedure in all cases. Nine patients had cholangitis develop, most cases being secondary to incomplete drainage. There was one perforation (0.08%). All other complications totaled 1.5%. Variables derived from cannulation technique associated with an increased risk for post-ERCP pancreatitis were precut access papillotomy (20%), multiple cannulation attempts (14.9%), sphincterotome use to achieve cannulation (13.1%), pancreatic duct manipulation (13%), multiple pancreatic injections (12.3%), guidewire use to achieve cannulation (10.2%), and the extent of pancreatic duct opacification (10%). Patient characteristics associated with an increased risk of pancreatitis were sphincter of Oddi dysfunction (21.7%) documented by manometry, previous ERCP-related pancreatitis (19%), and recurrent pancreatitis (16.2%). Pain during the procedure was an important indicator of an increased risk of post-ERCP pancreatitis (27%). Independent risk factors for post-ERCP pancreatitis were identified as a history of recurrent pancreatitis, previous ERCP-related pancreatitis, multiple cannulation attempts, pancreatic brush cytology, and pain during the procedure. CONCLUSIONS The most frequent ERCP-related complication was pancreatitis, which was mild in the majority of patients. The frequency of post-ERCP pancreatitis was similar for both diagnostic and therapeutic procedures. Bleeding was rare and mostly associated with sphincterotomy. Other complications such as cholangitis and perforation were rare. Specific patient- and technique-related characteristics that can increase the risk of post-ERCP complications were identified.

Therapeutic ERCP in outpatients

BACKGROUND We evaluated the safety of outpatient therapeutic ERCP since most complications are apparent within a few hours. METHODS We reviewed 190 patients undergoing planned outpatient therapeutic ERCP from a cohort of 409 consecutive therapeutic ERCP procedures. Patients were selected for outpatient therapeutic ERCP based on relative good health and overnight accommodation near our institution. RESULTS Outpatient therapeutic ERCPs included plastic biliary stent insertion (n = 71), biliary sphincterotomy (45), pancreatic stent insertion (28), Wallstent insertion (19), biliary balloon or catheter dilation (10), pancreatic balloon or catheter dilation (8), biliary stone extraction with prior sphincterotomy (7), pancreatic sphincterotomy (5), and duodenal ampullectomy (1). Admission was necessary in 31 (16%) because of complications in 22 (11.6%) and observation of post-ERCP symptoms in 9. Twenty-six (13%) of these patients were admitted directly from the endoscopy unit recovery room and 5 (3%) from home after a median interval of 24 hours following discharge (range 5 to 48 hours). Reasons for admission were pancreatitis in 17, hemorrhage in 3, cholangitis in 3, endoscopic but not clinical hemorrhage in 4, pain in 4, and vomiting in 1. Of the patients who were admitted from home, 3 had pancreatitis (following sphincterotomy in 1, pancreatic stenting in 1, pancreatic balloon dilation in 1) and 2 had hemorrhage (postsphincterotomy in 1 and ampullectomy in 1). In comparison, of the 219 consecutive inpatients undergoing therapeutic ERCP, 28 (13%) developed complications with 1 (0.4%) death. CONCLUSIONS A policy of selective outpatient therapeutic ERCP, with admission reserved for those with established or suspected complication, appears to be safe and reduces health care costs.

Features that may predict hospital admission following outpatient therapeutic ERCP

BACKGROUND Some patients are admitted following outpatient therapeutic ERCP because of adverse events. This study aimed to identify factors that may predict such admissions. METHODS We prospectively studied admissions for post-ERCP adverse events in 415 consecutive patients undergoing outpatient therapeutic ERCP. Potentially relevant predictors of admission were assessed by univariate analysis and in case of significance included in a multivariate analysis. RESULTS Admission was necessary in 41 patients (9.9%) because of complications and in 63 (15.2%) for observation of adverse events that did not progress to definable complications. Potential predictors of admission were evaluated comparing patients who required more than an overnight admission (n = 63) with those who did not (n = 352). Multivariate analysis identified three factors that were significant: pain during the procedure (odds ratio 3.8: 95% CI [1.8, 7.9]), history of pancreatitis (odds ratio 2.3: 95% CI [1.1, 4.7]) and performance of sphincterotomy (odds ratio 2.2: 95% CI [1.1, 4.3]). The presence of all these features was associated with a 66.7% likelihood of admission, whereas the absence of pain during the procedure, history of pancreatitis and performance of sphincterotomy made admission likely in only 11.0%, 9.8% and 10.7%, respectively, of the cases. CONCLUSIONS The occurrence of pain during the procedure, a history of pancreatitis and the performance of sphincterotomy were independent predictors of admission following outpatient therapeutic ERCP.

A prospective study of the management of the young Helicobacter pylori negative dyspeptic patient--can gastroscopies be saved in clinical practice?

BACKGROUND Helicobacter pylori status has been suggested as a means of selecting young dyspeptic patients for gastroscopy as patients who are H. pylori negative and do not exhibit alarm symptoms or ingest non-steroidal anti-inflammatory medication have a low risk of serious organic disease. AIM To determine if young patients with ulcer-like dyspepsia and found to be H. pylori negative on non-invasive testing could be reassured by this knowledge and not proceed to gastroscopy. PATIENTS One hundred and sixty-one consecutive attendees aged 45 years or less with a presenting complaint of epigastric pain or discomfort were prospectively recruited from open access gastroscopy referrals and gastroenterology clinics. METHODS Patients who were H. pylori negative on 13-carbon urea breath test were reassured of the likelihood of a normal gastroscopy, given lifestyle advice and also advised to take symptomatic therapy as required. Patients were reviewed at 6 weeks, 3 months and 6 months when symptoms and quality of life were reassessed. Patients proceeded to gastroscopy if at any review their dyspepsia score stayed the same or worsened. RESULTS Fifty-five H. pylori negative patients were recruited (30 male, mean age 31 years), two patients did not attend subsequent review. Thirty-two (58%) came to gastroscopy. Endoscopic diagnoses included 25 which were normal, three with gastro-oesophageal reflux disease, three with peptic ulcer disease and one with gastric erosions. Dyspepsia and quality of life scores showed significant improvement over 6 months. CONCLUSIONS This management strategy resulted in a 42% reduction in gastroscopies in H. pylori negative patients. Whilst the majority of patients endoscoped had normal findings, seven patients (22%) had pathology. Overall there were significant improvements in dyspepsia and quality of life at 6 month follow-up.

Percutaneous Endoscopic Gastrostomy Sites Infected by Methicillin-resistant staphylococcus aureus : Impact on Outcome

Background The impact of methicillin-resistant Staphylococcus aureus (MRSA) colonization of percutaneous endoscopic gastrostomy (PEG) sites on morbidity and mortality is uncertain. Aim We investigated the impact of known prior MRSA colonization on the incidence of symptomatic PEG site wound infection and mortality. Methods Consecutive patients who had PEG tubes inserted recently at our hospital were identified. The presence or absence of MRSA colonization before PEG placement was noted. Patients were observed for wound infection, and swabs were taken from the site if there was clinical infection. Mortality within 30 days of PEG placement was determined. Results A total of 83 patients underwent PEG placement; 23 (28%) of these patients had known MRSA colonization before PEG placement. Of these, 13 (57%) developed symptomatic MRSA infection of the PEG site. The remaining 60 patients (72%) had no known prior MRSA colonization. In these patients, 9 (15%) developed symptomatic MRSA infection of the PEG site. The overall incidence of wound infection was 37% (31) of the total undergoing PEG placement, of whom 71% (22) had developed MRSA infection. The mortality of those with symptomatic MRSA infection of the PEG site was 9% (2/22), whereas the mortality from non-MRSA–infected PEGs was 20% (12/61). Conclusion Patients with prior MRSA colonization had a significantly higher risk of developing symptomatic MRSA infection of the PEG site. However, there was still a significant risk (15%) of developing MRSA infection of the PEG site for patients with no known prior MRSA infection. MRSA infection of the PEG site did not affect mortality.

Diagnosis of common bile duct stones by intravenous cholangiography: prediction by ultrasound and liver function tests compared with endoscopic retrograde cholangiography

BACKGROUND Routine intravenous cholangiography using the safer contrast medium, meglumine iotroxate, may be a useful investigation prior to laparoscopic cholecystectomy for the detection of suspected common bile duct stones. We compared this with endoscopic cholangiography. METHODS Eighty-one consecutive nonjaundiced patients (mean age 62 years; range 20 to 90) with suspected common bile duct stones referred for endoscopic cholangiography to one center underwent intravenous cholangiography that was considered positive if it detected ductal stones. The ability of ultrasound scans and liver function tests to predict ductal stones was also assessed. RESULTS Sixty patients had both endoscopic and intravenous cholangiograms performed. Thirteen out of 27 patients with ductal stones confirmed by endoscopic cholangiography had positive intravenous cholangiograms, and 29 out of 30 with no stones had negative intravenous cholangiograms. The sensitivity for intravenous cholangiography was 48%, specificity 97%, positive predictive value 93%, negative predictive value 67%, and accuracy 73%. For ultrasound scans the positive predictive value was 69%; negative predictive value was 78%. For liver function tests the positive predictive value was 68%; negative predictive value was 93%. CONCLUSIONS Intravenous cholangiography cannot be recommended instead of endoscopic cholangiography except in situations where the latter is not readily available. Ultrasound and liver function tests are useful in predicting ductal stones.

Use of portal pressure studies in the management of variceal haemorrhage

Portal hypertension occurs as a complication of liver cirrhosis and complications such as variceal bleeding lead to significant demands on resources. Endoscopy is the gold standard method for screening cirrhotic patients however universal endoscopic screening may mean a lot of unnecessary procedures as the presence of oesophageal varices is variable hence a large time and cost burden on endoscopy units to carry out both screening and subsequent follow up of variceal bleeds. A less invasive method to identify those at high risk of bleeding would allow earlier prophylactic measures to be applied. Hepatic venous pressure gradient (HVPG) is an acceptable indirect measurement of portal hypertension and predictor of the complications of portal hypertension in adult cirrhotics. Varices develop at a HVPG of 10-12 mmHg with the appearance of other complications with HPVG > 12 mmHg. Variceal bleeding does not occur in pressures under 12 mmHg. HPVG > 20 mmHg measured early after admission is a significant prognostic indicator of failure to control bleeding varices, indeed early transjugular intrahepatic portosystemic shunt (TIPS) in such circumstances reduces mortality significantly. HVPG can be used to identify responders to medical therapy. Patients who do not achieve the suggested reduction targets in HVPG have a high risk of rebleeding despite endoscopic ligation and may not derive significant overall mortality benefit from endoscopic intervention alone, ultimately requiring TIPS or liver transplantation. Early HVPG measurements following a variceal bleed can help to identify those at risk of treatment failure who may benefit from early intervention with TIPS. Therefore, we suggest using HVPG measurement as the investigation of choice in those with confirmed cirrhosis in place of endoscopy for intitial variceal screening and, where indicated, a trial of B-blockade, either intravenously during the initial pressure study with assessment of response or oral therapy with repeat HVPG six weeks later. In those with elevated pressures, primary medical prophylaxis could be commenced with subsequent close monitoring of HVPG thus negating the need for endoscopy at this point. All patients presenting with variceal haemorrhage should undergo HVPG measurement and those with a gradient greater than 20 mmHg should be considered for early TIPS. By introducing portal pressure studies into a management algorithm for variceal bleeding, the number of endoscopies required for further intervention and follow up can be reduced leading to significant savings in terms of cost and demand on resources.

Long-term follow-up of patients with iron deficiency anaemia after a negative gastrointestinal evaluation.

Objectives Our aim was to determine whether patients who have had a negative gastrointestinal evaluation (i.e. oesophagogastroduodenoscopy and a colonic examination) for iron deficiency anaemia are subsequently found to have recurrent anaemia or significant pathology. Methods From a prospectively entered endoscopy database, we identified a cohort of patients who had negative upper and lower gastrointestinal (GI) investigations for iron deficiency anaemia. We carried out a retrospective chart review of these patients to determine their outcome after a GI evaluation. In particular, we wished to determine the proportion of patients who had recurrent anaemia, became transfusion dependent or were found to have significant pathology. Results Sixty-nine patients, with an average age of 65.8 years (range 29–87), were followed up for a median of 5 years and 10 months (range 7–109). In 57 patients (83%), the anaemia resolved after the initial treatment period. Fifteen patients (22%) died during the follow-up period, two from a GI cancer and 13 from non-GI-related causes. Six patients (9%) developed persistent anaemia severe enough to require recurrent blood or iron transfusions. Seventeen patients (25%) had a transient recurrent anaemia and four (6%) were diagnosed with GI malignancies during the follow-up. Conclusion For the majority of patients with the iron deficiency anaemia and a negative GI evaluation the outcome is favourable, although a proportion (6%) may subsequently be found to have significant GI pathology. We believe that this number could be minimized by the use of colonoscopy rather than barium enema. In addition, small bowel investigations should not be limited to those who are transfusion dependent, as is currently recommended.

A new technique to retrieve an intrabiliary stent: a case report ☆ ☆☆

Endoscopic placement of stents is routine in obstructive pancreaticobiliary disease. Perforation, pancreatitis, bleeding and cholangitis are early stent-related complications, whereas distal or proximal stent migration may present later. Management of a proximally migrated stent is a challenge for the endoscopist despite the choice of several different techniques. We describe a new technique we used to retrieve an intrabiliary stent whose distal end was embedded in the bile duct wall.

Cost effectiveness of screening for and eradication of Helicobacter pylori in young patients with dyspepsia. Comparison groups were not clear in study.

EDITOR,—A H Briggs et al compared the cost effectiveness of screening for and eradication of Helicobacter pylori in the management of dyspeptic patients under 45 in the community using decision analysis and concluded that cost savings in the strategy of screening for H pylori compared with treatment with cimetidine could take almost eight years to accrue.1 We think, however, that there are flaws and limitations in this study and that their conclusions should be interpreted with caution. In their analysis of …