UK wide survey on the prevention of post-ERCP pancreatitis.

OBJECTIVE: In 2010, the European Society of Gastrointestinal Endoscopy delivered guidelines on the prophylaxis of postendoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis (PEP). These included Grade A recommendations advising the use of prophylactic pancreatic stent (PPS) and non-steroidal anti-inflammatory drugs (NSAIDs) in high-risk cases. Our study aim was to capture the current practice of UK biliary endoscopists in the prevention of PEP. DESIGN: In summer 2012, an anonymous online 15-item survey was emailed to 373 UK consultant gastroenterologists, gastrointestinal surgeons and radiologists identified to perform ERCP. RESULTS: The response rate was 59.5% (222/373). Of the respondents, 52.5% considered ever using PPS for the prevention of PEP. PPS users always attempted insertion for the following procedural risk factors: pancreatic sphincterotomy (48.9%), suspected sphincter of Oddi dysfunction (46.5%), pancreatic duct instrumentation (35.9%), previous PEP (25.2%), precut sphincterotomy (8.5%) and pancreatic duct injection (7.8%). Prophylactic NSAID use was significantly associated with attempts at PPS placement (p<0.001). 64.1% of non-PPS users cited a lack of conviction in their benefit as the main reason for their decision. Self-reported pharmacological use rates for PEP prevention were: NSAIDs (34.6%), antibiotics (20.6%), rapid intravenous fluids (13.2%) and octreotide (1.6%). 6% routinely measured amylase post-ERCP. CONCLUSIONS: Despite strong evidence-based guidelines for prevention of PEP, less than 53% of ERCP practitioners use pancreatic stenting or NSAIDs. This suggests a need for the development of British Society of Gastroenterology guidelines to increase awareness in the UK. Even among stent users, PPS are being underused for most high-risk cases. Prophylactic pharmacological measures were rarely used as was routine post-ERCP serum amylase measurement.

Autoimmune pancreatitis complicated by spontaneous subcapsular splenic haemorrhage.

CONTEXT: Autoimmune pancreatitis is a rare but increasingly recognised condition with unique clinical, immunological and histological features. We report the first case of autoimmune pancreatitis associated with spontaneous splenic haemorrhage. CASE REPORT: A 75-year-old man presented with severe epigastric pain radiating to the back associated with nausea and vomiting. A CT-scan of his abdomen showed a large pseudocyst within the pancreatic tail as well as a subcapsular splenic haemorrhage. His IgG4 levels were elevated and clinical history and investigations were consistent with severe acute pancreatitis, but were negative for other known causes of pancreatic disease. The patient was started on steroid therapy and improved dramatically clinically, immunologically and radiologically thus confirming the diagnosis of autoimmune pancreatitis. His splenic haemorrhage was managed conservatively in view of his haemodynamic stablity and eventually self-resolved. CONCLUSION: Autoimmune pancreatitis should not be overlooked in cases of acute pancreatitis without other obvious etiology. Furthermore, superimposed splenic haemorrhage is a rare but important complication of autoimmune pancreatitis.

Hydronephrosis after embolization of internal iliac artery aneurysms.

The treatment of internal iliac artery aneurysms is aimed at the prevention of rupture. Traditionally, this is undertaken surgically; however, endovascular techniques are an acceptable alternative and these techniques are also not without complication. Herein, the authors describe the endovascular treatment of two patients with internal iliac aneurysms. Although the treatments were initially successful, both patients presented with ureteric obstruction and hydronephrosis 2 months later.