Predictive risk factors associated with cholangitis following ERCP.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is used for the management of many pancreaticobiliary disorders. It is generally safe with a few short-term complications. The risk factors for the development of post-ERCP cholangitis due to stent occlusion have not been previously described. This study identified such risk factors among patients undergoing ERCP and stent placement for pancreatic or biliary obstruction. METHODS: 3648 ERCPs performed at the University of Louisville from 2008 to 2016 were reviewed. Data including patient demographics, diagnostic, laboratory, and ERCP related data were included. Patients were classified as having post-ERCP cholangitis if they developed jaundice, fever, right upper quadrant abdominal pain, and confirmatory findings of stent occlusion and/or purulent drainage at the time of repeat ERCP. These patients were compared to those who did not develop post-ERCP cholangitis using univariate and multivariate analyses. RESULTS: A total of 431 patients met inclusion criteria. Of these, 57 (13.2%) developed post-ERCP cholangitis. The average age of patients was 57 years with 57% women and 43% men. On univariate analysis, patients developing post-ERCP cholangitis were more likely to be of increased age, have higher white blood cell count (WBC), total bilirubin (TBili), AST, ALT, and alkaline phosphatase (AlkPhos), and a decreased serum albumin level. Risk factors for post-ERCP cholangitis due to stent occlusion identified on multivariate analysis include: a diagnosis of cancer, the placement of multiple biliary stents at index ERCP, and low serum albumin level. CONCLUSIONS: The development of post-ERCP cholangitis due to stent occlusion is strongly associated with the presence of malignancy, the placement of multiple biliary stents, and low serum albumin. A decreased threshold to monitor for stent occlusion, including routine liver function tests and prophylactic stent removal or exchange, should be employed in patients with these characteristics.

Assessing the value of endoscopic ultrasound in predicting symptom severity and long-term clinical course in chronic pancreatitis.

BACKGROUND: To date, no studies have evaluated the correlation between number of endoscopic ultrasound (EUS) criteria met for chronic pancreatitis (CP) and symptom severity over the course of the disease. This study assessed the relationship between number of EUS-based diagnostic criteria for CP and CP severity over time. METHODS: A University of Louisville database was queried for patients undergoing EUS due to concern for chronic pancreatitis between 2005 and 2016. Patients were grouped based on EUS criteria met for CP and groups were compared along outcome and procedural variables. RESULTS: Of a total of 243 patients, 24, 129, and 90 patients met 1-3, 4-5, and ≥6 EUS diagnostic criteria, respectively. Median follow-up time was 33 months. Along all follow-up parameters, number of diagnostic criteria was positively correlated with an increased percentage of patients requiring operative intervention for chronic pancreatitis on univariate and multivariate analysis. CONCLUSIONS: In addition to the role of EUS criteria in establishing the diagnostic severity of patients with symptomatic chronic pancreatitis, the number of EUS-based criteria may help predict patients who will eventually require operative intervention and thus prompt referral to a pancreatobiliary surgeon earlier in the course of a patient's disease.

Outcomes of Endoscopic Stenting for Traumatic Biliary and Pancreatic Fistulae.

The role of endoscopic retrograde cholangiopancreatography (ERCP) in the trauma patient is limited. Therefore, reporting of outcomes is sparse in the literature. The purpose of this study was to review outcomes of patients who underwent ERCP for traumatic biliopancreatic injury. We retrospectively reviewed 1550 ERCPs, from a prospectively maintained database, performed by a single surgical endoscopist consulted by the trauma surgical service for the management of traumatic fistulae. Referral was made for patients with high output (greater than 200 mL/d) and/or persistent (failure to resolve within 30 days) fistulae and traumatic biliary stricture. Primary end point was postprocedural complications. Secondary end points included patient characteristics, stents placed, and duration of stenting. Seventeen patients underwent a total of 31 ERCPs for biliary and/or pancreatic injury resulting from abdominal trauma (eight penetrating, nine blunt). Fourteen patients had ERCP after laparotomy, with a mean interval to ERCP of 74 days. In three patients, ERCP was the only intervention required. Fourteen biliary stents were placed, seven of which were metallic. Ten pancreatic stents were placed; one proximally migrated but was successfully retrieved. Four patients had both ducts simultaneously stented. The mean duration of stenting was 158 days. All fistulae resolved after stenting. There were no serious complications.