Prognosis and risk factors of ERCP pancreatitis in elderly.

Post Endoscopic Retrograde Cholangiopancreatography (ERCP) pancreatitis is one of the most serious complications of ERCP. Our study aims to investigate the risk, predisposing factors and prognosis of pancreatitis after ERCP in elderly patients. Patients referred to the ERCP unit between April 2008 and 2012 and admitted to the hospital at least 1 day after the ERCP procedure were included to the study. Information including patient's demographics, diagnosis, imaging findings, biochemical analysis, details of the ERCP procedure and complications were recorded. The severity of post ERCP pancreatitis (PEP) was determined by revised Atlanta Criteria as well as APACHE II and Ranson scores. A total of 2902 ERCP patients were evaluated and 988 were included to the study. Patients were divided into two groups as ≥ 65 years old (494 patients, 259 F, 235 M) and < 65 years old (494 patients, 274 F, 220 M). PEP was diagnosed in 4.3% of patients aged 65 years and older. The female gender was risk factors in elderly for PEP. The Sphincter Oddi Dysfunction (SOD) and Juxta papillary diverticula (JPD) were higher in elderly patients with PEP. Age did not increase the risk of PEP development. The most important post ERCP pancreatitis risk factor in the elderly is the female gender, while the risk is enhanced slightly by SOD and JPD.

Magnetic compression anastomosis for patients with a disconnected bile duct after living-donor related liver transplantation: a pilot study.

BACKGROUND AND STUDY AIM: We present the use of the magnetic compression anastomosis (MCA) technique for treatment of disconnected bile duct after living-donor related liver transplantation (LDLT) using the recently introduced through-the-scope magnet. PATIENTS AND METHODS: The MCA technique was used in patients with disconnected bile duct who could not be treated with either percutaneous or endoscopic procedures. All patients already had a percutaneous external biliary drainage catheter before the procedure. The magnet was placed percutaneously into the proximal side of the obstruction by pushing a 5-Fr catheter over a guidewire. Concurrently, endoscopic retrograde cholangiopancreatography (ERCP) including endoscopic papillary sphincterotomy was performed. The sister magnet was then carefully advanced to the opposite side of the obstruction with a 5-Fr catheter over a guidewire. After the confirmation of biliary recanalization, a guidewire was passed through the stricture and a percutaneous dilation of the stricture was performed with a balloon-tipped catheter. Endoscopic balloon dilation of the stricture, insertion of two plastic stents and the removal of the internal drainage catheter were performed during the first ERCP session. Stent exchange and multiple side-by-side stent placements were planned at regular intervals (3 monthly) for all patients. RESULTS: A total of six LDLT patients with disconnected bile duct (aged 37 - 68, four men) underwent the MCA technique between September 2014 and July 2015. Biliary recanalization was achieved 13 - 42 days after the magnet placement procedure. The success rate of the procedure was 100 %. CONCLUSIONS: The MCA technique using a small magnet (diameter 2.4 mm) is effective and useful in LDLT patients with disconnected bile duct.

Nonradiation ERCP with endoscopic biliary sphincterotomy plus papillary balloon dilation for the treatment of choledocholithiasis during pregnancy.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is currently the treatment of choice for symptomatic choledocholithiasis in pregnant patients. We aimed to present our experience with pregnant patients who underwent nonradiation ERCP and to evaluate the safety and efficacy of a new technique. METHODS: A retrospective analysis of nonradiation ERCP in 22 pregnant patients with symptomatic choledocholithiasis between January 2002 and December 2013 was performed. The bile aspiration technique with wire-guided sphincterotome was used to confirm selective biliary cannulation. Transpapillary pancreatic septotomy was performed in cases with difficult biliary cannulation (n = 3). After endoscopic biliary sphincterotomy, endoscopic papillary balloon dilation was performed with a 6- or 8-mm dilation balloon in all patients to reduce the risk of recurrent cholangitis because of residual or additional stones. Stones were extracted by balloon sweeping after dilation. All patients were followed for 6 months after the ERCP procedure. RESULTS: Biliary cannulation was achieved in all patients. Endoscopic papillary balloon dilation was performed with a 6-mm balloon in 17 patients and an 8-mm balloon in five patients. The stones were extracted in 18 of the 22 patients by balloon sweeping, but no stones were extracted in the remaining four patients. There were two cases of mild post-ERCP pancreatitis. All patients delivered at term, and none experienced recurrence of choledocholithiasis and/or cholangitis during the 6-month follow-up. CONCLUSIONS: Endoscopic biliary sphincterotomy plus endoscopic papillary balloon dilation in nonradiation ERCP is a safe and effective treatment method for symptomatic choledocholithiasis during pregnancy.

A severe case of esophageal ulcer causing a tight stricture despite long-term D-penicillamine treatment.

D-penicillamine has long been used in the management of rheumatic diseases due to the effects on inhibition of collagen synthesis. Herein, we report a severe case of esophageal ulcer causing a tight stricture extending through the distal esophagus despite the long-term D-penicillamine treatment in a patient with Wilson's disease. D-penicillamine would theoretically be expected to contribute to the healing of an esophageal ulcer. However, the drug failed to have a favorable outcome, which is notable and worth reporting.

Patients with bulbar papilla and choledocholithiasis and their endoscopic management.

BACKGROUND/AIMS: This study presents the endoscopic management of twenty-one patients with biliary stones, deformity at the duodenal bulb, and a flat shaped papilla ectopically located at duodenal bulb. METHODOLOGY: Most of the patients were male with a mean age of 53.9 +/- 9.6 years. In four (19%) of the 21 patients stenotic parts in the bulbus were dilated with TTS balloons, thus allowing ectopic papillae to be reached in all of the cases. Papillary orifice and distal CBD were dilated with balloons from 4 mm diameter and increasing the diameter of the balloons stepwise to 6 to 15 mm. RESULTS: In 20 (95%) the patients, the stones could be extracted in either the first or subsequent endoscopy session as the cholangiography. In one patient, retroperitoneal perforation in the intrapancreatic segment of the CBD occured after dilatation of CBD with a 15 mm balloon, and an operation was necessary. CONCLUSION: The shared features which may constitute a unique clinical entity of the presented cases are 1) male gender, 2) bulbar papilla, 3) flat appearance of the major papilla endoscopically 4) deformed bulbus, and 5) presence of stones in the CBD. Bile duct stones can be treated with endoscopic balloon dilatation of the distal CBD and papilla.

[Ochrobactrum anthropi bacteremia developed after cholangiopancreatography]. / Olgu sunumu: kolanjiopankreatografi sonrasinda gelisen Ochrobactrum anthropi bakteriyemisi.

Ochrobactrum anthropi (formerly Achromobacter spp.) is an aerobic, motile, oxidase positive and lactose negative gram negative bacillus which is widely distributed in the environment and water sources. In recent publications, O. anthropi has an increasing importance as a nosocomial infection agent. The aim of this report was to present a case of O. anthropi bacteremia developed after endoscopic retrograde cholangiopancreatography (ERCP). A 89-year old female patient presented with high fever one day after ERCP performed due to klatskin tumour. O. anthropi had been grown in blood culture (BacT/ALERT 3D, bioMérieux, Durham, USA), and the isolate was identified by automatized system (VITEK, bioMerieux, Marcy l'Etoile, France). Since there was no clinical response to empirical ceftriaxone therapy, it was switched to meropenem, which was found effective by VITEK antibiotic susceptibility detection system. The patient was treated successfully with meropenem therapy (3 x 1 gr/day, 10 days). As a result, in case of suspected post-ERCP bacteremia, unconventional microorganisms such as O. anthropi should be taken into consideration.

Endoscopic injection therapy of bleeding Dieulafoy lesion of the stomach.

BACKGROUND/AIMS: Dieulafoy's lesion is a rare cause of upper gastrointestinal bleeding and is potentially life threatening. The aim of this study is to determine the clinical features of these lesions and the efficacy of the endoscopic injection sclerotherapy in patients with Dieulafoy's lesion. METHODOLOGY: Between January 1994 and December 2001, twenty-eight patients with upper gastrointestinal bleeding due to Dieulafoy's lesion were treated by endoscopic injection sclerotherapy. Efficacy of endoscopic therapy and clinical findings of these cases were analyzed. RESULTS: The study group consisted of 22 male (78.5%) and 6 female (21.5%) patients with a mean age of 57 years (range 22-82 years). Significant comorbidity was present in 22 (78.5%) patients. Hemoglobin values of the patients ranged from 5.4-10.3 g/dL at hospitalization. The median transfusion requirement was 5 (range 0-12) units. Dieulafoy's lesion was observed in the proximal half of stomach in 25 cases (89.3%), in the antrum in 2 cases (7.1%) and in the angulus in 1 case (3.5%). Endoscopic injection sclerotherapy was successful in stopping the bleeding in 26 out of 28 patients (92.8%). CONCLUSIONS: Dieulafoy's lesions mostly affect the proximal stomach and cause serious upper gastrointestinal bleeding. Endoscopic injection sclerotherapy is an effective and a safe therapeutic method for Dieulafoy's lesion.

Solid and cystic papillary neoplasms of the pancreas: report of four cases.

BACKGROUND/AIMS: In this report we present four cases with solid and cystic papillary neoplasms (SCPN) of the pancreas, and discuss the histopathological and immunohistochemical findings with a review of the literature. METHODS: The four cases reported here consisted of three women (ages 20-48, mean: 32) and one man (age: 58). The clinical diagnoses were confirmed with ultrasound (US) and computerized tomography (CT). The surgical management of the tumors included enucleation (1 patient), distal pancreatectomy with splenectomy (1) and distal pancreatectomy (2). RESULTS: The tumors were large (mean diameter of the resected tumor was 15 cm), had cystic degenerations between solid areas, and were distributed in the body and the tail of the pancreas. The cystic spaces contained hemorrhagic, necrotic and thrombotic material. The immunohistochemical studies revealed that the four tumors were all positive for a1 antitrypsin and neuron specific enolase, and were all negative for chromogranin. Vimentin and synaptophysin were positive in three different cases. The follow-up of the patients has been uneventful for 2, 1, 7 and 12 years, respectively. CONCLUSIONS: SCPN of the pancreas is an uncommon clinicopathologic entity with a relatively low grade malignant potential. The majority of the cases are young women. Fifty percent of the cases are asymptomatic, and the patients with symptoms generally suffer from an abdominal mass or abdominal pain. In spite of the characteristic macroscopic and microscopic aspects, the immunophenotypical view is nonspecific. Prognosis is excellent after complete surgical resection and recurrence is rarely seen. Metastatic spread is not expected and the tumor usually has a manner of local invasion. Acinar cell carcinoma, pancreatoblastoma and pancreatic endocrine tumor must be considered in the differential diagnosis.

Hydatid acute pancreatitis.

BACKGROUND/AIMS: Hydatid acute pancreatitis is a rare condition, mostly reported as case presentations. METHODS: A series of eight patients with hydatid acute pancreatitis, referred between January 1990 and January 2003, are reported. All patients presented acute pancreatitis confirmed with clinical presentation, radiologic examination and laboratory findings. All patients had elevated levels of blood amylase value (more than 500 U/L). Five patients (62%) had high bilirubin levels (2.1 to 3.4 mg/dl) during the initial hospitalization. Computed tomography findings revealed acute pancreatitis in four patients; two had associated pseudocyst formation. RESULTS: Endoscopic retrograde cholangiopancreatography was performed on all patients and revealed hydatid cystic material in the common bile duct secondary to cystobiliary rupture in all patients. All patients underwent endoscopic sphincterotomy that was performed after dilatation with extractor balloon, and hydatid material was removed in all. Six patients were operated on after the initial episode subsided. Drainage of the cyst, appropriate cavity management and T-tube drainage of the common bile duct was employed in all patients to control bile leakage after the operation. Scolices and hydatid membrane were detected during common bile duct exploration in all patients due to presentation of cystobiliary rupture. There was no mortality. Postoperative pulmonary infection and wound infection were encountered in one patient each. During two to 13 years' follow-up, one patient developed recurrent hydatid disease. Recurrent pancreatitis did not occur. CONCLUSIONS: Hydatid acute pancreatitis is a rare condition. However, it should be remembered in patients with abdominal pain, especially in endemic areas.

Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract.

BACKGROUND: Bile duct stones are still present in 10% to 15% of patients after the application of conventional endoscopic extraction techniques and require additional procedures for duct clearance. In the vast majority of these cases, there are 2 main problems: large stone size (>15 mm) and tapering of distal bile duct. METHODS: Fifty-eight patients in whom endoscopic sphincterotomy and standard basket/balloon extraction were unsuccessful in the removal of bile duct stones underwent dilation with a 10- to 20-mm diameter (esophageal/pyloric type) balloon at the same session. In 18 patients with tapered distal bile ducts (Group 1), 12- to 18-mm diameter balloon catheters were used to enlarge the orifice. In 40 patients with square, barrel shaped and/or large (>15mm) stones (Group 2), the sphincterotomy orifice was enlarged with 15- to 20-mm diameter balloon catheters. After dilatation, standard basket/balloon extraction techniques were used to remove the stone(s). RESULTS: Stone clearance was successful in 16 patients (89%) in Group 1 and 35 (95%) in Group 2. Complications occurred in 9 (15.5%) patients. CONCLUSION: Dilation with a large-diameter balloon after endoscopic sphincterotomy is a useful alternative technique in patients with bile duct stones that are difficult to remove with standard methods.