Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline.

ESGE recommends offering stone extraction to all patients with common bile duct stones, symptomatic or not, who are fit enough to tolerate the intervention.Strong recommendation, low quality evidence.ESGE recommends liver function tests and abdominal ultrasonography as the initial diagnostic steps for suspected common bile duct stones. Combining these tests defines the probability of having common bile duct stones.Strong recommendation, moderate quality evidence.ESGE recommends endoscopic ultrasonography or magnetic resonance cholangiopancreatography to diagnose common bile duct stones in patients with persistent clinical suspicion but insufficient evidence of stones on abdominal ultrasonography.Strong recommendation, moderate quality evidence.ESGE recommends the following timing for biliary drainage, preferably endoscopic, in patients with acute cholangitis, classified according to the 2018 revision of the Tokyo Guidelines:- severe, as soon as possible and within 12 hours for patients with septic shock- moderate, within 48 - 72 hours- mild, elective.Strong recommendation, low quality evidence.ESGE recommends endoscopic placement of a temporary biliary plastic stent in patients with irretrievable biliary stones that warrant biliary drainage.Strong recommendation, moderate quality of evidence.ESGE recommends limited sphincterotomy combined with endoscopic papillary large-balloon dilation as the first-line approach to remove difficult common bile duct stones. Strong recommendation, high quality evidence.ESGE recommends the use of cholangioscopy-assisted intraluminal lithotripsy (electrohydraulic or laser) as an effective and safe treatment of difficult bile duct stones.Strong recommendation, moderate quality evidence.ESGE recommends performing a laparoscopic cholecystectomy within 2 weeks from ERCP for patients treated for choledocholithiasis to reduce the conversion rate and the risk of recurrent biliary events. Strong recommendation, moderate quality evidence.

Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It provides practical advice on how to achieve successful cannulation and sphincterotomy at minimum risk to the patient. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations 1 ESGE suggests that difficult biliary cannulation is defined by the presence of one or more of the following: more than 5 contacts with the papilla whilst attempting to cannulate; more than 5 minutes spent attempting to cannulate following visualization of the papilla; more than one unintended pancreatic duct cannulation or opacification (low quality evidence, weak recommendation). 2 ESGE recommends the guidewire-assisted technique for primary biliary cannulation, since it reduces the risk of post-ERCP pancreatitis (moderate quality evidence, strong recommendation). 3 ESGE recommends using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation is difficult and repeated unintentional access to the main pancreatic duct occurs (moderate quality evidence, strong recommendation). ESGE recommends attempting prophylactic pancreatic stenting in all patients with PGW-assisted attempts at biliary cannulation (moderate quality evidence, strong recommendation). 4 ESGE recommends needle-knife fistulotomy as the preferred technique for precutting (moderate quality evidence, strong recommendation). ESGE suggests that precutting should be used only by endoscopists who achieve selective biliary cannulation in more than 80 % of cases using standard cannulation techniques (low quality evidence, weak recommendation). When access to the pancreatic duct is easy to obtain, ESGE suggests placement of a pancreatic stent prior to precutting (moderate quality evidence, weak recommendation). 5 ESGE recommends that in patients with a small papilla that is difficult to cannulate, transpancreatic biliary sphincterotomy should be considered if unintentional insertion of a guidewire into the pancreatic duct occurs (moderate quality evidence, strong recommendation).In patients who have had transpancreatic sphincterotomy, ESGE suggests prophylactic pancreatic stenting (moderate quality evidence, strong recommendation). 6 ESGE recommends that mixed current is used for sphincterotomy rather than pure cut current alone, as there is a decreased risk of mild bleeding with the former (moderate quality evidence, strong recommendation). 7 ESGE suggests endoscopic papillary balloon dilation (EPBD) as an alternative to endoscopic sphincterotomy (EST) for extracting CBD stones < 8 mm in patients without anatomical or clinical contraindications, especially in the presence of coagulopathy or altered anatomy (moderate quality evidence, strong recommendation). 8 ESGE does not recommend routine biliary sphincterotomy for patients undergoing pancreatic sphincterotomy, and suggests that it is reserved for patients in whom there is evidence of coexisting bile duct obstruction or biliary sphincter of Oddi dysfunction (moderate quality evidence, weak recommendation). 9 In patients with periampullary diverticulum (PAD) and difficult cannulation, ESGE suggests that pancreatic duct stent placement followed by precut sphincterotomy or needle-knife fistulotomy are suitable options to achieve cannulation (low quality evidence, weak recommendation).ESGE suggests that EST is safe in patients with PAD. In cases where EST is technically difficult to complete as a result of a PAD, large stone removal can be facilitated by a small EST combined with EPBD or use of EPBD alone (low quality evidence, weak recommendation). 10 For cannulation of the minor papilla, ESGE suggests using wire-guided cannulation, with or without contrast, and sphincterotomy with a pull-type sphincterotome or a needle-knife over a plastic stent (low quality evidence, weak recommendation).When cannulation of the minor papilla is difficult, ESGE suggests secretin injection, which can be preceded by methylene blue spray in the duodenum (low quality evidence, weak recommendation). 11 In patients with choledocholithiasis who are scheduled for elective cholecystectomy, ESGE suggests intraoperative ERCP with laparoendoscopic rendezvous (moderate quality evidence, weak recommendation). ESGE suggests that when biliary cannulation is unsuccessful with a standard retrograde approach, anterograde guidewire insertion either by a percutaneous or endoscopic ultrasound (EUS)-guided approach can be used to achieve biliary access (low quality evidence, weak recommendation). 12 ESGE suggests that in patients with Billroth II gastrectomy ERCP should be performed in referral centers, with the side-viewing endoscope as a first option; forward-viewing endoscopes are the second choice in cases of failure (low quality evidence, weak recommendation). A straight standard ERCP catheter or an inverted sphincterotome, with or without the guidewire, is recommended by ESGE for biliopancreatic cannulation in patients who have undergone Billroth II gastrectomy (low quality evidence, strong recommendation). Endoscopic papillary ballon dilation (EPBD) is suggested as an alternative to sphincterotomy for stone extraction in the setting of patients with Billroth II gastrectomy (low quality evidence, weak recommendation).In patients with complex post-surgical anatomy ESGE suggests referral to a center where device-assisted enteroscopy techniques are available (very low quality evidence, weak recommendation).

District general hospital networks can provide safe and effective hepatitis C treatment: results of a 5-year audit.

INTRODUCTION: Chronic hepatitis C treatment is well described in randomized-controlled trials (RCTs). We aimed to determine whether these findings can be extrapolated to treatment programmes delivered by nurse specialists in district general hospitals (DGHs). MATERIALS AND METHODS: Within the Dorset viral hepatitis network, chronic hepatitis C patients were treated in three DGHs by nurse specialists working under the supervision of four lead clinicians. Between January 2007 and January 2012, standard of care was ribavirin and pegylated interferon-α2a administered for 24 weeks (G2/3) and 48 weeks (G1/4). Retrospective analysis of the network's database was carried out and comparisons were made with a multicentre RCT. RESULTS: In total, 242 completed patient episodes were available for analysis. Ninety per cent (219) were treatment naive. G1 patients represented 49% (107) of this cohort; 2% (six) were hepatitis B/HIV coinfected and 97% (212) were Whites. Overall, 11% (23) were lost to follow-up within 24 weeks of completing treatment. On the basis of the intention to treat, the sustained virological response rates were 45 (48/107), 60 (63/105) and 57% (4/7) for patients infected with hepatitis C virus G1, G2/3 and G4, respectively. These results are comparable with RCT data (P=0.4973, 0.1359 and 0.9552). Treatment was discontinued in 3.7% (eight) of patients because of a laboratory abnormality and 9.6% (21) because of other medical complications or side-effect intolerance. These proportions are similar to those observed in the RCT (P=0.0873 and 0.5613). CONCLUSION: Specialist nurses supported by a network of DGHs can deliver a high-quality hepatitis C service across a broad geographical area.

Consenting patients for endoscopic retrograde cholangiopancreatography: results of a survey of 182 UK endoscopists and 2059 of their patients.

OBJECTIVES: To describe the endoscopic retrograde cholangiopancreatography (ERCP) consent process. METHOD: A prospective, multicentre study of ERCP, supplemented by questionnaires administered to participating endoscopists and their patients. RESULTS: A total 165 of 182 (91%) endoscopists completed a questionnaire describing personal practice with 140 of 165 (85%) routinely providing written information to patients; 120 of 165 (73%) routinely acquiring verbal consent on the day of ERCP; 23 of 165 (14%) delegating acquisition of consent to another team member and 59 of 165 (36%) usually/always describing alternative treatments to patients. Types of complication disclosed (and percentage of incidence quoted) varied significantly. A total of 2059 of 4561 (45%) patients completed the questionnaire following their first recorded procedure, at a mean of 11 days post-ERCP. Most (1968/2059; 96%) patients were satisfied with the explanation provided; they understood why ERCP was recommended (1935/2059; 94%) and recalled being informed of complications (1745/2059; 85%). Regression analysis of first-ever (nonurgent) ERCP suggested that patients were more likely to recall being informed of risk (odds ratio; 95% confidence interval) if they were younger (1.04 per 5-year decrease, 1.02-1.05), had an American Society of Anesthesiology score of less than 3 (2.0; 1.18-3.4); or had verbally consented more than 1 week in advance of ERCP (2.41, 1.02-5.71, when compared with those who consented on the day of ERCP). After ERCP 964 of 2059 (47%) patients were warned of specific symptoms that could arise. CONCLUSION: The ERCP consent process could be improved by consistent disclosure of risk, acquisition of verbal consent well in advance of the procedure, provision of information after ERCP and increased attention to older and more sick patients.

Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice.

OBJECTIVE: To examine endoscopic retrograde cholangio-pancreatography (ERCP) services and training in the UK. DESIGN: Prospective multicentre survey. SETTING: Five regions of England. PARTICIPANTS: Hospitals with an ERCP unit. OUTCOME MEASURES: Adherence to published guidelines, technical success rates, complications and mortality. RESULTS: Organisation questionnaires were returned by 76 of 81 (94%) units. Personal questionnaires were returned by 190 of 213 (89%) ERCP endoscopists and 74 of 91 (81%) ERCP trainees, of whom 45 (61%) reported participation in <50 ERCPs per annum. In all, 66 of 81 (81%) units collected prospective data on 5264 ERCPs, over a mean period of 195 days. Oximetry was used by all units, blood pressure monitoring by 47 of 66 (71%) and ECG monitoring by 37 of 66 (56%) units; 1484 of 4521 (33%) patients were given >5 mg of midalozam. Prothrombin time was recorded in 4539 of 5264 (86%) procedures. Antibiotics were given in 1021 of 1412 (72%) cases, where indicated. Patients' American Society of Anesthesiology (ASA) scores were 3-5 in 670 of 5264 (12.7%) ERCPs, and 4932 of 5264 (94%) ERCPs were scheduled with therapeutic intent. In total, 140 of 182 (77%) trained endoscopists demonstrated a cannulation rate >/=80%. The recorded cannulation rate among senior trainees (with an experience of >200 ERCPs) was 222/338 (66%). Completion of intended treatment was done in 3707 of 5264 (70.4%) ERCPs; 268 of 5264 (5.1%) procedures resulted in a complication. Procedure-related mortality was 21/5264 (0.4%). Mortality correlated with ASA score. CONCLUSION: Most ERCPs in the UK are performed on low-risk patients with therapeutic intent. Complication rates compare favourably with those reported internationally. However, quality suffers because there are too many trainees in too many low-volume ERCP centres.

Conservation of whole body nitric oxide metabolism in human alcoholic liver disease: implications for nitric oxide production.

OBJECTIVE: Patients with advanced liver diseases tend to develop a hyperdynamic circulation which complicates cirrhosis. Impairment of nitric oxide (NO) metabolism has been implicated in the pathogenesis of portal hypertension. The aim of this study was to determine nitric oxide synthase (NOS)-dependent whole body NO production in patients with decompensated liver cirrhosis and portal hypertension. MATERIAL AND METHODS: Ten patients with decompensated alcoholic liver disease and portal hypertension (Child-Pugh Classifications B and C with no signs of infection) and 10 age- and gender-matched control subjects received an intravenous infusion of L-[15N]2-arginine (50 micromol/min for 30 min). Urine and serum nitrite and nitrate concentrations were determined using ion chromatography-mass spectrometry. RESULTS: NOS-dependent whole body NO synthesis was estimated by the conversion of [15N]guanidino nitrogen of arginine to urine 15N-nitrite and 15N-nitrate. The amount of 15N-nitrite and 15N-nitrate in the urine of patients and control subjects was significantly correlated with the amount of urine nitrite and nitrate over 36 h (r=0.91 and 0.77, respectively, p<0.0001). However, neither a median of 12 h 15N-nitrite and 15N-nitrate nor nitrite and nitrate excretion in the urine was different between patients and control subjects, 46.4 (9.4-152.2) versus 98.7 (29.9-146.5) nmol/mmol creatinine and 20.6 (2.1-69.0) versus 40.0 (27.0-70.1) micromol/mmol creatinine, respectively. No differences were found in serum nitrite and nitrate concentrations and glomerular filtration rates between patients and control subjects, 111.4 (73.2-158.8) versus 109.3 (83.5-176.4) micromol/l. CONCLUSION: Our results contraindicate a greater basal NOS-dependent whole body NO production in patients with decompensated liver disease and portal hypertension.

Kayser-Fleischer like rings in alcoholic liver disease: a case report.

Kayser-Fleischer rings are brown pigmented rings that run along the periphery of the cornea. Situated in Descemet's membrane and being comprised of granules of deposited copper they have traditionally been thought of as pathognomic of Wilson's disease. However, they can also be seen in other forms of liver disease. We document a case of Kayser-Fleischer like rings occurring in alcoholic liver disease--a previously unreported association.