acute biliary pancreatitis
DESCRIPTION
Tomasz Marek. Acute biliary pancreatitis. 6th EAGE Postgraduate School in Gastroenterology Prague 2010. Department of Gastroenterology & Hepatology Medical University of Silesia in Katowic e, Poland. Acute biliary pancreatitis. Pathogenesis Diagnosis Determination of etiology - PowerPoint PPT PresentationTRANSCRIPT
Acute biliary pancreatitisAcute biliary pancreatitis
Tomasz MarekTomasz Marek
Department of Gastroenterology & HepatologyMedical University of Silesia in Katowice, PolandDepartment of Gastroenterology & HepatologyMedical University of Silesia in Katowice, Poland
6th EAGEPostgraduate School in Gastroenterology
Prague 2010
6th EAGEPostgraduate School in Gastroenterology
Prague 2010
Acute biliary pancreatitisAcute biliary pancreatitis
o Pathogenesiso Diagnosiso Determination of etiologyo Prognosiso Endoscopic treatment
o Pathogenesiso Diagnosiso Determination of etiologyo Prognosiso Endoscopic treatment
Opie, Bull John Hopkins Hosp 1901Opie, Bull John Hopkins Hosp 1901
Pathogenesis of biliary pancreatitisPathogenesis of biliary pancreatitis
Acute biliary pancreatitis (ABP)is triggered by obstruction of the ampulla of Vater
by migrating or impacted stones
Acute biliary pancreatitis (ABP)is triggered by obstruction of the ampulla of Vater
by migrating or impacted stones
Opie, Bull John Hopkins Hosp 1901Opie, Bull John Hopkins Hosp 1901Acosta & Ledesma, NEJM 1974Acosta & Ledesma, NEJM 1974
Pathogenesis of biliary pancreatitisPathogenesis of biliary pancreatitis
Common channel ?Common channel ? Obstruction !!!Obstruction !!!
Pathogenesis of biliary pancreatitisPathogenesis of biliary pancreatitis
Diagnosis of ABPDiagnosis of ABP
Diagnosis of ABPDiagnosis of ABP
o Paino Elevated enzymes
- lipase better than amylase- no specific cut-off, 2-3 x N ?
o Imaging studies- usually not necessary- US not perfect (intestinal gas)- CT should not be done within 72h if not for differential diagnosis
o Paino Elevated enzymes
- lipase better than amylase- no specific cut-off, 2-3 x N ?
o Imaging studies- usually not necessary- US not perfect (intestinal gas)- CT should not be done within 72h if not for differential diagnosis
Determination of biliary etiologyDetermination of biliary etiology
Determination of biliary etiologyDetermination of biliary etiology
o Elevated liver function tests (~ 2 x N)o Gallstones or sludge (?)o Dilated CBD (> 8 mm)o ERCP (added value):
- small CBD stones in non-dilated CBD- endoscopic signs of stone passage- biliary microlithiasis
o Elevated liver function tests (~ 2 x N)o Gallstones or sludge (?)o Dilated CBD (> 8 mm)o ERCP (added value):
- small CBD stones in non-dilated CBD- endoscopic signs of stone passage- biliary microlithiasis
CBD imaging in ABPCBD imaging in ABP
o Abdominal US not sensitive enougho MRCP
- small (especially impacted) stones may be missed- air bubbles may give false+ results- fluid collections may obscure CDB in severe cases
o EUS- may be not readily available 24/24h (ES delay?)- perfect when ERCP fails
o Abdominal US not sensitive enougho MRCP
- small (especially impacted) stones may be missed- air bubbles may give false+ results- fluid collections may obscure CDB in severe cases
o EUS- may be not readily available 24/24h (ES delay?)- perfect when ERCP fails
Determination of biliary etiologyDetermination of biliary etiology
CBD stones 326 (39.8%)1 pt lab criteria negative
Gallbladder stones only 402 (49.0%)24 pts lab criteria negative ?
Biliary microlithiasis 19 ( 2.3%)
Signs of stone passage 31 ( 3.8%)
Lab criteria only 42 ( 5.1%)
CBD stones 326 (39.8%)1 pt lab criteria negative
Gallbladder stones only 402 (49.0%)24 pts lab criteria negative ?
Biliary microlithiasis 19 ( 2.3%)
Signs of stone passage 31 ( 3.8%)
Lab criteria only 42 ( 5.1%)
ABP prognosisABP prognosis
o Small differences
o Glasgow Blamey - best of „classic” systems
o Bilirubin to be removed from AP III J
o CRP cut-off to be set higher180 mg/l works better than 150 mg/l
o ERCP can be used for prognosiswhen done for treatment
o Small differences
o Glasgow Blamey - best of „classic” systems
o Bilirubin to be removed from AP III J
o CRP cut-off to be set higher180 mg/l works better than 150 mg/l
o ERCP can be used for prognosiswhen done for treatment
ABP prognosisABP prognosis
ABP treatmentABP treatment
o Obstruction is the main elementof the pathogenesis of ABP
o The restoration of normal outflowof bile and pancreatic juiceshould constitute an effective, cause-directed treatmentof acute biliary pancreatitis
o Endoscopic sphincterotomycould be the method of choice
o Obstruction is the main elementof the pathogenesis of ABP
o The restoration of normal outflowof bile and pancreatic juiceshould constitute an effective, cause-directed treatmentof acute biliary pancreatitis
o Endoscopic sphincterotomycould be the method of choice
ABP treatmentABP treatment
ES for ABP – First casesES for ABP – First cases
o It is the greatest pleasureof the endoscopistto remove impacted stonein patient with acute pancreatits
o It is the greatest pleasureof the endoscopistto remove impacted stonein patient with acute pancreatits
ABP treatmentABP treatment
ABP treatmentABP treatment
ERCP / ES for ABPERCP / ES for ABP
1988 - 1988 - NeoptolemosNeoptolemos et al., Leicester, UK (Lancet) et al., Leicester, UK (Lancet)
1993 - 1993 - FanFan et al., Hong-Kong, Hong-Kong (NEJM) et al., Hong-Kong, Hong-Kong (NEJM)
1995 - 1995 - FölschFölsch et al., Kiel, Germany (NEJM) et al., Kiel, Germany (NEJM) (multicenter study) (multicenter study)
2006 – 2006 – AcostaAcosta et al., Los Angeles, USA (Ann Surg) et al., Los Angeles, USA (Ann Surg)
2007 - 2007 - Oria Oria et al., Buenos-Aires, Argentina (Ann Surg)et al., Buenos-Aires, Argentina (Ann Surg)
Randomized comparisonsRandomized comparisonsof endoscopic sphincterotomy (ES)of endoscopic sphincterotomy (ES)
versus conventional management (CM)versus conventional management (CM)for acute biliary pancreatitisfor acute biliary pancreatitis
CMCM
12%12%61%61%34%34%
ERCPERCP
12%12%24%24%17%17%
CMCM
0%0%18%18% 8% 8%
ERCPERCP
0%0% 4% 4% 2% 2%
ABPABP
Predicted mildPredicted mildPredicted severePredicted severeTotalTotal
ComplicationsComplications MortalityMortality
o 121 patients (62 CM, 59 ERCP)o ERCP / ES > 48 & < 72 ho 121 patients (62 CM, 59 ERCP)o ERCP / ES > 48 & < 72 h
o ERCP only after 48 hours (severity stratification) o ES only in patients with CBD stones (33% ERCP)o Trend only observed for mortality
o ERCP only after 48 hours (severity stratification) o ES only in patients with CBD stones (33% ERCP)o Trend only observed for mortality
Neoptolemos Neoptolemos et al., et al., Lancet 1988Lancet 1988
ERCP / ES for ABP – Neoptolemos et al.ERCP / ES for ABP – Neoptolemos et al.
o 195 patients, 127 ABP (64 CM, 63 ERCP)o ERCP / ES < 24 ho 195 patients, 127 ABP (64 CM, 63 ERCP)o ERCP / ES < 24 h
o ES only in patients with CBD stones (38% ERCP)o Significant reduction of biliary sepsis in ES groupo Trend only observed for mortality
o ES only in patients with CBD stones (38% ERCP)o Significant reduction of biliary sepsis in ES groupo Trend only observed for mortality
CMCM
17%17%54%54%33%33%
ERCPERCP
18%18%13%13%16%16%
CMCM
0%0%18%18% 8% 8%
ERCPERCP
0%0% 3% 3% 2% 2%
ABPABP
Predicted mildPredicted mildPredicted severePredicted severeTotalTotal
ComplicationsComplications MortalityMortality
Fan Fan et al., et al., NEJM 1993NEJM 1993
ERCP / ES for ABP – Fan et al.ERCP / ES for ABP – Fan et al.
o 238 patients, (112 CM, 126 ERCP)o ERCP / ES < 72 ho 238 patients, (112 CM, 126 ERCP)o ERCP / ES < 72 h
o Exclusion of patients with jaundice (Bil > 5.0 mg/dL)o ES only in CBD stones (46% ERCP / 12% CM group)o Few cases/center; ERCP mortality 5x vs. UK / HK
o Exclusion of patients with jaundice (Bil > 5.0 mg/dL)o ES only in CBD stones (46% ERCP / 12% CM group)o Few cases/center; ERCP mortality 5x vs. UK / HK
Folsch et al., NEJM 1995Folsch et al., NEJM 1995
CMCM
51%51%
11%11%
ERCPERCP
46%46%
1%1%
CMCM
4%4%
ERCPERCP
8%8%
ABPABP
TotalTotal
ComplicationsComplications MortalityMortality
New onset jaundiceNew onset jaundice
ERCP / ES for ABP – Fölsch et al.ERCP / ES for ABP – Fölsch et al.
o 61 patients (31 CM, 30 ERCP)o ERCP / ES > 24 h & < 48 h of onseto 61 patients (31 CM, 30 ERCP)o ERCP / ES > 24 h & < 48 h of onset
o Complicated designo Patiens with obstruction (Bil ↓ checked every 6h)o ERCP for patients with no spontaneous disobstructiono ES – ERCP 43% < 48 h, CM 10% > 48 h
o Complicated designo Patiens with obstruction (Bil ↓ checked every 6h)o ERCP for patients with no spontaneous disobstructiono ES – ERCP 43% < 48 h, CM 10% > 48 h
Acosta et al., Ann Surg 2006Acosta et al., Ann Surg 2006
CMCM
29%29%
ERCPERCP
7%7%
CMCM
0%0%
ERCPERCP
0%0%
ABPABP
TotalTotal
ComplicationsComplications MortalityMortality
ERCP / ES for ABP – Acosta et al.ERCP / ES for ABP – Acosta et al.
o 238 patients, 102 randomized (51 CM, 51 ERCP)o ERCP / ES > 24 h of onseto 238 patients, 102 randomized (51 CM, 51 ERCP)o ERCP / ES > 24 h of onset
o Bil >=1.2 mg/dL + CBD >= 8mm on USo Acute cholangitis (temp >= 38.4 C) excludedo ES 76% ERCP group (CBDS)o No difference in organ failure score
o Bil >=1.2 mg/dL + CBD >= 8mm on USo Acute cholangitis (temp >= 38.4 C) excludedo ES 76% ERCP group (CBDS)o No difference in organ failure score
Oria et al., Ann Surg 2007Oria et al., Ann Surg 2007
CMCM
18%18%
ERCPERCP
21%21%
CMCM
2%2%
ERCPERCP
4%4%
ABPABP
TotalTotal
ComplicationsComplications MortalityMortality
ERCP / ES for ABP – Oria et al.ERCP / ES for ABP – Oria et al.
AOCAOC Jaundice Jaundice Sev AP Old/unfit Sev AP Old/unfito Atlanta ’94Atlanta ’94 X X X Xo BSG ’98BSG ’98 X X X X X Xo SSAT ’98SSAT ’98 X Xo Santorini ’99Santorini ’99 X X X X X Xo SNFGE ’01SNFGE ’01 X X X Xo WCG ’02WCG ’02 X X X X X X XXo JSAEM ’02JSAEM ’02 X X X X X Xo IAP ’03IAP ’03 X X X Xo BSG ’05BSG ’05 X X X X X X XXo ACG ’06ACG ’06 X X X X X? X? XXo AGA ’07 AGA ’07 X X X X X? X? XX
AOCAOC Jaundice Jaundice Sev AP Old/unfit Sev AP Old/unfito Atlanta ’94Atlanta ’94 X X X Xo BSG ’98BSG ’98 X X X X X Xo SSAT ’98SSAT ’98 X Xo Santorini ’99Santorini ’99 X X X X X Xo SNFGE ’01SNFGE ’01 X X X Xo WCG ’02WCG ’02 X X X X X X XXo JSAEM ’02JSAEM ’02 X X X X X Xo IAP ’03IAP ’03 X X X Xo BSG ’05BSG ’05 X X X X X X XXo ACG ’06ACG ’06 X X X X X? X? XXo AGA ’07 AGA ’07 X X X X X? X? XX
ERCP / ES for ABP – GuidelinesERCP / ES for ABP – Guidelines
o All guidelines recommend the use of ERCP/ESin settings with high suspicion of CBD stones,jaundice and cholangitis
oMajority of guidelines recommend ERCP/ESas an emergency procedure(as soon as possible)
o No guidelines recommend the useof ERCP/ES in predicted mild pancreatitis(OK if the prognosis system is perfect and it can provide the prognosis on admission)
o All guidelines recommend the use of ERCP/ESin settings with high suspicion of CBD stones,jaundice and cholangitis
oMajority of guidelines recommend ERCP/ESas an emergency procedure(as soon as possible)
o No guidelines recommend the useof ERCP/ES in predicted mild pancreatitis(OK if the prognosis system is perfect and it can provide the prognosis on admission)
ERCP / ES for ABP – GuidelinesERCP / ES for ABP – Guidelines
n (793)%
Time P-E (h)Bilirubin (mg/dL)ALT (U)ALP (U)GGT (U)Amylase (U)Lipase (U)CBD Ø (mm)
n (793)%
Time P-E (h)Bilirubin (mg/dL)ALT (U)ALP (U)GGT (U)Amylase (U)Lipase (U)CBD Ø (mm)
IMPS131
16.5 %
325.2413314710
20741186613.2
IMPS131
16.5 %
325.2413314710
20741186613.2
CBDS206
26.0 %
373.4350259571
16051002011.7
CBDS206
26.0 %
373.4350259571
16051002011.7
no CBDS456
57.5 %
342.9392210492
141581218.7
no CBDS456
57.5 %
342.9392210492
141581218.7
p
0.0540.0000.1130.0000.0000.0000.0000.000
p
0.0540.0000.1130.0000.0000.0000.0000.000
Prediction of CBD stonesPrediction of CBD stones
n (792)
Bilirubin
0 - 1 mg/dL1 - 3 mg/dL3 - 5 mg/dL > 5 mg/dL
n (792)
Bilirubin
0 - 1 mg/dL1 - 3 mg/dL3 - 5 mg/dL > 5 mg/dL
IMPS
7 ( 6%)32 (10%)39 (24%)53 (29%)
IMPS
7 ( 6%)32 (10%)39 (24%)53 (29%)
CBDS
33 (25%)84 (26%)38 (24%)51 (28%)
CBDS
33 (25%)84 (26%)38 (24%)51 (28%)
no CBDS
90 (69%)204 (64%) 85 (53%) 76 (42%)
no CBDS
90 (69%)204 (64%) 85 (53%) 76 (42%)
Prediction of CBD stones – BilirubinPrediction of CBD stones – Bilirubin
n (740)
CBD diameter
0 - 4 mm5 - 8 mm9 - 12 mm > 12 mm
n (740)
CBD diameter
0 - 4 mm5 - 8 mm9 - 12 mm > 12 mm
IMPS
1 ( 3%)20 ( 7%)44 (15%)45 (33%)
IMPS
1 ( 3%)20 ( 7%)44 (15%)45 (33%)
CBDS
4 (11%)50 (19%)84 (28%)54 (39%)
CBDS
4 (11%)50 (19%)84 (28%)54 (39%)
no CBDS
32 (87%)199 (74%)169 (57%) 38 (28%)
no CBDS
32 (87%)199 (74%)169 (57%) 38 (28%)
Prediction of CBD stones – CBD diameterPrediction of CBD stones – CBD diameter
n (759)
Time: Pain – ERCP
0 – 6 h 6 – 12 h12 – 18 h > 18 h
n (759)
Time: Pain – ERCP
0 – 6 h 6 – 12 h12 – 18 h > 18 h
IMPS
2 (40%) 15 (30%) 20 (24%)101 (16%)
IMPS
2 (40%) 15 (30%) 20 (24%)101 (16%)
No IMPS
3 (60%) 35 (70%) 65 (76%)518 (84%)
No IMPS
3 (60%) 35 (70%) 65 (76%)518 (84%)
Prediction of impacted stone – ES timingPrediction of impacted stone – ES timing
n (759)
Time: Adm – ERCP
0 – 2 h2 – 4 h4 – 6 h > 6 h
n (759)
Time: Adm – ERCP
0 – 2 h2 – 4 h4 – 6 h > 6 h
IMPS
24 (32%) 49 (21%) 18 (13%) 47 (15%)
IMPS
24 (32%) 49 (21%) 18 (13%) 47 (15%)
No IMPS
52 (68%)185 (79%)121 (87%)263 (85%)
No IMPS
52 (68%)185 (79%)121 (87%)263 (85%)
Prediction of impacted stone – ES timingPrediction of impacted stone – ES timing
Prediction of impacted stone – ES timingPrediction of impacted stone – ES timing
n (789)%
Temp (C)Bilirubin (mg/dL)ALT (U)ALP (U)GGT (U)WBC (G/L)CRP (mg/L)CBD Ø (mm)
n (789)%
Temp (C)Bilirubin (mg/dL)ALT (U)ALP (U)GGT (U)WBC (G/L)CRP (mg/L)CBD Ø (mm)
no AOC703
89.1 %
37.5 3.138822852712.451.8 9.7
no AOC703
89.1 %
37.5 3.138822852712.451.8 9.7
AOC86
10.9 %
37.5 5.535933773214.692.514.0
AOC86
10.9 %
37.5 5.535933773214.692.514.0
p
0.4450.0000.3830.0000.0000.0000.0000.000
p
0.4450.0000.3830.0000.0000.0000.0000.000
Prediction of acute cholangitisPrediction of acute cholangitis
o CBD stones are difficult to be predicted
o ES in patients with no CBD stones ?
o ES causes decompression of pancreatic and bile ducts(papillary edema may develop after stone passage)
o ES prevents the repeated obstruction of the papillatriggering the next episode of ABP
o ES can lead to removal of possible ERC-invisible CBD stones (very rare ~ 3%)
o CBD stones are difficult to be predicted
o ES in patients with no CBD stones ?
o ES causes decompression of pancreatic and bile ducts(papillary edema may develop after stone passage)
o ES prevents the repeated obstruction of the papillatriggering the next episode of ABP
o ES can lead to removal of possible ERC-invisible CBD stones (very rare ~ 3%)
ERCP / ES for ABP – ES for all patients?ERCP / ES for ABP – ES for all patients?
o 280 patients, 205 randomized (102 CM, 103 ERCP)o ERCP / ES < 24 ho 280 patients, 205 randomized (102 CM, 103 ERCP)o ERCP / ES < 24 h
o ES in 75 patients with impacted stone w/o randomo ES in 100% of ES group (irrespective of CBD stones)o ES useful in both predicted mild and severe cases
o ES in 75 patients with impacted stone w/o randomo ES in 100% of ES group (irrespective of CBD stones)o ES useful in both predicted mild and severe cases
CMCM
25%25%74%74%38%38%
EESS
10%10%39%39%17%17%
CMCM
5%5%33%33%13%13%
EESS
0%0% 4% 4% 2%2%
ABPABP
Predicted mildPredicted mildPredicted severePredicted severeTotalTotal
ComplicationsComplications MortalityMortality
Nowak et al., Gastroenterology 1995 (abstract)Nowak et al., Gastroenterology 1995 (abstract)
ERCP / ES for ABP – Nowak et al.ERCP / ES for ABP – Nowak et al.
o 976 patients, 253 randomized (126 CM, 127 ERCP)o ERCP / ES < 12 h (median 5 h)o 976 patients, 253 randomized (126 CM, 127 ERCP)o ERCP / ES < 12 h (median 5 h)
o ES w/o random in jaundice, AOC, CBD stones, etc.o ERCP for all, randomization after negative ERCo Stratification for gallbladder stoneso ES 100% ES group
o ES w/o random in jaundice, AOC, CBD stones, etc.o ERCP for all, randomization after negative ERCo Stratification for gallbladder stoneso ES 100% ES group
CMCM
48%48%
EESS
25%25%
CMCM
5%5%
EESS
1%1%
ABPABP
TotalTotal
ComplicationsComplications MortalityMortality
Nowakowska et al., Gut 2010 (abstract)Nowakowska et al., Gut 2010 (abstract)
ERCP / ES for ABP – Nowakowska et al.ERCP / ES for ABP – Nowakowska et al.
o 78 patients with cholestasis (26 CM, 52 ERCP)o ERCP / ES < 72 h from onseto 78 patients with cholestasis (26 CM, 52 ERCP)o ERCP / ES < 72 h from onset
o Patients with severe ABP from PROPATRIA studyo Prospective study, no randomizationo Cholestasis (Bil > 2.3, CBD > 8 (10) mm)o ES 87% ERCP
o Patients with severe ABP from PROPATRIA studyo Prospective study, no randomizationo Cholestasis (Bil > 2.3, CBD > 8 (10) mm)o ES 87% ERCP
CMCM
54%54%
EESS
25%25%
CMCM
15%15%
EESS
6%6%
ABPABP
TotalTotal
ComplicationsComplications MortalityMortality
Van Santvoort et al., Ann Surg 2009Van Santvoort et al., Ann Surg 2009
ERCP / ES for ABP – van Santvoort et al.ERCP / ES for ABP – van Santvoort et al.
7 RCTs, 1107 patients, (547 CM, 560 ERCP)7 RCTs, 1107 patients, (547 CM, 560 ERCP)
CMCM34 %34 %33 %33 %51 %51 %29%29%18 %18 %38 %38 %48 %48 %40 %40 %
ERCPERCP17 %17 %16 %16 %46 %46 % 7%7%22 %22 %17 %17 %25 %25 %25 %25 %
CMCM 8.2 %8.2 % 7.9 %7.9 % 3.6 %3.6 % 0.0%0.0%
2.0 %2.0 %12.7 %12.7 % 4.8 %4.8 % 6.2 %6.2 %
ERCPERCP1.7 %1.7 %1.6 %1.6 %7.9 %7.9 %0.0%0.0%3.9 %3.9 %2.2 %2.2 %0.8 %0.8 %2.9 %2.9 %
NeoptolemosNeoptolemosFanFanFölschFölschAcostaAcostaOriaOriaNowakNowakNowakowskaNowakowskaTotalTotal
ComplicationsComplications MortalityMortality
ERCP / ES for ABP – Pooled analysisERCP / ES for ABP – Pooled analysis
ERCP / ES for ABP – Pooled analysisERCP / ES for ABP – Pooled analysis
o Designs totally different
o Different entry criteria
o Different treatment regimens
o Different outcome criteria
o Designs totally different
o Different entry criteria
o Different treatment regimens
o Different outcome criteria
ERCP / ES for ABP – Pooled analysisERCP / ES for ABP – Pooled analysis
oMay be difficult
o Pre-cut necessary up to 35%
o Failure rate: 69/820 (8.5%)
o Safe – complications: 12 / 820 (1.5%)
o Consumes extensive resourcesTeam on call: 3-5 doctors and nurses
oMay be difficult
o Pre-cut necessary up to 35%
o Failure rate: 69/820 (8.5%)
o Safe – complications: 12 / 820 (1.5%)
o Consumes extensive resourcesTeam on call: 3-5 doctors and nurses
ERCP / ES for ABPERCP / ES for ABP
Year Q1 Q2 Q3 Q4 Tot P/Wk
2001 45 41 34 54 174 3.32002 44 49 46 73 212 4.12003 59 54 65 56 234 4.52004 71 76 65 47 259 5.0
P/Wk 4.2 4.2 4.0 4.4
Weekly max: 15 cases (Mar 27 - Apr 2, 04)Daily max: 5 cases (Nov 16, 01)
(8 additional days - 4 cases/d)
Year Q1 Q2 Q3 Q4 Tot P/Wk
2001 45 41 34 54 174 3.32002 44 49 46 73 212 4.12003 59 54 65 56 234 4.52004 71 76 65 47 259 5.0
P/Wk 4.2 4.2 4.0 4.4
Weekly max: 15 cases (Mar 27 - Apr 2, 04)Daily max: 5 cases (Nov 16, 01)
(8 additional days - 4 cases/d)
ERCP / ES for ABP in KatowiceERCP / ES for ABP in Katowice
o ABP is triggered by obstructionof major duodenal papilla by biliary stones
o Rapid identification of biliary etiologyis of great importance
o Urgent ERCP / ES decreases complicationsand mortality rates
o As the CBD stones identification is not perfectand there is no time for severity assessmenturgent ES should be done in all patients with ABP
o ABP is triggered by obstructionof major duodenal papilla by biliary stones
o Rapid identification of biliary etiologyis of great importance
o Urgent ERCP / ES decreases complicationsand mortality rates
o As the CBD stones identification is not perfectand there is no time for severity assessmenturgent ES should be done in all patients with ABP
Acute biliary pancreatitis - SummaryAcute biliary pancreatitis - Summary
ERCP for ABP prognosisERCP for ABP prognosis
No swellingNo swelling Minor swelling,limited to peripapillaryarea
Minor swelling,limited to peripapillaryarea
Severe swellingwith extensiveinvolvementof D2, bluishdiscoloration
Severe swellingwith extensiveinvolvementof D2, bluishdiscoloration
Moderateswelling withextensive involvementof D2
Moderateswelling withextensive involvementof D2
DGE MUSK 2000-2005DGE MUSK 2000-2005
ERCP for ABP prognosisERCP for ABP prognosis
DGE MUSK 2000-2005DGE MUSK 2000-2005
Duodenal swellingDuodenal swelling
DGE MUSK 2000-2005DGE MUSK 2000-2005
Normal duodenumNormal duodenum Deformed duodenal loopD2 deformed and narrowed
Deformed duodenal loopD2 deformed and narrowed
Duodenal swellingDuodenal swelling
DGE & DPATMUSK
2000-2005
DGE & DPATMUSK
2000-2005Mucosal hyperemiaMucosal hyperemia
Edema of submucosal layerEdema of submucosal layer
Duodenal swellingDuodenal swelling
Normal duodenumNormal duodenum Marked thickening of D2 wallMarked thickening of D2 wall
DGE & DRAD MUSK, Helimed 2000-2005DGE & DRAD MUSK, Helimed 2000-2005
20 mm20 mm
Duodenal swellingDuodenal swelling
DGE & DRAD MUSK, Helimed 2000-2005DGE & DRAD MUSK, Helimed 2000-2005
D2 swellinglimited toperipapillaryarea
D2 swellinglimited toperipapillaryarea
D2 swellinglimited toantero-medialwall
D2 swellinglimited toantero-medialwall
Duodenal swellingDuodenal swelling
DGE & DRAD MUSK, Helimed 2000-2005DGE & DRAD MUSK, Helimed 2000-2005
Severe swellingwith circularD2 involvement;lumen barely visiblein the most severe cases
Severe swellingwith circularD2 involvement;lumen barely visiblein the most severe cases
Duodenal swellingDuodenal swelling
n (851)%
% severe% surgery% mortality
SGS-10
n (851)%
% severe% surgery% mortality
SGS-10
N69081%
31 4 2
3.9
N69081%
31 4 2
3.9
MLD405%
48 5 3
4.9
MLD405%
48 5 3
4.9
MOD88
10%
7216 8
6.0
MOD88
10%
7216 8
6.0
SEV334%
944236
7.9
SEV334%
944236
7.9
p
0.00000.00000.0000
0.0000
p
0.00000.00000.0000
0.0000
Duodenopathy gradeDuodenopathy grade
Marek et al., Gut 2005 (abstract)Marek et al., Gut 2005 (abstract)
Duodenal swellingDuodenal swelling
o Gastric stasis (I 9%; S 73%; RR=2.1)o Erosive gastropathy (I 9%; S 55%; RR=1.5)o Unident. / v. small papilla (I 5%; S 55%; RR=1.8)o Unident. / tight orifice (I 17%; S 54%; RR=1.5)o Failed initial CBD access (I 9%; S 61%; RR=1.7)o Small CBD Ø ≤ 4 mm (I 5%; S 62%; RR=1.8)o Erosive duodenopathy !!! (I 5%; S 31%; RR=0.7)
o Gastric stasis (I 9%; S 73%; RR=2.1)o Erosive gastropathy (I 9%; S 55%; RR=1.5)o Unident. / v. small papilla (I 5%; S 55%; RR=1.8)o Unident. / tight orifice (I 17%; S 54%; RR=1.5)o Failed initial CBD access (I 9%; S 61%; RR=1.7)o Small CBD Ø ≤ 4 mm (I 5%; S 62%; RR=1.8)o Erosive duodenopathy !!! (I 5%; S 31%; RR=0.7)
I = incidenceS = severe API = incidenceS = severe AP
ERCP for ABP prognosisERCP for ABP prognosis
EasyNormalDifficultFailed initial
p
EasyNormalDifficultFailed initial
p
Severe%
30394161
0.000
Severe%
30394161
0.000
Surgery %
3 51014
0.001
Surgery %
3 51014
0.001
Mortality%
2 3 511
0.004
Mortality%
2 3 511
0.004
n
308203266 74
n
308203266 74
Marek et al., UEGW 2006Marek et al., UEGW 2006
ERCP for ABP prognosis – Ease of CBD cannulationERCP for ABP prognosis – Ease of CBD cannulation
mm
0 ÷ 4 5 ÷ 8 9 ÷ 1213 +
p
mm
0 ÷ 4 5 ÷ 8 9 ÷ 1213 +
p
Severe%
62423420
0.000
Severe%
62423420
0.000
Surgery %
19 7 6 1
0.000
Surgery %
19 7 6 1
0.000
Mortality%
11 4 2 1
0.021
Mortality%
11 4 2 1
0.021
n
37269297137
n
37269297137
Marek et al., UEGW 2006Marek et al., UEGW 2006
ERCP for ABP prognosis – CBD diameterERCP for ABP prognosis – CBD diameter
• ERCP should not be done purely for prognostic assessment
• ERCP should not replace current prognostic systems
• When urgent ERCP is done for treatmentof acute episode of ABP,it may be of value to record findingscarrying possible prognostic information
• ERCP should not be done purely for prognostic assessment
• ERCP should not replace current prognostic systems
• When urgent ERCP is done for treatmentof acute episode of ABP,it may be of value to record findingscarrying possible prognostic information
ERCP for ABP prognosisERCP for ABP prognosis
Prognosis of ABPMajor duodenal papilla
Prognosis of ABPMajor duodenal papilla
Unident. to smallNormalLarge / v. largeW impacted stone
p
Unident. to smallNormalLarge / v. largeW impacted stone
p
Severe%
55313232
0.000
Severe%
55313232
0.000
Surgery %
14 5 4 1
0.000
Surgery %
14 5 4 1
0.000
Mortality%
10 2 3 0
0.000
Mortality%
10 2 3 0
0.000
n
237271256 87
n
237271256 87
Marek et al., UEGW 2006Marek et al., UEGW 2006
Pancreatic duodenopathyPancreatic duodenopathy
n (851)n CT (162)
DuodenumWall thick. (mm)Diameter (mm)Lumen (mm)L/D (%)
n (851)n CT (162)
DuodenumWall thick. (mm)Diameter (mm)Lumen (mm)L/D (%)
N69075
6.023.314.561
N69075
6.023.314.561
MLD4023
6.8
24.714.557
MLD4023
6.8
24.714.557
MOD8844
7.826.413.551
MOD8844
7.826.413.551
SEV3320
9.426.0 9.035
SEV3320
9.426.0 9.035
p
0.00000.00290.00040.0000
p
0.00000.00290.00040.0000
Duodenopathy gradeDuodenopathy grade
Marek et al., Gut 2005 (abstract)Marek et al., Gut 2005 (abstract)
n (851)%
Age (y)Sex (% F)BMI (kg/m2)SE failure (%)
n (851)%
Age (y)Sex (% F)BMI (kg/m2)SE failure (%)
N69081%
57.273
28.94
N69081%
57.273
28.94
MLD405%
62.153
30.613
MLD405%
62.153
30.613
MOD88
10%
60.759
31.917
MOD88
10%
60.759
31.917
SEV334%
65.149
32.370
SEV334%
65.149
32.370
p
0.00770.00010.00000.0000
p
0.00770.00010.00000.0000
Duodenopathy gradeDuodenopathy grade
Marek et al., Gut 2005 (abstract)Marek et al., Gut 2005 (abstract)
n (851)%
CRPmax48 mg/LIL-6max48 pg/mLWBCmax48 G/LAP-Ocum48 (score)CTSI72h (score)
n (851)%
CRPmax48 mg/LIL-6max48 pg/mLWBCmax48 G/LAP-Ocum48 (score)CTSI72h (score)
N69081%
12312010.5 9.6 1.7
N69081%
12312010.5 9.6 1.7
MLD405%
16314411.812.2 2.3
MLD405%
16314411.812.2 2.3
MOD88
10%
23226714.912.8 3.5
MOD88
10%
23226714.912.8 3.5
SEV334%
29925914.618.8 4.9
SEV334%
29925914.618.8 4.9
p
0.00000.00000.00000.00000.0000
p
0.00000.00000.00000.00000.0000
Marek et al., Gut 2005 (abstract)Marek et al., Gut 2005 (abstract)
Duodenopathy gradeDuodenopathy grade
Patients flow
958 18 No ERCP
Urgent ERCP
77 Failed ERC
Successful ERC
976 48 Non-biliary AP,
late phase ABPEarly phase of ABP
(within 48 h of pain)
1024Acute pancreatitis
8% / 958
CM
Stratification for gallbladder stonesRANDOMIZATION
126 131 ES
881385 CBD stones
43% / 881No CBD stone(s) 496
239 Indications for ES w/o CBDS(jaundice, AOC, pregnancy, children, etc.)
92% / 958
56% / 881
172
Impacted stone
18% / 95820% / 881
27% / 881257No other indicationsfor ES29% / 881
101 GBS + 25 GBS -
105 GBS + 26 GBS -
4 CBD mini-stones
127 ESITT PP