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