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Antibiotic prophylaxis with piperacillin (pip) does not prevent ERCP-induced cholangitis
Abstracts
/Netherlands
Journal
gest that endoscopy can be useful for diagnosis by revealing the graft protruding through the bowel wall, but data are scarce. We therefore reviewed 20 cases (18 patients) of aortoenteric fistula (3 primary, 17 secondary to prosthesis) during the period 1984-1994. Mean age at presentation was 69 years (range 56-95), time span between graft insertion and clinical presentation 5.4 years (range 1-12) and M/F ratio 17/l. TWO patients had repeated fistulae; 7 cases had,an acute presentation with shock; in 13 cases there was a more prolonged course; 16 cases had haematemesis, melaena or haematochezia. A so-called warning “herald” bleed before massive haemorrhage was not reported in any case. Three cases presented with fever of unknown origin, and 2 iron deficiency anaemia. Mean Hb was 4.8 (2.5-9.1) mM/I. Upper intestinal endoscopy (performed in 18 cases) revealed the graft protuding into the lumen in only 3 patients, all cases with subacute presentation with fever of unknown origin. In 1 patient a Dieulafoy lesion was diagnosed, but subsequent surgery revealed a fistula. In 2 other cases colonoscopy (performed because of iron deficiency anaemia) revealed ischaemic colitis and a carcinoma, but at subsequent surgery a fistula was diagnosed. CT scan (performed in 3 cases) did not show a specific image, but in all 3 cases was considered highly suspicious for fistula. Surgery (18x) or abduction (2x) revealed fistula to duodenum in 16 cases and to ileum in 4 cases. Hospital mortality was 55%. Conclusions: Most aorto-enteric fistulae have an subacute, prolonged presentation. Endoscopy can diagnose fistula in a minority, particularly in cases with subacute presentation of fever of unknown origin, Although endoscopy should be performed to exclude other causes of bleeding (e.g., ulcer), a negative examination does not argue against the diagnosis of fistula. Video
duodeno-jejunoscopy
with
the Olympus
Koningsberger,
G.P. van Berge Henegouwen,
Department Netherlands.
Gastroenterology,
of
University
SIF-100. J.C. J.W. Bogaard.
Hospital,
Utrecht,
Although regular endoscopes can enter the jejunum, enteroclysis is superior for imaging of the small bowel. It has a sensitivity of 90% for tumours, but only 20% for bleeding lesions, and the yield drops when bleeding is not acute or minor. Erythrocyte scanning and angiography have similar drawbacks. The horizontal duodenum remains an obscure alley in enteroclysis. Spiral-CT may emerge as a useful imaging technique for small bowel abnormalities. The Olympus SIF-100 video jejunoscope has a forward viewing, wide angle (140”) optical system and a working length of 2.17 m. The biopsy channel is 2.8 mm and the outer diameter is 11.2 mm. The endoscope has all the regular technical abilities, although the steering is somewhat less direct due to length. An overtube is inserted once the duodenum is reached, facilitating further introduction. However, invariantly some length was lost in the stomach. We have performed 29 duodeno-jejunoscopies with an average of l/wk. 50% derived from other hospitals. Acute or intermittent chronic blood loss was the main indication in 23 cases, 3 were referred for a tumour, 2
of Medicine
47 (1995)
A21
AI -A42
for hypoalbuminaemia and 1 for upper GI Crohn’s disease. The whole procedure takes 15-30 min and was done under sedation with midazolam iv. It is easy to perform with intact anatomy and few intra-abdominal adhesions and is also feasible on the ICU. The Treitz ligament may form a slight impediment, where a guide-wire can help. The average reach in the jejunum (X-ray-confirmed) was 70 cm past Treitz, with a maximum of 100 cm, improving with experience. Before withdrawal, 1 cc of glucagon was given i.v. The diagnostic yield was 58.6%. Abnormalities were found in the duodenum (47%) the jejunum (29%), and in both (24%). Single or multiple bleeding sites were found in 52%. Heater-probe therapy could only be performed in 10%. Angiodysplasias were seen 5 times. Two ischaemic ulcerations on surgical anastomoses were detected. A watermelon stomach, an adenocarcinoma at Treitz and multiple bleeding hamartomas were diagnosed once. At 75 cm in the jejunum a leiomyosarcoma was encountered. Secondary phlebectasia/lymphangiectasia was seen in chronic right-sided heart congestion, and (congenital) intestinal lymphangiectasia was diagnosed in another patient. A perforation of the horizontal duodenum was caused by a non-Hodgkin GALToma. A duodenal stenosis was due to Crohn’s disease, and an extremely rare folliclecentre-cell lymphoma was diagnosed. Conclusion: Although a controlled study is needed, this small series warrants the use of (videokiuodeno-jejunoscopy in specialized centres. Antibiotic prophylaxis with ERCP-induced eholaagitis.
piperacillin
(pip)
does not prevent
S.J. van den Hazel ‘, P. Speelman *, G.N.J. Tytgat *, J. Dankert 3, D.J. van Leeuwen 4. Departments of ’ Gastroenterology, 2 Intern& Medicine and 3 Medical Microbiology, Academic Medical Netherlands; 4 Division of Gastroenterology, abama, Birmingham, AL, USA.
Centre, Amsterdam, University of Al-
Antibiotic prophylaxis is widely used in the prevention of ERCP-induced cholangitis, but its efficacy remains to be proven. We report a double-blind, placebo-controlled trial of the efficacy of single-dose PIP in reducing the incidence of acute cholangitis (AC) within 1 week after ERCP. Patients who underwent ERCP for suspected biliary stones or a distal common bile duct obstruction were selected. Major exclusion criteria were a previous ERCP within 7 days, a biliaty endoprosthesis in situ, and use of antimicrobial agents or fever within 7 days prior to the procedure. PIP (4 g) or placebo was given (i.v.) f30 min before ERCP. AC was diagnosed when there was fever of > 38”C, a need for antibiotic treatment, and no symptoms indicating a source of infection outside the biliary tree. Between April 1991 and June 1994, 551 patients were included. During ERCP stones were found in 147 patients, a malignant distal obstruction in 203, other pathology in 88, and a normal biliary tract in 113. Of the 281 patients on placebo, 17 developed AC (6.0%) as compared to 12 of 270 patients on PIP (4.4%, RR = 0.73, 95% CI 0.36-1.51, p -= 0.40). Analyzing patients with stones or a malignancy separately, there was still no significant advantage of PIP over placebo.
A22
Abstracts
/Netherlands
Journal
Conclusion: Single-dose PIP does not reduce the incidence of acute cholangitis after ERCP in patients with suspected bihary tract stones or a malignant distal common bile duct obstruction. Endosonography: gastric folds.
a valuable
tool
in the examination
of large
E.B.J. van Essen, P. Fockens, H.M. van Dullemen, G.N.J. Tytgat. Department of Gustroenterology, Academic
Medical
Centre,
Amsterdam,
Netherlands.
Large gastric folds or a thickened gastric wall at CT-scan or trans-abdominal ultrasonography (US) can be a difficult diagnostic problem when biopsies are negative. Between 8/91 and 11/94, 27 patients (mean age 57.7 yr, range 38-81; 15 male) with suspicion of a thickened gastric wall were referred for endosonographic (ES) evaluation. All patients had negative histology; in 1 no biopsies had been taken because of acute bleeding; 19 patients were referred because of large gastric folds at gastroscopy; 8 patients had a thickened stomach wall at CT or US and/or a rigid stomach wall at endoscopy or barium X-ray. Complaints of early satiety were reported by 15 patients. ES was performed with Olympus GF-UM 3 or GF-UM 20 (7.5/12 MHz) echoendoscopes. ES showed a normal wall layer size and structure in 5 patients; 4 patients had focal abnormalities. 18 patients had diffuse thickening of gastric layers 2 (5 pts), 3 (1 pt) or 2, 3 and 4 (12 pts). ES suggested malignancy in 16 patients (ES diagnosis: 12 linitis plastica, 1 adenocarcinoma, 1 leiomyosarcoma, 1 nonHodgkin lymphoma, 1 peritoneal metastasis outside the stomach). ES suggested a benign cause of the gastric wall thickening in 11 cases (ES diagnosis: 3 Menetrier’s disease, 3 gastritis, 5 no abnormalities). Malignancy was later proven in 15/16 patients in whom ES had suggested it. In all patients with a final diagnosis of linitis plastica, ES showed a diffuse thickening of layers 2, 3 and 4. In 2 patients the linitis was metastatic to lobulated breast cancer. Follow-up of the 11 patients in whom ES suggested a benign cause, no malignancy was diagnosed after a median follow-up of 12 months (range 2-29). Overall, ES provided a correct diagnosis in 22 of the 27 patients. In the group of 5 patients in whom ES was wrong, 2 cases of gastritis were diagnosed as Menetrier’s, 2 cases of gastritis were diagnosed as normal, and 1 case of gastric Crohn’s disease was falsely diagnosed as linitis plastica. Conclusion: ES is a valuable method in evaluation of patients in whom gastric wall thickening is suspected and biopsies are negative for malignancy. It was possible to differentiate between malignant and benign causes in 26 of 27 patients. No malignancy was missed with ES. ES should be used early in the evaluation of this group of patients. Long-term
follow-up after endoscopic sphincterotomy (EST) for bile duct stones in patients younger than 60 years. Report on 100 patients with a median follow-up of 15 years.
J.J.G.H.M. Bergman, S. van der Mey, E.A.J. Rauws, G.N.J. Tytgat, K. Huibregtse. Department of Gastroenterology Academic
Medical
Centre,
Amsterdam,
Netherlands.
We retrospectively evaluated the rate of late complications after EST for bile duct stones.
of Medicine
47 (1995)
AI -A42
Patients: Patients had to meet the following inclusion criteria: (1) treated between 1976 and 1980, (2) complete stone removal after EST, (3) prior cholecystectomy or elective cholecystectomy within 2 months after EST, and (4) 60 years or younger at the time of ERCP. A total of 100 patients were selected from 3 independent databases. Methods: Information was obtained from general practitioners and patients by telephone. Patients were asked to complete a postal questionnaire and a blood sample was obtained for liver function tests. Results: Information was obtained on 94 patients (94%), in the majority of cases (87%) from multiple sources. Of the patients alive at time of follow-up, questionnaires and blood samples were obtained in 89%. There were 26 males and 68 females with a mean age of 51 years (range 23-60). Nine patients had a gallbladder in situ and underwent elective cholecystectomy within 2 months after EST, 85 patients had undergone cholecystectomy, 8 days to 39 years before. Early complications ( < 30 days) occurred in 14 patients (15%). One patient died of a retroperitoneal perforation. During a median period of 15 years (range 3-18) 22 patients (24%) developed a total of 36 late complications. There were 21 patients with symptoms of recurrent bile duct stones and 1 patient with acute pancreatitis. Other late complications, like recurrent ascending cholangitis or malignant degeneration, were not observed. ERCP was performed in 20 patients and demonstrated bile duct stones in 13, combined with stenosis of the EST-opening in 9 patients. Late complications were initially managed endoscopically and/or conservatively. One patient underwent surgery after failed endoscopic treatment and 1 patient died of cholangitis before she could undergo an ERCP. Twelve other patients died of unrelated causes during follow-up. Conclusions: After EST for bile duct stones, late complications occur in a significant proportion of patients. Stone recurrence remains the most important problem and can usually be managed endoscopically.
Short-term atic bile
endoscopic duct strictures
stent therapy in primary
for dominant extrahepsclerosing cholangkis.
A.W.M. van Milligen de Wit, J. van Bracht, E.A.J. Rauws, G.N.J. Tytgat, K. Huibregtse. Department of Gustroenterology, Academic
Medical
Centre,
Amsterdam,
Netherlands.
The duration of stent placement for the optimal and safe treatment of symptomatic dominant extrahepatic bile duct strictures in primary sclerosing cholangitis (PSC) is not known. The duration. of stent placement is ideally determined by the time required to achieve the optimal dilatory effect with a minimum of complications. Previously, stents were left in situ for at least 6, but mostly 12 weeks. This is frequently complicated by stent clogging. We conducted a prospective trial to determine the efficacy of l-week stent placement in PSC patients with symptomatic dominant extrahepatic bile duct strictures. Patients: In the first half of 1994 10 PSC patients (4F/6M) were eligible for endoscopic stent intervention. Mean age of patients was 46 (23-69) years and PSC was present for a mean
/Netherlands
Journal
gest that endoscopy can be useful for diagnosis by revealing the graft protruding through the bowel wall, but data are scarce. We therefore reviewed 20 cases (18 patients) of aortoenteric fistula (3 primary, 17 secondary to prosthesis) during the period 1984-1994. Mean age at presentation was 69 years (range 56-95), time span between graft insertion and clinical presentation 5.4 years (range 1-12) and M/F ratio 17/l. TWO patients had repeated fistulae; 7 cases had,an acute presentation with shock; in 13 cases there was a more prolonged course; 16 cases had haematemesis, melaena or haematochezia. A so-called warning “herald” bleed before massive haemorrhage was not reported in any case. Three cases presented with fever of unknown origin, and 2 iron deficiency anaemia. Mean Hb was 4.8 (2.5-9.1) mM/I. Upper intestinal endoscopy (performed in 18 cases) revealed the graft protuding into the lumen in only 3 patients, all cases with subacute presentation with fever of unknown origin. In 1 patient a Dieulafoy lesion was diagnosed, but subsequent surgery revealed a fistula. In 2 other cases colonoscopy (performed because of iron deficiency anaemia) revealed ischaemic colitis and a carcinoma, but at subsequent surgery a fistula was diagnosed. CT scan (performed in 3 cases) did not show a specific image, but in all 3 cases was considered highly suspicious for fistula. Surgery (18x) or abduction (2x) revealed fistula to duodenum in 16 cases and to ileum in 4 cases. Hospital mortality was 55%. Conclusions: Most aorto-enteric fistulae have an subacute, prolonged presentation. Endoscopy can diagnose fistula in a minority, particularly in cases with subacute presentation of fever of unknown origin, Although endoscopy should be performed to exclude other causes of bleeding (e.g., ulcer), a negative examination does not argue against the diagnosis of fistula. Video
duodeno-jejunoscopy
with
the Olympus
Koningsberger,
G.P. van Berge Henegouwen,
Department Netherlands.
Gastroenterology,
of
University
SIF-100. J.C. J.W. Bogaard.
Hospital,
Utrecht,
Although regular endoscopes can enter the jejunum, enteroclysis is superior for imaging of the small bowel. It has a sensitivity of 90% for tumours, but only 20% for bleeding lesions, and the yield drops when bleeding is not acute or minor. Erythrocyte scanning and angiography have similar drawbacks. The horizontal duodenum remains an obscure alley in enteroclysis. Spiral-CT may emerge as a useful imaging technique for small bowel abnormalities. The Olympus SIF-100 video jejunoscope has a forward viewing, wide angle (140”) optical system and a working length of 2.17 m. The biopsy channel is 2.8 mm and the outer diameter is 11.2 mm. The endoscope has all the regular technical abilities, although the steering is somewhat less direct due to length. An overtube is inserted once the duodenum is reached, facilitating further introduction. However, invariantly some length was lost in the stomach. We have performed 29 duodeno-jejunoscopies with an average of l/wk. 50% derived from other hospitals. Acute or intermittent chronic blood loss was the main indication in 23 cases, 3 were referred for a tumour, 2
of Medicine
47 (1995)
A21
AI -A42
for hypoalbuminaemia and 1 for upper GI Crohn’s disease. The whole procedure takes 15-30 min and was done under sedation with midazolam iv. It is easy to perform with intact anatomy and few intra-abdominal adhesions and is also feasible on the ICU. The Treitz ligament may form a slight impediment, where a guide-wire can help. The average reach in the jejunum (X-ray-confirmed) was 70 cm past Treitz, with a maximum of 100 cm, improving with experience. Before withdrawal, 1 cc of glucagon was given i.v. The diagnostic yield was 58.6%. Abnormalities were found in the duodenum (47%) the jejunum (29%), and in both (24%). Single or multiple bleeding sites were found in 52%. Heater-probe therapy could only be performed in 10%. Angiodysplasias were seen 5 times. Two ischaemic ulcerations on surgical anastomoses were detected. A watermelon stomach, an adenocarcinoma at Treitz and multiple bleeding hamartomas were diagnosed once. At 75 cm in the jejunum a leiomyosarcoma was encountered. Secondary phlebectasia/lymphangiectasia was seen in chronic right-sided heart congestion, and (congenital) intestinal lymphangiectasia was diagnosed in another patient. A perforation of the horizontal duodenum was caused by a non-Hodgkin GALToma. A duodenal stenosis was due to Crohn’s disease, and an extremely rare folliclecentre-cell lymphoma was diagnosed. Conclusion: Although a controlled study is needed, this small series warrants the use of (videokiuodeno-jejunoscopy in specialized centres. Antibiotic prophylaxis with ERCP-induced eholaagitis.
piperacillin
(pip)
does not prevent
S.J. van den Hazel ‘, P. Speelman *, G.N.J. Tytgat *, J. Dankert 3, D.J. van Leeuwen 4. Departments of ’ Gastroenterology, 2 Intern& Medicine and 3 Medical Microbiology, Academic Medical Netherlands; 4 Division of Gastroenterology, abama, Birmingham, AL, USA.
Centre, Amsterdam, University of Al-
Antibiotic prophylaxis is widely used in the prevention of ERCP-induced cholangitis, but its efficacy remains to be proven. We report a double-blind, placebo-controlled trial of the efficacy of single-dose PIP in reducing the incidence of acute cholangitis (AC) within 1 week after ERCP. Patients who underwent ERCP for suspected biliary stones or a distal common bile duct obstruction were selected. Major exclusion criteria were a previous ERCP within 7 days, a biliaty endoprosthesis in situ, and use of antimicrobial agents or fever within 7 days prior to the procedure. PIP (4 g) or placebo was given (i.v.) f30 min before ERCP. AC was diagnosed when there was fever of > 38”C, a need for antibiotic treatment, and no symptoms indicating a source of infection outside the biliary tree. Between April 1991 and June 1994, 551 patients were included. During ERCP stones were found in 147 patients, a malignant distal obstruction in 203, other pathology in 88, and a normal biliary tract in 113. Of the 281 patients on placebo, 17 developed AC (6.0%) as compared to 12 of 270 patients on PIP (4.4%, RR = 0.73, 95% CI 0.36-1.51, p -= 0.40). Analyzing patients with stones or a malignancy separately, there was still no significant advantage of PIP over placebo.
A22
Abstracts
/Netherlands
Journal
Conclusion: Single-dose PIP does not reduce the incidence of acute cholangitis after ERCP in patients with suspected bihary tract stones or a malignant distal common bile duct obstruction. Endosonography: gastric folds.
a valuable
tool
in the examination
of large
E.B.J. van Essen, P. Fockens, H.M. van Dullemen, G.N.J. Tytgat. Department of Gustroenterology, Academic
Medical
Centre,
Amsterdam,
Netherlands.
Large gastric folds or a thickened gastric wall at CT-scan or trans-abdominal ultrasonography (US) can be a difficult diagnostic problem when biopsies are negative. Between 8/91 and 11/94, 27 patients (mean age 57.7 yr, range 38-81; 15 male) with suspicion of a thickened gastric wall were referred for endosonographic (ES) evaluation. All patients had negative histology; in 1 no biopsies had been taken because of acute bleeding; 19 patients were referred because of large gastric folds at gastroscopy; 8 patients had a thickened stomach wall at CT or US and/or a rigid stomach wall at endoscopy or barium X-ray. Complaints of early satiety were reported by 15 patients. ES was performed with Olympus GF-UM 3 or GF-UM 20 (7.5/12 MHz) echoendoscopes. ES showed a normal wall layer size and structure in 5 patients; 4 patients had focal abnormalities. 18 patients had diffuse thickening of gastric layers 2 (5 pts), 3 (1 pt) or 2, 3 and 4 (12 pts). ES suggested malignancy in 16 patients (ES diagnosis: 12 linitis plastica, 1 adenocarcinoma, 1 leiomyosarcoma, 1 nonHodgkin lymphoma, 1 peritoneal metastasis outside the stomach). ES suggested a benign cause of the gastric wall thickening in 11 cases (ES diagnosis: 3 Menetrier’s disease, 3 gastritis, 5 no abnormalities). Malignancy was later proven in 15/16 patients in whom ES had suggested it. In all patients with a final diagnosis of linitis plastica, ES showed a diffuse thickening of layers 2, 3 and 4. In 2 patients the linitis was metastatic to lobulated breast cancer. Follow-up of the 11 patients in whom ES suggested a benign cause, no malignancy was diagnosed after a median follow-up of 12 months (range 2-29). Overall, ES provided a correct diagnosis in 22 of the 27 patients. In the group of 5 patients in whom ES was wrong, 2 cases of gastritis were diagnosed as Menetrier’s, 2 cases of gastritis were diagnosed as normal, and 1 case of gastric Crohn’s disease was falsely diagnosed as linitis plastica. Conclusion: ES is a valuable method in evaluation of patients in whom gastric wall thickening is suspected and biopsies are negative for malignancy. It was possible to differentiate between malignant and benign causes in 26 of 27 patients. No malignancy was missed with ES. ES should be used early in the evaluation of this group of patients. Long-term
follow-up after endoscopic sphincterotomy (EST) for bile duct stones in patients younger than 60 years. Report on 100 patients with a median follow-up of 15 years.
J.J.G.H.M. Bergman, S. van der Mey, E.A.J. Rauws, G.N.J. Tytgat, K. Huibregtse. Department of Gastroenterology Academic
Medical
Centre,
Amsterdam,
Netherlands.
We retrospectively evaluated the rate of late complications after EST for bile duct stones.
of Medicine
47 (1995)
AI -A42
Patients: Patients had to meet the following inclusion criteria: (1) treated between 1976 and 1980, (2) complete stone removal after EST, (3) prior cholecystectomy or elective cholecystectomy within 2 months after EST, and (4) 60 years or younger at the time of ERCP. A total of 100 patients were selected from 3 independent databases. Methods: Information was obtained from general practitioners and patients by telephone. Patients were asked to complete a postal questionnaire and a blood sample was obtained for liver function tests. Results: Information was obtained on 94 patients (94%), in the majority of cases (87%) from multiple sources. Of the patients alive at time of follow-up, questionnaires and blood samples were obtained in 89%. There were 26 males and 68 females with a mean age of 51 years (range 23-60). Nine patients had a gallbladder in situ and underwent elective cholecystectomy within 2 months after EST, 85 patients had undergone cholecystectomy, 8 days to 39 years before. Early complications ( < 30 days) occurred in 14 patients (15%). One patient died of a retroperitoneal perforation. During a median period of 15 years (range 3-18) 22 patients (24%) developed a total of 36 late complications. There were 21 patients with symptoms of recurrent bile duct stones and 1 patient with acute pancreatitis. Other late complications, like recurrent ascending cholangitis or malignant degeneration, were not observed. ERCP was performed in 20 patients and demonstrated bile duct stones in 13, combined with stenosis of the EST-opening in 9 patients. Late complications were initially managed endoscopically and/or conservatively. One patient underwent surgery after failed endoscopic treatment and 1 patient died of cholangitis before she could undergo an ERCP. Twelve other patients died of unrelated causes during follow-up. Conclusions: After EST for bile duct stones, late complications occur in a significant proportion of patients. Stone recurrence remains the most important problem and can usually be managed endoscopically.
Short-term atic bile
endoscopic duct strictures
stent therapy in primary
for dominant extrahepsclerosing cholangkis.
A.W.M. van Milligen de Wit, J. van Bracht, E.A.J. Rauws, G.N.J. Tytgat, K. Huibregtse. Department of Gustroenterology, Academic
Medical
Centre,
Amsterdam,
Netherlands.
The duration of stent placement for the optimal and safe treatment of symptomatic dominant extrahepatic bile duct strictures in primary sclerosing cholangitis (PSC) is not known. The duration. of stent placement is ideally determined by the time required to achieve the optimal dilatory effect with a minimum of complications. Previously, stents were left in situ for at least 6, but mostly 12 weeks. This is frequently complicated by stent clogging. We conducted a prospective trial to determine the efficacy of l-week stent placement in PSC patients with symptomatic dominant extrahepatic bile duct strictures. Patients: In the first half of 1994 10 PSC patients (4F/6M) were eligible for endoscopic stent intervention. Mean age of patients was 46 (23-69) years and PSC was present for a mean