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Can liver function tests be entirely normal in suppurative cholangitis?
ERCP-BILIARY 457
459
INJECTION THERAPY IN THE TREATMENT OF SEVERE BLEEDING AFTER ENDOSCOPIC SPHINCTEROTOMY Llach J, V~zsconez C, Bordas JM, Gin6s A, Mondelo F, Ter~s J. Gastrointestinal Endoscopy Unit. Hospital Clinic. University of Barcelona. Spain.
PROSPECTIVE STUDIES ON POST ERCP/ES ACUTE PANCREATITIS. SIED LOMBARDIA PROCOP Group reported by: E. Masci, G. Toti, G. Minoli, F. Cosentino, A. Mariani, S. Guerini, E. Meroni, G. Missale, A. Lomazzl, A. Prada, U. Comln, C. Crosta, A. Tittobello S. Raffaele Hospital, University of Milan, Italy AIM: of our study was to assess risk factors for post ERCP/ES acute pancreatitis due to endoscopic maneuvers on Vater's papilla in a prospective Italian multlcentric study. METHOD: A 400-variable data-base considering variable of procedure, indication for procedure, the clinical condition of the patient, the morphology of the papilla, of biliary and pancreatic ducts and the associated procedure or stenring, was collected for all patients undergoing ERCP/ES in 12 centres in Lombardia. RESULT: 1693 patients submitted to 1908 procedures on biliary and pancreatic ducts were included in the study. 97 complications were observed with 3 related deaths. The most frequent complication that we observed was the acute pancrearitis. An attack of acute pancreatitis was observed in 31 patients (1.6%), mild in 26 (1,36%) and necrotizing in 5 (0.26%). In all cases, the outcome of acute pancreatitis was favorable requiring surgery in 2 of the necrotizing forms and conservative treatment in all the rest. Comparing patients with this complication, with overall patients submitted to ERCP/ES, were observed a positive correlation for acute pancreatkis with needle-knife ES (p < 0.05), injection of pancreatic duct (p < 0.007) and acinarization (p < 0.0001). No related factors were failure of cannulation, repeated injection of pancreatic duct, injection of biliary ducts only, CBD < 1 cm, small papilla and pre-cut. CONCLUSIONS: The incidence of post ERCP/ES complications in our series is lower to that reported in recent large prospective series in the literature. Factors which increase risk of pancreatkis only include opacification of pancreatic ducts and acinarizarion.
Since its introduction into endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy (ES) has become a common procedure to remove bile-duct stones and to facilitate the placement of stents through malignant and benign biliary strictures and for other biliary and pancreatic problems. Clinically significant hemorrhage after sphincterotomy occurs in 0,42% of patients, and in some cases considered severe, surgery may be required. We report the effect of endoscopic injection therapy in the treatment of severe hemorrhage after ES. Of the 760 patients who underwent biliary sphincterotomy, clinically significant hemorrhage (hematemesis and/or melena with hypotansion requiring at least four units of blood) occurred in 4 (0.5%). In all of these patients with severe bleeding, ES was performed to remove stones, and coagulopathy was present in two of them. Clinical recognition of hemorrhage was delayed 48, 72, 116 and 120 hours after ES. Duodenoscopy revealed arterial bleeding from the apical area of the papilla, and endoscopic injection therapy (adrenaline and polidocanol; 1-3 ml and 3-9 ml, respectively) into the bleeding site was effective in arresting hemorrhage in all of them. No patient required surgery and no clinical or biochemical complications related to the injection therapy were observed. Our experience shows that postsphincterotomy bleeding can be safely and effectively controlled by endoscopic injection therapy, thereby avoiding surgery in these patients.
1"458
460
ENDOSCOPIC SNARE AMPULLECTOMY FOR RESECTION OF BENIGN AMPULLARY NEOPLASMS, JA Martin,GB Haber,PP Kortan,I RalJmsn, M Abodl, GA DuVsll, JA Dorale, S Silva. The Wellesley Hospital, Universityof Toronto,Ontario,Canada. BACKGROUND: Traditionalmanagementfor benign ampuflary neoplasms has be?nsurgical. However,endoScol~Cresection and ablationcan providedefinitive, non-operativelmatmentfor benign lesions and in patients for whom ~nimallyinvasiveinterventionis preferable. PATIENTSAND METHOD~: 14 patientswith benignampullaryneoplasms,12 with adenoma, 1 with hamertoma, and 1 with adenomyoma,underwent endoscopic resectionbetween 10/89 and 10/96. 6 had familial adenomatouspolyposis(FAP). Mean age was 57 (range 34-83); 4 were female. 5 had dilated CBD, and 1 had CBD stones. Billarysphinoterotomy(EBS) was performedin 7 prior to, and 1 at, ampuliactomy to increase biopsy yield, provide drainage, and/or facilitate stone extraction.All resectionswere performedwith a monopoiarpolypestomysnare; 10 were performedin piecemealfashion, 4 on-bloc, and 8 with submucosal saline injection. 10 had pancreaticstent placementat ampullectomy, 4 had biliary stent placement,and 4 had neither. 1 patientreceivedcoaguletivetissueablationat index ampullectomywith argon plasma(x)agulation(APC). Patientshave beenfollowed with duedenoscopyand biopsy, with repeat resection or ablationwhere residual adenomawas identified,to the presenttime. RESULTS: Indexampullectomywas successful in eliminatingall abnormaltissue in 2 of 11 patientswith edanoma. 9 patients required F/U snare resections(6) and/or thermal ablation(6) with APC, YAG laser, bipolaror monopelarcoagulation (mean2.4 F/U ablations). Amongthe initial 12 patientswith adenoma,2 have died (1 complication,1 unrelated)and 10 others continuewith F/U. 6 of these have no evidence of abenoma. 2 continue with endoscopic surveillance for residual adenoma(1 FAP)and 2 otherswith FAP and high-gradedysplesiawere referredfor surgery. One refused and the other is currently receiving chemotherapy for desmoid tumor. Mean length of F/U was 31 months (range of 2-86). 30-day mortality and proCaduro-relatedmortalitywere 1/14 (7%): a patientwho developed pancreatitis post-ampullantomydied 6 days post-procadure with sepsis and multiorgan system failure; this patient had not undergone post-smpullectomy pancreaticstent placemenL Prosadure-relatadmorbiditywas 1/14 (7%): one patient developedbleedingat the ampullectomysite four hours pest-procedure,requiring operativehemostasle. Migrationof a bltiary stent found incidentallyon F/U ERCP was the singularasymptomaticprosadure-retatedcomplication. CONCLUSIONS: Endoscopicampullectomyis a reasonabletherapeuticoption in properly selented patients. Surveillanceduodenoscopy/biopsy is indicated to monitorfor ranurrenco, especiallyin FAP. Prophylacticpancreaticstent placement may protectagainstamputiectomy-ralatedpanoreatitle.
Can Liver F"unotton Tests Be Entirely Normal in Suppurative C h o ~ ? John McK~, Kenneth Miller, Andrew Marshall, Samir Shah, Ram Chuttani. Division of Gastroenterology Beth Israel Deaconess Medical Center, Boston, Massachusetts Ahn." (l) To examine if patiants with suppurative chotangitiscan have normal liver function tests (LFTs). (2) To characterize the clinical presentation and response to therapy in these patients. A retrospective review using the Clinquery| database was performed in a tertiary care center. Patients were identified with the following inclusion criteria: (1) normal transaminases, alkaline phosphatase and bilirubin on presentation (2) confmned cholangitis: purulent bile and (or) bacteremia of biliary origin. The clinical course and subsequent therapy was reviewed in all patients. Any delay in diagnosis due to the unusual presentation was documented. 491 patients had a discharge diagnosis of cholangitis. 7 patients met the inclusion criteria. The average delay in their diagnosis was 5.5 days (0-17 days). These patients were predominantly elderly females (mean age: 77.9 years). All 7 presented with abdominal pain, nausea, or vomiting. The use of prior antibiotics or steroids was found in the majority of these patients (5/7). Their clinical course is summarized in the table below:
VOLUME 45, NO. 4, 1997
Patient Tempat Abnormal Followup Diagnosis Biliary Patient Age & Sex PresentationUltrasound LFT'sAbnl Delay DrainageSurvival 88 F 101.0~ No 6 days 10 days Yes Yes 80 F 101.2~ Yes 6 days none No Yes 66 F 101.8~ Yes 1 days 1 day Yes Yes 79 F 100.7~ Yes 17 days 17 days Yes Yes 87 F 101.7~ Yes not done 0.5 days Yes No 77 M 98,6~ Yes 8 days 8 days Yes Yes 68 F 101.0~ Yes 1 days 1 day Yes Yes (1) Suppurative choiangitis can occur in the presence of normal LFTs. (2) This atypical presentation may delay diagnosis and effective therapy. (3) Predisposing factors include elderly females, prior antibiotics and steroid use.
GASTROINTESTINAL ENDOSCOPY A B 1 3 9
459
INJECTION THERAPY IN THE TREATMENT OF SEVERE BLEEDING AFTER ENDOSCOPIC SPHINCTEROTOMY Llach J, V~zsconez C, Bordas JM, Gin6s A, Mondelo F, Ter~s J. Gastrointestinal Endoscopy Unit. Hospital Clinic. University of Barcelona. Spain.
PROSPECTIVE STUDIES ON POST ERCP/ES ACUTE PANCREATITIS. SIED LOMBARDIA PROCOP Group reported by: E. Masci, G. Toti, G. Minoli, F. Cosentino, A. Mariani, S. Guerini, E. Meroni, G. Missale, A. Lomazzl, A. Prada, U. Comln, C. Crosta, A. Tittobello S. Raffaele Hospital, University of Milan, Italy AIM: of our study was to assess risk factors for post ERCP/ES acute pancreatitis due to endoscopic maneuvers on Vater's papilla in a prospective Italian multlcentric study. METHOD: A 400-variable data-base considering variable of procedure, indication for procedure, the clinical condition of the patient, the morphology of the papilla, of biliary and pancreatic ducts and the associated procedure or stenring, was collected for all patients undergoing ERCP/ES in 12 centres in Lombardia. RESULT: 1693 patients submitted to 1908 procedures on biliary and pancreatic ducts were included in the study. 97 complications were observed with 3 related deaths. The most frequent complication that we observed was the acute pancrearitis. An attack of acute pancreatitis was observed in 31 patients (1.6%), mild in 26 (1,36%) and necrotizing in 5 (0.26%). In all cases, the outcome of acute pancreatitis was favorable requiring surgery in 2 of the necrotizing forms and conservative treatment in all the rest. Comparing patients with this complication, with overall patients submitted to ERCP/ES, were observed a positive correlation for acute pancreatkis with needle-knife ES (p < 0.05), injection of pancreatic duct (p < 0.007) and acinarization (p < 0.0001). No related factors were failure of cannulation, repeated injection of pancreatic duct, injection of biliary ducts only, CBD < 1 cm, small papilla and pre-cut. CONCLUSIONS: The incidence of post ERCP/ES complications in our series is lower to that reported in recent large prospective series in the literature. Factors which increase risk of pancreatkis only include opacification of pancreatic ducts and acinarizarion.
Since its introduction into endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy (ES) has become a common procedure to remove bile-duct stones and to facilitate the placement of stents through malignant and benign biliary strictures and for other biliary and pancreatic problems. Clinically significant hemorrhage after sphincterotomy occurs in 0,42% of patients, and in some cases considered severe, surgery may be required. We report the effect of endoscopic injection therapy in the treatment of severe hemorrhage after ES. Of the 760 patients who underwent biliary sphincterotomy, clinically significant hemorrhage (hematemesis and/or melena with hypotansion requiring at least four units of blood) occurred in 4 (0.5%). In all of these patients with severe bleeding, ES was performed to remove stones, and coagulopathy was present in two of them. Clinical recognition of hemorrhage was delayed 48, 72, 116 and 120 hours after ES. Duodenoscopy revealed arterial bleeding from the apical area of the papilla, and endoscopic injection therapy (adrenaline and polidocanol; 1-3 ml and 3-9 ml, respectively) into the bleeding site was effective in arresting hemorrhage in all of them. No patient required surgery and no clinical or biochemical complications related to the injection therapy were observed. Our experience shows that postsphincterotomy bleeding can be safely and effectively controlled by endoscopic injection therapy, thereby avoiding surgery in these patients.
1"458
460
ENDOSCOPIC SNARE AMPULLECTOMY FOR RESECTION OF BENIGN AMPULLARY NEOPLASMS, JA Martin,GB Haber,PP Kortan,I RalJmsn, M Abodl, GA DuVsll, JA Dorale, S Silva. The Wellesley Hospital, Universityof Toronto,Ontario,Canada. BACKGROUND: Traditionalmanagementfor benign ampuflary neoplasms has be?nsurgical. However,endoScol~Cresection and ablationcan providedefinitive, non-operativelmatmentfor benign lesions and in patients for whom ~nimallyinvasiveinterventionis preferable. PATIENTSAND METHOD~: 14 patientswith benignampullaryneoplasms,12 with adenoma, 1 with hamertoma, and 1 with adenomyoma,underwent endoscopic resectionbetween 10/89 and 10/96. 6 had familial adenomatouspolyposis(FAP). Mean age was 57 (range 34-83); 4 were female. 5 had dilated CBD, and 1 had CBD stones. Billarysphinoterotomy(EBS) was performedin 7 prior to, and 1 at, ampuliactomy to increase biopsy yield, provide drainage, and/or facilitate stone extraction.All resectionswere performedwith a monopoiarpolypestomysnare; 10 were performedin piecemealfashion, 4 on-bloc, and 8 with submucosal saline injection. 10 had pancreaticstent placementat ampullectomy, 4 had biliary stent placement,and 4 had neither. 1 patientreceivedcoaguletivetissueablationat index ampullectomywith argon plasma(x)agulation(APC). Patientshave beenfollowed with duedenoscopyand biopsy, with repeat resection or ablationwhere residual adenomawas identified,to the presenttime. RESULTS: Indexampullectomywas successful in eliminatingall abnormaltissue in 2 of 11 patientswith edanoma. 9 patients required F/U snare resections(6) and/or thermal ablation(6) with APC, YAG laser, bipolaror monopelarcoagulation (mean2.4 F/U ablations). Amongthe initial 12 patientswith adenoma,2 have died (1 complication,1 unrelated)and 10 others continuewith F/U. 6 of these have no evidence of abenoma. 2 continue with endoscopic surveillance for residual adenoma(1 FAP)and 2 otherswith FAP and high-gradedysplesiawere referredfor surgery. One refused and the other is currently receiving chemotherapy for desmoid tumor. Mean length of F/U was 31 months (range of 2-86). 30-day mortality and proCaduro-relatedmortalitywere 1/14 (7%): a patientwho developed pancreatitis post-ampullantomydied 6 days post-procadure with sepsis and multiorgan system failure; this patient had not undergone post-smpullectomy pancreaticstent placemenL Prosadure-relatadmorbiditywas 1/14 (7%): one patient developedbleedingat the ampullectomysite four hours pest-procedure,requiring operativehemostasle. Migrationof a bltiary stent found incidentallyon F/U ERCP was the singularasymptomaticprosadure-retatedcomplication. CONCLUSIONS: Endoscopicampullectomyis a reasonabletherapeuticoption in properly selented patients. Surveillanceduodenoscopy/biopsy is indicated to monitorfor ranurrenco, especiallyin FAP. Prophylacticpancreaticstent placement may protectagainstamputiectomy-ralatedpanoreatitle.
Can Liver F"unotton Tests Be Entirely Normal in Suppurative C h o ~ ? John McK~, Kenneth Miller, Andrew Marshall, Samir Shah, Ram Chuttani. Division of Gastroenterology Beth Israel Deaconess Medical Center, Boston, Massachusetts Ahn." (l) To examine if patiants with suppurative chotangitiscan have normal liver function tests (LFTs). (2) To characterize the clinical presentation and response to therapy in these patients. A retrospective review using the Clinquery| database was performed in a tertiary care center. Patients were identified with the following inclusion criteria: (1) normal transaminases, alkaline phosphatase and bilirubin on presentation (2) confmned cholangitis: purulent bile and (or) bacteremia of biliary origin. The clinical course and subsequent therapy was reviewed in all patients. Any delay in diagnosis due to the unusual presentation was documented. 491 patients had a discharge diagnosis of cholangitis. 7 patients met the inclusion criteria. The average delay in their diagnosis was 5.5 days (0-17 days). These patients were predominantly elderly females (mean age: 77.9 years). All 7 presented with abdominal pain, nausea, or vomiting. The use of prior antibiotics or steroids was found in the majority of these patients (5/7). Their clinical course is summarized in the table below:
VOLUME 45, NO. 4, 1997
Patient Tempat Abnormal Followup Diagnosis Biliary Patient Age & Sex PresentationUltrasound LFT'sAbnl Delay DrainageSurvival 88 F 101.0~ No 6 days 10 days Yes Yes 80 F 101.2~ Yes 6 days none No Yes 66 F 101.8~ Yes 1 days 1 day Yes Yes 79 F 100.7~ Yes 17 days 17 days Yes Yes 87 F 101.7~ Yes not done 0.5 days Yes No 77 M 98,6~ Yes 8 days 8 days Yes Yes 68 F 101.0~ Yes 1 days 1 day Yes Yes (1) Suppurative choiangitis can occur in the presence of normal LFTs. (2) This atypical presentation may delay diagnosis and effective therapy. (3) Predisposing factors include elderly females, prior antibiotics and steroid use.
GASTROINTESTINAL ENDOSCOPY A B 1 3 9