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Endoscopic Retrograde Cholangiopancreatography in Infants: A Single Center 10 Year Experience
done laproscopically and as ambulatory procedures. A significant proportion of older adults still get open CCY.
AGA Abstracts
Su1287 Natural History of Unexplained Biliary Dilatation Nicholas M. Kelly, Benjamin Tharian, Tony Tham Mann-Whitney test analysis Table 2 - Comparison of proportions of elevated LFTs in the 2 groups
Introduction: Unexplained bile duct dilation is common. There are no studies regarding the natural history of bile duct dilation or how these patients should be managed. We sought to retrospectively identify a cohort of patients with biliary dilation on MRCP and assess the incidence of sinister pathology. Methods: MRCP database was searched to identify patients with biliary dilation. Data was collected on patient demographics, radiological diagnosis, diameter of common bile duct, liver function tests (LFTs) and what further investigations and follow up was carried out. Patients with unexplained biliary dilation at MRCP were followed up via search of radiological database, clinical record database and hospital notes. Results: 1386 MRCP results were reviewed from May 2005 to July 2009. 348 (25.1%) were identified in which a dilated bile duct was reported but no definite obstructing lesion was seen. 17 (4.9%) were excluded (referred from outside institution, follow up unavailable), leaving 331 for review. Of these, presumed diagnoses for biliary dilatation were gallstones (n=146, 44.1%), post-cholecystectomy (n=87, 26.3%), pancreatitis (n=27, 8.1%), cholecystitis (n=17, 5.1%), duodenal diverticulum (n=4, 1.2%), choledochocele (n=1, 0.3%) and strawberry gallbladder (n=1, 0.3%). There were 48 (14.5%) cases of unexplained biliary dilation constituting the follow up group. Females predominated (n=31, 64.6%). Mean age was 65 years (range 34-96). Mean duct diameter was 11mm (range 7-22). Follow up was available on 44 patients (91.6%). Mean follow up was 35 months (range 6-64). 12 (27.3%) were jaundiced (bilirubin >2mg/dL) in the 6 months prior to MRCP and 24 (54.5%) had obstructive LFTs (elevated GGT and ALP). 8 (18.2%) patients had ERCP. All were normal except 1 (12.5%), showing choledocholithiasis. 9 (20.5%) patients had duodenoscopy, all were normal. 1 patient (2.3%) had an endoscopic ultrasound, which was normal. Mortality was 13.6% (n=6; 1 acute myocardial infarction, 1 respiratory failure, 1 uterine carcinoma, 1 intracranial haemorrhage, 1 unknown, 1 pancreatic carcinoma). 2 (4.5%) were diagnosed with carcinoma head of pancreas 14 months and 8 months after their MRCP. Both were jaundiced. One was an 87yr old female who had ERCP which confirmed duct dilation but no obstructive cause. A 3rd CT scan 14 months later confirmed metastatic carcinoma from head of pancreas. The other was a 34 yr old man diagnosed with carcinoma head of pancreas 8 months later after presenting with obstructive jaundice followed by an ERCP and stent. He died 21 months after his MRCP. Conclusions: In 3 years of follow up of unexplained biliary dilatation, 4.5% of patients were diagnosed with a malignant etiology. We recommend that all patients with unexplained duct dilation, especially with jaundice, be closely followed up and considered for endoscopic ultrasound.
Fisher's Exact Test Analysis Su1289 Endoscopic Retrograde Cholangiopancreatography in Infants: A Single Center 10 Year Experience Dov Wengrower, Eran Goldin, Ishay Benuri, Michael Wilschanski, Eyal Shteyer Background. Endoscopic retrograde cholangiopancreatography (ERCP) is not as widely used in children as in adults and performed in few specialized centers. Most infants undergo ERCP due to cholestasis. Distinguishing extrahepatic biliary atresia (EHBA), from other causes of prolonged neonatal cholestasis may be challenging. EHBA is the leading indication for liver transplantation in children, and timely Kasai portoenterostomy (KP) may alter its natural history. When investigation is equivocal, performing an ERCP before an intraoperative cholangiogram may lead to other diagnoses and avoid an invasive procedure. The aim of this study is to review the experience of ERCP in children under the age of 3 months in a single national referral center. Methods: We conducted a retrospective chart review of all babies under the age of 3 months who underwent ERCP between the years 20002010. Data on demographics, diagnosis, anesthesia type, treatments, and complications were collected. Results: ERCP were performed on 27 babies less then 3 months old. There were 14 males (51%), and median age at time of procedure was 55 days (range, 33-89 days). A clinical indication in all infants was prolonged cholestasis. Abdominal ultrasound was normal in 16 infants, and others showed small gallbladder (5), biliary stones (4) and dilated bile ducts (2). Ten children underwent prior liver biopsy which was inconclusive. ERCP lead to the diagnosis of biliary atresia in 12 infants. Five infants had a normal exam and in 6, papilla cannulation failed or the ducts did not fill. In others, ERCP showed choledocal cyst (2), biliary stones (1), dilated bile ducts (1) and in one, the papilla was not detected. The final diagnoses in our cohort was EHBA (14), biliary stones (5), neonatal hepatitis (3) choledocal cyst (2) paucity of intrahepatic bile duct and congenital hepatic fibrosis (1). In the babies in which exam failed three had biliary atresia, 1 had paucity of bile ducts and 1 biliary stones. One baby was lost from follow-up. In 6 (22%) infants with clinical suspicion of EHBA, a normal ERCP ruled out the diagnosis and avoided an intra-operative cholangiogram. In children who were diagnosed with EHBA by ERCP, KP was performed without delay. General anesthesia was performed in all but one infant, by dedicated anesthesiologists. None of the infants had significant complications including pancreatitis from the procedure. Conclusions: In infants younger then 3 months of age, ERCP is feasible and safe. It may serve as an additional diagnostic tool in neonatal cholestasis in unclear cases and may prevent more invasive procedures. ERCP may be part of the algorithm of neonatal cholestasis, when it is available and other investigations fail to confirm a diagnosis.
Su1288 Abnormal Liver Function Tests in Acute Cholecystitis With and Without Choledocholithiasis Nicholas M. Kelly, Tony Tham Background & Aims: In acute cholecystitis, the presence of abnormal liver function tests (LFTs) is thought to indicate choledocholithiasis. We sought to determine the incidence of abnormal LFTs in patients with acute cholecystitis and examine their usefulness at predicting choledocholithiasis. Methods: A retrospective search was undertaken for the diagnosis of acute cholecystitis from 1st January 2007 - 31st December 2009. Those with complications (liver/GB abscesses & perforations) were excluded. Data was collected on patient age, sex, LFTs (bilirubin, gamma-glutamyl transferase (GGT), aspartate aminotransferase (AST) & alkaline phosphatase (ALP)) and imaging performed. Choledocholithiasis was diagnosed if bile duct stones were present on one of these modalities: ultrasound, CT, MRCP or ERCP. Statistics: Sensitivity and specificity were calculated for each LFT measured for the diagnosis of choledocholithiasis. Mann-Whitney test was used to analyse the difference between groups. Association of the incidence of elevated LFTs and choledocholithiasis was tested using Fishers exact test. Factor analysis was performed and the factor was used as the predictor variable for binary logistic regression. Results: 155 patients were identified with acute cholecystitis. 15 (9.7%) were excluded (complicated cholecystitis n=5, missing data n=9, wrongly coded n=1). Final analysis included 140 (Females n=77, 55.0%). Mean (range) age was 59.3yrs (18-94). 17 (12.1%) had choledocholithiasis. Mean bilirubin 1.7mg/dL (range 0.1-9.6; reference range 2.1-2.9), GGT 204.6U/L (range 7-1448; reference range 5-39), AST 89.3U/ L (range 9-684; reference range 13-35) and ALP 148.7 (range 35-658; reference range 4298). Bilirubin was elevated in 20 patients (14.3%), GGT in 100 (71.4%), AST in 57 (40.7%) and ALP in 69 (49.3%). Table 1 shows the comparison of LFTs for the 2 groups. Table 2 shows the comparison proportions of elevated results in the 2 groups. Sensitivity and specificity for the diagnosis of choledocholithiasis for bilirubin were 47.0% and 90.2%, for GGT 100% & 32.5%, for AST 70.6% & 63.4% and for ALP 76.5% and 54.5% respectively. Factor analysis showed that elevation of all 4 liver enzymes is predictive of choledocholithiasis (p<0.001). Conclusions: Abnormal LFTs are common with acute cholecystitis and do not necessarily imply the presence of bile duct stones. The incidence of abnormal LFTs in those with cholecystitis was 72.4%, largely attributable to an elevated GGT. Patients with choledocholithiasis are more likely to have significantly higher values of bilirubin, GGT, AST and ALP and also more likely to have more than one elevated at the same time. Elevation of all 4 liver enzymes is predictive of choledocholithiasis. Table 1 - Comparison of LFT values in the 2 groups
AGA Abstracts
Su1290 Long-Term Follow-up Study of Gallbladder in Situ After Endoscopic Common Duct Stone Removal in Korean Patients Joon Hyun Cho, Kyeong Ok Kim, Si Hyung Lee, Tae Nyeun Kim Background & Aims: Although there has been much debate over the fate of the gallbladder(GB) after endoscopic common bile duct(CBD) stone removal, subsequent cholecystectomy is generally recommended in patients with GB stone. However, the components of CBD stones in Korea, which are almost pigment stones, are different from those in western countries. Therefore, the natural course of the Korean patients with GB in-situ is likely to be different from that of patients in western countries. We assessed the natural course of the patients with GB in-situ following endoscopic removal of CBD stone to identify further biliary events and to evaluate the need for prophylactic cholecystectomy. Methods: We retrospectively analyzed 461 patients who had undergone endoscopic CBD stone removal between January 2000 and December 2004. Patients were excluded if there was evidence of concomitant intrahepatic stones(16 patients) or pancreatobiliary malignancies(20 patients), a history of previous cholecystectomy(147 patients) or insufficient follow-up(46 patients). 232 patients were consequently enrolled in this study and followed by medical record review or telephone interview. Results: After endoscopic CBD stone removal, 68 patients(30.6%) underwent subsequent cholecystectomy(cholecystectomy group) and 164 patients(60.4%) didn't(GB in-situ group). In the GB in-situ group, 44 patients had GB stones. With a median follow-up of 5.7 years, 10 patients(14.7%) in cholecystectomy group and 31 patients(20.0%) in GB in-situ group developed recurrent CBD stone. Cumulative recurrence rates of CBD stone were not significantly different between two groups(log rank, p=0.215) and the mean time to recurrence of CBD stone was similar between both groups(39.2 months vs 32.7, p=0.548). During the follow-up period, 6 patients(13.6%) in GB in-situ group with GB stone and 3 patients(2.5%) in GB-in-situ group without GB stone developed acute cholecystitis (log rank, p=0.003). Cumulative recurrence rates of CBD stone were not significantly different
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AGA Abstracts
Su1287 Natural History of Unexplained Biliary Dilatation Nicholas M. Kelly, Benjamin Tharian, Tony Tham Mann-Whitney test analysis Table 2 - Comparison of proportions of elevated LFTs in the 2 groups
Introduction: Unexplained bile duct dilation is common. There are no studies regarding the natural history of bile duct dilation or how these patients should be managed. We sought to retrospectively identify a cohort of patients with biliary dilation on MRCP and assess the incidence of sinister pathology. Methods: MRCP database was searched to identify patients with biliary dilation. Data was collected on patient demographics, radiological diagnosis, diameter of common bile duct, liver function tests (LFTs) and what further investigations and follow up was carried out. Patients with unexplained biliary dilation at MRCP were followed up via search of radiological database, clinical record database and hospital notes. Results: 1386 MRCP results were reviewed from May 2005 to July 2009. 348 (25.1%) were identified in which a dilated bile duct was reported but no definite obstructing lesion was seen. 17 (4.9%) were excluded (referred from outside institution, follow up unavailable), leaving 331 for review. Of these, presumed diagnoses for biliary dilatation were gallstones (n=146, 44.1%), post-cholecystectomy (n=87, 26.3%), pancreatitis (n=27, 8.1%), cholecystitis (n=17, 5.1%), duodenal diverticulum (n=4, 1.2%), choledochocele (n=1, 0.3%) and strawberry gallbladder (n=1, 0.3%). There were 48 (14.5%) cases of unexplained biliary dilation constituting the follow up group. Females predominated (n=31, 64.6%). Mean age was 65 years (range 34-96). Mean duct diameter was 11mm (range 7-22). Follow up was available on 44 patients (91.6%). Mean follow up was 35 months (range 6-64). 12 (27.3%) were jaundiced (bilirubin >2mg/dL) in the 6 months prior to MRCP and 24 (54.5%) had obstructive LFTs (elevated GGT and ALP). 8 (18.2%) patients had ERCP. All were normal except 1 (12.5%), showing choledocholithiasis. 9 (20.5%) patients had duodenoscopy, all were normal. 1 patient (2.3%) had an endoscopic ultrasound, which was normal. Mortality was 13.6% (n=6; 1 acute myocardial infarction, 1 respiratory failure, 1 uterine carcinoma, 1 intracranial haemorrhage, 1 unknown, 1 pancreatic carcinoma). 2 (4.5%) were diagnosed with carcinoma head of pancreas 14 months and 8 months after their MRCP. Both were jaundiced. One was an 87yr old female who had ERCP which confirmed duct dilation but no obstructive cause. A 3rd CT scan 14 months later confirmed metastatic carcinoma from head of pancreas. The other was a 34 yr old man diagnosed with carcinoma head of pancreas 8 months later after presenting with obstructive jaundice followed by an ERCP and stent. He died 21 months after his MRCP. Conclusions: In 3 years of follow up of unexplained biliary dilatation, 4.5% of patients were diagnosed with a malignant etiology. We recommend that all patients with unexplained duct dilation, especially with jaundice, be closely followed up and considered for endoscopic ultrasound.
Fisher's Exact Test Analysis Su1289 Endoscopic Retrograde Cholangiopancreatography in Infants: A Single Center 10 Year Experience Dov Wengrower, Eran Goldin, Ishay Benuri, Michael Wilschanski, Eyal Shteyer Background. Endoscopic retrograde cholangiopancreatography (ERCP) is not as widely used in children as in adults and performed in few specialized centers. Most infants undergo ERCP due to cholestasis. Distinguishing extrahepatic biliary atresia (EHBA), from other causes of prolonged neonatal cholestasis may be challenging. EHBA is the leading indication for liver transplantation in children, and timely Kasai portoenterostomy (KP) may alter its natural history. When investigation is equivocal, performing an ERCP before an intraoperative cholangiogram may lead to other diagnoses and avoid an invasive procedure. The aim of this study is to review the experience of ERCP in children under the age of 3 months in a single national referral center. Methods: We conducted a retrospective chart review of all babies under the age of 3 months who underwent ERCP between the years 20002010. Data on demographics, diagnosis, anesthesia type, treatments, and complications were collected. Results: ERCP were performed on 27 babies less then 3 months old. There were 14 males (51%), and median age at time of procedure was 55 days (range, 33-89 days). A clinical indication in all infants was prolonged cholestasis. Abdominal ultrasound was normal in 16 infants, and others showed small gallbladder (5), biliary stones (4) and dilated bile ducts (2). Ten children underwent prior liver biopsy which was inconclusive. ERCP lead to the diagnosis of biliary atresia in 12 infants. Five infants had a normal exam and in 6, papilla cannulation failed or the ducts did not fill. In others, ERCP showed choledocal cyst (2), biliary stones (1), dilated bile ducts (1) and in one, the papilla was not detected. The final diagnoses in our cohort was EHBA (14), biliary stones (5), neonatal hepatitis (3) choledocal cyst (2) paucity of intrahepatic bile duct and congenital hepatic fibrosis (1). In the babies in which exam failed three had biliary atresia, 1 had paucity of bile ducts and 1 biliary stones. One baby was lost from follow-up. In 6 (22%) infants with clinical suspicion of EHBA, a normal ERCP ruled out the diagnosis and avoided an intra-operative cholangiogram. In children who were diagnosed with EHBA by ERCP, KP was performed without delay. General anesthesia was performed in all but one infant, by dedicated anesthesiologists. None of the infants had significant complications including pancreatitis from the procedure. Conclusions: In infants younger then 3 months of age, ERCP is feasible and safe. It may serve as an additional diagnostic tool in neonatal cholestasis in unclear cases and may prevent more invasive procedures. ERCP may be part of the algorithm of neonatal cholestasis, when it is available and other investigations fail to confirm a diagnosis.
Su1288 Abnormal Liver Function Tests in Acute Cholecystitis With and Without Choledocholithiasis Nicholas M. Kelly, Tony Tham Background & Aims: In acute cholecystitis, the presence of abnormal liver function tests (LFTs) is thought to indicate choledocholithiasis. We sought to determine the incidence of abnormal LFTs in patients with acute cholecystitis and examine their usefulness at predicting choledocholithiasis. Methods: A retrospective search was undertaken for the diagnosis of acute cholecystitis from 1st January 2007 - 31st December 2009. Those with complications (liver/GB abscesses & perforations) were excluded. Data was collected on patient age, sex, LFTs (bilirubin, gamma-glutamyl transferase (GGT), aspartate aminotransferase (AST) & alkaline phosphatase (ALP)) and imaging performed. Choledocholithiasis was diagnosed if bile duct stones were present on one of these modalities: ultrasound, CT, MRCP or ERCP. Statistics: Sensitivity and specificity were calculated for each LFT measured for the diagnosis of choledocholithiasis. Mann-Whitney test was used to analyse the difference between groups. Association of the incidence of elevated LFTs and choledocholithiasis was tested using Fishers exact test. Factor analysis was performed and the factor was used as the predictor variable for binary logistic regression. Results: 155 patients were identified with acute cholecystitis. 15 (9.7%) were excluded (complicated cholecystitis n=5, missing data n=9, wrongly coded n=1). Final analysis included 140 (Females n=77, 55.0%). Mean (range) age was 59.3yrs (18-94). 17 (12.1%) had choledocholithiasis. Mean bilirubin 1.7mg/dL (range 0.1-9.6; reference range 2.1-2.9), GGT 204.6U/L (range 7-1448; reference range 5-39), AST 89.3U/ L (range 9-684; reference range 13-35) and ALP 148.7 (range 35-658; reference range 4298). Bilirubin was elevated in 20 patients (14.3%), GGT in 100 (71.4%), AST in 57 (40.7%) and ALP in 69 (49.3%). Table 1 shows the comparison of LFTs for the 2 groups. Table 2 shows the comparison proportions of elevated results in the 2 groups. Sensitivity and specificity for the diagnosis of choledocholithiasis for bilirubin were 47.0% and 90.2%, for GGT 100% & 32.5%, for AST 70.6% & 63.4% and for ALP 76.5% and 54.5% respectively. Factor analysis showed that elevation of all 4 liver enzymes is predictive of choledocholithiasis (p<0.001). Conclusions: Abnormal LFTs are common with acute cholecystitis and do not necessarily imply the presence of bile duct stones. The incidence of abnormal LFTs in those with cholecystitis was 72.4%, largely attributable to an elevated GGT. Patients with choledocholithiasis are more likely to have significantly higher values of bilirubin, GGT, AST and ALP and also more likely to have more than one elevated at the same time. Elevation of all 4 liver enzymes is predictive of choledocholithiasis. Table 1 - Comparison of LFT values in the 2 groups
AGA Abstracts
Su1290 Long-Term Follow-up Study of Gallbladder in Situ After Endoscopic Common Duct Stone Removal in Korean Patients Joon Hyun Cho, Kyeong Ok Kim, Si Hyung Lee, Tae Nyeun Kim Background & Aims: Although there has been much debate over the fate of the gallbladder(GB) after endoscopic common bile duct(CBD) stone removal, subsequent cholecystectomy is generally recommended in patients with GB stone. However, the components of CBD stones in Korea, which are almost pigment stones, are different from those in western countries. Therefore, the natural course of the Korean patients with GB in-situ is likely to be different from that of patients in western countries. We assessed the natural course of the patients with GB in-situ following endoscopic removal of CBD stone to identify further biliary events and to evaluate the need for prophylactic cholecystectomy. Methods: We retrospectively analyzed 461 patients who had undergone endoscopic CBD stone removal between January 2000 and December 2004. Patients were excluded if there was evidence of concomitant intrahepatic stones(16 patients) or pancreatobiliary malignancies(20 patients), a history of previous cholecystectomy(147 patients) or insufficient follow-up(46 patients). 232 patients were consequently enrolled in this study and followed by medical record review or telephone interview. Results: After endoscopic CBD stone removal, 68 patients(30.6%) underwent subsequent cholecystectomy(cholecystectomy group) and 164 patients(60.4%) didn't(GB in-situ group). In the GB in-situ group, 44 patients had GB stones. With a median follow-up of 5.7 years, 10 patients(14.7%) in cholecystectomy group and 31 patients(20.0%) in GB in-situ group developed recurrent CBD stone. Cumulative recurrence rates of CBD stone were not significantly different between two groups(log rank, p=0.215) and the mean time to recurrence of CBD stone was similar between both groups(39.2 months vs 32.7, p=0.548). During the follow-up period, 6 patients(13.6%) in GB in-situ group with GB stone and 3 patients(2.5%) in GB-in-situ group without GB stone developed acute cholecystitis (log rank, p=0.003). Cumulative recurrence rates of CBD stone were not significantly different
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