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Is there a synergistic effect of mixed bacterial infection in biliary stent blockage?
ERCP-BILIARY 377
3?9
ERCP in the management of pancreaticobiliary Disease during Pregnancy. Son Y. Kim M.D.; Dominic K.H. Wong M.D. Div. of Gastroenterology Henry Ford Hospital. Detroit, Michigan
Where have all the Type I sphincter of Oddi patients gone? ~ , P Tamasky, B Pineau, W Coyle, C Brooker, J Cunningharn, P Cotton, R Hawes. Digestive Disease Center, Medical University of South Carolina, Charleston ~ : The Geenen-Hogan classification (GH) has been used to predict the likelihoodof finding sphincter of Oddi dysfunction (SOD) and previous reports suggest a correlafionwith outcome after sphincterotomy (Type I > Type II > Type III). By definition, Type I patients (pts) have typical pain, elevated liver/pancreas lab tests dudng pain, dilated duct(s) and delayed drainage of contrast. The purpose of this retrospective study was to stratify our suspected SOD according to strict GH cdteria and review their manometry results. Methods; We determined the GHC of all patients with postcholecystectomypath IPCP) and those with unexplained pancreatitis who were referred for ERCP/SOM Patients with prior biliary or pancreatic sphincterotomy (N=22) and patients with pancreatitis due to alcohol (N=19) were excluded. Results: SOM was successfullyobtained in 109/110(99%) from one or both ducts. The GH for each group
Despite relatively low surgical mortality and morbidity to the mother during pregnancy, cholecystectomy for gallstone pancreatits or cholecystits is usually delayed until delivery of the fetus due to higher risk of fetal wastage with surgical procedures during the first and second trimesters. In turn ERCP and endoscopic sphincterotomy has become the nonsurgical procedure of choice in the management of biliary pancreatitis and choledocholithiases during pregnancy. However, fetal exposure to radiation is of concern. We describe two pregnant patients who underwent therapeutic ERCP for pancreaticobiliarydiscase during the first ttimester of pregnancy. A 34 year old female, 14 weeks gestation,S/P lap choleeystectomy was admitted with RUQ pain, nausea, and vomiting. Ultrasound exam showed intra and extra hepatic dilatation without gallstones. Liver function tests were normal. Persisting colicky pain necessitated an ERCP on the third day of hospitalization. During the procedure, the abdomen was shielded with a 5 mm lead apron and only 36" of fluoroscopy time (<30 mRons) was required to cannulate the CBD, A 8 mm sphincterotomy was preformed with balloon extraction of six jagged white cholesterol calculi.The second case involves a 24 year old female, 9 weeks pregnant admitted with chills, diaphoresis and RUQ pain. Ultrasound revealed multiple gallbladder stones without cholecystitis. Admission amylase and lipase were normal. A severe attack of similar pain on the third day of hospitalization was noted with elevation of amylase to 2263 and lipase of 8000.Urgent ERCP with sphincterotomy was performed with successful extraction of a CBD stone, Again, lead shielding was provided over the lower abdomen and radiation exposure was limited to 12" of fluoroscopy time(
was:
GHC
Type I
Type II
Type III
PCP
0/72
18/72 (25%)
54/72 (75~
Unexplained 0/38 37/38 (97%) 1/38 (3%) Pancreatitis Seven of 72 (9.7%) PCP pts had objective lab findings that did not fulfill the strict GH (>2x nl AST & ALP on 2 occasions) yet 5 of the 7 had abnormal SOM Of 72 PCP pts, 25 had prior ERCP's, but only 3/25 (12%) had biliaq/drainage assessed, and in no case was this done property(pt in supine position immediately after contrast injection). Sixtyone percent of patients with Type II PCP, 74 % of patients with Type III PCP, and 68% of patients with Type II pancreatic pain were found to have SOD. Sumrnae/: (1)Type I GH patients are rarely seen at referral canters. One explanationfor this is that Type I patients are treated in the community without the use of SOM (2) Drainage times are not being performed to evaluate for SOD and we suggest that modifications should be made to the GH to reflect this change in practice.
t378
t380
SPHINCTER OF ODDI MANOMETRY (SOM) OF BOTH DUCTS AFTER CONSCIOUS SEDATION WITH MEPERIDINE. W KnaDple, P Tamasky, "~ Coyle, B Pineau, J Cunningham, P Cotton, R Hawes. Digestive Disease Center. Medical University of South Carolina, Charleston SOM has been reported to be successful in obtaining at least one duct in about 75% of attempts. Meperidine has been reported to have no significant affect on basal SO pressures and is being increasingly used to achieve conscious sedation for SOM. The aims of this study were to determine cannulation success and concordance for both biliary and pancreatic SOM in patients (pts) undergoing SOM where meperidine is used. Methods: In an 18 month period, 163 pts underwent ERCP with attempted SOM of both ducts; 41 pts were excluded (22 had a previous biliary or pancreatic sphioeterotomy and 19 had a diagnosis of pancreatitis due to alcohol) which left 122 pts as the subject of this report. 72 pts with post-cholecystectomypain (62F, 10M), 12 pts with pain and gallbladder in situ (10F,2M), and 38 patients with unexplained pancreatitis (26F,12M) were studied. SOM was performed with a standard triple lumen aspirating catheter (Wilson-Cook) and considered abnormal if both perfused leads measured > 40mmHg. R e s u l t s : Successful SOM was obtained from one or both ducts in 121 of 122 (99%) pts. SOM was successful from both ducts in 100 of 122 (82%) and are tabulated below.
IS THERE A SYNERGISTIC EFFECT OF MIXED BACTERIAL INFECTION IN BILIARY STENT BLOCKAGE? K Lam, YL Liu, T Desta, rE. Libby, ~.Lg.l,tag. Divisions of Gastroenterology, UC Davis Medical t Center, Sacramento, CA., and New England Medical Center, Boston, MA. Bacterial biofilm formation and sludge deposition is a recognized cause of biliary stem blockage. Culture of biliary sludge showed a mixed infection with gram+ve and gram-ve bacteria. Broad spectnun antibiotic coverage has been recommended for prophylaxis and prevention of steta blockage. However, animal studies showed that prophylactic ciprofloxacin which selectively suppress the gram-ve bacteria resulted in prolonged stent patency despite the stents being colonized by gram+ve bacteria. In this study, we tested a possible synergistic effect between gram+ve and gram-ve bacteria in adherence and biofilm formation. Method: selected clinical isolates of E. coli and Enterococci were cultured in separate chemostats to acheive a steady growth (106 CFU/ml) for 3 days and then perfused separately through Modified Robins Devices (2 for E. coli and 1 for Enterooncci), containing 10 Fr stern pieces. After 48 hours, the Enterococci suspension was perfused via a sidearm attachment to the 2nd MRD (E + En) initially perfused with E. coli. The stents pieces were removed daily and aniaysed by bacteriological culture and electron microscopy for bacterial adherence and biofilm formation. Resulls: the mean value of the bacteria adhered are expressed as colony forming units (CFU)/sq.cm. Number of bacteria adhered to stents. Single Perfusinn Combined Perfusion (E +En) Time (day) E.coli Emerococei E.coli Enterococci 1 1.5x10" No growth N/A N/A 2 8.5x10~ No growth N/A N/A 3 3.1x10~ No growth 2.3x10~ 3.5xI0 z 4 4.5x10~ No growth 2.5x10r 8.1x10~ Conclusion: Gram-ve E. coli are more adherent than gram+ve Enterococci. Presence of E. coli facilitates the attachment of Eoterococei suggesting that there is a synergistic effect between gram posititve and gram negative bacteria in adherence and biofilm formation. Further study is in progress to determine if selective treatment with antibiotic against gram-re bacteria is sufficient in preventing stent blockage.
I SOM I Pain Only Pancreatitis
Both NI
Both Abnl
TBiliary
T Panc
24
26
6
13
12
11
4
4
Total N=100 36 (36%) 37 (37%) 10 (10%) 17 (17%) Summary: The overall concordance for biliary and pancreatic SOM was 73%. Ofpts with abnormal SOM, 27 (42%) had abnormalities confined to only one duct. Conclusions: 1) Improved sedation using meperidine appears to improve cannulation success. 2) Concordance rates of SOM are similar with and without meperidine. 3) Diagnostic information is increased by studying both ducts since isolated sphincter dysfunction is common in pts with SOD. 4) If SOM in either duct is normal, manometry should be attempted in the other duct.
VOLUME 43, NO. 4, 1996
GASTROINTESTINAL ENDOSCOPY 3 8 5
3?9
ERCP in the management of pancreaticobiliary Disease during Pregnancy. Son Y. Kim M.D.; Dominic K.H. Wong M.D. Div. of Gastroenterology Henry Ford Hospital. Detroit, Michigan
Where have all the Type I sphincter of Oddi patients gone? ~ , P Tamasky, B Pineau, W Coyle, C Brooker, J Cunningharn, P Cotton, R Hawes. Digestive Disease Center, Medical University of South Carolina, Charleston ~ : The Geenen-Hogan classification (GH) has been used to predict the likelihoodof finding sphincter of Oddi dysfunction (SOD) and previous reports suggest a correlafionwith outcome after sphincterotomy (Type I > Type II > Type III). By definition, Type I patients (pts) have typical pain, elevated liver/pancreas lab tests dudng pain, dilated duct(s) and delayed drainage of contrast. The purpose of this retrospective study was to stratify our suspected SOD according to strict GH cdteria and review their manometry results. Methods; We determined the GHC of all patients with postcholecystectomypath IPCP) and those with unexplained pancreatitis who were referred for ERCP/SOM Patients with prior biliary or pancreatic sphincterotomy (N=22) and patients with pancreatitis due to alcohol (N=19) were excluded. Results: SOM was successfullyobtained in 109/110(99%) from one or both ducts. The GH for each group
Despite relatively low surgical mortality and morbidity to the mother during pregnancy, cholecystectomy for gallstone pancreatits or cholecystits is usually delayed until delivery of the fetus due to higher risk of fetal wastage with surgical procedures during the first and second trimesters. In turn ERCP and endoscopic sphincterotomy has become the nonsurgical procedure of choice in the management of biliary pancreatitis and choledocholithiases during pregnancy. However, fetal exposure to radiation is of concern. We describe two pregnant patients who underwent therapeutic ERCP for pancreaticobiliarydiscase during the first ttimester of pregnancy. A 34 year old female, 14 weeks gestation,S/P lap choleeystectomy was admitted with RUQ pain, nausea, and vomiting. Ultrasound exam showed intra and extra hepatic dilatation without gallstones. Liver function tests were normal. Persisting colicky pain necessitated an ERCP on the third day of hospitalization. During the procedure, the abdomen was shielded with a 5 mm lead apron and only 36" of fluoroscopy time (<30 mRons) was required to cannulate the CBD, A 8 mm sphincterotomy was preformed with balloon extraction of six jagged white cholesterol calculi.The second case involves a 24 year old female, 9 weeks pregnant admitted with chills, diaphoresis and RUQ pain. Ultrasound revealed multiple gallbladder stones without cholecystitis. Admission amylase and lipase were normal. A severe attack of similar pain on the third day of hospitalization was noted with elevation of amylase to 2263 and lipase of 8000.Urgent ERCP with sphincterotomy was performed with successful extraction of a CBD stone, Again, lead shielding was provided over the lower abdomen and radiation exposure was limited to 12" of fluoroscopy time(
was:
GHC
Type I
Type II
Type III
PCP
0/72
18/72 (25%)
54/72 (75~
Unexplained 0/38 37/38 (97%) 1/38 (3%) Pancreatitis Seven of 72 (9.7%) PCP pts had objective lab findings that did not fulfill the strict GH (>2x nl AST & ALP on 2 occasions) yet 5 of the 7 had abnormal SOM Of 72 PCP pts, 25 had prior ERCP's, but only 3/25 (12%) had biliaq/drainage assessed, and in no case was this done property(pt in supine position immediately after contrast injection). Sixtyone percent of patients with Type II PCP, 74 % of patients with Type III PCP, and 68% of patients with Type II pancreatic pain were found to have SOD. Sumrnae/: (1)Type I GH patients are rarely seen at referral canters. One explanationfor this is that Type I patients are treated in the community without the use of SOM (2) Drainage times are not being performed to evaluate for SOD and we suggest that modifications should be made to the GH to reflect this change in practice.
t378
t380
SPHINCTER OF ODDI MANOMETRY (SOM) OF BOTH DUCTS AFTER CONSCIOUS SEDATION WITH MEPERIDINE. W KnaDple, P Tamasky, "~ Coyle, B Pineau, J Cunningham, P Cotton, R Hawes. Digestive Disease Center. Medical University of South Carolina, Charleston SOM has been reported to be successful in obtaining at least one duct in about 75% of attempts. Meperidine has been reported to have no significant affect on basal SO pressures and is being increasingly used to achieve conscious sedation for SOM. The aims of this study were to determine cannulation success and concordance for both biliary and pancreatic SOM in patients (pts) undergoing SOM where meperidine is used. Methods: In an 18 month period, 163 pts underwent ERCP with attempted SOM of both ducts; 41 pts were excluded (22 had a previous biliary or pancreatic sphioeterotomy and 19 had a diagnosis of pancreatitis due to alcohol) which left 122 pts as the subject of this report. 72 pts with post-cholecystectomypain (62F, 10M), 12 pts with pain and gallbladder in situ (10F,2M), and 38 patients with unexplained pancreatitis (26F,12M) were studied. SOM was performed with a standard triple lumen aspirating catheter (Wilson-Cook) and considered abnormal if both perfused leads measured > 40mmHg. R e s u l t s : Successful SOM was obtained from one or both ducts in 121 of 122 (99%) pts. SOM was successful from both ducts in 100 of 122 (82%) and are tabulated below.
IS THERE A SYNERGISTIC EFFECT OF MIXED BACTERIAL INFECTION IN BILIARY STENT BLOCKAGE? K Lam, YL Liu, T Desta, rE. Libby, ~.Lg.l,tag. Divisions of Gastroenterology, UC Davis Medical t Center, Sacramento, CA., and New England Medical Center, Boston, MA. Bacterial biofilm formation and sludge deposition is a recognized cause of biliary stem blockage. Culture of biliary sludge showed a mixed infection with gram+ve and gram-ve bacteria. Broad spectnun antibiotic coverage has been recommended for prophylaxis and prevention of steta blockage. However, animal studies showed that prophylactic ciprofloxacin which selectively suppress the gram-ve bacteria resulted in prolonged stent patency despite the stents being colonized by gram+ve bacteria. In this study, we tested a possible synergistic effect between gram+ve and gram-ve bacteria in adherence and biofilm formation. Method: selected clinical isolates of E. coli and Enterococci were cultured in separate chemostats to acheive a steady growth (106 CFU/ml) for 3 days and then perfused separately through Modified Robins Devices (2 for E. coli and 1 for Enterooncci), containing 10 Fr stern pieces. After 48 hours, the Enterococci suspension was perfused via a sidearm attachment to the 2nd MRD (E + En) initially perfused with E. coli. The stents pieces were removed daily and aniaysed by bacteriological culture and electron microscopy for bacterial adherence and biofilm formation. Resulls: the mean value of the bacteria adhered are expressed as colony forming units (CFU)/sq.cm. Number of bacteria adhered to stents. Single Perfusinn Combined Perfusion (E +En) Time (day) E.coli Emerococei E.coli Enterococci 1 1.5x10" No growth N/A N/A 2 8.5x10~ No growth N/A N/A 3 3.1x10~ No growth 2.3x10~ 3.5xI0 z 4 4.5x10~ No growth 2.5x10r 8.1x10~ Conclusion: Gram-ve E. coli are more adherent than gram+ve Enterococci. Presence of E. coli facilitates the attachment of Eoterococei suggesting that there is a synergistic effect between gram posititve and gram negative bacteria in adherence and biofilm formation. Further study is in progress to determine if selective treatment with antibiotic against gram-re bacteria is sufficient in preventing stent blockage.
I SOM I Pain Only Pancreatitis
Both NI
Both Abnl
TBiliary
T Panc
24
26
6
13
12
11
4
4
Total N=100 36 (36%) 37 (37%) 10 (10%) 17 (17%) Summary: The overall concordance for biliary and pancreatic SOM was 73%. Ofpts with abnormal SOM, 27 (42%) had abnormalities confined to only one duct. Conclusions: 1) Improved sedation using meperidine appears to improve cannulation success. 2) Concordance rates of SOM are similar with and without meperidine. 3) Diagnostic information is increased by studying both ducts since isolated sphincter dysfunction is common in pts with SOD. 4) If SOM in either duct is normal, manometry should be attempted in the other duct.
VOLUME 43, NO. 4, 1996
GASTROINTESTINAL ENDOSCOPY 3 8 5