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PO.64 IS EARLY ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY USEFUL IN THE MANAGEMENT OF ACUTE BILIARY PANCREATITIS? A META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS
Abstracts / Digestive and Liver Disease 40S (2008), S1–S195 1 serious rectal bleeding from post-APC ulcer). No procedure related deaths occurred. Conclusions: APC appears to be safe and effective modality in the treatment of various gastrointestinal conditions. # R. Therapeutic endoscopy 3. Laser/Argon therapy
PO.64 IS EARLY ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY USEFUL IN THE MANAGEMENT OF ACUTE BILIARY PANCREATITIS? A META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS A. Moretti ∗ , C. Papi, A. Aratari, V. Festa, M. Tanga, M. Koch, L. Capurso Gastroenterology Unit “San Filippo Neri” Hospital, Roma Background and aim: The aim of our study was to compare early endoscopic retrograde cholangiopancreatography (ERCP) with conservative management for the treatment of acute biliary pancreatitis: a meta-analysis of prospective randomized trials. Material and methods: Pertinent studies were selected from the Medline, Embase, and the Cochrane Library Databases, references from published articles and reviews. Conventional meta-analysis according to DerSimonian and Laird method was used for the pooling of the results. The Rate Difference (RD) (95%CI) and the Number Needed to Treat (NNT) were used as a measure of the therapeutic effect. Results: Five prospective randomized trials including 702 patients were selected. Overall complications and mortality rates were 31% and 6% respectively. In predicted severe pancreatitis the pooled RD for complications in early ERCP was –38.5% (95%CI -53% to -23.9%); p < 0.0001; NNT = 3. In predicted mild pancreatitis the pooled RD for complications in early ERCP was 1.8% (95%CI -5.6% to 9.3%); p=0.6. No mortality was observed in predicted mild pancreatitis. In predicted severe pancreatitis the pooled RD for mortality in the early ERCP group was –4.3% (95%CI -16% to 7.5%); p < 0.24. Conclusions: Early ERCP reduces pancreatitis-related complications in patients with predicted severe pancreatitis although mortality rate is not affected. In predicted mild pancreatitis early ERCP has no advantage compared to conservative management. # R. Therapeutic endoscopy 5. ERCP
PO.65 DO WE NEED TO STOP THE ANTICOAGULATING THERAPY IN ENDOSCOPIC PROCEDURES? M. Cirillo ∗ ,1 , G. Gargiulo 1 , A. Germano 1 , B. Ciambriello 2 , P. Della Rocca 2 , F. Frattolillo 2 , C. Fedele 2 , M. Sannino 1 , F. Piantadosi 1 , R. De Falco 1 , N. Gennarelli 1 , R. Lobello 1 1
Chirurgia dell’Apparato Digerente, Policlinico Federico II, Napoli; Scuola di Specializzazione in Chirurgia dell’Apparato Digerente ed Endoscopia Digestiva Chirurgica, Università degli Studi Federico II, Napoli
2
Background and aim: Endoscopic examinations are frequently required in patients with cardiologic or cerebrovascular diseases. Often these patients are treating with anticoagulant or antiplatelet agents. Management of anticoagulating therapy requires some considerations. Material and methods: Several things must be examined when we consider the management of anticoagulating therapy (NSAD, ticlopidine, aspirin, warfarin, etc.) and while we prepear a patient for the endoscopic examination. Bleeding is the first risk associated with the procedure. Secondly is to be considered the potentially increased risk of bleeding if the procedure is performed in the setting therapy. A discontinuing anticoagulating therapy can encrease thromboembolic risk. Very important is the timing of cessation and of reinstitution of
S193
the therapy. Do we also need to monitor the coagulation while the therapy is interrupted? In the last twelve months were observed 108 patients (age range 36-90 years, 59 males) treated with anticoagulanting therapy for cardiologic, cerebrovascular or hematological diseases: 63 pts (58,3%) who underwent diagnostic endoscopies and 45 pts who underwent operative procedures. Results: Elective diagnostic endoscopies there is no need to discontinue therapy. In therapeutic procedures (gastrointestinal polipectomies) our approach includes: stopping the anticoagulanting therapy and administering a low-molecular-weight-heparin (4.000 U. subcutaneously/die). Low-molecular-weight-heparin should be administered for two weeks before and two more weeks after the operating procedure. During this period the patient’s international normalized ratio (INR) is in the subtherapeutic range. No bleeding was observed after polypectomy in these patients. The risk of thromboembolic accident was unchanged. The decisions to continue, to stop, to modify, to add or to resume anticoagulation drugs must be made on an individual case basis, balancing both the risk of bleeding and the risk of a thromboembolic event. Conclusions: Disclosure of the estimated relative risks and benefits of management strategies to the patient is recommended. For complex cases we should be considered a consultation with the patient’s referring physician, cardiologist, neurologist or hematologist. It is important to remember that bridging therapy and resumption of oral anticoagulation immediately after performing an endoscopic procedure can result in an increase risk of bleeding. # S. Endoscopy complications
PO.66 ATYPICAL HEPATIC ANGIOMA: AN ISSUE IN DIFFERENTIAL DIAGNOSTICS G. Iannetti ∗ ,1 , S. Capodicasa 1 , C. Schiavone 2 1 Presidio Opedaliero, Pescara; 2 Università G.D’Annunzio, Chieti Pescara
Background and aim: The favorable cost-benefit ratio and the easy execution make the US test the first examination for the study and follow-up of oncology patients. Unfortunately, however, in certain conditions this test is not highly specific, like in the case of atypical hepatic angiomas with hypoechogenic aspect. This poses significant problems during follow-up of oncology patients for the differential diagnosis with metastasis. Our study aimed at assessing the effectiveness of contrast enhanced ultrasound (CEUS) in diagnosing focal hypoechogenic lesions in oncology patients without recourse to further instrumental tests such as CT or NMR which result in higher costs and require more time to produce an accurate diagnosis. Material and methods: From January 2005 to January 2007 in our ultrasound office we observed 50 oncology patients. 33 of these were found to have focal hypoechogenic lesions on conventional US and later underwent CEUS examination. The results where then compared with the CT scan. Results: Of the 50 patients initially tested by conventional US, 33 were found to have focal hypoechogenic lesions. When these later underwent CEUS test, 25 lesions showed the typical metastasis behavior without enhancement in the three vascular phases and 8 lesions showed the same behavior as the surrounding parenchymal tissue as in “focal steatosis”. Subsequently, the 33 lesions were also tested with CT confirming the presence of metastasis in 22 of them. 3 were found to be questionable and 8 showed “focal steatosis”. The 3 patients found with questionable lesions on CT were also tested by NMR, which diagnosed angiomatosis lesions, later confirmed by echoguided biopsy. The histological picture was characterized by a significant fibrotic component both perilesional and intralesional. Conclusions: With CEUS, atypical hepatic angiomas may be misdiagnosed as metastasis; the significant fibrotic component is likely to be the
PO.64 IS EARLY ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY USEFUL IN THE MANAGEMENT OF ACUTE BILIARY PANCREATITIS? A META-ANALYSIS OF RANDOMISED CONTROLLED TRIALS A. Moretti ∗ , C. Papi, A. Aratari, V. Festa, M. Tanga, M. Koch, L. Capurso Gastroenterology Unit “San Filippo Neri” Hospital, Roma Background and aim: The aim of our study was to compare early endoscopic retrograde cholangiopancreatography (ERCP) with conservative management for the treatment of acute biliary pancreatitis: a meta-analysis of prospective randomized trials. Material and methods: Pertinent studies were selected from the Medline, Embase, and the Cochrane Library Databases, references from published articles and reviews. Conventional meta-analysis according to DerSimonian and Laird method was used for the pooling of the results. The Rate Difference (RD) (95%CI) and the Number Needed to Treat (NNT) were used as a measure of the therapeutic effect. Results: Five prospective randomized trials including 702 patients were selected. Overall complications and mortality rates were 31% and 6% respectively. In predicted severe pancreatitis the pooled RD for complications in early ERCP was –38.5% (95%CI -53% to -23.9%); p < 0.0001; NNT = 3. In predicted mild pancreatitis the pooled RD for complications in early ERCP was 1.8% (95%CI -5.6% to 9.3%); p=0.6. No mortality was observed in predicted mild pancreatitis. In predicted severe pancreatitis the pooled RD for mortality in the early ERCP group was –4.3% (95%CI -16% to 7.5%); p < 0.24. Conclusions: Early ERCP reduces pancreatitis-related complications in patients with predicted severe pancreatitis although mortality rate is not affected. In predicted mild pancreatitis early ERCP has no advantage compared to conservative management. # R. Therapeutic endoscopy 5. ERCP
PO.65 DO WE NEED TO STOP THE ANTICOAGULATING THERAPY IN ENDOSCOPIC PROCEDURES? M. Cirillo ∗ ,1 , G. Gargiulo 1 , A. Germano 1 , B. Ciambriello 2 , P. Della Rocca 2 , F. Frattolillo 2 , C. Fedele 2 , M. Sannino 1 , F. Piantadosi 1 , R. De Falco 1 , N. Gennarelli 1 , R. Lobello 1 1
Chirurgia dell’Apparato Digerente, Policlinico Federico II, Napoli; Scuola di Specializzazione in Chirurgia dell’Apparato Digerente ed Endoscopia Digestiva Chirurgica, Università degli Studi Federico II, Napoli
2
Background and aim: Endoscopic examinations are frequently required in patients with cardiologic or cerebrovascular diseases. Often these patients are treating with anticoagulant or antiplatelet agents. Management of anticoagulating therapy requires some considerations. Material and methods: Several things must be examined when we consider the management of anticoagulating therapy (NSAD, ticlopidine, aspirin, warfarin, etc.) and while we prepear a patient for the endoscopic examination. Bleeding is the first risk associated with the procedure. Secondly is to be considered the potentially increased risk of bleeding if the procedure is performed in the setting therapy. A discontinuing anticoagulating therapy can encrease thromboembolic risk. Very important is the timing of cessation and of reinstitution of
S193
the therapy. Do we also need to monitor the coagulation while the therapy is interrupted? In the last twelve months were observed 108 patients (age range 36-90 years, 59 males) treated with anticoagulanting therapy for cardiologic, cerebrovascular or hematological diseases: 63 pts (58,3%) who underwent diagnostic endoscopies and 45 pts who underwent operative procedures. Results: Elective diagnostic endoscopies there is no need to discontinue therapy. In therapeutic procedures (gastrointestinal polipectomies) our approach includes: stopping the anticoagulanting therapy and administering a low-molecular-weight-heparin (4.000 U. subcutaneously/die). Low-molecular-weight-heparin should be administered for two weeks before and two more weeks after the operating procedure. During this period the patient’s international normalized ratio (INR) is in the subtherapeutic range. No bleeding was observed after polypectomy in these patients. The risk of thromboembolic accident was unchanged. The decisions to continue, to stop, to modify, to add or to resume anticoagulation drugs must be made on an individual case basis, balancing both the risk of bleeding and the risk of a thromboembolic event. Conclusions: Disclosure of the estimated relative risks and benefits of management strategies to the patient is recommended. For complex cases we should be considered a consultation with the patient’s referring physician, cardiologist, neurologist or hematologist. It is important to remember that bridging therapy and resumption of oral anticoagulation immediately after performing an endoscopic procedure can result in an increase risk of bleeding. # S. Endoscopy complications
PO.66 ATYPICAL HEPATIC ANGIOMA: AN ISSUE IN DIFFERENTIAL DIAGNOSTICS G. Iannetti ∗ ,1 , S. Capodicasa 1 , C. Schiavone 2 1 Presidio Opedaliero, Pescara; 2 Università G.D’Annunzio, Chieti Pescara
Background and aim: The favorable cost-benefit ratio and the easy execution make the US test the first examination for the study and follow-up of oncology patients. Unfortunately, however, in certain conditions this test is not highly specific, like in the case of atypical hepatic angiomas with hypoechogenic aspect. This poses significant problems during follow-up of oncology patients for the differential diagnosis with metastasis. Our study aimed at assessing the effectiveness of contrast enhanced ultrasound (CEUS) in diagnosing focal hypoechogenic lesions in oncology patients without recourse to further instrumental tests such as CT or NMR which result in higher costs and require more time to produce an accurate diagnosis. Material and methods: From January 2005 to January 2007 in our ultrasound office we observed 50 oncology patients. 33 of these were found to have focal hypoechogenic lesions on conventional US and later underwent CEUS examination. The results where then compared with the CT scan. Results: Of the 50 patients initially tested by conventional US, 33 were found to have focal hypoechogenic lesions. When these later underwent CEUS test, 25 lesions showed the typical metastasis behavior without enhancement in the three vascular phases and 8 lesions showed the same behavior as the surrounding parenchymal tissue as in “focal steatosis”. Subsequently, the 33 lesions were also tested with CT confirming the presence of metastasis in 22 of them. 3 were found to be questionable and 8 showed “focal steatosis”. The 3 patients found with questionable lesions on CT were also tested by NMR, which diagnosed angiomatosis lesions, later confirmed by echoguided biopsy. The histological picture was characterized by a significant fibrotic component both perilesional and intralesional. Conclusions: With CEUS, atypical hepatic angiomas may be misdiagnosed as metastasis; the significant fibrotic component is likely to be the