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Yield of sphincter of Oddi manometry in referred patients
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Abstracts
Conclusion: Use of antibiotic with or without a cholerectic agent does not prevent stent occlusion or mortality in patients with malignant biliary obstruction.
234 Prevalence of and risk of bleeding from gastric varices found incidentally at upper endoscopy in patients with pancreatitis Linder Jeffrey D, Arguedas Miguel R, Linder Sheri D, Geels Wilma, Wilcox* C. Mel, Baron Todd H. University of Alabama at Birmingham, Birmingham, AL, United States. Purpose: The prevalence of gastric varices in patients with pancreatitis and the incidence of clinically significant bleeding from these varices has not been well studied. Methods: Patients with acute and/or chronic pancreatitis undergoing upper endoscopy (EGD, ERCP, enteroscopy) from 1/1/95 to 5/1/00 were identified from review of our endoscopy database. Gastric varices were defined as varicosities in the gastric cardia, fundus or body that did not extend past the gastroesophageal junction. Patients were excluded if the were known or found to have cirrhosis. Follow-up to assess for bleeding was performed by review of medical records and/or phone interview. Results: Of the 597 pancreatitis patients undergoing upper endoscopy during the study period, 60 (10%) were found to have gastric varices. There were 41 men, and the median age of the patients was 48 years (range 13 to 82). There were 121 endoscopies performed (mean 2 endoscopies per patient) including 14 EGDs, 105 ERCPs and 2 small bowel enteroscopies. Indications for endoscopy were: pseudocyst, 21 (35%), abdominal pain, 19 (32%), drainage of pancreatic necrosis, 7 (12%), recurrent pancreatitis 5 (8.3%), pancreatic duct leak 3 (5.0%), and other 5 (8.3%). The most common etiologies of pancreatitis were alcohol in 22 patients (36.7%), idiopathic 18 (30.0%), and gallstones 9 (15.0%). 28 patients (46.7%) has chronic pancreatitis, 15 (25.0%) acute pancreatitis, 13 (21.6%) acute necrotizing pancreatitis, and 4 (6.7%) with recurrent pancreatitis. Mean follow-up was 28 months with 5 patients lost to follow-up; 4 patients had died, none from gastrointestinal bleeding. Two patients presented with bleeding at the time gastric varices were initially found. On follow up, only two patients had bled from gastric varices 24.5 months (range 1– 48) from the time of the index endoscopy. The presence of gastric varices was associated with fluid collections (p ⬍ 0.05), acute necrotizing pancreatitis (p ⬍ 0.05), and alcohol as an etiology (p ⬍ 0.05). Conclusions: Gastric varices develop in the setting of pancreatitis in 10% of patients. Strong associations with gastric varices and pancreatitis include fluid collection, acute necrotizing pancreatitis and alcoholic pancreatitis. It appears that at least in the short term, the risk of gastric variceal bleeding in this setting is very low.
235 Yield of sphincter of Oddi manometry in referred patients Linder MD Jeffrey D, Geels RN Wilma, Wilcox MD* C Mel. University of Alabama at Birmingham, Birmingham, AL, United States.
AJG – Vol. 95, No. 9, 2000
Purpose: Recent studies suggest a high prevalence of sphincter of Oddi dysfunction (SOD) in patients referred to specialized centers for sphincter manomety (SOM). Methods: From 9/98 to 4/00, we prospectively identified patients referred to our center for SOM. Patients were classified as either biliary or pancreatic SOD according to the modified Milwaukee classification. Patients underwent SOM of the biliary or pancreatic sphincter based on the suspicion for disease. SOD was diagnosed when the mean basal sphincter pressure was ⬎40 mm Hg. Standard cholangiography and/or pancreatography was performed following manometry. Results: Of the 59 patients undergoing SOM, the procedure could be performed in 51 patients (7 patients unable to perform, pancreas divisum in one). Of these 51 patients, there were 43 women and 8 men (median age 46 years, range 7 to 74 years). Prior to SOM, patients were classified by the Modified Milwaukee classification as biliary type I in 1 patient, type II in 8, and type III in 21; pancreatic type I in 4 patients, type II in 14, and type III in 3. Indications for SOM included abdominal pain in 35 patients (68.6%), recurrent pancreatitis in 12 (23.5%), chronic pancreatitis in 3 (7%) and acute pancreatitis in 1 (2%). Overall 30 patients (59%) were found to have SOD. Abnormal biliary sphincter pressures was found in 19 patients (37.2%), abnormal pancreatic sphincter pressures in 10 (19.6%), and abnormal biliary and pancreatic sphincter pressures in 1 (2%). SOD was found in 4 pancreatic type I patients (100%), 7 type II patients (50%), and 3 type III patients (100%) with mean sphincter pressures of 83 mm Hg, 96 mm Hg, and 102 mm Hg, respectively. SOD was found in one biliary type I patient (100%), 4 type II patients (50%), and 11 type III patients (52.4%) with a mean pressures of 92 mm Hg, 47 mm Hg, and 80 mm Hg, respectively. Conclusions: Our results confirm the high percentage of SOD in patients referred for SOM, especially those patients with unexplained pancreatitis.
236 Analyzing ERCP practice by a modified degree of difficulty scale: A multicenter database analysis Madhotra Ravi, Cotton* Peter B, Vaughn James, Barkun Alan, Leung Joseph, Libby Eric, Nickl Nicholas, Schutz Steve, Jowell Paul. Medical University of South Carolina, Charleston, South Carolina, United States. Purpose: Technical success at ERCP and associated complications may be influenced by many factors. To achieve reliable outcome data on endoscopic procedures requires properly structured metrics. Outcome results will be more real if comparisons are made according to procedural difficulty; a grading system has been proposed recently. Methods: We developed a modified degree of difficulty scale: Grade 1: diagnostic ERCP, standard sphincterotomy, stone extraction (⬍10 mm), stents for extrahepatic malignancy and nasobiliary drains, Grade 2: diagnostic ERCP in Billroth II, minor papilla cannulation, stone extraction (⬎10 mm), and therapy of hilar tumors and benign biliary strictures; Grade 3: diagnostic ERCP in Roux-en-Y/Whipple, choledochoand pancreatoscopy, manometry, endotherapy for Billroth II, intrahepatic stone extraction and all pancreatic endotherapies. Data from 7 North American centers using GI Trac database on 8094 ERCPs was analyzed to determine technical success rates according to the 3 grades. Results: The distribution was: 60% grade 1, 11% grade 2, and 29% grade 3 with considerable variation between centers (Table 1). Center 3 performed significantly more grade 3 procedures. The technical success rates for grade 1 procedures were very high and in grades 2 and 3 success rates were significantly lower. Conclusions: Technical success rates depend on the grade of difficulty for a particular ERCP procedure. It may be helpful to include this modified difficulty level scale in future outcome studies, credentialing and benchmarking.
Abstracts
Conclusion: Use of antibiotic with or without a cholerectic agent does not prevent stent occlusion or mortality in patients with malignant biliary obstruction.
234 Prevalence of and risk of bleeding from gastric varices found incidentally at upper endoscopy in patients with pancreatitis Linder Jeffrey D, Arguedas Miguel R, Linder Sheri D, Geels Wilma, Wilcox* C. Mel, Baron Todd H. University of Alabama at Birmingham, Birmingham, AL, United States. Purpose: The prevalence of gastric varices in patients with pancreatitis and the incidence of clinically significant bleeding from these varices has not been well studied. Methods: Patients with acute and/or chronic pancreatitis undergoing upper endoscopy (EGD, ERCP, enteroscopy) from 1/1/95 to 5/1/00 were identified from review of our endoscopy database. Gastric varices were defined as varicosities in the gastric cardia, fundus or body that did not extend past the gastroesophageal junction. Patients were excluded if the were known or found to have cirrhosis. Follow-up to assess for bleeding was performed by review of medical records and/or phone interview. Results: Of the 597 pancreatitis patients undergoing upper endoscopy during the study period, 60 (10%) were found to have gastric varices. There were 41 men, and the median age of the patients was 48 years (range 13 to 82). There were 121 endoscopies performed (mean 2 endoscopies per patient) including 14 EGDs, 105 ERCPs and 2 small bowel enteroscopies. Indications for endoscopy were: pseudocyst, 21 (35%), abdominal pain, 19 (32%), drainage of pancreatic necrosis, 7 (12%), recurrent pancreatitis 5 (8.3%), pancreatic duct leak 3 (5.0%), and other 5 (8.3%). The most common etiologies of pancreatitis were alcohol in 22 patients (36.7%), idiopathic 18 (30.0%), and gallstones 9 (15.0%). 28 patients (46.7%) has chronic pancreatitis, 15 (25.0%) acute pancreatitis, 13 (21.6%) acute necrotizing pancreatitis, and 4 (6.7%) with recurrent pancreatitis. Mean follow-up was 28 months with 5 patients lost to follow-up; 4 patients had died, none from gastrointestinal bleeding. Two patients presented with bleeding at the time gastric varices were initially found. On follow up, only two patients had bled from gastric varices 24.5 months (range 1– 48) from the time of the index endoscopy. The presence of gastric varices was associated with fluid collections (p ⬍ 0.05), acute necrotizing pancreatitis (p ⬍ 0.05), and alcohol as an etiology (p ⬍ 0.05). Conclusions: Gastric varices develop in the setting of pancreatitis in 10% of patients. Strong associations with gastric varices and pancreatitis include fluid collection, acute necrotizing pancreatitis and alcoholic pancreatitis. It appears that at least in the short term, the risk of gastric variceal bleeding in this setting is very low.
235 Yield of sphincter of Oddi manometry in referred patients Linder MD Jeffrey D, Geels RN Wilma, Wilcox MD* C Mel. University of Alabama at Birmingham, Birmingham, AL, United States.
AJG – Vol. 95, No. 9, 2000
Purpose: Recent studies suggest a high prevalence of sphincter of Oddi dysfunction (SOD) in patients referred to specialized centers for sphincter manomety (SOM). Methods: From 9/98 to 4/00, we prospectively identified patients referred to our center for SOM. Patients were classified as either biliary or pancreatic SOD according to the modified Milwaukee classification. Patients underwent SOM of the biliary or pancreatic sphincter based on the suspicion for disease. SOD was diagnosed when the mean basal sphincter pressure was ⬎40 mm Hg. Standard cholangiography and/or pancreatography was performed following manometry. Results: Of the 59 patients undergoing SOM, the procedure could be performed in 51 patients (7 patients unable to perform, pancreas divisum in one). Of these 51 patients, there were 43 women and 8 men (median age 46 years, range 7 to 74 years). Prior to SOM, patients were classified by the Modified Milwaukee classification as biliary type I in 1 patient, type II in 8, and type III in 21; pancreatic type I in 4 patients, type II in 14, and type III in 3. Indications for SOM included abdominal pain in 35 patients (68.6%), recurrent pancreatitis in 12 (23.5%), chronic pancreatitis in 3 (7%) and acute pancreatitis in 1 (2%). Overall 30 patients (59%) were found to have SOD. Abnormal biliary sphincter pressures was found in 19 patients (37.2%), abnormal pancreatic sphincter pressures in 10 (19.6%), and abnormal biliary and pancreatic sphincter pressures in 1 (2%). SOD was found in 4 pancreatic type I patients (100%), 7 type II patients (50%), and 3 type III patients (100%) with mean sphincter pressures of 83 mm Hg, 96 mm Hg, and 102 mm Hg, respectively. SOD was found in one biliary type I patient (100%), 4 type II patients (50%), and 11 type III patients (52.4%) with a mean pressures of 92 mm Hg, 47 mm Hg, and 80 mm Hg, respectively. Conclusions: Our results confirm the high percentage of SOD in patients referred for SOM, especially those patients with unexplained pancreatitis.
236 Analyzing ERCP practice by a modified degree of difficulty scale: A multicenter database analysis Madhotra Ravi, Cotton* Peter B, Vaughn James, Barkun Alan, Leung Joseph, Libby Eric, Nickl Nicholas, Schutz Steve, Jowell Paul. Medical University of South Carolina, Charleston, South Carolina, United States. Purpose: Technical success at ERCP and associated complications may be influenced by many factors. To achieve reliable outcome data on endoscopic procedures requires properly structured metrics. Outcome results will be more real if comparisons are made according to procedural difficulty; a grading system has been proposed recently. Methods: We developed a modified degree of difficulty scale: Grade 1: diagnostic ERCP, standard sphincterotomy, stone extraction (⬍10 mm), stents for extrahepatic malignancy and nasobiliary drains, Grade 2: diagnostic ERCP in Billroth II, minor papilla cannulation, stone extraction (⬎10 mm), and therapy of hilar tumors and benign biliary strictures; Grade 3: diagnostic ERCP in Roux-en-Y/Whipple, choledochoand pancreatoscopy, manometry, endotherapy for Billroth II, intrahepatic stone extraction and all pancreatic endotherapies. Data from 7 North American centers using GI Trac database on 8094 ERCPs was analyzed to determine technical success rates according to the 3 grades. Results: The distribution was: 60% grade 1, 11% grade 2, and 29% grade 3 with considerable variation between centers (Table 1). Center 3 performed significantly more grade 3 procedures. The technical success rates for grade 1 procedures were very high and in grades 2 and 3 success rates were significantly lower. Conclusions: Technical success rates depend on the grade of difficulty for a particular ERCP procedure. It may be helpful to include this modified difficulty level scale in future outcome studies, credentialing and benchmarking.