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ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

This article was originally published in The Gray Sheet

Executive Summary

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY followed by endoscopic papillotomy, if appropriate, should be performed "as early as possible" for patients with acute pancreatitis, Sheung- Tat Fan, MS, et al., Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong, recommend in a study published in the Jan. 28 New England Journal of Medicine. The study found that there was a decrease in biliary sepsis if patients with acute pancreatitis underwent emergency ERCP, followed by endoscopic papillotomy for treatment of ampullary and common-bile-duct stones, within 24 hours of being admitted to the hospital. The 195-patient study was designed to assess the effectiveness of early interventional stone removal in light of the fact that stones may pass spontaneously soon after admission. The study compared two patient groups: 97 patients who, within 24 hours, had emergency ERCP, followed by endoscopic papillotomy if ampullary and common-bile-duct stones were identified; and 98 patients who received initial conservative treatment and selective ERCP with or without endoscopic papillotomy only if their condition deteriorated. If stones were identified by ERCP, the endoscopic papillotomy was performed with a cutting needle (for ampullary stones) or a papillotome (for common-bile-duct stones). A nasobiliary-drainage catheter was inserted if stone removal was incomplete. Twelve of the 98 patients in the conservative treatment group developed biliary sepsis while none of the 97 patients in the aggressive treatment group developed the condition. "Persistent" ampullary or common-bile-duct stones were identified in all patients who had "unrelenting" biliary sepsis. The study results also indicated that there were no major differences in the incidence of local or systemic complications of acute pancreatitis between the two groups although there was "slightly lower" hospital mortality in the aggressive treatment group. Five patients in the emergency ERCP group and nine patients in the conservative treatment group died. Fan et al. conclude that "emergency ERCP and endoscopic papillotomy within 24 hours after admission in patients with acute pancreatitis are safe and effective in reducing the incidence of biliary sepsis and are indicated in the management of acute pancreatitis irrespective of the predicted severity and suspected cause." In an editorial commenting on the study, Robin Williamson, MD, Royal Postgraduate Medical School, Hammersmith Hospital, London, England, states that "the early diagnosis of gallstones in acute pancreatitis is inaccurate without ERCP." However, he adds that "the applicability of an aggressive endoscopic policy may depend on the proportion of alcoholic patients in the local population of patients with acute pancreatitis." Manipulation of the papilla theoretically is injurious in alcoholics, he notes. Williamson concludes that "the absence of any other specific therapy that is of proved value in this disease would argue for additional studies to determine the overall value" of endoscopic treatment. He said that "meanwhile, the treatment should be seriously considered for certain patients: those with an attack that is predicted to be severe, those whose pancreatitis does not subside with conservative measures (especially if gallstones are suspected), and above all, those in whom jaundice, fever, and chills suggest concomitant acute cholangitis."
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