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Comparison of Endoscopic Retrograde Cholangiopancreatography (ERCP) and Magnetic Resonance Cholangiopancreatography (MRCP) in Bile Duct Imaging  [PDF]
Mehmet Ali Ery?lmaz, ?mer Karahan, ?smet Tolu, Ahmet Oku?, Serden Ay, Bar?? Sevin?, Ahmet Hakan Hal?c?
Surgical Science (SS) , 2012, DOI: 10.4236/ss.2012.310097
Abstract: Purpose: The aim of this study was to compare magnetic resonance cholangiopancreatography (MRCP) with endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing bile duct pathologies. Materials and Methods: We documented the data of 171 patients with both ERCP and MRCP between January 2009 and December 2010 at the Konya Education and Research Hospital. Results: Of the 171 patients, 100 (58.5%) were female and 71 (41.5%) were male. The median age was 63 (55 to 89). ERCP was used to diagnose bile duct stones in 102 (59%) patients, bile duct tumour in 14 (8%) patients, hydatic cysts opening up to the bile duct in 4 (2%) patients and bile duct stenosis in 3 (1.8%) patients. For the detection of bile duct stones, MRCP had a sensitivity of 92%, a specificity of 74% and a diagnostic accuracy of 83%. For bile duct tumours, MRCP had a sensitivity of 85%, a specificity of 98% and a diagnostic accuracy rate of 92%. Conclusion: In our centre, the results of MRCP and ERCP were similar for the last two years. However, MRCP was superior with respect to diagnosis as it was cheaper and non-invasive. Thus, ERCP should be preferred for therapeutic processes.
Recurrent cholangitis in the tropics: Worm or cast?  [cached]
Jain P,Gandhi V,Desai P,Doctor N
Journal of Postgraduate Medicine , 2010,
Abstract: The development of biliary casts is very rare, especially in non-liver transplant patients. The etiology of these casts is uncertain but several factors have been proposed which lead to bile stasis and/or gallbladder hypo-contractility and promote cast formation. Here, we report a 54-year-old male, with diabetes and ischemic heart disease, who presented with recurrent attacks of cholangitis. Magnetic resonance cholangiopancreatography revealed linear T1 hyperintense and T2 hypointense filling defects in the right and left hepatic ducts extending into the common hepatic duct, and a calculus in the lower common bile duct, raising a suspicion of worm in the biliary tree. In view of failed attempts at extraction on endoscopy, patient underwent surgery. At exploration, biliary casts and stones were extracted from the proximal and the second order bile ducts, with the help of intraoperative choledochoscopy and a bilio-enteric anastomosis was accomplished. Although endoscopic retrieval of the biliary cast can be employed as first-line management, surgery should be considered in case it fails.
Deep common bile duct cannulation time at endoscopic retrograde cholangiopancreatography: a forgotten parameter for assessment of endoscopic competence?  [cached]
Mohammad Wehbi,Emad Qayed,Tanvi Dhere,Chetan Gondha
Gastroenterology Insights , 2010, DOI: 10.4081/gi.2010.e7
Abstract: The rate of successful deep common bile duct cannulation (DCBD) at endoscopic retrograde cholangiopancreatography (ERCP) is usually used as a surrogate marker of competence at ERCP. There are few data regarding the time spent on cannulation at ERCP. This prospective study aimed to evaluate the time spent on DCBD cannulation at ERCP and to provide a rationale for establishing the DCBD cannulation time as another parameter in assessment of ERCP competence. This is a prospective study performed in a single tertiary university-based referral center. DCBD cannulation time as well as the fluorescence time and the cost of cannulation tools during DCBD cannulation were measured. The mean DCBD cannulation was 12.5±13.6 minutes. Eighty-percent of the cannulation was achieved within 10 min, 10% achieved in 10-30 min, and the remaining in longer than 30 min. The longer cannulation time was associated with increased the cost of cannulation ($79/cannulation versus $387/ cannulation, P<0.001), as well as increasing the radiation exposure times (3.1 min/cannulation vs. 25 min/cannulation, P<0.001). In addition to the success rate of DCBD cannulation, the DCBD cannulation time should be considered as another parameter in the assessment of endoscopic competence in ERCP.
A rare etiology of post-endoscopic retrograde cholangiopancreatography pneumoperitoneum  [cached]
Stelios F Assimakopoulos, Konstantinos C Thomopoulos, Sofia Giali, Christos Triantos, Dimitrios Siagris, Charalambos Gogos
World Journal of Gastroenterology , 2008,
Abstract: Major complications of endoscopic retrograde cholangiopancreatography (ERCP) include pancreatitis, hemorrhage, cholangitis, and duodenal perforation. The occurrence of free air in the peritoneal cavity post-ERCP is a rare event (< 1%), which is usually the result of duodenal or ductal perforation related to therapeutic ERCP with sphincterotomy. We describe for the first time a different aetiology of pneumoperitoneum, in an 84-year-old woman with pancreatic cancer and a large hepatic metastasis, after ERCP with common bile duct stent deployment. Our patient developed, pneumoperitoneum due to air leakage from rupture of intrahepatic bile ducts and Glisson’s capsule in the area of a peripheral large hepatic metastasis. The potential mechanism underlying this complication might be post-ERCP pneumobilia and increased pressure of intrahepatic bile ducts leading to rupture of intrahepatic bile ducts in the liver metastatic mass owing to neoplastic tissue friability. This case indicates the need for close clinical and radiological observation of patients with hepatic masses (primary or metastatic) subjected to ERCP. In such patients, avoidance of excessive air insufflation during ERCP and/or placement of a nasogastric tube for bowel decompression immediately after ERCP might be a reasonable strategy to prevent such unusual complications.
The Accuracy of Transabdominal Ultrasound in Detection of the Common Bile Duct Stone as Compared to Endoscopic Retrograde Cholangiopancreatography (with Literature Review)  [PDF]
Taha Ahmed M. Alkarboly, Salah Mohamad Fatih, Hiwa Abubaker Hussein, Talar M. Ali, Heero Ismael Faraj
Open Journal of Gastroenterology (OJGas) , 2016, DOI: 10.4236/ojgas.2016.610032
Introduction: Common bile duct stone (CBDS) is a common clinical problem that can cause serious complications, such as acute cholangitis and pancreatitis. It is important to have an accurate, safe, and reliable method for the definitive diagnosis of CBDS before proceeding to therapeutic endoscopic retrograde cholangiopancrea-tography (ERCP). Objective: To compare the accuracy of trans-abdominal ultra-sound (TAUS) as a diagnostic tool at our institution—Kurdistan Centre for Gastroen-terology & Hepatology (KCGH)—with invasive tool like ERCP in the diagnosis of bile duct stones, using specificity, sensitivity, and positive and negative predictive values. Patient and Method: After obtaining ethical committee approval & informed consent from every patient. This was a prospective study conducted on 71 patients (24 male patients and 47 females patients) where suspected to have CBDS depending on history, clinical suspicion and blood tests. Their ages range between (2 - 88 years). Both TAUS and ERCP were performed. Final diagnosis was confirmed de-pending on ERCP as it served as a diagnostic standard in diagnosing CBDS. Result: In 71 patients suspected to have CBDS by TAUS, only 46 patients had stone (65%), and 55 patients had stone by ERCP (77%). In our result, sensitivity, specificity, pos-itive predictive value and negative predictive value for TAUS were 80%, 87.5%, 65.5% and 56%, respectively. Conclusion: TAUS can play an important role as an initial screening procedure for CBDS detection because of the various advantages like easy availability, cost effectiveness, no requirement of contrast material and lack of ionizing radiation but should done with other imaging modality to avoid se-rious complication of ERCP.
Endoscopic retrograde cholangiopancreatography during pregnancy without radiation  [cached]
Adem Akcakaya, Orhan Veli Ozkan, Ismail Okan, Orhan Kocaman, Mustafa Sahin
World Journal of Gastroenterology , 2009,
Abstract: AIM: To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy.METHODS: Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCl and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure.RESULTS: The mean age of the patients was 28 years (range, 21-33 years). The mean gestational age for the fetus was 23 wk (range, 14-34 wk). Five patients underwent ERCP because of choledocholithiasis and/or choledocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen.CONCLUSION: Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.
Diagnostic and Therapeutic Value of ERCP in Acute Cholangitis  [PDF]
Kenan Buyukasik,Ahmet Burak Toros,Hasan Bektas,Aziz Ari,Mehmet Mehdi Deniz
ISRN Gastroenterology , 2013, DOI: 10.1155/2013/191729
Abstract: Cholangitis, with a clinical spectrum between acute ascending cholangitis and acute fulminant cholangitis, the mildest and the most severe forms, respectively, is the infection of bile ducts with a potential of serious mortality and morbidity. Obstruction of the bile ducts followed by infection, with E. coli being the most commonly isolated agent, is common to all forms of cholangitis. Biliary obstruction is caused by choledocholithiasis mostly. “Choledochal pressure” is the most important factor, determining morbidity. If the pressure exceeds 25?cm H2O, which is the critical value, immune dysfunction ensues. Sepsis is common if the infection of biliary ducts is suppurative. Mortality and morbidity are inevitable if left untreated or drained late. The objective of this study is, in the stand point of the current literature, to analyse the diagnostic, therapeutic success and complication rates of ERCP (Endoscopic retrograde cholangiopancreatography) in patients with a diagnosis of acute purulent cholangitis with no response to medical treatment. 1. Introduction Inflammation of the biliary ducts is called cholangitis. Inflammatory process usually begins extrahepatically and easily spreads intrahepatically, causing bacteriemia. Cholangitis was first defined by Charcot in 1877. Obstruction of the biliary ducts and presence of a superposing bacterial infection are common features in cholangitis. The mildest clinical form is ascending cholangitis, and the most severe form is acute fulminant cholangitis. Not every biliary obstruction is associated with cholangitis but there is surely a biliary obstruction in every cholangitis case [1–4]. “Reynolds pentad” was defined with the addition of mental confusion and septic shock, in 1959, by Reynolds and Dragon, to the clinical findings known as “Charcot triad” (fever, abdominal pain, and jaundice) [5, 6]. Biliary obstruction is caused by choledocholithiasis mostly. Moreover, malignancy, benign strictures, and interventions to the biliary ducts may be the cause of biliary obstruction. Bacterial contamination of the biliary ducts may be caused by ascending infection or portal bacteriemia. That means cholangitis clinically. “Choledochal pressure” is the most important factor, determining morbidity. If the pressure exceeds 25?cm H2O, which is the critical value, hepatic defence mechanisms against infection are disrupted and immune dysfunction ensues. Obstruction of the biliary ducts, increased intraluminal pressure, and infected bile are important in the pathogenesis of cholangitis. In 25–40% of the cases, associated
A retroperitoneal abscess caused by Haemophilus parainfluenza after endoscopic retrograde cholangiopancreatography and open cholecystectomy with a common bile duct exploration: a case report
Shonak B Patel, Zubair A Hashmi, Robert J Marx
Journal of Medical Case Reports , 2010, DOI: 10.1186/1752-1947-4-170
Abstract: We present the case of a 68-year-old Caucasian female who developed a retroperitoneal abscess caused by H. parainfluenza after open cholecystectomy and common bile duct exploration. This presented nearly five weeks post-operatively. She underwent a second operation to drain the abscess, and was subsequently placed on appropriate antibiotics.A retroperitoneal abscess due to H. parainfluenza is extremely rare. It is a normal inhabitant of the human respiratory tract. To the best of our knowledge, there have been only a few reported cases of these abscesses, and they mainly involve the psoas muscle. The retroperitoneal abscess originated from the oropharynx, most likely after the endoscopic retrograde cholangiopancreatography was performed. With the advent of Natural Orifice Translumenal Endoscopic Surgery, oral decontamination will need to be considered to decrease the potential for such infections.Haemophilus parainfluenza is generally regarded as a commensal bacterium in the respiratory tract. It has been known to provoke respiratory tract infections, otitis, and meningitis. However, little is known about its ability to colonize other sites. A search of the literature reveals only one reported case of H. parainfluenza in the gastrointestinal tract [1]. We now report a second case in which a 68-year-old presented with a retroperitoneal abscess due to H. parainfluenza after open cholecystectomy and common bile duct (CBD) exploration.A 68-year-old Caucasian female with a history of hypertension and hysterectomy (approximately 20 years ago) presented to the hospital with dehydration and right upper quadrant pain. A computed tomography (CT) scan of our patient obtained as an out-patient showed irregular thickening of the gallbladder wall associated with stones, but there was no evidence of cholecystitis. Both the intrahepatic and extrahepatic biliary ducts were dilated approximately to the level of the CBD, but indicated no choledocolithiasis. A follow-up endoscopic retr
Bacterial cholangitis causing secondary sclerosing cholangitis: A case report
Pieter CJ ter Borg, Henk R van Buuren, Annekatrien CTM Depla
BMC Gastroenterology , 2002, DOI: 10.1186/1471-230x-2-14
Abstract: A 48-year-old woman presented with an episode of acute biliary pancreatitis that was complicated by pancreatic abcess formation. After 3 months she had an episode of severe pyogenic (E. Coli) cholangitis that recurred over the subsequent 7 months on a further two occasions. Initially, cholangiography suggested the presence of extra-biliary intrahepatic abcesses while repeated investigations demonstrated development of multiple segmental biliary duct strictures. After maintenance antibiotic treatment was started, no episodes of cholangitis occurred over a 14-month period.Sclerosing cholangitis can rapidly develop after an episode of bacterial cholangitis. Extra-biliary involvement of the hepatic parenchyma with abcess formation may be a risk factor for developing this rare but particularly severe complication.Secondary sclerosing cholangitis following pyogenic cholangitis is usually listed among the many potential causes of biliary stricture formation (Table) [1,2]. However, in the literature indexed in Medline we could find only one such case, indicating that this is an extremely rare condition. We hereby report a second case, documented by cholangiography, of rapidly progressive sclerosing cholangitis secondary to bacterial cholangitis.A previously healthy 48 year-old woman of Moroccan origin was admitted because of abdominal pain and nausea. A diagnosis of acute pancreatitis was made, based on elevated urinary and serum amylase levels and ultrasound imaging. Endoscopic retrograde cholangiopancreatography (ERCP) showed normal bile ducts, but suggested presence of biliary sludge, and biliary sphincterotomy was performed. In the following weeks four laparotomies were required for drainage of multiple pancreatic abcesses. Three months after the initial presentation, the patient was readmitted with jaundice, right upper quadrant abdominal pain and fever, and a clinical diagnosis of cholangitis was made. Laboratory tests demonstrated a total serum bilirubin level of 53
Utilidad de la colangiopancreatografía retrógrada endoscópica para tratar la litiasis de la vía biliar principal Usefulness of endoscopic retrograde cholangiopancreatography to treat main bile duct lithiasis
Juan Yerandy Ramos Contreras,Ludmila Martínez Leyva,Mirtha Infante Velázquez,Maritza de la Rosa Ortega
Revista Cubana de Medicina Militar , 2012,
Abstract: Introducción: la litiasis de la vía biliar principal constituye una de las principales indicaciones de la colangiopancreatografía retrógrada endoscópica. Con este procedimiento se pueden extraer los cálculos mediante un proceder muy poco invasivo. Objetivo: determinar la utilidad de la colangiopancreatografía en el tratamiento de la litiasis coledociana. Métodos: estudio descriptivo y retrospectivo de los resultados de las colangiopancreatografías realizadas en pacientes con litiasis de la vía biliar principal, entre el 2009 y el 2010. La muestra quedó constituida por 31 pacientes. Se utilizaron porcentajes, medias y desviaciones estándar para el resumen de la información. Se realizaron procedimientos técnicos para determinar la capacidad predictiva de la ecografía y la fosfatasa alcalina en el diagnóstico de la litiasis coledociana. Resultados: la mayoría de los pacientes fueron del sexo femenino. Un porcentaje elevado presentó edades por encima de los 60 a os y se trataron algunos que rebasaron los 90. Se logró la extracción de cálculos en el 60,8 %. El ultrasonido mostró una sensibilidad del 51,61 % (IC 95 %: 32,41-70,82) y especificidad del 88,98 % (IC: 83,14-94,82) para el diagnóstico de la litiasis. La fosfatasa alcalina no mostró precisión para el diagnóstico (área bajo la curva= 0,501). Conclusiones: se confirma la utilidad de la colangiopancreatografía retrógrada endoscópica para el tratamiento de la litiasis coledociana. La capacidad predictiva del ultrasonido y de la fosfatasa alcalina es baja, cuando se compara con los resultados de dicho proceder. Introduction: lithiasis of the main bile duct is one of the main indications for endoscopic retrograde cholangiopancreatography (ERCP). This procedure can remove stones using a minimally invasive procedure. Objective: to determine the usefulness of cholangiopancreatography in the treatment of choledocholithiasis. Methods: a retrospective and descriptive study of the results of cholangiopancreatography performed in patients with lithiasis of the main bile duct from 2009 and 2010. The sample was 31 patients. Percentages, mean and standard deviation were used to compile the information. Technical procedures were performed to determine the predictive ability of ultrasound and alkaline phosphatase in the diagnosis of choledocholithiasis. Results: most patients were female. A high percentage were older than 60 years and some were older than 90. Stone removal was achieved in 60.8 %. The ultrasound showed 51.61 % of sensitivity (95 % CI 32.41 to 70.82) and 88.98 % of specificity (CI 83.14 to 94.82) for th
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