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Yin J, Wang D, He Y, Sha H, Zhang W, Huang W. The safety of not implementing endoscopic nasobiliary drainage after elective clearance of choledocholithiasis: a systematic review and meta-analysis. BMC Surg 2024; 24:239. [PMID: 39174997 PMCID: PMC11342491 DOI: 10.1186/s12893-024-02535-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 08/16/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND Endoscopic nasobiliary drainage (ENBD) is used as a drainage technique in patients with choledocholithiasis after stone removal. However, ENBD can cause discomfort, displacement, and other complications. This study aims to evaluate the safety of not using ENBD following elective clearance of choledocholithiasis. METHODS Relevant studies were identified by searching PubMed, Web of Science, EMBASE, EBSCO, and Cochrane Library from their inception until August 2023. The main outcomes assessed were postoperative complications and postoperative outcomes. Subgroup analyses were conducted based on study design types and treatment procedures. RESULTS Six studies, including three randomized controlled trials (RCTs) and three cohort studies, were analyzed. Among these, four studies utilized endoscopic techniques, and two employed surgical methods for choledocholithiasis clearance. The statistical analysis showed no significant difference in postoperative complications between the no-ENBD and ENBD groups, including pancreatitis (RR: 1.55, p = 0.36), cholangitis (RR: 1.81, p = 0.09), and overall complications (RR: 1.25, p = 0.38). Regarding postoperative outcomes, the subgroup analysis indicated that the bilirubin normalization time was longer in the no-ENBD group compared to the ENBD group in RCTs (WMD: 0.24, p = 0.07) and endoscopy studies (WMD: 0.23, p = 0.005), although the former did not reach statistical difference. There was also no significant difference in the length of postoperative hospital stay between the groups (WMD: -0.30, p = 0.60). CONCLUSION It appears safe to no- ENBD after elective clearance of choledocholithiasis.
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Affiliation(s)
- Jie Yin
- Department of General Surgery, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang, China
| | - Dongying Wang
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yujing He
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Hongcun Sha
- Department of General Surgery, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang, China
| | - Wenhao Zhang
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Wei Huang
- Department of General Surgery, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang, China.
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Goyal H, Sachdeva S, Sherazi SAA, Gupta S, Perisetti A, Ali A, Chandan S, Tharian B, Sharma N, Thosani N. Early prediction of post-ERCP pancreatitis by post-procedure amylase and lipase levels: A systematic review and meta-analysis. Endosc Int Open 2022; 10:E952-E970. [PMID: 35845027 PMCID: PMC9286773 DOI: 10.1055/a-1793-9508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/13/2022] [Indexed: 10/28/2022] Open
Abstract
Background and study aims Post-ERCP pancreatitis (PEP) is the most common complication attributed to the procedure, its incidence being approximately 9.7 %. Numerous studies have evaluated the predictive efficacy of post-procedure serum amylase and lipase levels but with varied procedure-to-test time intervals and cut-off values. The aim of this meta-analysis was to present pooled data from available studies to compare the predictive accuracies of serum amylase and lipase for PEP. Patients and methods A total of 18 studies were identified after a comprehensive search of various databases until June 2021 that reported the use of pancreatic enzymes for PEP. Results The sample size consisted of 11,790 ERCPs, of which PEP occurred in 764 (6.48 %). Subgroups for serum lipase and amylase were created based on the cut-off used for diagnosing PEP, and meta-analysis was done for each subgroup. Results showed that serum lipase more than three to four times the upper limit of normal (ULN) performed within 2 to 4 hours of ERCP had the highest pooled sensitivity (92 %) for PEP. Amylase level more than five to six times the ULN was the most specific serum marker with a pooled specificity of 93 %. Conclusions Our analysis indicates that a lipase level less than three times the ULN within 2 to 4 hours of ERCP can be used as a good predictor to rule out PEP when used as an adjunct to patient clinical presentation. Multicenter randomized controlled trials using lipase and amylase are warranted to further evaluate their PEP predictive accuracy, especially in high-risk patients.
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Affiliation(s)
- Hemant Goyal
- University of Texas at Houston, McGovern School of Medicine, Texas, United States,Mercer University School of Medicine, Internal Medicine, Macon, Georgia, United States
| | - Sonali Sachdeva
- Boston University Medical Center, Medicine, Boston, Masschusetts, United States
| | | | - Shweta Gupta
- John H. Stroger Hospital of Cook County, Medicine, Chicago, Illinois, United States
| | - Abhilash Perisetti
- Parkview Health System, Advanced Interventional Oncology and Surgical Endoscopy, Fort Wayne, Indiana, United States
| | - Aman Ali
- Wilkes-Barre General Hospital, Endoscopy, Wilkes-Barre, Pennsylvania, United States
| | - Saurabh Chandan
- CHI Health Creighton University Medical Center, Gastroenterology & Hepatology, Omaha, Nebraska, United States
| | - Benjamin Tharian
- University of Arkansas for Medical Sciences, Department of Medicin, Division of Gastroenterology & Hepatology, Little Rock, Arkansas, United States
| | - Neil Sharma
- Parkview Health System, Advanced Interventional Oncology and Surgical Endoscopy, Fort Wayne, Indiana, United States
| | - Nirav Thosani
- University of Texas McGovern Medical School, Gastroenterology, Hepatology and Nutrition, Houston, Texas, United States
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Mo Y, Zhang X, Lao Y, Wang B, Li X, Zheng Y, Ding W. Fentanyl alleviates intestinal mucosal barrier damage in rats with severe acute pancreatitis by inhibiting the MMP-9/FasL/Fas pathway. Immunopharmacol Immunotoxicol 2022; 44:757-765. [PMID: 35616237 DOI: 10.1080/08923973.2022.2082304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Fentanyl is an analgesic used against pancreatitis-related pain, while whether it ameliorates severe acute pancreatitis (SAP) has yet to be checked. The present study aims to determine fentanyl-delivered effect on SAP and the mechanism underlying this effect. METHODS Rat SAP models were established, following fentanyl treatment. The serum activity of amylase (AMY), lipase (LIP) and diamine oxidase (DAO) was detected by enzyme-linked immunosorbent assay. Histological examination was performed in the pancreatic and intestinal tissues with hematoxylin-eosin staining. After transfection with matrix metalloproteinase (MMP)9 overexpression plasmids, Caco-2 monolayers were treated with fentanyl and subsequently exposed to lipopolysaccharide (LPS). The transepithelial electrical resistance (TEER) value was determined in rat intestinal mucosa through an Ussing chamber assisted by Analyze & Acquire, and in Caco-2 cell monolayers through a voltohmmeter. Intestinal mucosa and paracellular permeabilities were determined by fluorescein isothiocyanate (FITC)-labeled dextran assay. The expressions of ZO-1, Occludin, MMP9, Fas and Fas ligand (FasL) in rat intestinal mucosa and/or Caco-2 monolayers were analyzed by qRT-PCR or/and western blot. RESULTS Fentanyl alleviated SAP-related histological alterations in the pancreas and intestines, reduced the elevated levels of SAP-related AMY, LIP and DAO, but promoted the levels of ZO-1 and Occludin. In SAP rats and Caco-2 monolayers, SAP-related or LPS-induced TEER value decreases, permeability increases, and increases in the expressions of MMP9, Fas and FasL were reversed partly by fentanyl. Notably, MMP9 overexpression could reverse the above fentanyl-delivered in vitro effects. CONCLUSION Fentanyl alleviates intestinal mucosal barrier damage in rats with SAP by inhibiting the MMP9/FasL/Fas pathway.
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Affiliation(s)
- Yunchao Mo
- Clinical Pharmacy, Central People's Hospital of Zhanjiang
| | - Xiangdong Zhang
- Surgical Intensive Care Unit, Central People's Hospital of Zhanjiang
| | - Yongguang Lao
- Surgical Intensive Care Unit, Central People's Hospital of Zhanjiang
| | - Bizhu Wang
- Pharmacy Department, Central People's Hospital of Zhanjiang
| | - Xinmei Li
- Surgical Intensive Care Unit, Central People's Hospital of Zhanjiang
| | - Yuhong Zheng
- Surgical Intensive Care Unit, Central People's Hospital of Zhanjiang
| | - Weihua Ding
- Surgical Intensive Care Unit, Central People's Hospital of Zhanjiang
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Márta K, Gede N, Szakács Z, Solymár M, Hegyi PJ, Tél B, Erőss B, Vincze Á, Arvanitakis M, Boškoski I, Bruno MJ, Hegyi P. Combined use of indomethacin and hydration is the best conservative approach for post-ERCP pancreatitis prevention: A network meta-analysis. Pancreatology 2021; 21:1247-1255. [PMID: 34353727 DOI: 10.1016/j.pan.2021.07.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Post-ERCP pancreatitis (PEP) is a life-threatening complication. Given the lack of a causative treatment for pancreatitis, it is of vital importance to minimize this risk of PEP. Multi-target preventive therapy may be the best choice for PEP prevention as disease development is multifactorial. AIM We aimed to assess the efficacy of a combination of indomethacin and hydration - type and amount - for PEP prevention via a network meta-analysis. METHODS Through a systematic search in three databases, we searched all randomized controlled trials involving hydration and indomethacin and ranked the PEP preventive efficacy with a Bayesian network meta-analysis using the PRISMA for Network Meta-Analyses (PRISMA-NMA) guideline. The RoB2 tool was used for risk of bias assessment, surface under the cumulative ranking curve (SUCRA) for ranking and PROSPERO for the study protocol [reg. no. CRD42018112698]. We used risk ratios (RR) for dichotomous data with 95% credible intervals (95% CrI). RESULTS The quantitative analysis included 7559 patients from 24 randomized controlled trials. Based on the SUCRA values, a combination of lactated Ringer's and indomethacin is more effective than single therapy with a 94% certainty. The percent relative risk ratios estimate preventive efficacy 70-99% higher for combinations than single therapies. Aggressive hydration with indomethacin (SUCRA 100%) is also significantly more effective than all other interventions (percent relative effect 94.3-98.1%). CONCLUSIONS A one-hit-on-each-target therapeutic approach is recommended in PEP prevention with an easily accessible combination of indomethacin and aggressive hydration for all average and high-risk patients without contraindication.
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Affiliation(s)
- Katalin Márta
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Noémi Gede
- Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Margit Solymár
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Jenő Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary; First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Tél
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary; First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Áron Vincze
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Marianna Arvanitakis
- Gastroenterology Department, Gastrointestinal Cancer Unit, Erasme Hospital University, Brussels, Belgium
| | - Ivo Boškoski
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Italy
| | - Marco J Bruno
- Department of Gastroenterology & Hepatology, Erasmus Medical Center, University Medical Center Rotterdam, the Netherlands
| | - Péter Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Centre for Translational Medicine, Semmelweis University, Budapest, Hungary.
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The prognostic value of serum and urine amylase levels and blood count parameters in assessing the risk of post-endoscopic pancreatitis development. GASTROENTEROLOGY REVIEW 2021; 16:132-135. [PMID: 34276840 PMCID: PMC8275959 DOI: 10.5114/pg.2021.106664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/30/2020] [Indexed: 11/17/2022]
Abstract
Introduction Detection of post-endoscopic pancreatitis (PEP) in the first hours after endoscopic retrograde cholangiopancreatography (ERCP) can limit its consequences, while excluding it can provide safe discharge of the patient. Therefore, a simple, clinically available test is needed for this purpose. Aim The assessment of the risk of PEP development based on serum and urine amylase levels and parameters included in blood counts 4 h after ERCP. Material and methods The study included 398 patients after therapeutic ERCP. Four hours after the procedure was completed, serum and urine amylase levels and blood count parameters were analysed. Results The optimal serum amylase level for PEP detection was 516 UI/l, with ACC = 0.94, sens. 77.8%, spec. 0.95; positive predictive value (PPV) 0.412, negative predictive value (NPV) 0.98, positive likelihood factor (LR+) 14.93, and negative likelihood factor (LR-) 0.23. The serum amylase level for exclusion of PEP was 184 UI/l with ACC 0.79, sens. 0.83, spec. 0.79, PPV 0.16, NPV 0.99, and LR- 0.21. The optimal urine amylase level for detection and exclusion (based on Youden index) was 575 UI/l, sens. 83.33%, spec. 81.3%, PPV 0.172, NPV 0.99, LR+ 4.44, and LR- 0.20. Conclusions Serum amylase levels above 516 UI/l at 4 h after ERCP should be an indication for further observation in hospital, and levels below 184 UI/l may justify safe discharge of the patient. Additional determinations of urine amylase levels and parameters included in blood counts do not improve the diagnostic capacity for the detection or exclusion of PEP risk.
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Boškoski I, Costamagna G. How to Prevent Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastroenterology 2020; 158:2037-2040. [PMID: 32197979 DOI: 10.1053/j.gastro.2020.03.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS; and Centre for Endoscopic Research, Therapeutics and Training (CERTT), Catholic University of Rome, Rome, Italy.
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS; and Centre for Endoscopic Research, Therapeutics and Training (CERTT), Catholic University of Rome, Rome, Italy
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Serum lipase as a biomarker for early prediction and diagnosis of post-endoscopic retrograde cholangiopancreatography pancreatitis. Ir J Med Sci 2019; 189:163-170. [PMID: 31463894 DOI: 10.1007/s11845-019-02089-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/23/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Lipase is one of the diagnostic criteria for acute pancreatitis; however, the value of serum lipase in the early prediction and diagnosis for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis remains controversial. AIMS We evaluate the 3-h post-ERCP serum amylase and lipase activities for early prediction of postoperative pancreatitis (PEP) and compare the 24-h post-ERCP serum amylase and lipase activities in the diagnosis of PEP. METHODS Clinical information of patients who underwent ERCP from January 2017 to December 2018 at our hospital were retrospectively reviewed. Receiver operating characteristic (ROC) curves were performed for 3-h and 24-h post-ERCP serum amylase and lipase activities to evaluate predictive and diagnostic values, respectively. RESULTS A total of 498 cases with ERCP were finally enrolled, in which 36 cases of PEP were confirmed. ROC curves for 3-h post-ERCP amylase and lipase activities depicted areas under the curve (AUCs) of 0.88 (P < 0.001, 95% confidence intervals [CI] 0.82-0.93) and 0.90 (P < 0.001, 95% CI 0.86-0.93), respectively. The difference showed no significance using Z test (Z = 0.69, P > 0.05). AUCs for 24-h amylase and lipase activities were 0.83 (P < 0.001, 95% CI 0.77-0.89) and 0.94 (P < 0.001, 95% CI 0.90-0.99), respectively, and the difference was significant (Z = 3.04, P < 0.05). CONCLUSIONS For early prediction of PEP, 3-h post-ERCP serum lipase activity is at least as good as that of amylase. For diagnosis of PEP, 24-h post-ERCP serum lipase is a much better indicator than that of amylase. Together, this study suggests that serum lipase should be given priority in the early prediction and diagnosis of PEP.
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8
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Lee YK, Yang MJ, Kim SS, Noh CK, Cho HJ, Lim SG, Hwang JC, Yoo BM, Kim JH. Prediction of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Using 4-Hour Post-Endoscopic Retrograde Cholangiopancreatography Serum Amylase and Lipase Levels. J Korean Med Sci 2017; 32:1814-1819. [PMID: 28960034 PMCID: PMC5639062 DOI: 10.3346/jkms.2017.32.11.1814] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 08/04/2017] [Indexed: 01/08/2023] Open
Abstract
Early post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) prediction may allow safe same-day outpatients discharge after ERCP and earlier proper management. This study aimed to assess the usefulness of the 4-hour post-ERCP serum amylase and lipase levels for PEP early prediction and to investigate predictive cut-off values for 4-hour post-ERCP serum amylase and lipase levels for safe discharge and urgent initiation of resuscitation. The data of 516 consecutive patients with native papilla who underwent ERCP between January 2013 and August 2014 were retrospectively reviewed. Serum amylase and lipase levels were measured before, and 4 and 24 hours after ERCP. PEP occurred in 16 (3.1%) patients. The receiver-operator characteristic curve for 4-hour post-ERCP serum amylase and lipase levels showed that the areas under the curve were 0.919 and 0.933, respectively, demonstrating good test performances as predictors for PEP (both P values < 0.001). The amylase level > 1.5 × the upper limit of reference (ULR) was found useful for PEP exclusion with a sensitivity of 93.8%, while 4 × ULR was found useful to guide preventive therapy with the best specificity of 93.2%. Similarly, the lipase level 2 × ULR showed best sensitivity, while 8 × ULR had the best specificity. Logistic regression analysis showed that 4-hour post-ERCP amylase level > 4 × ULR, lipase level > 8 × ULR, precut sphincterotomy, and pancreatic sphincterotomy were significant predictors for PEP. In conclusion, 4-hour post-ERCP amylase and lipase levels are useful early predictors of PEP that can ensure safe discharge or prompt resuscitation after ERCP.
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Affiliation(s)
- Yeon Kyung Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Min Jae Yang
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Soon Sun Kim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Choong Kyun Noh
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Hyo Jung Cho
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Sun Gyo Lim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Jae Chul Hwang
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Byung Moo Yoo
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Jin Hong Kim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea.
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Rompianesi G, Hann A, Komolafe O, Pereira SP, Davidson BR, Gurusamy KS, Cochrane Upper GI and Pancreatic Diseases Group. Serum amylase and lipase and urinary trypsinogen and amylase for diagnosis of acute pancreatitis. Cochrane Database Syst Rev 2017; 4:CD012010. [PMID: 28431198 PMCID: PMC6478262 DOI: 10.1002/14651858.cd012010.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The treatment of people with acute abdominal pain differs if they have acute pancreatitis. It is important to know the diagnostic accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase for the diagnosis of acute pancreatitis, so that an informed decision can be made as to whether the person with abdominal pain has acute pancreatitis. There is currently no Cochrane review of the diagnostic test accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase for the diagnosis of acute pancreatitis. OBJECTIVES To compare the diagnostic accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase, either alone or in combination, in the diagnosis of acute pancreatitis in people with acute onset of a persistent, severe epigastric pain or diffuse abdominal pain. SEARCH METHODS We searched MEDLINE, Embase, Science Citation Index Expanded, National Institute for Health Research (NIHR HTA and DARE), and other databases until March 2017. We searched the references of the included studies to identify additional studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. We also performed a 'related search' and 'citing reference' search in MEDLINE and Embase. SELECTION CRITERIA We included all studies that evaluated the diagnostic test accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase for the diagnosis of acute pancreatitis. We excluded case-control studies because these studies are prone to bias. We accepted any of the following reference standards: biopsy, consensus conference definition, radiological features of acute pancreatitis, diagnosis of acute pancreatitis during laparotomy or autopsy, and organ failure. At least two review authors independently searched and screened the references located by the search to identify relevant studies. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from the included studies. The thresholds used for the diagnosis of acute pancreatitis varied in the trials, resulting in sparse data for each index test. Because of sparse data, we used -2 log likelihood values to determine which model to use for meta-analysis. We calculated and reported the sensitivity, specificity, post-test probability of a positive and negative index test along with 95% confidence interval (CI) for each cutoff, but have reported only the results of the recommended cutoff of three times normal for serum amylase and serum lipase, and the manufacturer-recommended cutoff of 50 mg/mL for urinary trypsinogen-2 in the abstract. MAIN RESULTS Ten studies including 5056 participants met the inclusion criteria for this review and assessed the diagnostic accuracy of the index tests in people presenting to the emergency department with acute abdominal pain. The risk of bias was unclear or high for all of the included studies. The study that contributed approximately two-thirds of the participants included in this review was excluded from the results of the analysis presented below due to major concerns about the participants included in the study. We have presented only the results where at least two studies were included in the analysis.Serum amylase, serum lipase, and urinary trypsinogen-2 at the standard threshold levels of more than three times normal for serum amylase and serum lipase, and a threshold of 50 ng/mL for urinary trypsinogen-2 appear to have similar sensitivities (0.72 (95% CI 0.59 to 0.82); 0.79 (95% CI 0.54 to 0.92); and 0.72 (95% CI 0.56 to 0.84), respectively) and specificities (0.93 (95% CI 0.66 to 0.99); 0.89 (95% CI 0.46 to 0.99); and 0.90 (95% CI 0.85 to 0.93), respectively). At the median prevalence of 22.6% of acute pancreatitis in the studies, out of 100 people with positive test, serum amylase (more than three times normal), serum lipase (more than three times normal), and urinary trypsinogen (more than 50 ng/mL), 74 (95% CI 33 to 94); 68 (95% CI 21 to 94); and 67 (95% CI 57 to 76) people have acute pancreatitis, respectively; out of 100 people with negative test, serum amylase (more than three times normal), serum lipase (more than three times normal), and urinary trypsinogen (more than 50 ng/mL), 8 (95% CI 5 to 12); 7 (95% CI 3 to 15); and 8 (95% CI 5 to 13) people have acute pancreatitis, respectively. We were not able to compare these tests formally because of sparse data. AUTHORS' CONCLUSIONS As about a quarter of people with acute pancreatitis fail to be diagnosed as having acute pancreatitis with the evaluated tests, one should have a low threshold to admit the patient and treat them for acute pancreatitis if the symptoms are suggestive of acute pancreatitis, even if these tests are normal. About 1 in 10 patients without acute pancreatitis may be wrongly diagnosed as having acute pancreatitis with these tests, therefore it is important to consider other conditions that require urgent surgical intervention, such as perforated viscus, even if these tests are abnormal.The diagnostic performance of these tests decreases even further with the progression of time, and one should have an even lower threshold to perform additional investigations if the symptoms are suggestive of acute pancreatitis.
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Affiliation(s)
- Gianluca Rompianesi
- University of Modena and Reggio EmiliaInternational Doctorate School in Clinical and Experimental MedicineModenaItaly
| | | | | | - Stephen P Pereira
- Royal Free Hospital CampusUCL Institute for Liver and Digestive HealthUpper 3rd FloorLondonUKNW3 2PF
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryPond StreetLondonUKNW3 2QG
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Hayashi S, Nishida T, Shimakoshi H, Shimoda A, Amano T, Sugimoto A, Takahashi K, Mukai K, Matsubara T, Yamamoto M, Nakajima S, Fukui K, Inada M. Combination of two-hour post-endoscopic retrograde cholangiopancreatography amylase levels and cannulation times is useful for predicting post-endoscopic retrograde cholangiopancreatography pancreatitis. World J Gastrointest Endosc 2016; 8:777-784. [PMID: 28042392 PMCID: PMC5159676 DOI: 10.4253/wjge.v8.i20.777] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/30/2016] [Accepted: 09/21/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To estimate the efficacy of 2 h post-endoscopic retrograde cholangiopancreatography (ERCP) serum amylase levels and other factors for predicting post-ERCP pancreatitis. METHODS This was a retrospective, single-center cohort study of consecutive patients who underwent ERCP from January 2010 to December 2013. Serum amylase levels were measured 2 h post-procedure, and patient- and procedure-related pancreatitis (PEP) risk factors were analyzed using a logistic model. RESULTS A total of 1520 cases (average age 72 ± 12 years, 60% male) were initially enrolled in this study, and 1403 cases (725 patients) were ultimately analyzed after the exclusion of 117 cases. Fifty-five of these cases developed PEP. We established a 2 h serum amylase cutoff level of two times the upper limit of normal for predicting PEP. Multivariate analysis revealed that a cannulation time of more than 13 min [odds ratio (OR) 2.28, 95%CI: 1.132-4.651, P = 0.0210] and 2 h amylase levels greater than the cutoff level (OR = 24.1, 95%CI: 11.56-57.13, P < 0.0001) were significant predictive factors for PEP. Forty-seven of the 55 patients who developed PEP exhibited 2 h amylase levels greater than the cutoff level (85%), and six of the remaining eight patients who developed PEP (75%) required longer cannulation times. Only 2 of the 1403 patients (0.14%) who developed PEP did not exhibit concerning 2 h amylase levels or require longer cannulation times. CONCLUSION These findings indicate that the combination of 2 h post-ERCP serum amylase levels and cannulation times represents a valuable marker for identifying patients at high risk for PEP.
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Chan HH, Lai KH, Lin CK, Tsai WL, Lo GH, Hsu PI, Wei MC, Wang EM. Effect of somatostatin in the prevention of pancreatic complications after endoscopic retrograde cholangiopancreatography. J Chin Med Assoc 2008; 71:605-609. [PMID: 19114324 DOI: 10.1016/s1726-4901(09)70002-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The unique clinical role of endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing and treating biliary tree diseases cannot be completely replaced by other modern imaging modalities such as magnetic resonance cholangiopancreatography. However, post-ERCP pancreatitis is one of the most common and life-threatening complications. Prophylactic medication in the prevention of pancreatitis during ERCP is still controversial. The objective of the present study was to investigate the role of different regimens of somatostatin in the prevention of acute pancreatitis after ERCP and analyze the risk factors contributing to post-ERCP complications. METHODS From July 1999 to September 2000, 133 patients with benign biliary disease who received ERCP for diagnosis or treatment were enrolled. Group A patients received a bolus of somatostatin infusion before ERCP, followed by continuous infusion for 12 hours. Group B patients received a bolus of somatostatin before ERCP only, and group C patients were the controls who did not receive somatostatin treatment. Serum amylase levels before and 24 hours after ERCP, and abdominal pain were recorded. RESULTS There were no significant differences in bile duct and pancreatic duct visualization, ratio of diagnostic and therapeutic ERCP, procedure time, post-procedural hyperamylasemia and pancreatitis among the 3 groups. For patients with visualization of the pancreatic duct, the incidences of hyperamylasemia (serum amylase > or = 220 U/L) were higher than in patients without visualization of the pancreatic duct (p < 0.001). All 6 patients with post-ERCP pancreatitis had pancreatic duct visualization, and recovered after conservative treatment. CONCLUSION Continuous infusion of somatostatin after ERCP does not seem to be helpful in the prevention of pancreatic complications after ERCP. Pancreatic duct visualization is a risk factor for pancreatic complications.
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Affiliation(s)
- Hoi-Hung Chan
- Division of Gastroenterology, Kaohsiung Veterans General Hospital, Kaohsiung, Taipei, Taiwan, ROC
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12
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Ito K, Fujita N, Noda Y, Kobayashi G, Horaguchi J, Takasawa O, Obana T. Relationship between post-ERCP pancreatitis and the change of serum amylase level after the procedure. World J Gastroenterol 2007; 13:3855-60. [PMID: 17657841 PMCID: PMC4611219 DOI: 10.3748/wjg.v13.i28.3855] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To clarify the relationship between the change of serum amylase level and post-ERCP pancreatitis.
METHODS: Between January 1999 and December 2002, 1291 ERCP-related procedures were performed. Serum amylase concentrations were measured before the procedure and 3, 6, and 24 h afterward. The frequency and severity of post-ERCP pancreatitis and the relationship between these phenomena and the change in amylase level were estimated.
RESULTS: Post-ERCP pancreatitis occurred in 47 patients (3.6%). Pancreatitis occurred in 1% of patients with normal amylase levels 3 h after ERCP, and in 1%, 5%, 20%, 31% and 39% of patients with amylase levels elevated 1-2 times, 2-3 times, 3-5 times, 5-10 times and over 10 times the upper normal limit at 3 h after ERCP, respectively (level < 2 times vs≥ 2 times, P < 0.001). Of the 143 patients with levels higher than the normal limit at 3 h after ERCP followed by elevation at 6 h, pancreatitis occurred in 26%. In contrast, pancreatitis occurred in 9% of 45 patients with a level higher than two times the normal limit at 3 h after ERCP followed by a decrease at 6 h (26% vs 9%, P < 0.05).
CONCLUSION: Post-ERCP pancreatitis is frequently associated with an increase in serum amylase level greater than twice the normal limit at 3 h after ERCP with an elevation at 6 h. A decrease in amylase level at 6 h after ERCP suggests the unlikelihood of development of post-ERCP pancreatitis.
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Affiliation(s)
- Kei Ito
- Department of Gastroenterology, Sendai City Medical Center, 5-22-1, Tsurugaya, Miyagino-ku, Sendai, Miyagi 983-0824, Japan.
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13
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Ito K, Fujita N, Noda Y, Kobayashi G, Horaguchi J, Takasawa O, Obana T, Endo T, Nakahara K. RISK MANAGEMENT OF ENDOSCOPIC SPHINCTEROTOMY FOR CHOLEDOCHOLITHIASIS. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.2007.00714.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Abstract
Pancreatitis is the most common complication after endoscopic retrograde cholangio-pancreatography (ERCP); the reported incidence of this complication varies from less than 1% to 40%, but a rate of 4%-8% is reported in most prospective studies involving non-selected patients. Differences in criteria for defining pancreatitis, methods of data collection, and patient populations (i.e. number of high-risk patients included in the published series) are factors that are likely to affect the varying rates of post-ERCP pancreatitis. The severity of post-ERCP pancreatitis (PEP) can range from a minor inconvenience with one or two days of added hospitalization with full recovery to a devastating illness with pancreatic necrosis, multiorgan failure, permanent disability, and even death. Although, most episodes of PEP are mild (about 90%), a small percentage of patients (about 10%) develop moderate or severe pancreatitis. In the past, PEP was often viewed as an unpredictable and unavoidable complication, with no realistic strategy for its avoidance. New data have aided in stratification of patients into PEP risk categories and new measures have been introduced to decrease the risk of PEP. As most ERCPs are performed on an outpatient basis, the majority of patients will not develop PEP and can be discharged. Alternatively, early detection of those patients who will go on to develop PEP can guide decisions regarding hospital admission and aggressive management. In the last decade, great efforts have been addressed toward prevention of this complication. Points of emphasis have included technical measures, pharmacological prophylaxis, and patient selection. This review provides a comprehensive, evidence-based assessment of published data on PEP and current suggestions for its avoidance.
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Affiliation(s)
- Ayman M Abdel Aziz
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN 46202, USA
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15
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Abid GH, Siriwardana HP, Holt A, Ammori BJ. Mild ERCP-induced and non-ERCP-related acute pancreatitis: two distinct clinical entities? J Gastroenterol 2007; 42:146-51. [PMID: 17351804 DOI: 10.1007/s00535-006-1979-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2006] [Accepted: 11/15/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the hypothesis that mild endoscopic retrograde cholangiopancreatography (ERCP)-induced acute pancreatitis (AP) runs a distinctly shorter clinical course compared with mild attacks caused by other etiological factors. METHODS ERCP-induced AP was defined as the persistence of postprocedure abdominal pain requiring analgesia for at least 24 h in association with hyperamylasemia of more than three times the normal value. Among 2552 patients who had undergone ERCP between 1996 and 2002 in two different hospitals, mild AP developed after "elective" ERCP in 48 (group I). Among a random sample of 10% of 700 patients admitted with AP to both hospitals during the same study period, 58 had mild non-ERCP-related AP (group II). Results shown are medians. RESULTS Patients in group I had significantly shorter durations of pain (55 vs. 114 h, P < 0.0001), analgesic intake (56 vs.93 h, P = 0.007), and intravenous hydration (48 vs. 80 h, P < 0.0001), a lower opiate analgesic requirement (58 mg morphine equivalent vs. 100 mg, P = 0.001), a shorter time to resumption of oral diet (3 vs. 5 days, P < 0.0001), and a shorter hospital stay (4 vs. 7 days, P < 0.0001) than patients in group II. CONCLUSIONS The current definitions of ERCP-induced AP select a cohort of patients whose mild attacks run a significantly shorter and milder course than non-ERCP-related mild attacks. A new consensus definition of ERCP-induced AP that describes attacks of similar clinical course is needed.
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Affiliation(s)
- Ghalib H Abid
- Department of Surgery, Manchester Royal Infirmary, Manchester, UK
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16
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Lella F, Bagnolo F, Rebuffat C, Scalambra M, Bonassi U, Colombo E. Use of the laparoscopic-endoscopic approach, the so-called "rendezvous" technique, in cholecystocholedocholithiasis: a valid method in cases with patient-related risk factors for post-ERCP pancreatitis. Surg Endosc 2006; 20:419-23. [PMID: 16424987 DOI: 10.1007/s00464-005-0356-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Accepted: 10/21/2005] [Indexed: 12/14/2022]
Abstract
BACKGROUND Several studies have shown the efficacy and effectiveness of the combined endoscopic-laparoscopic "rendezvous" technique for treatment of gallbladder and bile duct stones without complications, particularly pancreatitis. The so-called rendezvous technique consists of laparoscopic cholecystectomy standards with intraoperative cholangiography followed by endoscopic sphincterotomy (EST). The sphincterotome is driven across the papilla through a guidewire inserted by the transcystic route. This method allows easier and faster cannulation, thus avoiding papillary edema and pancreatic trauma. The aim of this study was to evaluate whether this method is effective in eliminating ductal stones and to verify whether the risk of postprocedure pancreatitis is diminished. METHODS From January 2002 to September 2004, we enrolled 256 patients with cholecystocholedolithiasis detected by transabdominal ultrasound and magnetic resonance cholangiopancreatography. One hundred and twenty of these had one or more patient-related risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, so they were randomized into two groups of 60 patients. In group A, the patients were treated in a single step with videolaparoscopic cholecystectomy, intraoperative cholangiography, and EST during the surgical procedure with the rendezvous technique. In group B, preoperative ERCP and EST were performed by using a traditional method of bile duct cannulation. RESULTS No cases of post-ERCP pancreatitis were observed in group A, whereas six cases of acute post-ERCP pancreatitis occurred in group B (five mild and one moderate) (p = 0.0274). No procedure-related mortality was recorded. CONCLUSION In cholecysthocholedocholithiasis, the combined laparoscopic-endoscopic approach prevents post-ERCP pancreatitis in cases with patient-related risk factors for this complication.
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Affiliation(s)
- F Lella
- Department of Gastroenterology, Policlinico San Marco, Corso Europa 7, 24040 Zingonia (BG), Italy.
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17
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Sheehan SJ, Lee JH, Wells CK, Topazian M. Serum amylase, pancreatic stents, and pancreatitis after sphincter of Oddi manometry. Gastrointest Endosc 2005; 62:260-5. [PMID: 16046992 DOI: 10.1016/s0016-5107(05)00332-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Serum amylase levels 2 hours after ERCP predict postprocedure pancreatitis. The value of serum amylase measurements after sphincter of Oddi manometry (SOM) and the effect of pancreatic-duct stent placement on serum amylase are unknown. METHODS Records were reviewed for 88 SOM patients who had serum amylase measured 2 hours after the procedure. Post-SOM pancreatitis was defined as pain with a >3-fold elevation of serum amylase on the morning after SOM. "Possible pancreatitis" was defined as pain with a <3-fold elevation of serum amylase on the morning after SOM. RESULTS Post-SOM pancreatitis and possible pancreatitis each occurred in 13% of the study cohort. Post-SOM pancreatitis was associated with the absence of a pancreatic stent and occurred in 0% of patients without a stent who had normal 2-hour serum amylase vs. 67% with elevated 2-hour serum amylase (p < 0.01). Among patients who received a stent, pancreatitis occurred in 6%, regardless of whether the 2-hour serum amylase was elevated. Possible pancreatitis occurred mainly in patients who received stents, and it also was associated with elevation of the 2-hour serum amylase. CONCLUSIONS Elevation of the serum amylase level 2 hours after SOM predicts post-SOM pancreatitis but only in patients who do not receive a pancreatic stent. Among patients who received a stent, elevated 2-hour serum amylase levels predict subsequent findings that may be caused by attenuated pancreatitis.
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Affiliation(s)
- Sean J Sheehan
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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18
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Al-Bahrani AZ, Ammori BJ. Clinical laboratory assessment of acute pancreatitis. Clin Chim Acta 2005; 362:26-48. [PMID: 16024009 DOI: 10.1016/j.cccn.2005.06.008] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2005] [Revised: 06/13/2005] [Accepted: 06/14/2005] [Indexed: 12/20/2022]
Abstract
BACKGROUND Several biochemical markers in blood and urine have been investigated to establish their clinical application in patients with acute pancreatitis (AP). The relevant studies are reviewed and critically appraised. METHODS Medline and the World Wide Web were searched and the relevant literature was classified under the following categories: (1) diagnosis of AP and (2) prediction of: a) disease severity, b) pancreatic necrosis and its secondary infection, c) organ failure and death, and d) disease etiology. RESULTS AND CONCLUSIONS Serum lipase is a more reliable diagnostic marker of AP than serum amylase. Urinary strip tests for trypsinogen activation peptide (TAP) and trypsinogen-2 provide a reliable early diagnosis of AP. Useful predictors of severity may include serum procalcitonin and urinary TAP and trypsinogen-2 on admission, serum interleukins-6 and -8 and polymorphonuclear elastase at 24 h, and serum C-reactive protein (CRP) at 48 h. Other markers such as amyloid A and carboxypeptidase B activation peptide (CAPAP) need further investigation. Biochemical prediction of pancreatic necrosis requires 72 h to reach reliability and is impractical. However, the daily monitoring of serum procalcitonin provides a non-invasive detection of infected necrosis; the promising role of phospholipase A(2) in this regard requires further investigation. Early transient hypertransaminasemia reliably predicts biliary etiology, while serum carbohydrate-deficient transferrin and trypsin may predict an alcoholic etiology.
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19
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Abstract
BACKGROUND Pancreatitis occurs in up to 30% of patients who undergo ERCP. This study tested the hypothesis that post-ERCP pancreatitis can be avoided by initially accessing the bile duct with a soft-tipped Teflon tracer 0.035-inch guidewire. METHODS A single endoscopist performed ERCP in 400 consecutive patients with pancreatobiliary disease who were randomized to two groups. In Group A (200 patients), the bile duct was first accessed by insertion of a soft-tipped Teflon tracer (diameter 0.035 inch) guidewire through a 6F, double channel sphincterotome, followed by cannulation, injection of contrast, and sphincterotomy. In Group B (200 patients), the bile duct was opacified by using traditional methods of cannulation. RESULTS No case of acute pancreatitis was detected in Group A, whereas, 8 cases were observed in Group B (6 mild, one moderate, one severe) (p < 0.01). In 9 patients in Group A vs. 39 in Group B (p < 0.001), the serum amylase rose to more than 5 times the upper normal limit during the 24 hours after the procedure. There was no procedure-related mortality. CONCLUSIONS Accessing the bile duct with a soft-tipped tracer guidewire prevents post-ERCP pancreatitis.
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Affiliation(s)
- Fausto Lella
- Department of Gastroenterology and Gastrointestinal Endoscopy Unit, Policlinico San Marco, Zingonia, Italy
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20
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Abstract
In the past decade, our understanding of the genetic basis, pathogenesis, and natural history of pancreatitis has grown strikingly. In severe acute pancreatitis, intensive medical support and non-surgical intervention for complications keeps patients alive; surgical drainage (necrosectomy) is reserved for patients with infected necrosis for whom supportive measures have failed. Enteral feeding has largely replaced the parenteral route; controversy remains with respect to use of prophylactic antibiotics. Although gene therapy for chronic pancreatitis is years away, our understanding of the roles of gene mutations in hereditary and sporadic pancreatitis offers tantalising clues about the disorder's pathogenesis. The division between acute and chronic pancreatitis has always been blurred: now, genetics of the disorder suggest a continuous range of disease rather than two separate entities. With recognition of pancreatic intraepithelial neoplasia, we see that chronic pancreatitis is a premalignant disorder in some patients. Magnetic resonance cholangiopancreatography and endoscopic ultrasound are destined to replace endoscopic retrograde cholangiopancreatography for many diagnostic indications in pancreatic disease.
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Affiliation(s)
- R M S Mitchell
- Division of Gastroenterology, Duke University Medical Center, Durham, NC 27710, USA
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21
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Madhotra R, Lombard M. Endoscopic retrograde cholangiopancreatography should no longer be used as a diagnostic test: the case against. Dig Liver Dis 2002; 34:375-80. [PMID: 12118957 DOI: 10.1016/s1590-8658(02)80133-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Endoscopic retrograde cholangiopancreatography has been used successfully in diagnosis of pancreatico-biliary diseases. Over the past decade, there have been tremendous developments in radiological technologies which have led to the emergence of new and less invasive modalities like endoscopic ultrasound and spiral computed tomography and magnetic resonance cholangiopancreatography. Understandably, the usefulness of diagnostic endoscopic retrograde cholangiopancreatography is being questioned primarily because of its potential attendant complications. Therefore, this controversial question needs to be debated in the gastroenterology community. In this article, we compare the efficacy of newer diagnostic tools with existing "gold standard" modality--endoscopic retrograde cholangiopancreatography, and put forward our arguments in favour of a continuing role for endoscopic retrograde cholangiopancreatography as a diagnostic tool in certain circumstances.
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Affiliation(s)
- R Madhotra
- Department of Gastroenterology, Royal Liverpool University Hospitals, UK
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22
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Abstract
Pancreatitis is rightly the most feared complication of endoscopic retrograde cholangiopancreatography (ERCP). Ten percent to 15% of cases of post-ERCP pancreatitis (PEP) are severe by clinical and radiologic criteria. Such cases carry significant morbidity and mortality and are responsible for the vast majority of ERCP-related deaths. The prediction and prevention of PEP have been of great interest to endoscopists since the introduction of ERCP 30 years ago. Prediction and diagnosis of PEP have become more accurate with the widespread availability of serum amylase estimation. A variety of cytokines (eg, interleukin -1, IL-6, and IL-8) and acute phase reactants (eg, C-reactive protein) are also elevated in the serum in acute pancreatitis, and these form the basis of evolving tests for PEP. Urine testing (for amylase) in acute pancreatitis is obsolete, but it may soon undergo a revival in the form of a rapid (3-minute) dipstick test for trypsinogen-2, a sensitive and specific test for this disease. The prevention of PEP takes multiple forms. The following steps are recommended for clinicians: 1) avoid ERCP when other, less invasive or noninvasive imaging tests can do the job (eg, CT or magnetic resonance imaging); 2) avoid high-risk (of PEP) procedures, such as needle-knife papillotomy, balloon dilation of the biliary sphincter, and pancreatic sphincterotomy, and take steps to reduce risk when these procedures are unavoidable; 3) ensure that those who perform ERCP have adequate training and experience; and 4) consider pharmacologic intervention. Despite a depressing catalog of drug interventions that have failed over the years (eg, antihistamines, anticholinergics, and corticosteroids), three agents have recently shown promise: somatostatin; its octapeptide analogue, octreotide; and gabexate mesylate, a protease inhibitor.
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Affiliation(s)
- John Baillie
- Division of Gastroenterology, Duke University Medical Center, Box 3189, Durham, NC 27710, USA.
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Abstract
BACKGROUND Acute pancreatitis can develop after either ERCP or endoscopic sphincterotomy (ES). The pathogenesis of this complication remains poorly understood. METHODS The frequency and severity of acute pancreatitis were retrospectively evaluated after 17,602 ERCP procedures and 3003 ES procedures. Pancreatitis was diagnosed and evaluated according to the scoring system of Ranson and criteria developed in Japan. RESULTS Pancreatitis developed after 15 (0.09%) of 17,602 ERCP procedures and 13 (0.43%) of 3003 ES procedures (p = 0.0001, chi-square). The severity of pancreatitis (Ranson score) was less than 3 in 10 cases of ERCP-induced pancreatitis and from 3 to 5 in 5 cases. One (7%) of the 15 patients with ERCP-related pancreatitis died. All 13 patients with ES-induced pancreatitis had a Ranson score of less than 3; none died (p = 0.04, Fisher exact test). The ERCP pancreatitis score (Japanese criteria) beyond 48 hours after the onset of pancreatitis increased in 5 (33%) of the 15 patients with ERCP-induced pancreatitis; the score did not increase in any of the 13 patients with ES-induced pancreatitis (p = 0.04, Fisher exact test). CONCLUSIONS Although the frequency of ES-induced pancreatitis is significantly higher than that of post-ERCP pancreatitis, the frequency of severe pancreatitis within 48 hours and worsening of pancreatitis after 48 hours is significantly lower with ES-induced pancreatitis. Our hypothesis is that the lowering of pancreatic intraductal pressure after ES mitigates the severity of postprocedure pancreatitis.
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Borda F, Jiménez FJ, Vila J, Carral D, Zozaya JM, Pastor G, Aznarez R. [Cost effectiveness study on the use of somatostatin for reduction of acute pancreatitis after ERCP]. GASTROENTEROLOGIA Y HEPATOLOGIA 2001; 24:292-6. [PMID: 11459565 DOI: 10.1016/s0210-5705(01)70177-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Recent studies show that intravenous injection of somatostatin before endoscopic retrograde cholangiopancreatography (ERCP) is associated with a significant reduction in the rate of post-ERCP acute pancreatitis. The lack of data in our environment led us to study the possible economic benefits of somatostatin administration, obtained through the reduction of costs due to post-ERCP acute pancreatitis. MATERIAL AND METHODS Theoretical study of the direct costs of post-ERCP acute pancreatitis using Markov's tree decisions. The costs of the group pre-treated with intravenous administration of 3 mg of somatostatin were compared with those of the control group. Post-ERCP rates of pancreatitis of 10% were accepted in the control group and rates of 3% were accepted in the somatostatin group. The costs of the different types of pancreatitis were as follows: costs with and without complications and with surgical intervention were based on the diagnosis related group-weights applied by the Ministry of Health in the Contract-program of the Health Service of Navarre for 1999. A sensitivity analysis was carried out to determine the rate of post-ERCP pancreatitis from which an economic benefit would be obtained in the group pre-treated with somatostatin. RESULTS Mean theoretical cost per procedure was 121,640 pesetas for the control group and 105,539 for the group pre-treated with somatostatin. Saving per patient was 13.26% (16,101 pesetas). The sensitivity analysis revealed that in the control group premedication produced an economic benefit starting from a pancreatitis rate of 4.2%. CONCLUSIONS Independently of the clinical benefit signifying the reduction of post-ERCP pancreatitis, somatostatin administration led to a saving of 16,101 pesetas per patient. Accepting that the pancreatitis rate in the treated group was proportionately reduced, the sensitivity analysis showed that premedication produced an economic benefit starting from a pancreatitis rate of 4.2% in the control group.
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Affiliation(s)
- F Borda
- Servicio de Digestivo. Hospital de Navarra. Pamplona
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25
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Testoni PA, Bagnolo F. Pain at 24 hours associated with amylase levels greater than 5 times the upper normal limit as the most reliable indicator of post-ERCP pancreatitis. Gastrointest Endosc 2001; 53:33-9. [PMID: 11154486 DOI: 10.1067/mge.2001.111390] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The frequency of post-ERCP/sphincterotomy pancreatitis is between 1.3% and 7.6% in prospective studies. This range likely reflects differences in definitions of pancreatitis and methods of data collection. METHODS To identify clinical findings and enzymatic values consistent for clinical pancreatitis at 24 hours, the post-ERCP/sphincterotomy course of 1185 procedures was prospectively recorded. Patients were evaluated for pancreatic-type pain, white blood cell count, and serum amylase before and 24 hours after the procedure; pain and amylase levels were also recorded 6 to 8 hours after the procedure. CT was performed in all patients with pain associated with amylase levels greater than 3 times normal. All patients were evaluated clinically at 48 hours. RESULTS Pancreatic-type pain never occurred in cases with amylase levels lower than 3 times normal; it was significantly (p < 0.001) associated with amylase levels greater than 5 times normal, either 6 to 8 hours or 24 hours after the procedure. Leukocytosis and CT findings consistent with pancreatitis were observed only in patients (41.7% and 29.5%, respectively) with 24-hour amylase levels greater than 5 times normal. None of the 18 patients with pain at 24 hours and serum amylase lower than 5 times normal had symptoms that persisted at 48 hours. Twenty-five (41.7%) of the 60 patients with pain at 24 hours and amylase higher than 5 times normal had 48-hour pain at 48 hours and hyperamylasemia. CONCLUSIONS Features consistent with clinical pancreatitis were present only among patients with pancreatic-type pain at 24 hours and amylase levels higher than 5 times normal. Additional follow-up is required for these patients.
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Affiliation(s)
- P A Testoni
- Division of Gastroenterology and Gastrointestinal Endoscopy, University Vita-Salute San Raffaele, IRCCS San Raffaele Hospital, Milan, Italy
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26
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Testoni PA, Bagnolo F, Natale C, Primignani M. Incidence of post-endoscopic retrograde-cholangiopancreatography/sphincterotomy pancreatitis depends upon definition criteria. Dig Liver Dis 2000; 32:412-8. [PMID: 11030187 DOI: 10.1016/s1590-8658(00)80262-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The reported incidence of post-endoscopic retrograde-cholangiopancreatography/sphincterotomy pancreatitis ranges between 1.3% and 12.8%. This may likely reflect different definitions of pancreatitis and methods of data collection, rather than differences in patient populations, indications and endoscopic expertise. AIMS The present study evaluated the incidence of post-endoscopic retrograde-cholangiopancreatography/sphincterotomy pancreatitis using different definition criteria and different data collection methods. PATIENTS The 24-hour clinical and enzymatic course of 1185 procedures was recorded. METHODS Pancreatic-like pain and hyperamylasaemia were evaluated either 6 to 8 hours or 24 hours after the procedure; computed tomography scan was performed in those patients with 24-hour pancreatic pain associated with hyperamylasaemia more than three times the upper normal limit. Results. Computed tomography scan findings consistent with pancreatitis were observed in 1.9% of cases, only among those patients with 24-hour pancreatic-like pain and hyperamylasaemia over five times the upper normal limit. The 6-8-hour and 24-hour pancreatic-like pain was associated with serum amylase levels at least three times higher in 11.7% and 6.6% and five times higher or more in 7.4% and 5.1%, respectively; 6-8 and 24-hour hyperamylasaemia higher than five times the upper normal limit, irrespective of pancreatic-like pain, was reported in 8.3% and in 6.9% of cases. No patients with serum amylase values lower than three times the upper normal limit had clinical symptoms. CONCLUSIONS The incidence of post-procedure pancreatitis ranged from 1.9% to 11.7% depending on the definition criteria adopted.
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Affiliation(s)
- P A Testoni
- Division of Gastroenterology and Gastrointestinal Endoscopy, University Vita-Salute San Raffaele, IRCCS San Raffaele Hospital, Milan, Italy
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Riemann JF. Incidence of post-endoscopic retrograde cholangiopancreatography/sphincterotomy pancreatitis depends upon definition criteria. Dig Liver Dis 2000; 32:419-21. [PMID: 11030188 DOI: 10.1016/s1590-8658(00)80263-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- J F Riemann
- Department of Gastroenterology and Hepatology, Klinikum der Stadt Ludwigshafen gGmbH, Ludwigshafen, Germany.
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