Three-hour post-ERCP amylase level: a useful indicator for early prediction of post-ERCP pancreatitis

Association of periampullary diverticulum types with post-ERCP hyperamylasemia: a retrospective observational study

BACKGROUND

This study aimed to assess the prevalence of periampullary diverticulum (PAD) among endoscopic retrograde cholangiopancreatography (ERCP) patients in Southwestern Turkey and investigate the association between the new PAD classification, post-ERCP hyperamylasemia, and post-ERCP pancreatitis (PEP).

MATERIALS AND METHODS

We retrospectively reviewed 1,317 ERCP procedures performed between January 1, 2022, and December 31, 2023, at Antalya Training and Research Hospital. The PAD type was determined according to the He-xian Shi classification. Hyperamylasemia was defined as an increase of three times the normal level of amylase at 4 to 6 h, and PEP was defined as hyperamylasemia along with abdominal pain lasting more than 24 h.

RESULTS

A total of 594 naive patients who underwent ERCP were analyzed. PAD was present in 137 patients (23.1%), and the success rate of choledochal cannulation in the first ERCP procedure was 94.3%. There was no difference in the choledochal cannulation rate between patients with and without PAD (95.6%-93.4%, p = 0.59). Asymptomatic hyperamylasemia was observed in 19.3% of the patients. Post-ERCP hyperamylasemia rates were similar between patients with and without PAD (17.5% and 21.2% respectively, p = 0.31). PEP was observed in 8.0% of the patients. Presence of PAD was not a risk factor for post-ERCP pancreatitis (7.3% compared to 8.8%, p = 0.82). When we checked the results according to the type of PAD, the prevalence of post-ERCP hyperamylasemia was significantly lower in patients with type 2b PAD than in those with type 1 and type 2a patients.

CONCLUSION

PAD is a common finding in ERCP patients, with a prevalence of 23.1% in our cohort. The rate of choledochal cannulation, post ERCP hyperamylasemia and PEP did not differ between the patients with and without PAD. However, the type of PAD is important; post-ERCP hyperamylasemia is significantly lower in patients with type 2b than in type 1 and type 2a PAD patients. Different subtypes of PAD may have different associations on ERCP outcomes. Further investigations with refined and standardized PAD classification systems are needed.

Analysis of the efficacy and safety of endoscopic retrograde cholangiopancreatography for the treatment of pediatric pancreatobiliary diseases

BACKGROUND

Traditional surgical procedures are highly invasive and risky for children with pancreatic and biliary diseases. Endoscopic retrograde cholangiopancreatography (ERCP) has been used mostly in adults because it is a safe and effective surgical procedure. Its application in children will contribute to the treatment and prognosis of children with pancreatic and biliary diseases.

AIM

To analyze the efficacy and safety of ERCP for the treatment of pediatric pancreatobiliary diseases.

METHODS

A retrospective study was performed using the medical records of 101 pediatric patients who received treatment for pancreatobiliary diseases at Children's Hospital Capital Institute of Pediatrics from April 2022 to April 2024. The patients were divided into an observation group (n = 52, treated with ERCP) and a control group (n = 49, treated with traditional surgical methods). Diagnostic and therapeutic outcomes of ERCP were statistically analyzed. Treatment efficacy, time to resume eating, and hospital stay duration were compared between the two groups. Indicators of liver function were monitored preoperatively and one week postoperatively. Dynamic changes in C-reactive protein (CRP) and serum amylase levels were assessed preoperatively and at 6 and 24 hours postoperatively. Postoperative complications were also compared. Logistic multivariate regression was used to analyze the independent effect of ERCP on outcomes.

RESULTS

For the observation group, 36 and 16 patients were diagnosed with biliary and pancreatic diseases, respectively. Compared with the control group, the observation group exhibited a higher overall effective rate (P < 0.05), shorter times to resume eating, shorter hospital stays (P < 0.05), and significantly improved postoperative liver function (P < 0.05). CRP and serum amylase levels were significantly increased in both groups at 6 and 24 hours postoperatively (P < 0.05), but were significantly lower in the observation group (P < 0.05). The observation group also had a lower incidence of complications (P < 0.05). ERCP was an independent factor affecting treatment efficacy, length of hospital stay, total bilirubin, aspartate aminotransferase, and alanine aminotransferase, CRP, serum amylase, and the occurrence of complications in children with pancreaticobiliary diseases (P < 0.05).

CONCLUSION

ERCP effectively enhances the treatment efficacy of pediatric pancreatobiliary diseases, with a reduced inflammatory response, faster postoperative recovery, and fewer complications. ERCP is a safe and effective diagnostic and therapeutic method for pediatric pancreatobiliary diseases.

Tailored Hydration With Lactated Ringer's Solution for Postendoscopic Retrograde Cholangiopancreatography Pancreatitis Prevention: A Randomized Controlled Trial

INTRODUCTION

Aggressive hydration using lactated Ringer's solution prevents postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Concerns of this strategy are large volume and lengthy hydration. Our study aimed to evaluate the efficacy of tailored aggressive hydration (TAH) for PEP prevention.

METHODS

In this prospective, multicenter, double-blinded, randomized trial conducted across 3 tertiary Korean hospitals, patients who underwent ERCP for the first time were randomly assigned (1:1) to the tailored standard hydration (TSH) and TAH groups. The TSH group received 1.5 mL/kg/hr lactated Ringer's solution during and after ERCP, whereas the TAH group was administered a 20 mL/kg bolus post-ERCP and 3 mL/kg/hr during and after the procedure. Both groups were assessed for elevated serum amylase levels and pain 4-6 hours after ERCP. If both were absent, hydration was discontinued. If either was present, hydration was continued at the original rate until 8 hours. The primary end point was PEP development and was analyzed on an intention-to-treat analysis.

RESULTS

A total of 344 patients were randomly assigned to treatment groups (171 to the TSH group and 172 to the TAH group). PEP was observed in 9.4% (16/171) in the TSH group and 3.5% (6/172) in the TAH group (relative risk 0.37, 95% confidence interval 0.15-0.93, P = 0.03). No difference was identified between the 2 groups in PEP severity ( P = 0.80) and complications related to volume overload ( P = 0.32).

DISCUSSION

TAH according to the presence of abdominal pain or elevated serum amylase levels at 4-6 hours after ERCP is safe and prevents PEP development.

Early prediction of post-endoscopic retrograde cholangiopancreatography pancreatitis via dynamic changes of leukocyte: A retrospective study

BACKGROUND

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remains a major concern for clinicians. Hence early identification of PEP is meaningful to minimize medical risks.

AIMS

This study aims to explore the value of dynamic leukocyte changes for early prediction of PEP.

METHODS

Patients from January 2017 to December 2018 (training set) and January 2019 to December 2022 (test set) were retrospectively reviewed. The dynamic changes of leukocyte, neutrophil, and lymphocyte were examined to evaluate the diagnostic value of PEP.

RESULTS

A total of 498 patients (36 PEP cases) in training set and 948 patients (71 PEP cases) in test set were analyzed. Four predictors were finally identified in training set containing margin and ratio of 3h-post ERCP leukocyte count (Po Leu) to pre-ERCP leukocyte count (Pr Leu), 3h post-ERCP neutrophil-to-lymphocyte ratio (NLR) and pre-ERCP fibrinogen levels. ROC analysis revealed the optimal thresholds were 2.3 (x109/L), 1.6, 4.8 and 3.1 (g/L), respectively. The sensitivity and specificity of Po Leu - Pr Leu and Po Leu/Pr Leu were 71.0%, 82.7%, 66.1% and 86.3% to diagnosis PEP in patients with hyperamylasemia.

CONCLUSIONS

For early identification of PEP, the elevation of amylase and lipase still exhibits the highest sensitivity, while the dynamic changes of leukocyte would be helpful for the different diagnosis of hyperamylasemia.

Postprocedure serum amylase or lipase levels predict postendoscopic retrograde cholangiopancreatography pancreatitis: Meta-analysis of diagnostic test accuracy studies and utility assessment

OBJECTIVES

We aimed to clarify the clinical utility of measuring serum pancreatic enzymes after endoscopic retrograde cholangiopancreatography (ERCP) for the purpose of predicting post-ERCP pancreatitis (PEP) by a meta-analysis of diagnostic test accuracy studies.

METHODS

Studies on the prediction accuracy of PEP by serum amylase or lipase measured at 2, 3, and 4 h after ERCP were collected. A literature search was performed in PubMed and the Cochrane Library database for studies published between January 1980 and March 2023. The quality of individual studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2. Data were analyzed using Meta-DiSc 2.0 software.

RESULTS

We searched the databases and identified 20 observational studies (12,313 participants). PEPs were defined according to criteria by Cotton or modified Cotton, revised Atlanta criteria, or the Japanese criteria. Meta-analysis of eight studies (4389 participants) showed a pooled sensitivity of 71.1% (95% confidence interval [CI] 56.1-82.5) and pooled specificity of 91.2% (95% CI 85.9-94.6) for the serum amylase cut-off value at 3 times the upper limit of normal (ULN). Another meta-analysis of five studies (1970 participants) showed a pooled sensitivity of 85.8% (95% CI 61.9-95.7) and pooled specificity of 85.3% (95% CI 81.9-88.1) for the serum lipase cut-off value at 3 times ULN.

CONCLUSION

Despite a high risk of bias due to various reference standards, this updated meta-analysis and the utility assessment by a decision tree showed the utility of serum amylase or lipase levels more than 3 times ULN measured 2-4 h after ERCP for predicting PEP.

Effect of rectal indomethacin on the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography for choledocholithiasis: a prospective randomized clinical trial

BACKGROUND AND AIM

the aim of this study was to evaluate the efficacy and safety of rectal indomethacin for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in patients with common bile duct (CBD) stones.

METHODS

a total of 167 patients undergoing ERCP between November 2019 and November 2022 for CBD stones in the First Affiliated Hospital of Dalian Medical University were prospectively analyzed. The patients were divided into an indomethacin group (n = 58) and a control group (n = 109). The primary endpoint was the percent of patients who experienced PEP.

RESULTS

PEP was observed in a total of 26 patients (15.57 %); four patients (6.90 %) in the indomethacin group and 22 (20.18 %) in the control group (p = 0.042). Mild, moderate and severe PEP was observed in three (5.17 %), one (1.72 %) and zero patients, respectively, in the indomethacin group, and in eleven (10.09 %), nine (8.26 %) and two (1.83 %) patients, respectively, in the control group. There was one case (0.92 %) of death due to PEP in the control group. No cases of moderate or severe bleeding were observed in either group.

CONCLUSIONS

rectal indomethacin is an effective and safe method to prevent PEP for patients with CBD stones undergoing ERCP.

Analysis of risk factors and construction of predictive model for post-endoscopic retrograde cholangiopancreatography pancreatitis

Objective

To explore the risk factors of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and to establish a predictive model.

Methods

This was a retrospective observational study. Patients diagnosed with calculous cholangitis and treated with ERCP (n=998) in The First People's Hospital of Linping District from January 2014 to September 2022 were included. Risk factors of PEP were identified using univariate and multivariate logistic regression, and a nomograph prediction model was established based on the identified independent risk factors.

Results

PEP occurred in 52 patients (5.2%). Logistic regression analysis showed that common bile duct diameter, history of PEP, operation time, intubation frequency, pancreatic ducts visualization, and Sphincter of Oddi dysfunction (SOD) were independent risk factors for inducing PEP (P<0.05). The calibration curve showed that the predicted probability of occurrence of the nomograph model was consistent with the actual probability of occurrence. The C-index value calculated by the Bootstrap method was 0.966, suggesting the nomograph prediction model has a good discrimination ability. The AUC of the nomograph prediction model ROC curve was 0.966 (95% CI: 0.857-0.941), suggesting good prediction efficiency, and the decision analysis curve shows a high value.

Conclusions

Independent risk factors for PEP are large diameter of common bile duct, history of pancreatitis, long operation time, high intubation frequency, pancreatic ducts visualization, and SOD. The nomogram prediction model based on the above independent risk factors has good prediction ability.

Predictors of Post-ERCP Pancreatitis (P.E.P.) in Choledochal Lithiasis Extraction

In the present era, post-ERCP pancreatitis (PEP) stands out as one of the most commonly occurring complications associated with endoscopic choledochal lithiasis extraction. The ability to predict the occurrence of such an event, particularly by utilizing absolute values and ratio dynamics of the emergency blood tests, constitutes the primary step in effectively managing a patient with a complex pathology. The study involved 134 patients who performed ERCP to extract choledochal lithiasis (n = 48 with PEP and n = 86 without PEP). The results revealed increased risks of post-ERCP pancreatitis in women and lower risks in those who benefited from manipulation of the main bile duct with the Dormia probe and dilatation balloon (OR: 2.893 CI 95%: 1.371-6.105, p = 0.005 and respectively OR: 0.346 CI 95%: 0.156-0.765, p = 0.009), without biliary stent placement. Moreover, the results brought novel elements to the literature, showing that higher values of CRPR (OR: 4.337 CI 95%: 1.945-9.668; p < 0.001), TBIR (4.004 CI 95%: 1.664-9.634; p = 0.002) and NLR post-ERCP (3.281 CI 95%: 1.490-7.221; p = 0.003) are predictive for PEP. Nevertheless, lower total bilirubin levels upon admission are predictive of PEP with an OR of 5.262 (95% confidence interval: 2.111-13.113, p < 0.001).

Early prediction of post-ERCP pancreatitis by post-procedure amylase and lipase levels: A systematic review and meta-analysis

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.

Assessment of changes in blood pancreatic lipase activities using FDC-v-LIP in dogs that underwent various surgical procedures

OBJECTIVE

To describe the perioperative changes in blood pancreatic lipase activity and explore the contributing clinical factors associated with these changes.

DESIGN

Prospective observational study.

SETTING

University teaching hospital.

ANIMALS

One hundred and four dogs underwent various surgical procedures under general anesthesia.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Blood pancreatic lipase activities, which were measured using FUJI DRI-CHEM v-Lip-P (FDC-v-Lip), significantly increased postoperatively compared to preoperative measurements (premedian 58.5 U/L [range, 23-157] vs. postmedian 80 U/L [range, 22-1000], P < 0.0001). The patient with a postoperative increase in FDC-v-Lip over the normal range (35 dogs [33.6%]) had significantly higher preoperative FDC-v-Lip values.

CONCLUSIONS

In this study, dogs had significantly increased pancreas-specific lipase activities after surgical procedures under general anesthesia. Direct contributors to the increase and its relevance to clinical and histological pancreatitis should be determined in the future.

The novel SARS-CoV-2 pandemic: Possible environmental transmission, detection, persistence and fate during wastewater and water treatment

The contagious SARS-CoV-2 virus, responsible for COVID-19 disease, has infected over 27 million people across the globe within a few months. While literature on SARS-CoV-2 indicates that its transmission may occur predominantly via aerosolization of virus-laden droplets, the possibility of alternate routes of transmission and/or reinfection via the environment requires considerable scientific attention. This review aims to collate information on possible transmission routes of this virus, to ascertain its fate in the environment. Concomitant with the presence of SARS-CoV-2 viral RNA in faeces and saliva of infected patients, studies also indicated its occurrence in raw wastewater, primary sludge and river water. Therefore sewerage system could be a possible route of virus outbreak, a possible tool to assess viral community spread and future surveillance technique. Hence, this review looked into detection, occurrence and fate of SARS-CoV-2 during primary, secondary, and tertiary wastewater and water treatment processes based on published literature on SARS-CoV and other enveloped viruses. The review also highlights the need for focused research on occurrence and fate of SARS-CoV-2 in various environmental matrices. Utilization of this information in environmental transmission models developed for other enveloped and enteric viruses can facilitate risk assessment studies. Preliminary research efforts with SARS-CoV-2 and established scientific reports on other coronaviruses indicate that the threat of virus transmission from the aquatic environment may be currently non-existent. However, the presence of viral RNA in wastewater provides an early warning that highlights the need for effective sewage treatment to prevent a future outbreak of SARS-CoV-2.