Biliary Pancreatitis

1. Biliary Pancreatitis Bryan Thompson April 26, 2004 Gastroenterology Grand Rounds

2. Study #1 Neoptolemos et al United Kingdom 1983 to 1987 Single center All pts with amylase > 1000 IU/ml and pain typical for pancreatitis had abdominal u/s and �biochemical prediction of gallstones� within 24 hours of admission

3. Study #1 Neoptolemos et al Disease severity predicted by modified Glasgow criteria Mild attack 0-2 of the following, severe attack > 3 of the following: Age > 55 years WBC > 15 Glucose > 180 mg/dL BUN > 45 mg/dL PaO2 < 60 mm Hg Albumin < 3.2 mg/dL Calcium < 8 mg/dL LDH > 600 IU/L

4. Study #1 Neoptolemos et al Pts �suspected� of having gallstones were stratified by predicted severity Exclusion criteria: pregnancy, < 18 y.o., h/o EtOH abuse or acute intake, other identifiable cause of pancreatitis Cholangitis and elevated bilirubin were not exclusion criteria Randomized ERCP + ES within 72 hours of admission Conservative therapy All ERCPs performed by a single, skilled endoscopist After day 5, all pts offered ERCP + ES if felt indicated No ERCPs in conservative arm prior to day 5

5. Study #1 Neoptolemos et al Outcomes Local Complications: pseudocysts, ascites, duodenal obstruction Systemic Complications: respiratory failure, pleural effusion, pneumonia, cardiovascular failure, renal failure, DIC, CVA, death Cholangitis and sepsis not listed as outcomes

6. Study #1 Neoptolemos et al

7. Study #1 Neoptolemos et al

8. Study #1 Neoptolemos et al 6 pts in ERCP arm and 5 in Conservative arm had cholangitis If these pts were excluded: Overall complication rate was 11% with ERCP and 33% with conservative therapy (p = 0.02) Overall complication rate in predicted severe pancreatitis was 15% with ERCP and 60% with conservative therapy (P = 0.003)

9. Study #1 Neoptolemos et al Length of Hospitalization (days)

10. Study #1 Neoptolemos et al Statistically significant decrease in morbidity and length of hospitalization with ERCP in pts predicted to have severe pancreatitis Trend towards improvement in mortality but not statistically significant ERCP is safe in acute pancreatitis Successful in 80% of pts Only complication was lumbar osteitis

11. Study #1 Neoptolemos et al Limitations Pts with cholangitis randomized No allowance for early ERCP in conservative therapy group, strength or weakness of study? Mean time to ERCP not mentioned Single center and endoscopist

12. Study #2 Fan et al Hong Kong 1988-91 Single hospital All pts with amylase > 1000 IU/ml and pain typical for pancreatitis Exclusion criteria: prior Billroth II surgery, prior history of non biliary pancreatitis, post ERCP pancreatitis

13. Study #2 Fan et al Randomized ERCP within 24 hours of admission Conservative Therapy ERCP during acute phase for the following: Rising fever, leukocytosis and tachycardia Increasing jaundice or serum bilirubin Shock not responding to IV therapy ERCP routinely after resolution of pancreatitis

14. Study #2 Fan et al Predicted severity determined by admission BUN and glucose If glucose > 198 mg/dL or BUN > 45 mg/dL, categorized as severe Outcomes Local complications: pancreatic abscess, pseudocyst, phlegmon, and bleeding pseudoaneursym Systemic complications: renal failure, respiratory failure, cardiogenic shock, bleeding gastric erosions, and DIC Biliary sepsis: acute cholangitis or cholecystitis

15. Study #2 Fan et al 64% of pts in ERCP group and 63% in Conservative group had biliary pancreatitis 87 of 97 pts in ERCP group had successful ERCP 27 pts in Conservative group required early ERCP, successful in 25 of 27 10 for cholangitis 10 for sepsis 7 for organ failure

16. Study #2 Fan et al

17. Study #2 Fan et al

18. Study #2 Fan et al If only patients with biliary pancreatitis are included

19. Study #2 Fan et al Statistically significant decrease in biliary sepsis in pts predicted to have severe pancreatitis in ERCP group Statistically significant decrease in morbidity with ERCP in pts with biliary pancreatitis Trend towards improvement in mortality but not statistically significant

20. Study #2 Fan et al Limitations Included all causes of pancreatitis Less commonly used means of predicting severity of pancreatitis Length of hospitalization not analyzed

21. Study #3 Folsch et al Germany 1989 to 1994 Multicenter Biliary pancreatitis Gallstones on ultrasound or CT or 2 of the following 3 laboratory abnormalities Alkaline phosphatase > 125 U/L Alanine aminotransferase > 75 U/L Bilirubin > 2.3 mg/dL

22. Study #3 Folsch et al Exclusion criteria included bilirubin > 5 mg/dL Randomized to ERCP within 72 hours of symptom onset or conservative therapy ERCP in conservative group for temp > 102.2o F, increase in bilirubin > 3 mg/dL within 5 days, or persistent biliary cramps Severity predicted by modified Glasgow criteria

23. Study #3 Folsch et al ERCP Group ERCP successful in 121(96%) of 126 pts 46% had choledocholithiasis 2 pts had bleeding following sphincterotomy, 1 required PRBC transfusion Otherwise no direct complications related to ERCP Conservative Group 22 of 112 pts had ERCP within 3 wks of symptom onset 8 for increasing bilirubin, 8 for elevated temperature, and 6 for persistent biliary cramps ERCP successful in 19

24. Study #3 Folsch et al

25. Study #3 Folsch et al Study terminated early as increased deaths with ERCP made it highly unlikely that superiority of ERCP would be shown Conclusion: ERCP not beneficial in acute biliary pancreatitis without biliary obstruction or sepsis Results unaffected by classifying pts based on predicted disease severity

26. Study #3 Folsch et al Study criticized because many centers only contributed 2 � 3 pts and it was theorized that these centers probably did not have �expert� endoscopists

27. Suggested Approach