Detection of choledocholithiasis: comparison of unenhanced helical CT and endoscopic retrograde cholangiopancreatography

PURPOSE: To compare unenhanced helical computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) in the detection of common bile duct calculi. MATERIALS AND METHODS: Within 13 months, 51 patients (aged 18-94 years) with clinically suspected choledocholithiasis underwent unenhanced helical CT immediately before undergoing ERCP. CT scans were evaluated for the presence of bile duct stones, ampullary stones, the gallbladder and gallbladder stones, intrahepatic biliary dilatation, and the size of the bile duct at the porta hepatis and in the pancreatic head. ERCP images were evaluated for the presence of bile duct or ampullary stones, as well as for biliary dilatation. RESULTS: Unenhanced helical CT depicted common bile duct stones in 15 of 17 patients found to have stones at ERCP. Three patients had stones impacted at the ampulla, all of which were detected with CT. In addition, there was one false-positive finding at CT. CT had a sensitivity of 88%, a specificity of 97%, and an accuracy of 94% in the diagnosis of common bile duct stones. CONCLUSION: Unenhanced helical CT is useful for evaluating suspected choledocholithiasis.     

Endoscopic treatment of symptomatic choledocholithiasis

BACKGROUND/AIMS: Today, different endoscopic techniques are available to treat choledocholithiasis. These techniques include mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), laserlithotripsy (LL), and extracorporal shock-wave lithotripsy (ESWL). These techniques have to compete with laparoscopic stone removal which is performed with increasing frequency at some centers. METHODOLOGY: We report the results of treatment of choledocholithiasis and compare the results with a meta-analysis of studies in whom endoscopic and laparoscopic techniques were applied. From 1994-1995, 217 patients with symptomatic choledocholithiasis were treated using endoscopic retrograde cholangiography (ERC). RESULTS: Overall, complete stone removal was successful in 98% of all patients and only 5 patients had to undergo surgery. Complete endoscopic removal of stones was achieved in 70% during the first ERC session. In 47 patients consecutive ERC sessions with application of EML, EHL, or ESWL were necessary to completely remove the stones. Complication rate was 5% and included pancreatitis and bleeding from papillotomy. There was no procedure-related mortality. CONCLUSION: The study suggests that today ERC remains the treatment of choice in most patients with symptomatic choledocholithiasis.     

Biliary ascariasis complicating endoscopic sphincterotomy for choledocholithiasis in India

Endoscopic sphincterotomy is the treatment of choice for patients with choledocholithiasis. Biliary ascariasis has been reported from many parts of the world but is common in Kashmir, India. We report five cases of biliary ascariasis of which four were the result of post-endoscopic sphincterotomy for choledocholithiasis. Therefore, biliary ascariasis is not an uncommon complication of endoscopic sphincterotomy.     

Endoscopic sphincterotomy in choledocholithiasis and an intact gallbladder

Endoscopic sphincterotomy (ES) with extraction of calculi is a basic method of treating choledocholithiasis in post-cholecystectomy patients (8, 9). Endoscopic treatment contributes to a considerable reduction of the indications for reoperation. The existing views concerning ES done in patients with preserved gallbladder, especially in the era of laparoscopic surgery, are still conflicting (3, 6). There are several options: cholecystectomy with removal of calculi in the common bile duct by ES in a subsequent stage, or vice versa-primary ES with ensuring cholecystectomy. The undertaking of independent surgical or endoscopic treatment is likewise practicable (2, 6).     

Prediction of recurrent choledocholithiasis by quantitative cholescintigraphy in patients after endoscopic sphincterotomy

BACKGROUND: Endoscopic sphincterotomy (EST) is widely used for the removal of stones from the bile duct, but stones recur in about one fifth of patients. AIMS: To investigate hepatic clearance by quantitative cholescintigraphy (QC) in patients after EST and to discern the relationship between biliary emptying and stone recurrence. METHODS: One hundred and forty nine patients who had EST and clearance of the bile duct for choledocholithiasis were selected. All patients were confirmed to have complete EST by sphincter of Oddi manometry and underwent QC soon after normalisation of liver function. Regular clinical follow up was performed for each patient. RESULTS: During a mean 36 month follow up, 22 (14.8%) patients developed recurrent stones in the bile duct. Irrespective of the status of the gall bladder, patients with recurrent stones had a slower hepatic clearance of radioisotope during QC compared with patients without stone recurrence, but only the differences in cholecystectomised patients had statistical significance. After carrying out multivariate analysis, one parameter of QC, percentage clearance of maximal count at 45 minutes, was found to be the only significant factor for stone recurrence. All recurrent stones in the common bile duct were successfully removed at endoscopy. CONCLUSION: Slower hepatic clearance as shown by QC is an important factor responsible for stone recurrence after sphincter ablation.     

Polymicrobial sepsis following endoscopic retrograde cholangiopancreatography

Cholangitis with polymicrobial sepsis followed endoscopic retrograde cholangiopancreatography in a patient without biliary tract obstruction. Inadequately disinfected endoscopy equipment was strongly implicated as the source of infection. Results with a new method of disinfection using gluteraldehyde are given.     

Endoscopic retrograde cholangiopancreatography in the evaluation of pancreatic disease

Endoscopic retrograde cholangiopancreatography (ERCP) was carried out in 98 patients with unexplained abdominal pain or known pancreatitis with recurrent pain. Patients with jaundice were excluded from the study. In 38 patients with a clinical diagnosis of pancreatitis, the radiological findings on ERCP were graded according to the criteria of Kasugai et al. Advanced pancreatitis was found in 20 patients (52,5%), moderate changes in 7 (18,4%) and minimal-change pancreatitis in 6 (15,8%). ERCP had normal pancreatic function tests. In 35 patients investigated for unexplained abdominal pain, changes consistent with pancreatitis were found in 7, pancreatic carcinoma in 5, a duodenal ulcer in 2, gallstones in 1 and a duodenal tumour in 1. ERCP was normal in 19 patients. A comparison of the findings on ERCP and the standard secretin-cholecystokinin pancreatic function test was available in 52 patients. There was a good agreement between the two tests in the patients with advanced or moderate pancreatitis as revealed by ERCP, but less agreement in the patients with minimal-change pancreatitis. A few patients with clinical pancreatitis and abnormal ERCP had normal pancreatic function tests. ERCP increases the diagnostic yield in patients suspected of having pancreatitis and is at present the only reliable method of diagnosing pancreatic carcinoma which is not evident by other non-operative techniques. ERCP is also of value in the assessment of the severity of pancreatitis and is a necessary investigation before pancreatic surgery to confirm or exclude cyst formation or the site of duct obstruction. The finding of an unsuspected cyst at ERCP necessitates early operation because of the danger of introducing infection during the procedure.     

Endoscopic retrograde cholangiopancreatography in the orthotopic liver transplant patient

BACKGROUND AND STUDY AIMS: Diagnostic imaging of the biliary tract is often required in liver transplant recipients, preoperatively to assess extent of biliary tract disease and postoperatively in patients with a suspected biliary complication due to an abnormal postoperative course. PATIENTS AND METHODS: Over a six-year period, 115 patients received 127 liver transplantations at our institution. Twenty-three preoperative ERCPs were performed in 17 patients, while 25 ERCPs were performed on 15 patients after liver transplantation. RESULTS: Preoperative ERCP in seven of 17 patients revealed a dominant biliary stricture as a result of primary sclerosing cholangitis (PSC); five of these patients were managed successfully with the placement of biliary endoprosthesis. An additional nine patients with PSC underwent brush cytology of the extrahepatic bile ducts to rule out coexisting cholangiocarcinoma; there were no positive results, although three were found to have coexisting cholangiocarcinoma after examination of the explanted liver. Postoperatively, nine of 15 patients were found to have biliary tract disease. These included five biliary strictures (three treated successfully by endoscopic dilation and stent therapy), two biliary leaks (treated by biliary endoprosthesis), one biloma (treated by percutaneous drainage) and one intraductal stone (treated successfully by sphincterotomy and stone extraction). The remaining six patients showed no abnormality at ERCP, and were subsequently diagnosed with allograft rejection. CONCLUSIONS: Diagnosis of biliary complications after hepatic transplantation is often problematic. Definitive characterization frequently requires cholangiography. Interventional biliary procedures, both endoscopic and percutaneous, can be used successfully to treat these complications; however, surgical revision and retransplantation are sometimes required.     

Complications related to diagnostic and therapeutic endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is examined from a variety of viewpoints in this article, including physician experience with ERCP and the environment in which the procedure is performed, the initial intent to treat, and complications, including their severity. Specific complications discussed include pancreatic hemorrhage, perforation, septic complications, complications related to stents, rare complications, and late complications following sphincterotomy.     

No routine antibiotic prophylaxis necessary in endoscopic retrograde cholangiopancreatography

Acute cholangitis is a serious complication and cause of death in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Some centres have adopted a policy of administering antibiotics before every ERCP procedure. The results of a recent clinical trial failed to support this policy. Antibiotic prophylaxis should be restricted to patients expected to develop incomplete drainage of the bile duct and to endocarditis prophylaxis.     

Failure of cefonicid prophylaxis for infectious complications related to endoscopic retrograde cholangiopancreatography

We performed a controlled study to evaluate the role of cefonicid in preventing infectious complications related to retrograde cholangiopancreatography (ERCP). Consecutive patients were randomized to receive prophylaxis with cefonicid (1 g intravenously) 1 hour before the procedure or to be untreated controls. During a 26-month period, 179 ERCPs, including 93 therapeutic procedures, were performed on 164 patients. Prophylaxis was administered before 88 procedures (49%). The rate of bacteremia among treated patients was similar to that among controls (3% vs. 2%, respectively; P = .4). The rate of cholangitis was also similar among both groups (8% vs. 2%, respectively; P = .07). There were no episodes of sepsis, and none of the patients died. The rate of bacteremia was also similar among patients undergoing diagnostic procedures and patients undergoing therapeutic procedures, but all cases of cholangitis occurred in the latter group (0 vs. 10%, respectively; P = .002). Nevertheless, the rate of cholangitis was not significantly changed by the use of prophylaxis (14% among treated patients vs. 5% among controls, P = .12). Therefore, infectious complications could not be prevented by cefonicid prophylaxis.     

Indications, clinical value and complications of endoscopic retrograde cholangiopancreatography

Endoscopy combined with endoscopic retrograde cholangiopancreatography is a unique tool providing a broad, precise yield of diagnostic information about diseases of the upper gastrointestinal tract. In the absence of gross anatomic disease, its diagnostic accuracy should exceed 90 per cent and risk be minuscule. The incidence of complications and, therefore, risk to the patient and proportional to the magnitude and remedial nature of the disease processes found. In the absence of diagnostic procedures for diseases of the biliary tree and pancreas that are riskless, the relationship of endoscopic retrograde cholangiopancreatography risk to diagnostic value and patient salvage emphasizes the value of endoscopy combined with endoscopic retrograde cholangiopancreatography as the diagnostic procedure of choice for patients with suspected disease of the biliary tract or pancreas. The unique value of endoscopic retrograde cholangiopancreatography in providing rapid visualization of diseases of the upper gastrointestinal tract mucosa combined with cholangiography and pancreatography is dramatized in the patient with upper abdominal pain syndrome with or without jaundice. In the face of a rapidly evolving illness and the potential need for early surgical intervention, barium studies are relatively contraindicated and have a poor diagnostic yield. By contrast, endoscopic retrograde cholangiopancreatography combined with endoscopy rapidly rules out, or, in the presence of disease of the upper gastrointestinal tract, permits the immediate use of subsequent diagnostic procedures. An experience with more than 1,000 procedures reveals that endoscopic retrograde cholangiopancreatography is an invaluable tool for the diagnosis and management of disease of the pancreas and biliary tract.     

Endoscopic retrograde cholangiopancreatography in the management of pancreatic and biliary disease

Endoscopic retrograde cholangiopancreatography is a new and valuable technique in the diagnosis of jaundice, pancreatic disease and obscure upper abdominal pain. Endoscopic sphincterotomy of the sphincter of Oddi and the extraction of stones from the common bile duct are an extension of this procedure already in use in several high-volume centres. Cannulation of the bile ducts and pancreatic ducts in tests of secretion and cytology will become increasingly common applications of the technique. In order to provide dependability and cost-effectiveness, specialists in this procedure must maintain a high volume, necessarily limiting it to a few practitioners. Use of a trained endoscopic technician, a radiologist trained in endoscopy, or an endoscopist trained in fluoroscopy and spot-filming may decrease the manpower costs of this procedure.