Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Emergency endoscopic retrograde cholangiopancreatography within 24 hours of hospitalization with or without endoscopic papillotomy reduced the incidence of biliary sepsis in patients with acute biliary pancreatitis

ACP J Club. 1993 May-June;118:67. doi:10.7326/ACPJC-1993-118-3-067


Source Citation

Fan ST, Lai EC, Mok FP, et al. Early treatment of acute biliary pancreatitis by endoscopic papillotomy. N Engl J Med. 1993 Jan 28;328:228-32.


Abstract

Objective

To compare the efficacy of emergency endoscopic retrograde cholangiopancreatography (ERCP), with or without endoscopic papillotomy within 24 hours of hospitalization, with initial conservative treatment and selective ERCP, with or without endoscopic papillotomy for patients with subsequent deterioration, in patients with acute biliary pancreatitis.

Design

Randomized controlled trial with follow-up to hospital discharge.

Setting

Queen Mary Hospital, Hong Kong.

Patients

195 patients (mean age 65 y, 115 women) with acute pancreatitis defined as severe upper abdominal pain with or without radiation to the back and repeated vomiting, and a serum amylase concentration > 1000 IU/L. Exclusion criteria were previous Billroth II gastrojejunostomy, previous attacks in which the diagnosis of biliary stones had been excluded, attacks initiated by ERCP, or diagnosis made after cardiac arrest.

Intervention

97 patients had emergency ERCP within 24 hours of admission, and if ≥ 1 stone was identified, endoscopic papillotomy was done. 98 patients received conservative treatment and had routine elective ERCP after the acute attack subsided if selective ERCP had not been done during the acute phase. Endoscopic papillotomy was also done if ≥ 1 stone was identified.

Main outcome measures

Development of local or systemic complications; biliary sepsis that failed to respond to conservative treatment and required emergency endoscopic or surgical intervention; and death during hospitalization.

Main results

127 patients proved to have biliary stones. No major differences in the incidence of local complications (10 in the emergency ERCP group vs 12 in the conservative treatment group) or systemic complications (10 vs 14) occurred. The incidence of biliary sepsis was lower in the group that had emergency ERCP than in the group that received conservative treatment (P = 0.001) (Table). The incidence of biliary sepsis among patients with mild pancreatitis was 0 (0%) in the emergency ERCP group and 4 (7%) in the conservative treatment group (P = 0.14), and among patients with severe pancreatitis, it was 0 (0%) and 8 (20%) (P = 0.008). All patients with biliary sepsis had persistent ampullary or common-bile-duct stones. 5 patients in the emergency ERCP group died in the hospital compared with 9 patients receiving conservative treatment (P = 0.4).

Conclusion

Emergency ERCP within 24 hours of hospitalization with or without endoscopic papillotomy reduced the incidence of biliary sepsis in patients with acute biliary pancreatitis.

Source of funding: Not stated.

For article reprint: Dr. S.T. Fan, Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong. FAX 852-2817-5496.


Table. Endoscopic retrograde cholangiopancreatography (ERCP) vs conservative treatment in patients with acute biliary pancreatitis*

Outcomes at hospital discharge ERCP Conservative Treatment RRR NNT (CI)
Biliary sepsis 0% 12% 100% 9 (6 to 17)

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.


Commentary

This report from Hong Kong provides important information for management of acute gallstone-associated pancreatitis. It should be considered, however, in conjunction with the only other published randomized controlled trial of ERCP and endoscopic sphincterotomy. This previous study concluded that sphincterotomy was of benefit in patients with severe but not mild, stone-associated, acute pancreatitis (1). The eradication of concomitant biliary sepsis might be important in reducing morbidity and mortality. The principal finding of the Hong Kong study that ERCP and sphincterotomy done within 24 hours of admission reduced biliary sepsis in patients with mild and severe pancreatitis is supportive of this. The conclusion that all patients with acute pancreatitis should have emergency ERCP cannot, however, be extrapolated to other parts of the world for several reasons.

First, choledocholithiasis is the predominant cause of acute pancreatitis in Hong Kong, often with no coexistent cholelithiasis (21 of 64 [33%] in this report). Second, patients with stone disease were not preselected compared with those with other diseases. In addition, ERCP was used for both diagnosis and therapy without other imaging modalities. Also, the prognostic scoring system used probably overestimated the number of patients with severe pancreatitis, which may have had an effect on the relative incidence of bile duct stones for mild and severe groups. Finally, no statistically significant difference was found in overall morbidity (18% vs 29%) and mortality (5% vs 9%) between the ERCP and conservatively treated groups. Comparison of outcome in patients with a "severe" score, however, shows an overall lower complication rate (22% vs 58%), a lower local complication rate (10% vs 28%), and a lower systemic complication rate (20% vs 33%). Analysis for those patients with bile duct stones and severe pancreatitis further accentuated these differences.

The Hong Kong findings, therefore, add support for expert endoscopic intervention at an early stage in acute gallstone-associated pancreatitis but suggest that only patients with severe disease are likely to benefit.

David L. Carr-Locke, MD
Harvard Medical SchoolBoston, Massachusetts, USA


Reference

1. Neoptolemos JP, Carr-Locke DL, London NJ, et al. Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones. Lancet. 1988;2:979-83.