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Emergency ERCP may be required in patients with severe cholangitis who rapidly deteriorate with multi-organ dysfunction and who cannot wait until the next available elective list. A significant proportion of patients require ventilatory and inotropic support. We describe our experience on the outcome of emergency ERCP in this cohort of critically ill patients.Medical records of cases undergoing ERCP between November 2008 and November 2011 were retrospectively reviewed. Patients who were in intensive care unit or required general anaesthesia due to haemodynamic compromise at the time of ERCP were included.Total of 2237 ERCPs were performed during this period, of which 36 (2%) emergency ERCP's were performed in 33 patients. The median age was 79 years. All procedures were performed under general anaesthesia in emergency operating room. In 27/36 procedures (75%), the patients required inotropes. Indications included cholangitis (78%), pancreatitis (14%) and post-operative bile leak (8%). Biliary cannulation was achieved in 100% of cases. Endoscopic findings included CBD stones (64%), CBD stones and an additional pathology (8%), bile leak (8%), CBD stricture (5%), Mirizzi's (3%) and blocked plastic stent (3%). In 23/36 (64%) procedures a stent was inserted. In 11/36 (30%) procedures a balloon trawl was sufficient to clear the bile duct. Thirty-day mortality was 25%. Although the 30-day mortality remains high due to multi-organ failure, ERCP is successful and effective in the majority of patients and results in a good outcome for this cohort of critically ill patients, in whom the prognosis is inevitably poor without emergency biliary drainage.

Consider hypothyroidism as a cause of non-alcoholic fatty liver disease

IntroductionPatients with head and neck cancers can require nutritional support during and after treatment of their cancers. This is commonly done via a gastrostomy. The original “pull though” PEG has an increased risk of tumour implantation at the PEG site. We therefore changed our practice to direct puncture gastrostomy insertion in 2004, using the PEXACT® (fresenius) gastrostomy system, for all head and neck cancer patients. We have previously reported our first year experience of 89 cases. We report our practice since then.MethodsAll PEXACTS® performed in the unit between November 2005 and November 2009 were identified, using our endoscopy reporting system and from referral register. Further information regarding each patient (readmissions, complications and mortality) was obtained from the hospital patient administration system.ResultsAccording to the data available to date, 319 PEXACT® insertions were identified in 317 patients. 79% of patients were male (n=251). Average age was 58 years (18–85 years). 99% (n=316) patients had a head and neck cancer as the indication. Insertion was successful in 99% (n=316) and unsuccessful in 3(0.9%) patients: 2 cases due to poor access and 1 case due to gastric intramucosal haematoma. All patients had prophylactic antibiotics on the ward prior to the procedure. In total six patients died within 30 days (1.9%), 1 within 7 days (0.3%). Of the 30-day deaths, 3 were due to disease progression, one neutropenic sepsis following chemotherapy and two had no record of the cause of death available. Two patients had major procedure related complications (0.6%). On both occasions complications was identified immediately. One of the patients had splenic injury during the procedure and required emergency surgery, the second patient had intra-abdominal haematoma due to laceration of gastric wall which was managed conservatively and resolved spontaneously with good outcome. Ten (3.1%) patients had unplanned admissions within 30 days of their procedure. Four patients were admitted within 7 days (1.3%). Reasons for readmission included displaced or blocked gastrostomy tube n=2 (0.6%), disease progression n=2 (0.6%), gastrostomy site infection n=3 (0.9%) and 1 (0.3%) patient developed an aspiration pneumonia secondary to alcohol excess. There have been no cases of tumour implantation to date. Late displacement of the gastrostomy tube (>30 days after insertion) was common (6.6%). Most were replaced at the bedside.ConclusionPEXACT® is a safe and reliable method of gastrostomy tube placement. Overall, our complication rate has fallen, with only two major procedure related complications during this period. There have been no procedure related deaths. There have been no cases of tumour implantation.

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