Timing of endoscopic therapy for acute bilio-pancreatic diseases: a practical overview

Abstract

Diseases of the pancreas and hepatobiliary tree often require a therapeutic approach with endoscopic retrograde cholangiopancreatography (ERCP), generally following noninvasive imaging techniques. Appropriate indications and the correct timing for urgent ERCP would benefit both patients and clinicians and allow optimal utilization of health resources. Indications for urgent (<24 h) ERCP include severe acute cholangitis, acute biliary pancreatitis with cholangitis, biliary or pancreatic leaks, in the absence of percutaneous drainage, and severe acute cholecystitis in patients who are unfit for surgery and do not respond to conservative management. In patients who have severe acute biliary pancreatitis with ongoing biliary obstruction but without cholangitis, early (<48-72 h) ERCP is indicated. This overview aims to provide decisional flowcharts that can be easily used for managing patients with acute bilio-pancreatic disorders when they are referred to the Emergency Department.

Endotherapy in Pancreatic Diseases

“…The role and timing of Endoscopic retrograde cholangiopancreatography (ERCP) in ABP is still a topic of debate in absence of cholangitis. 1 ERCP in patients with ABP is usually performed in patients with cholangitis (< 24 hours) or prolonged cholestasis (i.e., an elevated serum bilirubin level that fails to fall suggesting persistent biliary obstruction). The recently completed ABP: urgent ERCP with sphincterotomy versus Conservative treatment (APEC) trial randomized 230 patients with predicted severe ABP and the results of this study support a conservative strategy in patients with predicted severe ABP without cholangitis or persistent cholestasis.…”

“…2 EUS can help to confirm common bile duct stones before ERCP in absence of obvious signs of biliary obstruction and prevent unnecessary ERCP and consequent adverse events. 1…”

Rare Sequelae of Endoscopic Retrograde Cholangiopancreatography: Polymicrobial Bloodstream Infection and Hepatic Abscess in an Elderly Individual

“…Risk factors for complications include the difficulty of cannulation, sphincterotomy, percutaneous sphincterotomy, surgically altered anatomy, sphincter of Oddi dysfunction, periampullary diverticulum, cirrhosis, older age, and end-stage kidney disease [ 1 ]. Higher hospital and endoscopist procedure volumes have been associated with lower complication rates [ 4 ]. The most common serious complications of ERCP are pancreatitis, bleeding, perforation, and infections [ 5 ].…”

Manejo endoscópico de fugas biliares postquirúrgicas

“…La vesícula biliar funciona como el reservorio de bilis, La bilis es un líquido estéril con propiedades bacteriostáticas. La obstrucción de la vía biliar ocasiona alteración del flujo biliar generando una migración retrograda y proliferación bacteriana en la vía biliar lo cual conduce a enfermedades agudas que en algunas ocasiones requiere manejo quirúrgico (1). Las fugas biliares postquirúrgicas son una complicación grave poco común, sin embargo, bien documentada de la colecistectomía, resección hepática y otros procedimientos hepatobiliares (2,3) las lesiones de la vía biliar han aumentado en incidencia, presentándose hasta en un 13% de los casos de trasplante hepático, mientras que su aparición postcolecistectomía puede variar entre 0.2 y 2% de los casos según se realice por vía abierta o laparoscópica, respectivamente.…”