UEG Week 2018 Oral Presentations

2018 United European Gastroenterology journal  
Contact E-Mail Address: n.schepers@pancreatitis.nl Introduction: Patients with acute biliary pancreatitis may develop cholangitis, organ failure and other life-threatening complications. Early biliary decompression by endoscopic retrograde cholangiography (ERC) and biliary sphincterotomy may ameliorate the disease course, but previous randomized trials have shown conflicting results. Recent guidelines advise ERC in biliary pancreatitis only in case of cholangitis, and to consider ERC in case of
more » ... (persistent) cholestasis. Whether early ERC and biliary sphincterotomy is beneficial in patients with predicted severe acute biliary pancreatitis with or without cholestasis, but without cholangitis, remains debated. Aims and Methods: We randomized 230 patients in 25 Dutch hospitals with predicted severe acute biliary pancreatitis (based on an Acute Physiology and Chronic Health Evaluation [APACHE II] score of !8, a modified Imrie score of !3 or a C-reactive protein level of 4150 mg/L within 24 hours of admission) and without cholangitis, to early ERC with biliary sphincterotomy within 24 hours after presentation at the emergency department or conservative treatment with on-demand ERC in case of cholangitis or persistent cholestasis. The primary end point was a composite of death or major complications (i.e. new-onset persistent organ failure, cholangitis, bacteremia, pneumonia, pancreatic necrosis and pancreatic insufficiency) during 6 months of follow-up. Patients were stratified for the presence of cholestasis (based on a bilirubin level of 440mmol/L or a dilated common bile duct (defined as 48mm in patients 75 years or 410mm in patients 475 years)). Results: The primary end point occurred in 45 of 117 patients (39%) in the early ERC group compared with 50 of 113 patients (44%) in the conservative group (risk ratio 0.89; 95% confidence interval 0.68-1.15; p ¼ 0.37). 112 patients (96%) in the early ERC group underwent ERC at a median of 20 hours after presentation at the emergency department (interquartile range [IQR] 14-23 hours), and after a median of 29 hours after onset of symptoms (IQR 22-44 hours). Biliary sphincterotomy was performed in 90 patients (78%). In 35 of the 113 patients (31%) allocated to conservative treatment, ERC was performed later in the disease course for cholangitis or persisting cholestasis after a median of 8 days (IQR 3-34 days) after randomization. In the early ERC group, cholangitis occurred less often compared with conservative treatment (2% versus 10%; p ¼ 0.01) without significant differences in patient outcome including new-onset organ failure (19% versus 15%; p ¼ 0.45), death (7% versus 9%; p ¼ 0.57) or other components of the primary end point. In the conservative group with on-demand ERC, the total number of ERCs decreased with 66% (128 versus 44 ERCs) without negatively impacting overall outcome. In the subgroup of patients with cholestasis at randomization, no statistically significant difference in the primary end point was found (32% versus 43%; risk ratio 0.79; 95% confidence interval 0.57-1.10; p ¼ 0.18). Conclusion: In patients with predicted severe acute biliary pancreatitis without cholangitis, early ERC with endoscopic biliary sphincteromy within 24 hours after presentation at the emergency department did not reduce the primary end point of death or major complications.
doi:10.1177/2050640618792817 fatcat:pqcj7fncrjbn3ekteodnvx77qq