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ERCP for Gallstone Pancreatitis The new england journal of medicine transmitted helminth infections: systematic review and meta- neglected evidence-based policy? PLoS Negl Trop Dis 2013;7(7): analysis. JAMA 2008;299:1937-48. e2238. 3. Keiser J, Tritten L, Silbereisen A, Speich B, Adelfio R, Vargas 5. Geerts S, Gryseels B. Drug resistance in human helminths: M. Activity of oxantel pamoate monotherapy and combination current situation and lessons from livestock. Clin Microbiol Rev chemotherapy against Trichuris muris and hookworms: revival 2000;13:207-22. of an old drug. PLoS Negl Trop Dis 2013;7(3):e2119. 4. Nagpal S, Sinclair D, Garner P. Has the NTD community DOI: 10.1056/NEJMc1403068 ERCP for Gallstone Pancreatitis To the Editor: The article by Fogel and Sher- forms of imaging. Endoscopic ultrasonography man (Jan. 9 issue)1 about the clinical approach in and magnetic resonance cholangiopancreatogra- patients presenting with acute biliary pancreati- phy (MRCP) have completely replaced endoscopic tis may confuse readers, because the disease out- retrograde cholangiopancreatography (ERCP) to come can be associated with substantial mortal- evaluate patients in whom there is clinical or bio- ity2 when its cause is not properly recognized.3 logic suspicion of stones in the common bile duct. The patient described in the vignette has a very Certainly we would agree that first-line ERCP in high probability of biliary pancreatitis even in the patient in the vignette is not acceptable.5 the absence of dilatation or a stone in the com- Jean Louis Frossard, M.D. mon bile duct. Stones are suspected to cause Laurent Spahr, M.D. acute pancreatitis when the alanine aminotrans- Geneva University Hospital ferase level is at least three times the upper limit Geneva, Switzerland of the normal range (positive predictive value of [email protected] 4 No potential conflict of interest relevant to this letter was re- 95%). However, no biochemical or clinical find- ported. ing can be used in isolation as a predictive test 5 1. Fogel EL, Sherman S. ERCP for gallstone pancreatitis. N Engl for ductal stones. Physicians should consider J Med 2014;370:150-7. [Erratum, N Engl J Med 2014;370:488.] such variables in combination when deciding on 2. Frossard JL, Steer ML, Pastor CM. Acute pancreatitis. Lancet whether a patient needs further evaluation (Fig. 1). 2008;371:143-52. 3. Frossard JL, Morel PM. Detection and management of bile Patients with an intermediate risk of a stone in the duct stones. Gastrointest Endosc 2010;72:808-16. common bile duct should undergo noninvasive 4. Tenner S, Dubner H, Steinberg W. Predicting gallstone pan- Low risk (0–5%) Intermediate risk (>5–50%) High risk (>50%) Normal liver function-tests Age >55 yr Cholangitis Normal duct size on abdominal Cholecystitis Dilated duct >6 mm ultrasonography Dilated duct >6 mm Duct stone on ultrasonography Bilirubin level, 1.8–4.0 mg/dl Bilirubin level, >4 mg/dl Abnormal liver-test other than bilirubin Pancreatitis First-line endoscopic ultrasonography No further evaluation First-line ERCP or MRCP Figure 1. Risk Factors for Stones in the Common Bile Duct. Patients can be classified as having a low, intermediate, or high risk of stones in the common bile duct according to a combination of biologic and clinical factors. Appropriate therapy can be determined accordingly. ERCP denotes en- doscopic retrograde cholangiopancreatography, and MRCP magnetic resonance cholangiopancreatography. Adapted from Frossard and Morel.3 AUTHOR: Fogel FIGURE: 1 ARTIST: ts AUTHOR, PLEASE NOTE: Figure has been redrawn and type has been reset. 1954 n engl j med 370;20Please nejm.org check carefully. may 15, 2014 Issue date: 5-15-14 OLF: xx-xx-13 The New England Journal of Medicine Downloaded from nejm.org on January 7, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved. correspondence creatitis with laboratory parameters: a meta-analysis. Am J Gas- Foundation for Health Care Subsidies for studies of acute pan- troenterol 1994;89:1863-6. creatitis. No other potential conflict of interest relevant to this 5. Karakan T, Cindoruk M, Alagozlu H, Ergun M, Dumlu S, letter was reported. Unal S. EUS versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a pro- 1. Petrov MS, van Santvoort HC, Besselink MG, van der Heijden spective randomized trial. Gastrointest Endosc 2009;69:244-52. GJ, van Erpecum KJ, Gooszen HG. Early endoscopic retrograde cholangiopancreatography versus conservative management in DOI: 10.1056/NEJMc1403445 acute biliary pancreatitis without cholangitis: a meta-analysis of randomized trials. Ann Surg 2008;247:250-7. To the Editor: The indications for ERCP in sus- 2. Tse F, Yuan Y. Early routine endoscopic retrograde cholan- giopancreatography strategy versus early conservative manage- pected biliary pancreatitis are not as clearly es- ment strategy in acute gallstone pancreatitis. Cochrane Data- tablished as is suggested in the article by Fogel base Syst Rev 2012;5:CD009779. and Sherman. The only undisputed indication for 3. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013;13:Suppl 2:e1-e15. ERCP is concurrent cholangitis. In the absence of 4. Tenner S, Baillie J, DeWitt J, Vege SS. American College of cholangitis, with or without signs of bile-duct Gastroenterology guideline: management of acute pancreatitis. stones and obstruction, the indication for ERCP Am J Gastroenterol 2013;108:1400-15, 1416. [Erratum, Am J Gastroenterol 2014;109:302.] is not scientifically established, because studies have serious shortcomings. First, patient popula- DOI: 10.1056/NEJMc1403445 tions are heterogeneous, including some with cholangitis and some without. Second, patients with cholestasis are often not evaluated separate- To the Editor: The authors of the review of ly, so subgroup analysis is precluded. Third, ERCP in patients with acute biliary pancreatitis ERCP is often performed relatively late after hos- described the potential for the procedure itself to pital admission (i.e., within 48 to 72 hours). cause pancreatitis, but they did not mention Fourth, sphincterotomy is performed in only methods that have been shown recently to reduce about 50% of cases.1 Fifth, there is considerable the risk. variation in end-point definitions comprising A meta-analysis of 14 randomized, controlled less relevant outcomes (i.e., ascites and pleural trials showed that placement of small temporary effusion). Finally, the pooled sample sizes of pancreatic stents reduced the risk of post-ERCP meta-analyses involving patients with predicted pancreatitis in high-risk patients, at least in ex- severe biliary pancreatitis without cholangitis are pert centers (odds ratio, 0.39; 95% confidence too small to detect effects of ERCP with sphinc- interval, 0.29 to 0.53; P<0.001).1 Furthermore, terotomy on the end points of severe complica- the use of rectal indomethacin reduces the risk tions and death.1,2 These limitations of the evi- of post-ERCP pancreatitis in both high-risk and dence are acknowledged in recent guidelines.3,4 low-risk patients and has been shown to be A randomized trial with sphincterotomy as an more cost-effective than prophylactic pancreatic integral part of ERCP which is powered for rele- stent placement.2-5 vant clinical end points in predicted severe bili- Data are lacking from randomized trials to ary pancreatitis is under way (Current Controlled guide the use of these tools in patients with Trials number, ISRCTN97372133). gallstone pancreatitis, and there are unlikely to Nicolien J. Schepers, M.D. be any such trials, given the obvious difficulty in Erasmus University Medical Center attributing the cause of any postprocedure dete- Rotterdam, the Netherlands rioration. However, these relatively simple and [email protected] inexpensive approaches should perhaps be con- Hjalmar C. van Santvoort, M.D., Ph.D. sidered in patients with gallstone pancreatitis, University Medical Center Utrecht especially if the pancreatic duct has been manipu- Utrecht, the Netherlands lated. Marco J. Bruno, M.D., Ph.D. Mohammad Yaghoobi, M.D. Erasmus University Medical Center Medical University of South Carolina Rotterdam, the Netherlands Charleston, SC for the Dutch Pancreatitis Study Group [email protected] Dr. Schepers reports receiving grants from the Netherlands No potential conflict of interest relevant to this letter was re- Organization for Health Research and Development and the ported. n engl j med 370;20 nejm.org may 15, 2014 1955 The New England Journal of Medicine Downloaded from nejm.org on January 7, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved. The new england journal of medicine 1. Mazaki T, Mado K, Masuda H, Shiono M. Prophylactic pan- cholangitis should undergo early ERCP. ERCP is creatic stent placement and post-ERCP pancreatitis: an updated meta-analysis. J Gastroenterol 2014;49:343-55. not needed in most patients in whom laboratory 2. Elmunzer BJ, Scheiman JM, Lehman GA, et al. A randomized or clinical evidence of ongoing biliary obstruc- trial of rectal indomethacin to prevent post-ERCP pancreatitis. tion is absent. Alternatively, we suggest that pa- N Engl J Med 2012;366:1414-22. 3. Yaghoobi M, Rolland S, Waschke KA, et al. Meta-analysis: tients with biliary obstruction might benefit from rectal indomethacin for the prevention of post-ERCP pancreati- ERCP, although the evidence is not strong. Data tis. Aliment Pharmacol Ther 2013;38:995-1001. are lacking from additional prospective trials 4. Akbar A, Abu Dayyeh BK, Baron TH, Wang Z, Altayar O, Murad MH. Rectal nonsteroidal anti-inflammatory drugs are involving patients with gallstone pancreatitis. superior to pancreatic duct stents in preventing pancreatitis af- We agree with Yaghoobi that both pancreatic- ter endoscopic retrograde cholangiopancreatography: a network duct stents and rectal indomethacin are effective meta-analysis. Clin Gastroenterol Hepatol 2013;11:778-83.
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