Accurate diagnosis of bile duct strictures as malignant or benign is imperative for optimal patient management, but is frequently difficult. Histological and cytological samples can be obtained at ERCP. Various techniques have been studied and reported specificities are generally very high. Sensitivities are modest and variable. The reported sensitivity is 33–57% for brush cytology and 43–81% for transpapillary histology. The yield may be increased by combining two sampling methods.
Methods
Data was collected prospectively on all patients with bile duct strictures who underwent histology and cytology. Transpapillary, intraductal biopsies were obtained using a paediatric biopsy forceps (Boston Scientific, Radial Jaw 4, 2.0mm paediatric biopsy forceps, Hemel Hempstead, UK). Fluoroscopic guidance was used to selectively target the stricture. A minimum of 4 biopsies were obtained. Cytological samples were obtained using an over the wire brush (Boston Scientific, RX Biliary brush 2.1mm, Hemel Hempstead, UK). This involved multiple passes through the stricture and withdrawal of the brush in to the catheter after the final pass. On retrieval, the catheter was flushed with the cytology fixation fluid in to the cytology collection container and the brush was cut off and sent in the same container. The sample was delivered to the lab for processing to the lab immediately after the procedure. Patients diagnosed with benign strictures had a follow up with median length of 20 months (range 4–35).
Results
96 strictures were sampled using dual modality. 70 were malignant of which 49 were in the peri-hilar and proximal CBD and 21 in distal CBD. The sensitivity in diagnosis of malignant biliary strictures was 74% with an overall accuracy for all strictures of 81%. Histology was positive in 33/52 cases (63%) and cytology was positive in 29/52 cases (56%). Taken together, they yielded a significantly better result of 74%. The sensitivity was higher for peri-hilar (82%) as compared to distal strictures (57%). There were no false positives. No complications as direct result of either tissue acquisition techniques occurred.
Conclusion
A highly systematic approach and combination of histology and cytology offers a significant advantage in diagnostic accuracy for both malignant and benign strictures. The high yield on cytology in our study may reflect attention to detail and prompt processing in the lab. None of the techniques adopted required specialised equipment or skills and could be adopted by any ERCP unit
Disclosure of Interest
O. Noorullah: None Declared, V. Lekharaju: None Declared, C. W. Wadsworth: None Declared, K. Brougham: None Declared, N. Stern: None Declared, S. Hood: None Declared, C. Kaltsidis: None Declared, M. Terlizzo: None Declared, R. Sturgess Conflict with: Advisory board member and in receipt of honoraria from Olympus UK and Boston Scientific
Harmful alcohol use is associated with substantial health and economic burden.1 Patients with alcohol-related conditions (ARCs) present acutely to hospital with a wide spectrum of disorders, impacting a range of medical & surgical specialties - a major challenge to the organisation and delivery of effective care within a hospital. Public health metrics derived from hospital (coding) data provide useful top-level indicators but do not provide clinically-relevant information for hospital teams. Gastroenterologists are seen increasingly as potential leaders in alcohol services. The aim of this project is to develop clinically-meaningful analyses and metrics that allow clinicians to better-understand alcohol-related emergency admission data to help in service planning.
Methods
We analysed a 2-year download of HES data (~24M. care episodes) for acute NHS Trusts in England in IBM-SPSS stats package. Emergency admissions containing any alcohol code were extracted, all recorded diagnoses were tabulated and reviewed by clinical steering group. Logical baskets of conditions were generated, reflecting common clinical presentations and allocated to specialties. The resulting coding rules and hierarchies were applied to the national data to label each admission and summary data generated.
Results
Of 7,440,546 emergency admissions to 150 trusts, ARCs accounted for 228,994 (3%). 12 diagnostic-specialty categories of admission were defined, of which Hepatology (alcoholic liver disease) and Gastroenterology (other GI conditions) ranked 1st and 3rd for admissions (17.4% and 13.8%) with alcohol withdrawal/intoxication ranked 2nd (17.3%). Remaining categories fall within medical specialties (e.g. general neurology, cardiology, respiratory) with only 3.9% of admissions attributable to surgical conditions or trauma. Shortest mean LOS were Poisoning/Psychiatry admissions (1.97 days). Greatest single contributor to total bed days was Hepatology at 240,576 per year and (excluding cancer) this had highest inpatient mortality (18.2%).
Conclusion
3% of emergency admissions to English hospitals were for ARCs and the majority (95.7%) of admissions fall within the remit of physicians rather than surgeons. Half the recorded diagnoses for admitted patients are within the sub-specialties of hepatology or gastroenterology and these contribute the highest share of both bed days and mortality. This system of classifying hospital data provides a basis for re-design of services, manpower planning and potential metrics for performance.
Disclosure of Interest
None Declared.
Reference
Moriarty KJ, Platt H, Crompton S et al. Collabarative care for alcohol-related liver disease. Clin Med. 2007 Apr; 7(2):125–8.
It has been surmised that cholecystitis develops in 3.5 – 12 % of cases after Endoscopic Retrograde Cholangiopancreatography (ERCP) deployment of self-expandable metal stent (SEMS) for distal biliary obstruction (1). We performed a retrospective review to determine the incidence of cholecystitis after deployment of distal biliary SEMS in those with no previous history of cholecystectomy in a high volume Hepato-Pancreato-Biliary (HPB) centre.
Methods
All patients undergoing ERCP and SEMS placement at Wythenshawe Hospital in Manchester between January 21 to December 22. Data were analysed from the local comprehensive ERCP database. Post-ERCP Cholecystitis was defined as early (within 4 weeks), and late (4-6 weeks) after ERCP, with corresponding radiological imaging and suggestive symptoms. All patients, as per our local policy were given a single dose of intravenous Gentamicin as prophylaxis against biliary/gallbladder sepsis unless patients were already on antibiotics.
Results
A total of 207 patients were identified and included. Indications for SEMS included: Distal biliary obstruction of malignant aetiology (126); benign biliary strictures (73); post ampullectomy bleeding (1) and treatment of post sphincterotomy bleeding (7). There were 102 (49%) males and 105 (51%) females. Age range of patients: 50-70 years – 81 (39%); 70-80 years – 126 (61%). FC-SEMS (Fully Covered) were placed in 202 (97.5%) and UC-SEMS (Uncovered) 5 (2.5%). Cholecystitis occurred in 4 (1.9%) cases. This comprised early cholecystitis in 1 case (malignant); 3 cases developed late cholecystitis (malignant). All cases resolved were mild and self-limiting treated non-surgically with antibiotics. No patients underwent repeat ERCP for SEMS removal.
Conclusions
Our retrospective review has shown a lower than expected, incidence of Cholecystitis post-ERCP and SEMS insertion of 1.9%. To our surprise, all cases occurred in those with malignant biliary obstruction. Our lower incidence of cholecystitis may be related to prophylactic antibiotics. We do not, at present, have the data to calculate the incidence of cholecystitis in those undergoing ERCP without SEMS insertion, as it is hypothesized that the presence of non-sterile contrast injected into the gallbladder with incomplete drainage is the precipitant factor. Further studies are required to compare the rate of post-ERCP cholecystitis in those with and without SEMS placement.
We aimed to evaluate the diagnostic utility of single-operator peroral cholangioscopy (SOC) for indeterminate biliary lesions and its usefulness in electrohydraulic lithotripsy (EHL) of biliary stones not amenable to conventional endoscopic therapy.All patients undergoing SpyGlass SOC in four UK tertiary centres between 2008 and 2010 were retrospectively enrolled. Patients were followed up until death or the last clinic visit until May 2011. The operating characteristics of SOC for detecting malignant lesions and the stone clearance rate after SOC-guided EHL were calculated.A total of 165 patients underwent 179 SOC procedures. Sixty-six percent were referred for indeterminate biliary strictures, 13% for filling defects and 21% for SOC-guided EHL. Cannulation with the SOC system was successful in 95% but visualization was inadequate in 13%. Primary sclerosing cholangitis was a risk factor for failed cannulation and conscious sedation (vs. general anaesthesia) for inadequate visualization (P<0.05). The accuracy of SOC for diagnosing malignant lesions was 87%. SOC-guided biopsies were adequate in 72%. Obtaining at least four versus less than four biopsy specimens resulted more often in adequate samples (90 vs. 64%, P=0.037). Complete stone clearance could be achieved in 73% of patients. The adverse event rate was 9.6%. Cholangitis was the most common event (56%, one fatal).SOC is useful for the differential diagnosis of indeterminate biliary lesions and the treatment of 'difficult' biliary stones. The adequacy of SOC-guided biopsies is related to the number of specimens obtained. Primary sclerosing cholangitis is related to failed cannulation with the SOC system, whereas general anaesthesia is related to adequate visualization.
Aims Review endoscopically placed metal stents in the management of malignant hilar strictures in terms of technical (correct placement of self-expandable metal stents (SEMS)) and clinical success (bilirubin drop > 50%), safety, and outcomes.
Peritoneal seeding of cancer cells leading to peritoneal carcinomatosis (PC) is an ominous finding that has primarily been described in women with underlying ovarian malignancy. It is also a common development in patients with gastrointestinal malignancy and may sometimes occur in the absence of a known, identified primary malignancy. Peritoneal carcinomatosis resulting from a cancer of unknown primary (CUP) is a rare and ill-defined entity, and as a result, there is no clear guidance on the most effective management strategy for this group of patients. The indiscriminate use of numerous investigations in an attempt to identify a primary malignant focus is discouraged. A subjective approach to the patient, with the aim of identifying patients who would benefit from therapeutic management and those who should be managed with palliative intent, should be employed. Aggressive therapeutic measures such as cytoreduction, peritonectomy and hyperthermic intraoperative intraperitoneal chemotherapy may offer some long-term survival, but selection of appropriate patients is essential. Large randomized studies are needed in patients with PC secondary to CUP to determine the efficacy of such treatment options. Studies into the pathogenesis and molecular pathways of this condition are required to improve understanding and guide development of novel therapeutic strategies.
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)