The
n e w e ng l a n d j o u r na l
transmitted helminth infections: systematic review and metaanalysis. JAMA 2008;299:1937-48. 3. Keiser J, Tritten L, Silbereisen A, Speich B, Adelfio R, Vargas M. Activity of oxantel pamoate monotherapy and combination chemotherapy against Trichuris muris and hookworms: revival of an old drug. PLoS Negl Trop Dis 2013;7(3):e2119. 4. Nagpal S, Sinclair D, Garner P. Has the NTD community
of
m e dic i n e
neglected evidence-based policy? PLoS Negl Trop Dis 2013;7(7): e2238. 5. Geerts S, Gryseels B. Drug resistance in human helminths: current situation and lessons from livestock. Clin Microbiol Rev 2000;13:207-22. DOI: 10.1056/NEJMc1403068
ERCP for Gallstone Pancreatitis To the Editor: The article by Fogel and Sherman (Jan. 9 issue)1 about the clinical approach in patients presenting with acute biliary pancreatitis may confuse readers, because the disease outcome can be associated with substantial mortality2 when its cause is not properly recognized.3 The patient described in the vignette has a very high probability of biliary pancreatitis even in the absence of dilatation or a stone in the common bile duct. Stones are suspected to cause acute pancreatitis when the alanine aminotransferase level is at least three times the upper limit of the normal range (positive predictive value of 95%).4 However, no biochemical or clinical finding can be used in isolation as a predictive test for ductal stones.5 Physicians should consider such variables in combination when deciding on whether a patient needs further evaluation (Fig. 1). Patients with an intermediate risk of a stone in the common bile duct should undergo noninvasive
Low risk (0–5%)
Normal liver function-tests Normal duct size on abdominal ultrasonography
No further evaluation
forms of imaging. Endoscopic ultrasonography and magnetic resonance cholangiopancreatography (MRCP) have completely replaced endoscopic retrograde cholangiopancreatography (ERCP) to evaluate patients in whom there is clinical or biologic suspicion of stones in the common bile duct. Certainly we would agree that first-line ERCP in the patient in the vignette is not acceptable.5 Jean Louis Frossard, M.D. Laurent Spahr, M.D. Geneva University Hospital Geneva, Switzerland [email protected] No potential conflict of interest relevant to this letter was reported. 1. Fogel EL, Sherman S. ERCP for gallstone pancreatitis. N Engl
J Med 2014;370:150-7. [Erratum, N Engl J Med 2014;370:488.]
2. Frossard JL, Steer ML, Pastor CM. Acute pancreatitis. Lancet
2008;371:143-52.
3. Frossard JL, Morel PM. Detection and management of bile
duct stones. Gastrointest Endosc 2010;72:808-16.
4. Tenner S, Dubner H, Steinberg W. Predicting gallstone pan-
Intermediate risk (>5–50%)
High risk (>50%)
Age >55 yr Cholecystitis Dilated duct >6 mm Bilirubin level, 1.8–4.0 mg/dl Abnormal liver-test other than bilirubin Pancreatitis
Cholangitis Dilated duct >6 mm Duct stone on ultrasonography Bilirubin level, >4 mg/dl
First-line endoscopic ultrasonography or MRCP
First-line ERCP
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 endoscopic retrograde cholangiopancreatography, and MRCP magnetic resonance cholangiopancreatography. Adapted AUTHOR: Fogel from Frossard and Morel.3
1954
FIGURE:
1
ARTIST:
ts
AUTHOR, PLEASE NOTE: Figure has been redrawn and type has been reset. Please check carefully. 15, 2014 n engl j med 370;20 nejm.org may 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 Gastroenterol 1994;89:1863-6. 5. Karakan T, Cindoruk M, Alagozlu H, Ergun M, Dumlu S, Unal S. EUS versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a prospective randomized trial. Gastrointest Endosc 2009;69:244-52. DOI: 10.1056/NEJMc1403445
To the Editor: The indications for ERCP in suspected biliary pancreatitis are not as clearly established as is suggested in the article by Fogel and Sherman. The only undisputed indication for ERCP is concurrent cholangitis. In the absence of cholangitis, with or without signs of bile-duct stones and obstruction, the indication for ERCP is not scientifically established, because studies have serious shortcomings. First, patient populations are heterogeneous, including some with cholangitis and some without. Second, patients with cholestasis are often not evaluated separately, so subgroup analysis is precluded. Third, ERCP is often performed relatively late after hospital admission (i.e., within 48 to 72 hours). Fourth, sphincterotomy is performed in only about 50% of cases.1 Fifth, there is considerable variation in end-point definitions comprising less relevant outcomes (i.e., ascites and pleural effusion). Finally, the pooled sample sizes of meta-analyses involving patients with predicted severe biliary pancreatitis without cholangitis are too small to detect effects of ERCP with sphincterotomy on the end points of severe complications and death.1,2 These limitations of the evidence are acknowledged in recent guidelines.3,4 A randomized trial with sphincterotomy as an integral part of ERCP which is powered for relevant clinical end points in predicted severe biliary pancreatitis is under way (Current Controlled Trials number, ISRCTN97372133).
Foundation for Health Care Subsidies for studies of acute pancreatitis. No other potential conflict of interest relevant to this letter was reported. 1. Petrov MS, van Santvoort HC, Besselink MG, van der Heijden
GJ, van Erpecum KJ, Gooszen HG. Early endoscopic retrograde cholangiopancreatography versus conservative management in acute biliary pancreatitis without cholangitis: a meta-analysis of randomized trials. Ann Surg 2008;247:250-7. 2. Tse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev 2012;5:CD009779. 3. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013;13:Suppl 2:e1-e15. 4. Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013;108:1400-15, 1416. [Erratum, Am J Gastroenterol 2014;109:302.] DOI: 10.1056/NEJMc1403445
University Medical Center Utrecht Utrecht, the Netherlands
To the Editor: The authors of the review of ERCP in patients with acute biliary pancreatitis described the potential for the procedure itself to cause pancreatitis, but they did not mention methods that have been shown recently to reduce the risk. A meta-analysis of 14 randomized, controlled trials showed that placement of small temporary pancreatic stents reduced the risk of post-ERCP pancreatitis in high-risk patients, at least in expert centers (odds ratio, 0.39; 95% confidence interval, 0.29 to 0.53; P
n e w e ng l a n d j o u r na l
transmitted helminth infections: systematic review and metaanalysis. JAMA 2008;299:1937-48. 3. Keiser J, Tritten L, Silbereisen A, Speich B, Adelfio R, Vargas M. Activity of oxantel pamoate monotherapy and combination chemotherapy against Trichuris muris and hookworms: revival of an old drug. PLoS Negl Trop Dis 2013;7(3):e2119. 4. Nagpal S, Sinclair D, Garner P. Has the NTD community
of
m e dic i n e
neglected evidence-based policy? PLoS Negl Trop Dis 2013;7(7): e2238. 5. Geerts S, Gryseels B. Drug resistance in human helminths: current situation and lessons from livestock. Clin Microbiol Rev 2000;13:207-22. DOI: 10.1056/NEJMc1403068
ERCP for Gallstone Pancreatitis To the Editor: The article by Fogel and Sherman (Jan. 9 issue)1 about the clinical approach in patients presenting with acute biliary pancreatitis may confuse readers, because the disease outcome can be associated with substantial mortality2 when its cause is not properly recognized.3 The patient described in the vignette has a very high probability of biliary pancreatitis even in the absence of dilatation or a stone in the common bile duct. Stones are suspected to cause acute pancreatitis when the alanine aminotransferase level is at least three times the upper limit of the normal range (positive predictive value of 95%).4 However, no biochemical or clinical finding can be used in isolation as a predictive test for ductal stones.5 Physicians should consider such variables in combination when deciding on whether a patient needs further evaluation (Fig. 1). Patients with an intermediate risk of a stone in the common bile duct should undergo noninvasive
Low risk (0–5%)
Normal liver function-tests Normal duct size on abdominal ultrasonography
No further evaluation
forms of imaging. Endoscopic ultrasonography and magnetic resonance cholangiopancreatography (MRCP) have completely replaced endoscopic retrograde cholangiopancreatography (ERCP) to evaluate patients in whom there is clinical or biologic suspicion of stones in the common bile duct. Certainly we would agree that first-line ERCP in the patient in the vignette is not acceptable.5 Jean Louis Frossard, M.D. Laurent Spahr, M.D. Geneva University Hospital Geneva, Switzerland [email protected] No potential conflict of interest relevant to this letter was reported. 1. Fogel EL, Sherman S. ERCP for gallstone pancreatitis. N Engl
J Med 2014;370:150-7. [Erratum, N Engl J Med 2014;370:488.]
2. Frossard JL, Steer ML, Pastor CM. Acute pancreatitis. Lancet
2008;371:143-52.
3. Frossard JL, Morel PM. Detection and management of bile
duct stones. Gastrointest Endosc 2010;72:808-16.
4. Tenner S, Dubner H, Steinberg W. Predicting gallstone pan-
Intermediate risk (>5–50%)
High risk (>50%)
Age >55 yr Cholecystitis Dilated duct >6 mm Bilirubin level, 1.8–4.0 mg/dl Abnormal liver-test other than bilirubin Pancreatitis
Cholangitis Dilated duct >6 mm Duct stone on ultrasonography Bilirubin level, >4 mg/dl
First-line endoscopic ultrasonography or MRCP
First-line ERCP
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 endoscopic retrograde cholangiopancreatography, and MRCP magnetic resonance cholangiopancreatography. Adapted AUTHOR: Fogel from Frossard and Morel.3
1954
FIGURE:
1
ARTIST:
ts
AUTHOR, PLEASE NOTE: Figure has been redrawn and type has been reset. Please check carefully. 15, 2014 n engl j med 370;20 nejm.org may 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 Gastroenterol 1994;89:1863-6. 5. Karakan T, Cindoruk M, Alagozlu H, Ergun M, Dumlu S, Unal S. EUS versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a prospective randomized trial. Gastrointest Endosc 2009;69:244-52. DOI: 10.1056/NEJMc1403445
To the Editor: The indications for ERCP in suspected biliary pancreatitis are not as clearly established as is suggested in the article by Fogel and Sherman. The only undisputed indication for ERCP is concurrent cholangitis. In the absence of cholangitis, with or without signs of bile-duct stones and obstruction, the indication for ERCP is not scientifically established, because studies have serious shortcomings. First, patient populations are heterogeneous, including some with cholangitis and some without. Second, patients with cholestasis are often not evaluated separately, so subgroup analysis is precluded. Third, ERCP is often performed relatively late after hospital admission (i.e., within 48 to 72 hours). Fourth, sphincterotomy is performed in only about 50% of cases.1 Fifth, there is considerable variation in end-point definitions comprising less relevant outcomes (i.e., ascites and pleural effusion). Finally, the pooled sample sizes of meta-analyses involving patients with predicted severe biliary pancreatitis without cholangitis are too small to detect effects of ERCP with sphincterotomy on the end points of severe complications and death.1,2 These limitations of the evidence are acknowledged in recent guidelines.3,4 A randomized trial with sphincterotomy as an integral part of ERCP which is powered for relevant clinical end points in predicted severe biliary pancreatitis is under way (Current Controlled Trials number, ISRCTN97372133).
Foundation for Health Care Subsidies for studies of acute pancreatitis. No other potential conflict of interest relevant to this letter was reported. 1. Petrov MS, van Santvoort HC, Besselink MG, van der Heijden
GJ, van Erpecum KJ, Gooszen HG. Early endoscopic retrograde cholangiopancreatography versus conservative management in acute biliary pancreatitis without cholangitis: a meta-analysis of randomized trials. Ann Surg 2008;247:250-7. 2. Tse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev 2012;5:CD009779. 3. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013;13:Suppl 2:e1-e15. 4. Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013;108:1400-15, 1416. [Erratum, Am J Gastroenterol 2014;109:302.] DOI: 10.1056/NEJMc1403445
University Medical Center Utrecht Utrecht, the Netherlands
To the Editor: The authors of the review of ERCP in patients with acute biliary pancreatitis described the potential for the procedure itself to cause pancreatitis, but they did not mention methods that have been shown recently to reduce the risk. A meta-analysis of 14 randomized, controlled trials showed that placement of small temporary pancreatic stents reduced the risk of post-ERCP pancreatitis in high-risk patients, at least in expert centers (odds ratio, 0.39; 95% confidence interval, 0.29 to 0.53; P
