P1077 - Retracted Major Papilla in Primary Sclerosing Cholangitis: Creating an Endoscopic Grading System

Monday, October 25, 2021

10:30 AM – 4:15 PM PT

Location: Shoreline Exhibit Hall

Has Audio

Presenting Author(s)

Benjamin Bick, MD, MSCR

Indiana University School of Medicine
Indianapolis, IN, United States

Benjamin Bick, MD, MSCR¹, Mark Gromski, MD¹, Jeffrey Easler, MD¹, Evan Fogel, MD¹, Glen Lehman, MD¹, Daniel Baik, MD², Stuart Sherman, MD¹
¹Indiana University School of Medicine, Indianapolis, IN; ²Cooper University Hospital, Camden, NJ

Introduction: Primary sclerosing cholangitis (PSC) is a fibroinflammatory condition of the biliary tree. Retraction of the major papilla (MP) within the duodenal wall is felt to be pathognomonic of PSC, and likely occurs from bile duct shortening as PSC progresses. In order to study the clinical implication of retracted MP in PSC, we created an endoscopic grading system of severity.

Methods: This is a cross-sectional study of patients with PSC undergoing ERCP at our institution from 1/2012 to 3/2019. Included patients had PSC, no prior sphincterotomy, and adequate MP images to assess for retraction. Three high volume ERCP experts created a grading system. After a teaching session on the grading system, 7 investigators (1 trainee and 6 high volume ERCP physicians) were tested on severity of retraction in 60 selected images. Reliability of individual observers was calculated using kappa, and reliability of all observers was calculated using intraclass correlation coefficient (ICC). Kappa and ICC values >0.75 were deemed excellent.

Results: 774 ERCPs were performed in 259 patients with PSC, with 103 done without prior sphincterotomy, and 93 with adequate MP pictures to use in creating the grading system. The created grading system included: normal MP, flattened MP (nearly in line with the duodenal wall), and retracted MP (within an inverted segment of duodenal wall appearing like a shallow diverticulum, Fig 1). Supportive criteria for retracted MP included suprapapillary concavity (intraduodenal segment of bile duct inverted above MP, Fig 1) and “squid sign” ( >3 folds of duodenal wall stretched inferiorly from the MP, Fig 1). Of 60 selected images used to assess reliability, 21 had normal MP, 21 had flattened MP, and 18 had retracted MP, with squid sign in 5/18 with retracted MP and suprapapillary concavity in 14/18. Reliability of observers (Table 1): good to excellent for retraction in 5/7; good to excellent for suprapapillary concavity in 4/7; poor for squid sign in 6/7. ICC was 0.63 for retraction, 0.45 for suprapapillary concavity, and 0.18 for squid sign.

Discussion: This is the first grading system that classifies retraction of MP in PSC. Reliability among ERCP experts for grading degree of retraction and suprapapillary concavity was high. This supports use of this grading system to be utilized in future study to determine if retraction is associated with disease features, difficulty of ERCP, and ERCP-related complications in patients with PSC.

Figure: Figure 1: Examples of retracted MP in 3 patients, all with suprapapillary concavity (denoted by stars) and one (C) with squid sign (denoted by arrows)

	Retraction	Suprapapillary concavity	Squid sign
Observer 1	0.62 (0.46-0.79)	0.59 (0.35-0.83)	0.36 (0.02-0.70)
Observer 2	0.90 (0.80-0.99)	0.87 (0.73-1.00)	0.82 (0.57-1.00)
Observer 3	0.70 (0.55-0.85)	0.72 (0.54-0.91)	0.00 (-0.17-0.12)
Observer 4	0.72 (0.58-0.87)	0.61 (0.35-0.86)	0.00 (-0.08-0.02)
Observer 5	0.56 (0.40-0.71)	0.59 (0.33-0.84)	0.20 (-0.01-0.41)
Observer 6	0.49 (0.32-0.65)	0.19 (-0.07-0.45)	0.23 (0.05-0.40)
Observer 7	0.65 (0.49-0.81)	0.63 (0.39-0.86)	0.04 (-0.16-0.24)

Table: Table 1: Individual Observer Reliability of 7 ERCP Endoscopists On The Severity Of Major Papilla Retraction In PSC And Supportive Features Of Retraction (Suprapapillary Concavity And Squid Sign).

All reliability measurements were calculated using the kappa statistic

Disclosures:

Benjamin Bick indicated no relevant financial relationships.

Mark Gromski indicated no relevant financial relationships.

Jeffrey Easler: Boston Scientific – Consultant.

Evan Fogel: NIH/NIDDK – Grant/Research Support.

Glen Lehman: Cook Medical – Consultant.

Daniel Baik indicated no relevant financial relationships.

Stuart Sherman: Boston Scientific – Consultant. Cook Medical – Consultant. Olympus America – Consultant.

Benjamin Bick, MD, MSCR¹, Mark Gromski, MD¹, Jeffrey Easler, MD¹, Evan Fogel, MD¹, Glen Lehman, MD¹, Daniel Baik, MD², Stuart Sherman, MD¹. P1077 - Retracted Major Papilla in Primary Sclerosing Cholangitis: Creating an Endoscopic Grading System, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.