P0018 - MRCP vs ERCP: Evaluation of ASGE Guidelines in Acute Gallstone Pancreatitis with Predicted Intermediate/High Risk for Choledocholithiasis

Sunday, October 24, 2021

3:30 PM – 7:00 PM PT

Location: Shoreline Exhibit Hall

Has Audio

Presenting Author(s)

Supisara Tintara, MD

Beth Israel Deaconess Medical Center, Harvard Medical School
Boston, MA, United States

Supisara Tintara, MD¹, Ishani Shah, MD¹, William Yakah, BS¹, Awais Ahmed, MD¹, Cristina Sorrento, MD¹, Cinthana Kandasamy, MD¹, Darshan J. Kothari, MD², Steven D. Freedman, MD, PhD¹, Sunil G. Sheth, MD¹
¹Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; ²Duke University Medical Center, Durham, NC

Introduction:

Acute gallstone pancreatitis (AGP) is a common cause of acute pancreatitis (AP) and patients may also present with choledocholithiasis. The American Society for Gastrointestinal Endoscopy (ASGE) suggests a management algorithm based on probability for choledocholithiasis, recommending MRCP for patients with intermediate risk and ERCP for patients with high probability. Our study aimed to determine how often these guidelines were followed at our institution and assess outcomes when guidelines were not adhered to.

Methods:

We conducted a retrospective cohort study of AGP patients admitted to a tertiary care center from 2008-2018. AP was diagnosed using revised Atlanta criteria. AGP was defined as the presence of gallstones on imaging or with cholestatic pattern of liver injury in the absence of another cause. Patients were assigned low, intermediate or high risk based on ASGE guidelines. We then reviewed those patients who were in the intermediate and high risk categories. Our primary outcomes were the proportion of patients in the intermediate risk group undergoing MRCP first and the proportion of patients in the high risk group undergoing ERCP directly without preceding imaging. We also performed a t-test to analyze if there were outcome differences based on if guidelines were not adhered to.

Results:

We identified 235 patients with AGP: 79 patients were low risk, 79 patients were intermediate risk and 77 patients were high risk. In the intermediate risk group, 54 patients appropriately underwent MRCP first whereas 25 patients went directly to ERCP. Of these 25 patients, 9 patients had choledocholithiasis, 9 patients had sludge and 7 patients had a normal ERCP. One patient with normal ERCP suffered from post ERCP AP. Patients undergoing MRCP in this group had a significantly longer length of stay (LOS, 5.0 vs 4.0 days, p=0.02). In the high risk group, 83% appropriately had an ERCP without preceding imaging. Thirteen patients underwent MRCP first and had a longer LOS than those who underwent ERCP directly, which approached significance (4.3 v. 3.0 days, p=0.08).

Discussion:

We found that 2/3 of patients in the intermediate group and 83% of patients in the high risk group followed ASGE guidelines for management of choledocholithiasis in the setting of AGP. There was longer LOS for patients undergoing MRCP in both groups. Importantly, one patient who had a normal ERCP in the intermediate group without preceding MRCP suffered from post ERCP AP, highlighting the risk of unnecessary procedures.

	Intermediate risk			High risk
Demographics	ERCP first (n=25)	MRCP first (n=54)	p value	ERCP first (n=64)	MRCP first (n=13)	p value
Age (IQR)	63.0 [54.0, 76.0]	57.2 [42.0, 74.3]	0.134	59.0 [45.2, 71.0]	54.1 [49.3, 66.0]	0.724
BMI (IQR)	26.5 [22.7, 29.2]	28.1 [25.1, 34.5]	0.056	27.1 [22.6, 33.7]	25.6 [25.4, 29.7]	0.452
Female (%)	12 (48%)	34 (63%)	0.313	38 (59.4%)	7 (53.8%)	0.952
Race (%)			1.000			0.466
Caucasian	18 (75.0%)	38 (74.5%)		41 (66.1%)	10 (76.9%)
African American	5 (20.8%)	10 (19.6%)		12 (19.4%)	3 (23.1%)
Other	1 (4.17%)	3 (5.9%)		9 (14.5%)	0 (0%)
Charlson Comorbidity Index (%)			0.625			0.459
0	4 (16.0%)	13 (24.1%)		17 (26.6%)	2 (15.4%)
1-2	8 (32%)	19 (35.2%)		16 (25.0%)	4 (30.8%)
3-5	10 (40%)	14 (25.9%)		25 (39.1%)	4 (30.8%)
6 and above	3 (12.0%)	8 (14.8%)		6 (9.38%)	3 (23.1%)

Baseline laboratory (IQR)
Creatinine	0.80 [0.70, 1.10]	0.80 [0.70, 1.10]	0.878	0.80 [0.70, 1.00]	0.80 [0.60, 1.00]	0.752
White blood cell count	11.9 [9.70, 14.7]	10.4 [8.15, 14.4]	0.231	11.6 [8.25, 15.0]	7.60 [6.30, 10.6]	0.016
Lactate	1.40 [1.30, 1.80]	1.60 [1.22, 2.27]	0.694	1.60 [1.20, 2.40]	1.30 [1.20, 2.30]	0.746
Lipase	2988 [1817, 4030]	1948 [435, 4581]	0.268	2026 [814, 4355]	1142 [123, 5608]	0.260
Alanine transaminase	255 [147,551]	120 [45.0, 278]	0.037	264 [94.0, 442]	239 [154, 618]	0.544
Aspartate aminotransferase	238 [134, 491]	134 [45.8, 251]	0.033	237 [78.0, 355]	218 [87.0, 439]	0.654
Alkaline phosphatase	136 [102, 212]	111 [81.0, 160]	0.159	149 [98.8, 225]	165 [106, 401]	0.317
Total bilirubin	1.20 [0.70, 1.80]	1.10 [0.62, 1.70]	0.575	4.05 [2.58, 5.15]	4.30 [3.70, 6.40]	0.185
Severity of pancreatitis
BISAP (%)			0.656			0.531
0	7 (30.4%)	21 (40.4%)		26 (41.3%)	4 (36.4%)
1-2	12 (52.2%)	19 (36.5%)		20 (31.7%)	6 (54.5%)
3 and above	4 (17.4%)	12 (22.2%)		17 (26.5%)	1 (9.09%)
Modified Atlanta Criteria (%)			0.426			0.390
Mild	20 (83.3%)	35 (67.3%)		54 (84.4%)	9 (75.0%)
Moderate	4 (16.7%)	16 (30.8%)		7 (10.9%)	3 (25.0%)
Severe	0 (0%)	1 (1.92%)		3 (4.69%)	0 (0%)
Pancreatic necrosis (%)	1 (5.0%)	18 (33.3%)	0.029	6 (10.7%)	3 (25.0%)	0.190

Outcomes
Mean length of stay	4.00 [2.74, 5.00]	5.00 [4.00, 8.00]	0.019	3.00 [2.54, 5.00]	4.38 [4.00, 6.00]	0.077
30-day readmission	3 (12.0%)	11 (20.8%)	0.529	6 (9.52%)	2 (16.7%)	0.606
1-year readmission	5 (20.0%)	28 (51.9%)	0.015	19 (29.7%)	7 (53.8%)	0.114
1-year mortality	0 (0%)	1 (1.85%)	0.092	1 (1.56%)	0 (0%)	0.097
Days to enteral nutrition	2.00 [1.00, 2.50]	2.50 [1.00, 4.00]	0.162	2.00 [1.00, 2.00]	3.00 [2.00, 4.00]	0.097

Table: Gallstone pancreatitis patients with intermediate and high risk for choledocholithiasis: demographics and outcomes based on receiving ERCP or MRCP first. IQR = interquartile range, ERCP = endoscopic retrograde cholangiopancreatography, MRCP = magnetic resonance cholangiopancreatography, BMI = body mass index

Disclosures:

Supisara Tintara indicated no relevant financial relationships.

Ishani Shah indicated no relevant financial relationships.

William Yakah indicated no relevant financial relationships.

Awais Ahmed indicated no relevant financial relationships.

Cristina Sorrento indicated no relevant financial relationships.

Cinthana Kandasamy indicated no relevant financial relationships.

Darshan Kothari indicated no relevant financial relationships.

Steven Freedman indicated no relevant financial relationships.

Sunil Sheth indicated no relevant financial relationships.

Supisara Tintara, MD¹, Ishani Shah, MD¹, William Yakah, BS¹, Awais Ahmed, MD¹, Cristina Sorrento, MD¹, Cinthana Kandasamy, MD¹, Darshan J. Kothari, MD², Steven D. Freedman, MD, PhD¹, Sunil G. Sheth, MD¹. P0018 - MRCP vs ERCP: Evaluation of ASGE Guidelines in Acute Gallstone Pancreatitis with Predicted Intermediate/High Risk for Choledocholithiasis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.