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Yield of Repeat ERCP for Persistently Elevated LFTs After a Previously Normal Cholangiogram in Liver Transplant Patients with Choledochocholedochostomy Anastomosis Evan L. Fogel, Lee McHenry Jr., James L. Watkins, Suzette Schmidt, A. J. Tector, Jonathan A. Fridell, Stuart Sherman, Glen A. Lehman Background: Biliary tract complications occur in 20-30% of patients after orthotopic liver transplantation (OLT), with bile leaks and anastomotic strictures most often identified. ERCP is generally the preferredmethod of evaluation, and is usually performed for persistently elevated or rising LFTs post-OLT. A normal ERC suggests an alternative explanation for the abnormal LFTs (eg. rejection). However, exclusion of other causes may prompt a repeat ERCP. This study examines the yield of a 2nd ERCP, performed after a previously normal exam, in the evaluation of persistently abnormal or rising LFTs. Methods: From 1/99-10/ 03, patients who had a previously normal post-OLT ERC (with or without prior endoscopic intervention) and underwent repeat evaluation for the above indications were identified from our ERCP database. The biliary anastomosis had been established by choledochocholedochostomy in all patients. Complications were graded according to consensus criteria. Results: Overall, 34 patients (who underwent 46 follow-up ERCPs) were identified, 31 of which had biliary continuity established without a T-tube. Twenty-seven ERCPs were performed in 22 patients who had no prior therapy (Group 1), while 19 ERCPs were performed in 12 patients who had prior intervention but had subsequently normalized their cholangiograms (Group 2). Themean interval between the initial normal ERCand the follow-up study was 5.5 months (range 0.5-24.0) in Group 1 and 5.3 months (range 0.3-29) in Group 2. The findings at the 2nd ERC are as noted in the Table. In both groups, 63% of patients had a persistently normal study, while 37% had new pathology identified. Two patients developed pancreatitis (4.3%; 1 mild, 1 moderate) and one patient had a mild post-sphincterotomy bleed (overall complication rate 6.5%). Summary: In over one-third of patients with a previously-normal post-OLT ERC, new findings (strictures, most often) were identified at repeat ERC performed for persistently elevated or rising LFTs. Conclusion: Repeat ERC can identify the cause of persistently abnormal LFTs in a subset of OLT patients despite a previously normal ERC, and should be considered when an alternative explanation is not identified.

Background: Patients with gallbladder stones presenting with jaundice, deranged liver function tests (LFTs), dilated ducts on imaging or pancreatitis as possible indicators of common bile duct (CBD) stones usually undergo ERCP. Except for pancreatitis, it is unclear whether prophylactic ES should be performed in patients with a normal cholangiogram, in whom cholecystectomy is not proposed. Aim: To determine if prophylactic ES can prevent further biliary problems if a cholecystectomy is not planned for patients with suspected CBD stones and a normal cholangiogram. Methods: Endoscopic databases at two centers (Royal Victoria and Ulster Hospitals) were searched for patients with gallbladder stones presenting with jaundice, deranged LFTs or dilated ducts on ultrasound (USS), in whom a cholecystectomy was not planned. Endoscopic findings were noted. A telephone questionnaire was performed on all patients, or their carers if possible, to determine the frequency of recurrent biliary problems or repeat investigations. One center routinely performed prophylactic ES while the other did not. Results from the two groups were compared. Results: 41 patients met the inclusion criteria of whom 20 (7 male) had a ES and 21 (12 male) did not. The frequency of pre-ERCP jaundice (14 v 12; p=0.3), deranged LFTs (18 v 16; p=0.22), abdominal pain (15 v 15; p=0.8), dilated ducts (9 v 12; p=0.39) did not differ between the two groups. Post- ERCP recurrent abdominal pain (5 v 3; p=0.39), jaundice (3 v 1; p=0.28), pancreatitis (0 v 1; p=0.32) and repeat USS (2 v 1; p=0.52) or ERCP (1 v 1; p=0.97) did not differ between the two groups. Conclusions: Patients with gallstones and suspected CBD stones and a normal cholangiogram should not have a prophylactic sphincterotomy as it did not reduce the incidence of recurrent biliary problems.

Many hepatobiliary diseases are seen in IBD. PSC is the most common, occurring in 7.5% of patients with UC. The cause of PSC is not well understood, but PSC seems to be associated with genetic susceptibility, sharing some immunologic abnormalities with UC. A characteristic cholangiogram in a patient with abnormal liver function tests usually establishes the diagnosis. Liver biopsy is not essential but can help make the diagnosis of small duct PSC in patients with a normal cholangiogram. There are no medications that treat PSC effectively. Endoscopic dilation of dominant strictures reduces the frequency of cholangitis and may improve survival. OLT remains the only proven treatment of advanced PSC. Cholangiocarcinoma is a feared complication of PSC that is difficult to diagnose. Cholelithiasis, PBC, portal vein thrombosis, and hepatic abscess are hepatobiliary disorders that occur less frequently in IBD patients.

Background: DACP, as an adjunct to ERCP allows for direct visualization of the biliary duct and pancreatic duct.We aim to assess the technical feasibility of DACP for a variety of clinical indications and to determine its impact on disease management. Methods: 94 consecutive DACP examinations were performed in 57 patients with 3 groups of disorders, choledocholithiasis (CDL), biliary strictures(BS) and pancreatic disease(PD), age range (24 to 91 years; mean 69). All DACPs were performed using the Pentax FCP-8P or 9P. Data pertaining to indication, technical success, and clinical impact of DACP on disease management were collected and analyzed using cMore endoscopic database. Results: CDL (n=53, 27 pts ) Indications included stone fragmentation using EHL (n=34), evaluation of biliary tree post-stone removal (n=14), distinction between stone and stricture, evaluation of biliary tree for stones despite normal cholangiogram (n=5). Technical success was achieved in 29/53 DACPs. The 24/53 failures represent partial fragmentation of stones with EHL in 8 patients with extensive disease. Use of DACP resulted in complete removal of biliary tree stones in 10/34 examinations (10 patients) and demonstrated the presence of stones in 4 patients with normal post-interventional cholangiograms. Furthermore DACP helped to confirm the absence of stones after removal by basket or balloon in 11/12 patients. BS (n=33, 23 pts) Indications included evaluation of stricture(n=21) or Wallstent occlusion (n=4), and monitoring of cholangiocarcinoma progression in a single patient (n=7). Technical success was achieved in 29/33 cases. DACP assisted in confirming or clarifying the nature of a stricture in 16/29 cases, and in stent management in 20/29 cases. PD (n=7) Indications included evaluation of pancreatic duct obstruction in chronic pancreatitis (n=4) and malignancy (n=1), and evaluation of PD for IPMT (n=2). An additional use of DACP was in the evaluation of hemobilia (n=1) where no source was seen. There were no complications reported with the use of DACP. Conclusion: DACP is technically feasible in the management of pancreatico-biliary diseases. Lack of complete technical success in the use of EHL to fragment stones is due to extensive stone disease in a limited number of patients. Otherwise DACP impacts on the management of complicated biliary tract disease by clarifying cholangiograms, assisting in EHL stone fragmentation, and guiding stenting and surgical management.