Akut Biliyer Pankreatit Hastalarında ERCP Gereksinimi Tahmin Edilebilir mi?

Yıl 2019, Cilt: 11 Sayı: 1, 40 - 51, 01.01.2019

Musa Zorlu

Öz

Giriş: Akut biliyer pankreatitin (ABP) en sık nedeni
safra kesesi taş hastalığıdır. Hastaların büyük çoğunluğunda taşın düşmesi
sonucu spontan iyileşme gözlenirken, düşmediği durumlarda ERCP ve sfinkterotomi
işlemi ile taşın çıkartılması gerekebilir. Hangi hastada taşın spontan
düşüp-düşmeyeceğini önceden bilmek mümkün değildir. Bu nedenle ERCP kararı medikal
tedavi sırasında klinik durum ve laboratuvar değerlerine göre belirlenmektedir.
ERCP yapılmasına gerek duyulabilecek hastaların bilinmesi klinisyen açısından
öngörü sağlayacağı ve daha planlı bir tedavi sağlayacağı aşikardır. Bu
çalışmada ERCP yapılacak hastaları belirleyecek prediktif değerlerin
belirlenmesi amacıyla planlanmıştır.

Gereç ve Yöntem: ABP nedeniyle tedavi edilen 179 hasta
retrospektif olarak değerlendirildi. Hastalar ERCP yapılan (ERCP) ve spontan
gerileyen (MEDİKAL)  olmak üzere iki gruba
ayrıldı. Hastaların demografik verileri, komorbit hastalıkları, biliyer ranson
değerleri, biyokimyasal ve hemogram parametreleri ilk başvuru anında ve 48 saat
(h) sonra kaydedildi.

Bulgular: Grup MEDİKAL 160, grup ERCP ise 19 hastadan
oluşmaktaydı. Gruplar arası değerlendirmede yaş ERCP grubunda farklı
bulunurken, cinsiyet, biliyer ranson ve komorbit hastalıklarda fark bulunmadı. ROC
analizinde amilaz
(24h) <104.5,  amilaz (48h) <
123.5, total bilürübin (48h) <2.15, direk bilürübin (48h) <1.45,
kreatinin (48h)< 0.75 olan hastalarda ERCP yapılmasına gerek olmadığı
anlamlı bulundu. 48 h deki lojistik regresyon analizi sonucuna göre amilaz
değeri yüksek olan hastada 7.032, direk bilürübin değeri yüksek olan hastada
6.710, beyaz küre değeri yüksek olan hastada 4.287 kat fazla ERCP endikasyonu
olduğu gösterildi.

Sonuç:
ERCP yapılması gereken hastaları belirlemek için ilk 24 h’de amilaz değeri, 48
h’de ise amilaz, direk bilürübin, beyaz küre değerleri prediktif değer olarak
kullanılabilir. 

Anahtar Kelimeler

akut biliyer pankreatit, ERCP

Can ERCP Requirement be Predictable in Patients with Acute Biliary Pancreatitis ?

Öz

Introduction:
Gallstone disease is the most common cause of acute
pancreatitis. In many patients, spontaneous recovery is common after dropping
of the stones into the common bile duct. Whereas, endoscopic retrograde
cholangiopancreatography or sphincterotomy may be necessary to remove the stone
in some cases where spontaneous dropping did not occur. It is unpredictable in
which situations these gallstones will drop spontaneously. Therefore, the
decision to perform an ERCP is generally depended on the clinical course and laboratory
work-up. It is obvious that early prediction of the ERCP during admission will
provide improvisation of a structured treatment plan. The present study sought
to determine whether ERCP requirement might be predicted by some certain
parameters in patients with gallstone disease.

Patients
and methods: Clinical records of a total of 179 patients with acute
biliary pancreatitis (ABP) were retrospectively evaluated. Patients were
divided into two groups as to receive ERCP (ERCP group – 19 patients) or have
spontaneous recovery (Medical Group – 160 patients). Study data included
demographics, history of comorbid diseases, biliary Ranson Scale Scores and
laboratory findings. Parametric data were recorded on admission into the
hospital and the assessments were repeated at 48^th hour of
admission.

Results: Baseline
characteristics including gender, biliary Ranson Scale Score and frequency of
comorbidities were similar between two groups whereas age was significantly
higher in ERCP group. ROC analysis revealed that ERCP was significantly
unnecessary in patients with an amylase level <104.5 at 24^th hour
or <123.5 at 48^th hour, total bilirubin <2.15 at 48^th
hour, conjugated bilirubin <1.45 at 48^th hour or creatinine
<0.75 at 48^th hour. Logistic regression analysis revealed that
risk of ERCP requirement was 7.032 fold higher in patients with high amylase
levels, 6.710 fold higher in patients with high bilirubin levels, 4.287 fold
higher in patients with high white blood cell count at 48^th hour.

Conclusion:
ERCP requirement in gallstone disease may be predicted
by amylase levels at 24^th hour and by amylase, conjugated bilirubin
and white blood cell count at 48^th hour of admission. 

Anahtar Kelimeler

Acute biliary pancreatitis, ERCP

Kaynakça

• 1. Sekimoto M, Takada T, Kawarada Y,et al. JPN Guidelines fort he management of acute pancreatıtis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis.J Hepatobiliary Pancreat Surg 2006;13(1):10-24.
• 2. Braunwald E, Fauci AS. Kasper DL, Hauser SL, Longo DL, Jameson JL. Harrison İç Hastalıkları Prensipleri. In: Greenberger NJ, Toskes PP (eds) . Akut ve Kronik Pankreatit 15 Edisyon 2004.1792-803.
• 3. Acute Pancreatitis Classification Working Group . Classification of acute pankreatitis -2012 revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102-11
• 4. Yeung YP , I am BY, Yip AW APACHE system is better than Ranson system in the prediction of severity of acute pancreatitis Hepatobiliary Pancreat Dis Int. 2006;5:294-9
• 5. 5.Banks PA, Freeman ML. Practise guidelines in acut pancreatitis. American Journal of Gastroenteroloji 2006;101(10): 2749-400
• 6. Huang J, Chang CH, Wang JL, Kuo HK, Lin JW, Shau WY, et al. Nationwide epidemiological study of severe gallstone disease in Taiwan. BMC Gastroenterology 2009;9:63.
• 7. Fan ST ,Lai M ,Mok F et al.Early treatment of acute biliary pancreatitis by endoskopic papillotomy. N Eng J Med 1993;328:228-32
• 8. Nowak A, Nowakowska-Dulawa E, Marek T et al.Final results of the prospective randomized controlled study on endoskopic sphincterotomy versus conventıonal management in acute biliary pancreatitis (abstract) .Gastroenterology 1995;108:A380
• 9. Folsch U,Nitsche R,Ludtke R et al.Early ERCP and papillatomy compared with conservative treatment for acute biliary pancreatititis.N Eng J Med 1997;336;237-42
• 10. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence –based guidelines for the management of acute pancreatitis Pancreatology.2013;13:el-15.
• 11. American Gastroenterological Association (AGA) Institute on ‘’Management of Acute Pancreatitis ‘’ Clinical Practice and Economics Committee, AGA Instıtute Governing Board. AGA Institute medical position statement on acute pancreatitis.Gastroenterology. 2007;132(5):2019-21, supportıng literature revıew in Gastroenterology 2007 May ;132(5):2022.
• 12. Behrns KE,Asley SW,Hunter JG,Locke DC.Early ERCP for golstone pancreatitis:for whom and when? Journal of Gastrointestinal Surgery,12:629;633(2008)
• 13. Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, et al. Complications of endoscopic biliary sphincterotomy. New England Journal of Medicine 1996; 335(13):909–18.
• 14. Chang L,Lo S, Stabile BE,et al. Preoperative versus postoperative endoskopic retrograde cholangiopancreatography in mild to moderate gallstone pankreatitis: a prospectıve randomized trial. Ann Surg 2000;231:82-7.
• 15. Zarnescu NO,Costea R,Zarnescu(Vasiliu) EC,Neagu S. Clinico-biochemical factors to early predict biliary etiology of acute pancreatitis:age,female gender ,and ALT. Journal of Medicine and Life Vol.8,Issue 4, October-December 2015,pp.523-526
• 16. Liu CL,Fan ST,Lo CM,Tso WK,Wong Y,Poon RT et al. Clinico-biochemıcal prediction of biliary cause of acute pancreatitis in the era of endoscopic ultrasonography. Aliment Pharmacaol Ther 2005;22:423-431.
• 17. Levy P, Boruchowicz A, Hastier P,Pariente A,Thevenot T,Frossard JL et al. Diagnostic criteria in predicting a biliary origin of acute pancreatitits in the era of endoskopic ultrasound:multicentre prospective evaluation of 213 patients . Pancreatology .2005;5:450-456
• 18. Chang L, Lo SK, Stabile BE, Lewis RJ, de Virgilio C. Gallstone pankreatitis: a prospectıve study on the incidence of cholangitis and clinical predictors of retaıned common bile duct Stones. Am J Gastroenterol. 1998 Apr;93(4):527-31
• 19. Ranson JHC,Rifkind KM,Roses DT,et al: Prognostic signs and the role of operactıve management in acute pancreatitis. Surgery Gynecol Obstet 1974; 139:69-81