School of Medicine and Health Sciences Poster Presentations

Title

Low Serum Trypsin Levels Predict Deep Pancreatic Cannulation Failure during ERCP in Patients with Chronic Pancreatitis

Document Type

Poster

Keywords

pancreatitis; chronic; ecrp; cannulation

Publication Date

Spring 2017

Abstract

Background: Deep pancreatic cannulation failure (DPCF) during ERCP in patients with chronic pancreatitis (CP) can occur in the presence of duct obstruction due to strictures and/or stones. There are currently no simple preprocedure clinical or laboratory tests that can predict DPCF during ERCP. Since low serum trypsin levels have been correlated with advanced chronic pancreatitis and exocrine insufficiency, we hypothesized that it might be a useful preprocedure test for predicting DPCF.

Aim: To assess whether low serum trypsin levels predict DPCF failure of deep pancreatic duct cannulation during ERCP in patients with chronic pancreatitis. after adjusting for obstructing strictures and/or stones.

Method: All adult (>18 year of age) patients with definite CP who were referred to a multidisciplinary pancreatitis clinic between 2010-2015 and underwent a serum trypsin level measurement prior to ERCP for the management of abdominal pain were evaluated. Serum trypsin levels are obtained in all CP patients as part of their evaluation for exocrine insufficiency. Exclusion criteria included chronic kidney disease, prior pancreatic resection, and/or type 1 diabetes mellitus as these conditions can affect serum trypsin levels independent of CP. Definite CP was defined as abdominal pain and/or acute recurrent pancreatitis in the presence of calcification(s) on CT scan and endoscopic ultrasound EUS and/or moderate to severe ductal changes based on the MANNHEIM criteria. Low serum trypsin was defined as values < 19 ng/mL or <10 ng/mL based on laboratory assay. Failure of deep cannulation during ERCP was defined as the inability to advance any accessory (sphincterotome guidewire, cannula, and/or guidewire sphincterotome) upstream of an obstructing stricture and/or stone which would be necessary for the completion of therapeutic maneuvers (stone extraction, stricture dilation, stone extraction and stent placement). Heavy smoking and alcohol use was defined per NAPS2 study. Serum trypsin levels, pancreatic stone(s) and duct stricture were evaluated as Ffactors associated with DPCF during ERCP were evaluated using univariable and multivariable logistic regression analysis.

Results: Among 213 patients diagnosed with definite CP, 104 patients underwent trypsin measurements and ERCP, of whom 42 (40.4%) had low/undetectable serum trypsin levels and 37 (35.6%) had DPCF during ERCP. There were no significant differences between patients with and without DPCF low/ undetectable and normal trypsin levels with regards to age, gender, etiology, smoking, and pancreas divisum. Patients with DPCF were more likely to have low trypsin levels (68% vs. 25%, p<0.0001), obstructing stones (86% vs. 57%, p=0.02), and strictures (69%% vs. 30.9%, p=0.001) compared to those without DPCF. Patients with low/undetectable trypsin had significantly higher rates of heavy alcohol use (61.1%) (p=0.006) and calcifications (51.4%) (p=0.002) detected on CT scan or EUS. A total of 6 (54.5%) out of 11 patients who underwent ESWL after failure of ERCP, had successful deep pancreatic cannulation on subsequent ERCP. A low /undetectable serum trypsin level was significantly associated with DPCF in the both the univariable (OR: 6.13; 95% CI: 2.5-14.8; P<0.001) and multivariable (OR: 5.99; 95%CI: 2.13-16.83; P=0.001) analysis after adjusting for obstructing stones and stricture.

Conclusion: Preprocedural low serum trypsin levels independently predict DPCF during ERCP in patients with chronic pancreatitis. Consideration of ESWL prior to ERCP may increase successful deep pancreatic cannulation rates.

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Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

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Poster to be presented at GW Annual Research Days 2017.

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Low Serum Trypsin Levels Predict Deep Pancreatic Cannulation Failure during ERCP in Patients with Chronic Pancreatitis

Background: Deep pancreatic cannulation failure (DPCF) during ERCP in patients with chronic pancreatitis (CP) can occur in the presence of duct obstruction due to strictures and/or stones. There are currently no simple preprocedure clinical or laboratory tests that can predict DPCF during ERCP. Since low serum trypsin levels have been correlated with advanced chronic pancreatitis and exocrine insufficiency, we hypothesized that it might be a useful preprocedure test for predicting DPCF.

Aim: To assess whether low serum trypsin levels predict DPCF failure of deep pancreatic duct cannulation during ERCP in patients with chronic pancreatitis. after adjusting for obstructing strictures and/or stones.

Method: All adult (>18 year of age) patients with definite CP who were referred to a multidisciplinary pancreatitis clinic between 2010-2015 and underwent a serum trypsin level measurement prior to ERCP for the management of abdominal pain were evaluated. Serum trypsin levels are obtained in all CP patients as part of their evaluation for exocrine insufficiency. Exclusion criteria included chronic kidney disease, prior pancreatic resection, and/or type 1 diabetes mellitus as these conditions can affect serum trypsin levels independent of CP. Definite CP was defined as abdominal pain and/or acute recurrent pancreatitis in the presence of calcification(s) on CT scan and endoscopic ultrasound EUS and/or moderate to severe ductal changes based on the MANNHEIM criteria. Low serum trypsin was defined as values < 19 ng/mL or <10 ng/mL based on laboratory assay. Failure of deep cannulation during ERCP was defined as the inability to advance any accessory (sphincterotome guidewire, cannula, and/or guidewire sphincterotome) upstream of an obstructing stricture and/or stone which would be necessary for the completion of therapeutic maneuvers (stone extraction, stricture dilation, stone extraction and stent placement). Heavy smoking and alcohol use was defined per NAPS2 study. Serum trypsin levels, pancreatic stone(s) and duct stricture were evaluated as Ffactors associated with DPCF during ERCP were evaluated using univariable and multivariable logistic regression analysis.

Results: Among 213 patients diagnosed with definite CP, 104 patients underwent trypsin measurements and ERCP, of whom 42 (40.4%) had low/undetectable serum trypsin levels and 37 (35.6%) had DPCF during ERCP. There were no significant differences between patients with and without DPCF low/ undetectable and normal trypsin levels with regards to age, gender, etiology, smoking, and pancreas divisum. Patients with DPCF were more likely to have low trypsin levels (68% vs. 25%, p<0.0001), obstructing stones (86% vs. 57%, p=0.02), and strictures (69%% vs. 30.9%, p=0.001) compared to those without DPCF. Patients with low/undetectable trypsin had significantly higher rates of heavy alcohol use (61.1%) (p=0.006) and calcifications (51.4%) (p=0.002) detected on CT scan or EUS. A total of 6 (54.5%) out of 11 patients who underwent ESWL after failure of ERCP, had successful deep pancreatic cannulation on subsequent ERCP. A low /undetectable serum trypsin level was significantly associated with DPCF in the both the univariable (OR: 6.13; 95% CI: 2.5-14.8; P<0.001) and multivariable (OR: 5.99; 95%CI: 2.13-16.83; P=0.001) analysis after adjusting for obstructing stones and stricture.

Conclusion: Preprocedural low serum trypsin levels independently predict DPCF during ERCP in patients with chronic pancreatitis. Consideration of ESWL prior to ERCP may increase successful deep pancreatic cannulation rates.