Do endoscopic interventions make a difference in primary sclerosing cholangitis? clinical and endoscopic outcomes

ERCP in patients with primary sclerosing cholangitis (PSC) can be a challenging and occasionally gratifying opportunity for therapeutic intervention. Although there often appears to be initial radiological improvement, the benefit as measured by serial estimation of subsequent liver enzymes is questionable. The fluctuating course of the inflammatory process makes interpretation of serology even more difficult. Objective: To determine the success of therapeutic endoscopy in PSC when compared to diagnostic ERCP through evaluation of radiological, clinical and laboratory parameters before and after the procedure. Methods: All patients with PSC who underwent ERCP at our medical center between 1987 and 1997 were identified using a computerized database. Presenting symptoms, liver enzymes (AST, ALT, alkaline phosphatase) and bilirubin were recorded before ERCP. Clinical success was denned as resolution of presenting symptoms. Radiological success was defined as improvement in 2 of 3 liver enzymes by 50% or resolution of jaundice. Results: 104 patients underwent 204 procedures of which 56 ERCPs were diagnostic. Radiological improvement was seen in 60% of patients after therapeutic procedures and in no patient after diagnostic procedures. Clinical improvement was seen in 35% of patients after diagnostic ERCP and in 70% of therapeutic procedures (χ2 = 18.4, p=0.001). Mean reduction in ALT(U/L), AST(U/L), alkaline phosphatase (U/L) and bilirubin (mg/dl) in diagnostic and therapeutic groups was: Diagnostic P Therapeutic P ALT 47.3 0.007 36.1 0.0005 AST 35.6 0.030 45.7 0.0002 A/P 96.2 0.010 97.7 0.0001 Bilirubin 0.24 NS 1.11 0.0013 Laboratory improvement occurred in 35.3% of patients in the diagnostic ERCP group and 52.1% of the therapeutic ERCP group (χ2= 4.045, p=0.044). Conclusion: 1. In PSC, clinical improvement manifest by resolution of presenting symptoms is more common in patients undergoing therapeutic ERCP than diagnostic ERCP. 2. Liver enzymes improve following both diagnostic and therapeutic ERCP and should therefore not be relied upon to determine the success of the procedure. 3. Bilirubin level decreased in the therapeutic group but remain unchanged in the diagnostic group. 4. Laboratory improvement occurs more commonly in patients with PSC undergoing therapeutic ERCP than diagnostic ERCP.

Duke Scholars

Author Paul Simon Jowell Medicine, Gastroenterology

Author Malcolm Stanley Branch Medicine, Gastroenterology