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Early endoscopic retrograde cholangiopancreatography (ERCP) in acute gallstone pancreatitis without cholangitis

Early endoscopic retrograde cholangiopancreatography (ERCP) in acute gallstone pancreatitis without cholangitis

Best Practice Guidance

Summary

Early endoscopic retrograde cholangiopancreatography (ERCP) for acute gallstone pancreatitis without cholangitis is not recommended.

 

This guidance applies to adults aged 19 years and over.

Recommendation

Early ERCP in the treatment of acute gallstone pancreatitis, should only be performed if there is evidence of cholangitis or obstructive jaundice with imaging evidence of a stone in the common bile duct. Early ERCP refers to ERCP being performed on the same admission, ideally within 24 hours.

Rationale for recommendation

Gallstones are the most common cause of pancreatitis, causing up to 50% of cases. ERCP should be reserved for patients in whom therapeutic intervention is likely because ERCP is a very invasive procedure and carries a morbidity of 5-10% and a mortality rate of 0.1%- 0.5%. Risks associated with ERCP include risks of endoscopy and specific risks associated with ERCP, including pancreatitis, cholangitis, bleeding, and retroduodenal perforation.

ERCP is recommended for severe acute gallstone pancreatitis, dilatation of the common bile duct on imaging, jaundice, cholangitis or persistently abnormal and rising liver enzymes or if clinical deterioration occurs in patients with mild signs at presentation but who fail to improve after 48 hours.

Early ERCP for acute pancreatitis without cholangitis has been shown to have a higher mortality rate and is of little benefit in comparison to delayed ERCP.

Many gallstones are passed spontaneously.

Patient information

There is no specific EBI patient guidance for this intervention.

However, we recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.

Further information on patient involvement in EBI can be found on the EBI for patients section.

 

 

Make the most of your appointment using BRAN

2020

Coding

Estimated activity
  • 308 episodes during 2018/19
  • Age/sex std rate per 100,000 – 0.5
  • Reduction opportunity based on 25th percentile of activity across CCGs: not calculated.
  • Variation (age/sex std rates):
    • N-fold – 7.2
    • 10th percentile – 0.2
    • 25th percentile – 0.4
    • 50th percentile – 0.6
    • 90th percentile – 1.5

 

Codes

Procedure codes

J43.1 Endoscopic retrograde cholangiopancreatography and biopsy of lesion of ampulla of Vater

J43.2 Endoscopic retrograde cholangiopancreatography and biopsy of lesion of biliary or pancreatic system NEC

J43.3 Endoscopic retrograde cholangiopancreatography and collection of bile

J43.8 Other specified diagnostic endoscopic retrograde examination of bile duct and pancreatic duct

J43.9 Unspecified diagnostic endoscopic retrograde examination of bile duct and pancreatic duct

 

Diagnosis codes

K85.1 Biliary acute pancreatitis

Any other criteria (e.g. patient age)
The procedure occurs within the first 3 days of admission

Adult >= 19 years

 

Will the procedure be carried out in OP or as APC?

Admitted Patient Care

 

Coding logic

Where the procedure code in any position is:

J43.1 OR

J43.2 OR

J43.3 OR

J43.8 OR

J43.9

AND

Diagnosis code in any position is:

K85.1

AND

The procedure date is 3 days or fewer after the admission

date.

AND

The patient age is >= 19 years

 

SQL code
-- APCS Procedure
WHERE 1=1
-- Main Procedure
AND apcs.[Der_Procedure_All] LIKE '%J43[12389]%'
--Diagnosis
AND (APCs.[Der_Diagnosis_All] LIKE '%K851%')

-- With no APCE Procedure within 30 days
AND (
CASE WHEN apcep.[Primary_Procedure_Code] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Primary_Procedure_Date])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_2] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_2])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_3] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_3])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_4] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_4])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_5] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_5])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_6] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_6])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_7] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_7])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_8] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_8])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_9] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_9])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_10] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_10])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_11] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_11])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_12] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_12])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_13] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_13])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_14] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_14])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_15] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_15])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_16] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_16])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_17] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_17])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_18] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_18])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_19] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_19])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_20] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_20])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_21] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_21])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_22] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_22])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_23] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_23])<=3 THEN 1 ELSE 0 END +
CASE WHEN apcep.[Procedure_Code_24] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_24])<=3 THEN 1 ELSE 0 END )>0
Global cancer exclusion
APC
WHERE 1=1
-- Cancer Diagnosis Exclusion
AND (apcs.der_diagnosis_all not like '%C[0-9][0-9]%'
AND apcs.der_diagnosis_all not like '%D0%'
AND apcs.der_diagnosis_all not like '%D3[789]%'
AND apcs.der_diagnosis_all not like '%D4[012345678]%'
OR apcs.der_diagnosis_all IS NULL)
Additional Exclusions
-- Private Appointment Exclusion
AND apcs.Administrative_Category<>'02'

References

  1. What is ERCP? (Endoscopic Retrograde Cholangio-Pancreatography) Patient leaflet.
  2. Tse F, YuanY. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev 2012:(5)CD009779.
  3. NICE guideline (2018) Pancreatitis [NG104].
  4. Schuster k, Holena D, salim A, savage S, crandall M, american association for the surgery of trauma emergency surgery guideline summaries: 2018, acute appendicitis, acute cholecysttis, acute diveritculis, acute pancreatitis, and small bowel obstruction. Trauam surg acute care open. 2019; 4: e000281.
  5. Uy MC, Daez ML,Sy PP,Banez VP,Espinosa WZ, Talingdan-Te MC. Early ERCP in acute gallstone pancreatitis without cholangitis: a meta-analysis. JOP 2009; 10: 299–305.
  6. Michael F Byrne, Gallstone pancreatitis – who really needs an ERCP? Can J Gastroenterol. 2006 Jan; 20(1): 15–17.PMCID: PMC2538962. PMID: 16432554.
  7. Malik HT, Marti J, Darzi A, Mossialos E. Savings from reducing low-value general surgical interventions. Br J Surg. 2018 Jan;105(1):13-25. doi:10.1002/bjs.10719

How up to date is this information?

August 2022

Changes

August 2022 - Coding updated

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