Introduction

Managing biliopancreatic disease in elderly patients is a growing challenge, where the balance between benefit and risk becomes increasingly delicate. ERCP remains a fundamental tool, but its application in older adults requires individualized technical and clinical considerations. The aim of our study was to evaluate the characteristics of elderly patients who underwent ERCP.

Aims & Methods

We conducted a retrospective descriptive study from January 2019 to January 2025, including all patients aged ≥65 years who underwent ERCP. Collected data encompassed demographic characteristics, clinical presentation, procedural indications, technical success, therapeutic approaches, and procedure-related complications.

Results

We recorded 186 patients : 62.36% women (n=116) and 37.6% men (n=70), with a median age of 75 years [IQR: 71–80]. The most frequent presenting symptoms were biliary colic (43.4%, n=79), acute cholangitis (23.6%, n=43), cholestatic jaundice (11.8%, n=22), and acute pancreatitis (10.8%, n=20).
ERCP was indicated for benign pathology in the majority of cases, primarily for choledocholithiasis (56.5%, n=104). Other benign etiologies (11%, n=12) included post-cholecystectomy syndrome, biliary pancreatitis, bile duct injury, and Sump syndrome.
Malignant indications included pancreatic head tumors (20.7%, n=38), hilar cholangiocarcinoma (7.1%, n=13), ampullary carcinoma (6.5%, n=12), and gallbladder carcinoma (3.8%, n=7).
The technical success rate for benign pathology was 97.4% (n=113), with a failure rate of 2.6% (n=3). In malignant indications, the success rate was 90% (n=63), with failures (10%, n=7) primarily due to duodenal obstruction or an intradiverticular papilla.
Stenting strategies included uncovered self-expandable metal stents (33.2%, n=43), covered metal stents (3.8%, n=7), and plastic stents (7.6%, n=14).
Intra-procedural bleeding following sphincterotomy occurred in 2.7% of cases (n=3); two were managed with epinephrine injection and one with hemostatic clipping. No delayed post-procedural complications were reported.

Conclusion

ERCP appears to be a safe, effective, and well-tolerated procedure in elderly patients. When guided by appropriate indications and expert technique, age does not represent a limitation but rather a parameter requiring adapted procedural planning.

Clinical Case Summary

Schistosomiasis is a helminthiasis caused by a trematode of which seven species are reported and almost all of them produce digestive manifestation. Symptoms usually appear in those from non-endemic areas who have traveled to endemic ones.

We present a case of a 58-year-old male who presented with subacute abdominal pain and fever, together with C-reactive protein elevation and CT reported as acute perforated cholecystitis, so conservative management with antibiotic therapy was decided at first. During hospitalization, he started with progressive cholestasis and hyperbilirubinemia (maximum total bilirubin levels c. 15 mg/dl) together with high eosinophilia (>2000/mm3). MRI cholangiography was performed, showing stenosis at the bifurcation of the hepatic ducts with retrograde intrahepatic bile duct dilatation. It was later completed with ERCP, showing an area of stricture with marked fibrinoid tissue at the confluence, with biopsies negative for malignancy but highlighting the presence of fibrous tissue with marked eosinophilia, fibrinoid necrosis and PAS-positive structures, all suggestive of parasitic infestation. Finally, a temporary plastic stent was placed for a right biliary drainage. Serology results were positive for Schistosoma (then the patient confirmed history of multiple trips to Southeast Asia), so treatment with praziquantel was started, with progressive improvement of the analytics and symptoms.

Out of the endemic area, schistosomiasis is associated with significant morbidity and diagnostic delay. On the other hand, if the disease becomes chronic, the clinical picture may include colonic involvement -diarrhea, sometimes dysenteriform with hemorrhagic component, sub-occlusive symptoms- and also hepatic, leading to portal hypertension classically presinusoidal, due to granulomatous reactions produced by the eggs besides portal area. Therefore, the importance of investigating the epidemiological patient background is essential.

References

Image 1: during ERCP procedure

Clinical Case Summary

Introduction: Albendazole is a widely used anthelmintic, generally considered safe. While mild liver enzyme elevations are reported, severe drug-induced liver injury (DILI) is rare. We present a case of acute hepatotoxicity after a short course of albendazole, highlighting its potential hepatic risks.
Case presentation: A 13-year-old girl presented with abdominal pain, jaundice, nausea, vomiting, and diarrhea for two days. She had no history of travel, fever, or rash. She had received two doses of albendazole for deworming—15 and 3 days before symptom onset—with no other medication use.
Examination revealed left epigastric tenderness without hepatomegaly. Laboratory findings included markedly elevated liver enzymes (AST 2067 IU/L, ALT 2931 IU/L, ALP 135.58 IU/L, bilirubin 51.3 mg/dL) and prolonged INR (1.86). Viral, autoimmune, and metabolic causes were ruled out. Abdominal ultrasound showed mild hepatomegaly, and CT excluded other pathology.
The Roussel Uclaf Causality Assessment Method (RUCAM) score was 9, indicating a high likelihood of albendazole-induced hepatitis. The patient was treated with supportive care, with gradual improvement and full recovery.
Discussion: DILI is a key differential in acute hepatitis when other causes are excluded. Albendazole hepatotoxicity is rare, mainly reported in long-term therapy for hydatid disease. However, our patient developed severe hepatotoxicity after only two doses, suggesting idiosyncratic or immune-mediated injury. The absence of other risk factors strengthens the causal link.
Conclusion: This case highlights the risk of severe albendazole-induced hepatotoxicity even after short-term use. Given its widespread availability, clinicians should remain vigilant for DILI in children. Liver function monitoring should be considered in at-risk patients, and unnecessary prophylactic albendazole use should be discouraged.

References

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2. Choi GY, Yang HW, Cho SH, et al. Acute drug-induced hepatitis caused by albendazole. J Korean Med Sci. 2008;23(5):903-905.
3. Ríos D, Restrepo JC. Albendazole-induced liver injury: a case report. Colomb Med (Cali). 2013;44(2):118-120.
4. Garcia-Cortes M, Robles-Diaz M, et al. Drug-induced liver injury: an update. Arch Toxicol. 2020;94:3381.
5. Chalasani NP, Maddur H, Russo MW, et al. ACG Clinical Guideline: Diagnosis and Management of Idiosyncratic Drug-Induced Liver Injury. Am J Gastroenterol. 2021;116:878.