Introduction

Periampullary diverticulum (PAD) is associated with a higher incidence of biliary stone formation and common bile duct (CBD) obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) is an effective therapeutic procedure in case of biliary obstruction, however; the presence of PAD and its different types could affect ERCP outcome [1-3].

Aims & Methods

Aim: To study the impact of periampullary diverticulum on the outcome of ERCP regarding the cannulation technique, the procedure time, the success rate and the complications.
Method: A Retrospective study included all patients subjected to ERCP procedures at Qena university hospitals, South Valley University, Qena, Egypt from February 2019 to August 2023. ERCP Will be performed under general anaesthesia with endotracheal intubation according to our centre policy by an expert ERCP endoscopist using Pentax duodenoscopy (ED-3490TK, Pentax Incorporation, Tokyo, Japan). Papilla of vater will be examined endoscopically before starting cannulation trials to evaluate presence of diverticulum, type, size and its relation to the papilla. Data were analyzed using Statistics Package for Social Sciences (SPSS) version 26, p-value < 0.05 was considered significant.

Results

A Total of 686 patients subjected to ERCP procedure for different indications were included in this study, males were 273 patients (39.8%), the mean age was 53.7±17 years, the overall procedure success rate was 91% and the overall complications rate was 6%. Almost all cannulation techniques were used in our cases including wire-guided cannulation (WGC), transpapillary fistulotomy (TPF), double-guidewire technique (DGT), transpapillary papillotomy (TPP), and transpancreatic septotomy with pancreatic stent insertion (TPS). PAD was detected during ERCP procedure in 61 patients (9%). There was statistically significant higher age (65.3 vs 52.6, p< 0.001) and statistically insignificant higher frequency of males (41% versus 39.7%, p₌ 0.8) in patients with PAD compared to patients without PAD. During ERCP procedures, presence of PAD was associated with higher number of cannulation attempts (3.5 versus 2.5, p< 0.005), longer time required for cannulation (8 vs 5.1 minutes, p< 0.01), and amazingly; higher rate of cannulation success (100% vs 98%, p₌ 0.2), and longer total procedure time (50.4 ± 21.9 minutes vs 47.01 ± 24.04, p₌ 0.2). There was no significant predilection of certain cannulation technique in PAD patients; higher WGC: 68% vs 67%, higher TPS (1.8% vs 0.5%), equal chance for WGC: 24.6% vs 24.6% and less chance for TPP: 0.7 vs 0%. The overall procedure success rate was lower in PAD patients (85.2% vs 91.2%, p₌ 0.1). Post-ERCP pain was noticed more frequently in PAD patients (4.9% vs 3.4%, p₌ 0.5) while the overall complication rate with lower (1.6% vs 6.4%, p₌ 0.1).

Conclusion

We concluded that PAD is increasingly detected during ERCP procedure in elderly patients, and despite it requires higher number of cannulation attempts and longer time for cannulation, it has no negative impact on the overall success rate or complication rate of ERCP.

References

1. Chen L, Xia L, Lu Y, Bie L, Gong B. Influence of periampullary diverticulum on the occurrence of pancreaticobiliary diseases and outcomes of endoscopic retrograde cholangiopancreatography. Eur J Gastroenterol Hepatol. 2017;29:105–11.
2. Banerjee AK, Celentano V, Khan J, Longcroft-Wheaton G, Quine A, Bhandari P. Practical gastrointestinal investigation of iron deficiency anaemia:i] Expert Rev Gastroenterol Hepatol. 2018;12(3):249-256.
3. Omar MA. Effect of periampullary diverticulum on technical success and complications of endoscopic retrograde cholangiopancreatography: Single center experience. J Dig Endosc. 2015;6:149–57

Introduction

Hyponatremia is a frequent complication of cirrhosis and is a prognostic factor correlated with the severity of cirrhosis and influencing survival and the occurrence of complications, but this relationship is not yet well defined.

Aims & Methods

This was a single-centre retrospective descriptive and analytical study, including all cirrhotic patients admitted to our department in ascitic decompensation with hyponatremia between January 2019 and march 2025. The natremia threshold of 130 mmol/l was chosen because it is widely accepted to define hyponatraemia in cirrhotic patients. In our study, we compared 2 groups of patients: group A: fluid restriction + albumin infusion and group B: fluid restriction alone. Predictive factors of hyponatremia development and its impact on the outcome were evaluated. The aim of this study was to identify predictive factors of hyponatremia in cirrhotic patients with ascites, assess its prognostic impact on complications and survival, and compare the effectiveness of two treatment strategies—fluid restriction alone versus fluid restriction combined with albumin infusion—in correcting hyponatremia and improving clinical outcomes.

Results

Out of a total of 127 cirrhotic patients, forty patients with ascites and hyponatraemia (Na < 130 mmol/L) were included in the comparative analysis. These patients were divided into two groups: twenty patients received fluid restriction combined with albumin infusion (group A), and twenty patients received fluid restriction alone (group B). The mean age across both groups was 54.7 years, ranging from 19 to 80 years, with a sex ratio M/F of 0.7.
The causes of liver cirrhosis in our patients were: autoimmune (n=15), viral (n=11), undetermined (n=9), metabolic (n=2), genetic (n=2) and alcoholic (n=1).
Child-Pugh stage was B in 55% and C in 45%. The mean MELD score was 18 [7-48]. The prevalence of dilutional hyponatremia as defined by a serum sodium concentration ≤130 mmol/L or ≤135 mmol/L was 10.5% and 31.4% respectively.
The mean MELD score was 18, ranging from 7 to 48. The prevalence of dilutional hyponatremia, defined as serum sodium ≤130 mmol/L or ≤135 mmol/L, was 10.5% and 31.4%, respectively. A serum sodium level ≤130 mmol/L was significantly associated with more advanced liver disease, including Child-Pugh C (OR=7.84; p<0.001) and MELD >16 (OR=6.76; p=0.001).
Group A demonstrated a significantly greater improvement in natremia (mean increase of 4.5 mmol/L versus 1.2 mmol/L in group B; p=0.02), as well as a lower incidence of complications such as hepatic encephalopathy and hepatorenal syndrome. Although the difference in global survival at one year between the two groups (33.3% in group A vs. 12.5% in group B) The main precipitating factors of hyponatremia identified were excessive diuretic use (n=18), spontaneous bacterial peritonitis (n=12), gastrointestinal bleeding (n=6) and constipation (n=4). In several cases (n=8), multiple triggers were observed concurrently. The presence of hyponatremia was associated with a higher incidence of complications during hospitalization. Survival without complications was significantly reduced in patients with hyponatremia when a serum sodium concentration ≤135 mmol/L was used as the threshold (p=0.012). Moreover, survival free from hepatic encephalopathy and hepatorenal syndrome was significantly lower in hyponatremic patients (p<0.0001).
Analysis of prognostic factors revealed that serum sodium ≤130 mmol/L (HR=2.92; p=0.004), Child-Pugh C stage (HR=3.45; p=0.002), MELD score >18 (HR=2.67; p=0.007), and development of hepatic encephalopathy or hepatorenal syndrome during hospitalization (HR=4.21; p<0.001) were significantly associated with poor outcomes. Treatment of hepatic encephalopathy included systematic use of rifaximin and lactulose alongside management of the underlying precipitating factor. Overall survival at one year was significantly lower in patients with hyponatremia (22.5% vs. 68.7%), as was mean global survival (8.3 months vs. 32.8 months; p<0.0001).

Conclusion

Low serum sodium levels were significantly associated with more advanced liver disease and increased short-term morbidity and mortality in cirrhotic patients with ascites. Our findings suggest that albumin infusion, in addition to fluid restriction, is more effective in correcting hyponatremia and may help reduce the incidence of severe complications such as hepatic encephalopathy and hepatorenal syndrome. Therefore, serum sodium appears to be a valuable prognostic marker. The clinical benefit of correcting hyponatremia should be further confirmed in larger prospective studies.