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Treatment of recurrent C. difficile infection
FMT is an option for some patients
The case
A 67-year-old woman with a past medical history significant for diabetes mellitus type 2 and chronic kidney disease stage 3 was recently hospitalized for a community acquired pneumonia and treated for 5 days with moxifloxacin. In the week following this hospitalization, she began to have watery diarrhea and was found to have Clostridioides difficile diarrhea. She was treated with 10 days of oral vancomycin for her C. difficile infection (CDI). Approximately 3 weeks later, she again developed watery diarrhea with some abdominal cramping and has a leukocyte count of 22.4.
Key clinical questions
When is C. difficile considered recurrent?
C. difficile is considered recurrent when a patient experiences symptom onset and has a positive test in the 2-8 week period following the resolution of symptoms from the previous episode that had been confirmed with a positive test.1
What is the recurrence rate for C. difficile?
Of patients who are initially diagnosed with C. difficile, about 20%-35% develop recurrence of their infection, and of those who experience recurrence, roughly 40%-60% will experience a second recurrence.2
What are the risk factors for recurrent C. difficile?
Risk factors for recurrence of C. difficile include older age (older than 65 years), female sex, Caucasian ethnicity, ongoing antibiotic use, concurrent proton pump inhibitor use, and more severe initial disease.
Also, receiving antineoplastic chemotherapy, being an organ transplant recipient, chronic kidney disease, inflammatory bowel disease, hypogammaglobulinemia, or other immunodeficiency, as well as having exposure to infected adult or infant carrier of C. difficile have all been risk factors for recurrent disease. There is still some degree of ongoing controversy over the role of proton pump inhibitors as a risk factor.2
What are the treatment options for initial C. difficile infection?
The recent Infectious Diseases Society of America (IDSA) guidelines recommend treating for an initial CDI with a 10-day course of oral vancomycin or fidaxomicin instead of metronidazole. This change is based on a combined analysis of two large randomized controlled trials that demonstrated better clinical response rates with vancomycin, compared with metronidazole (81.1% vs. 72.7%; P = .002).1,3
What are the treatment options for first recurrence?
The data is overall limited in treatment of first recurrence of CDI. The IDSA guidelines recommend that a first recurrence of CDI may be treated with oral vancomycin followed by a tapered and pulsed regimen or with a 10-day course of fidaxomicin. If metronidazole was used for the first episode, a 10-day course of vancomycin can be used.1
What are the treatment options for second and subsequent recurrences?
Second or subsequent CDI recurrences may be treated with oral vancomycin as a tapered and pulsed-dose regimen or with fidaxomicin as described above, but this is based on low quality of evidence.
The IDSA guidelines strongly recommend fecal microbiota transplantation (FMT) for patients who have two or more C. difficile recurrences and in whom standard antibiotic treatment has not been successful. FMT has demonstrated high efficacy rates of 80%-90% for clinical remission of recurrent CDI.
FMT can be administered through various routes. The choice of delivery depends in part on local expertise, patient preference, cost, and risk of the procedure.1,4,5,6
What new therapies exist for reducing recurrence?
Bezlotoxumab is a humanized monoclonal antibody directed against C. difficile toxin B that was approved by the Food and Drug Administration in 2016 for prevention of recurrent CDI. Randomized placebo-controlled trials demonstrated that a single infusion of bezlotoxumab, given in combination with usual antibiotics for CDI in adults, was effective in reducing CDI recurrence within 12 weeks (rate of recurrent infection in both trials was 16.5% in the bezlotoxumab groups and 26.6% in the placebo groups).
In a post hoc analysis, the highest benefit was in patients with three or more risk factors: older than 65 years, history of CDI, immunocompromised status, or severe CDI. Although the best strategy for prevention of CDI recurrence remains to be determined, bezlotoxumab remains an option.7,8
Back to the case
The patient had a C. difficile polymerase chain reaction test sent that came back positive for C. difficile. Because she had previously been treated with a 10-day course of oral vancomycin, she was started on a tapered and pulsed-dose regimen of oral vancomycin. Five days later her diarrhea resolved, and her leukocyte count returned to normal.
Dr. Bell is associate clinical professor in the division of hospital medicine at the University of California, San Diego, Medical Center. Dr. Farkhondehpour is a hospitalist and assistant clinical professor at UC San Diego Health.
References
1. McDonald L et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar 19;66(7):987-994.
2. Hopkins R and Wilson R. Treatment of recurrent Clostridium difficile colitis: A narrative review. Gastroenterol Rep (Oxf). 2018 Feb;6(1):21-8.
3. Johnson S et al. (2014). Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: Results from two multinational, randomized, controlled trials. Clin Infect Dis. 2014 Aug 1;59(3):345-54.
4. van Nood E et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med. 2013 Jan 31;368(5):407-15.
5. Cammarota G et al. Randomised clinical trial: Faecal microbiota transplantation by colonoscopy vs. vancomycin for the treatment of recurrent Clostridium difficile infection. Aliment Pharmacol Ther. 2015 May;41(9):835-43.
6. Kelly C et al. Effect of fecal microbiota transplantation on recurrence in multiple recurrent Clostridium difficile infection. Ann Intern Med. 2016 Nov 1;165(9):609-16.
7. Gerding DN et al. Bezlotoxumab for prevention of recurrent Clostridium difficile infection in patients at increased risk for recurrence. Clin Infect Dis. 2018 Aug 16;67(5):649-56.
8. Wilcox M et al. Bezlotoxumab for prevention of recurrent Clostridium difficile infection. N Engl J Med. 2017 Jan 26;376(4):305-17.
FMT is an option for some patients
FMT is an option for some patients
The case
A 67-year-old woman with a past medical history significant for diabetes mellitus type 2 and chronic kidney disease stage 3 was recently hospitalized for a community acquired pneumonia and treated for 5 days with moxifloxacin. In the week following this hospitalization, she began to have watery diarrhea and was found to have Clostridioides difficile diarrhea. She was treated with 10 days of oral vancomycin for her C. difficile infection (CDI). Approximately 3 weeks later, she again developed watery diarrhea with some abdominal cramping and has a leukocyte count of 22.4.
Key clinical questions
When is C. difficile considered recurrent?
C. difficile is considered recurrent when a patient experiences symptom onset and has a positive test in the 2-8 week period following the resolution of symptoms from the previous episode that had been confirmed with a positive test.1
What is the recurrence rate for C. difficile?
Of patients who are initially diagnosed with C. difficile, about 20%-35% develop recurrence of their infection, and of those who experience recurrence, roughly 40%-60% will experience a second recurrence.2
What are the risk factors for recurrent C. difficile?
Risk factors for recurrence of C. difficile include older age (older than 65 years), female sex, Caucasian ethnicity, ongoing antibiotic use, concurrent proton pump inhibitor use, and more severe initial disease.
Also, receiving antineoplastic chemotherapy, being an organ transplant recipient, chronic kidney disease, inflammatory bowel disease, hypogammaglobulinemia, or other immunodeficiency, as well as having exposure to infected adult or infant carrier of C. difficile have all been risk factors for recurrent disease. There is still some degree of ongoing controversy over the role of proton pump inhibitors as a risk factor.2
What are the treatment options for initial C. difficile infection?
The recent Infectious Diseases Society of America (IDSA) guidelines recommend treating for an initial CDI with a 10-day course of oral vancomycin or fidaxomicin instead of metronidazole. This change is based on a combined analysis of two large randomized controlled trials that demonstrated better clinical response rates with vancomycin, compared with metronidazole (81.1% vs. 72.7%; P = .002).1,3
What are the treatment options for first recurrence?
The data is overall limited in treatment of first recurrence of CDI. The IDSA guidelines recommend that a first recurrence of CDI may be treated with oral vancomycin followed by a tapered and pulsed regimen or with a 10-day course of fidaxomicin. If metronidazole was used for the first episode, a 10-day course of vancomycin can be used.1
What are the treatment options for second and subsequent recurrences?
Second or subsequent CDI recurrences may be treated with oral vancomycin as a tapered and pulsed-dose regimen or with fidaxomicin as described above, but this is based on low quality of evidence.
The IDSA guidelines strongly recommend fecal microbiota transplantation (FMT) for patients who have two or more C. difficile recurrences and in whom standard antibiotic treatment has not been successful. FMT has demonstrated high efficacy rates of 80%-90% for clinical remission of recurrent CDI.
FMT can be administered through various routes. The choice of delivery depends in part on local expertise, patient preference, cost, and risk of the procedure.1,4,5,6
What new therapies exist for reducing recurrence?
Bezlotoxumab is a humanized monoclonal antibody directed against C. difficile toxin B that was approved by the Food and Drug Administration in 2016 for prevention of recurrent CDI. Randomized placebo-controlled trials demonstrated that a single infusion of bezlotoxumab, given in combination with usual antibiotics for CDI in adults, was effective in reducing CDI recurrence within 12 weeks (rate of recurrent infection in both trials was 16.5% in the bezlotoxumab groups and 26.6% in the placebo groups).
In a post hoc analysis, the highest benefit was in patients with three or more risk factors: older than 65 years, history of CDI, immunocompromised status, or severe CDI. Although the best strategy for prevention of CDI recurrence remains to be determined, bezlotoxumab remains an option.7,8
Back to the case
The patient had a C. difficile polymerase chain reaction test sent that came back positive for C. difficile. Because she had previously been treated with a 10-day course of oral vancomycin, she was started on a tapered and pulsed-dose regimen of oral vancomycin. Five days later her diarrhea resolved, and her leukocyte count returned to normal.
Dr. Bell is associate clinical professor in the division of hospital medicine at the University of California, San Diego, Medical Center. Dr. Farkhondehpour is a hospitalist and assistant clinical professor at UC San Diego Health.
References
1. McDonald L et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar 19;66(7):987-994.
2. Hopkins R and Wilson R. Treatment of recurrent Clostridium difficile colitis: A narrative review. Gastroenterol Rep (Oxf). 2018 Feb;6(1):21-8.
3. Johnson S et al. (2014). Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: Results from two multinational, randomized, controlled trials. Clin Infect Dis. 2014 Aug 1;59(3):345-54.
4. van Nood E et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med. 2013 Jan 31;368(5):407-15.
5. Cammarota G et al. Randomised clinical trial: Faecal microbiota transplantation by colonoscopy vs. vancomycin for the treatment of recurrent Clostridium difficile infection. Aliment Pharmacol Ther. 2015 May;41(9):835-43.
6. Kelly C et al. Effect of fecal microbiota transplantation on recurrence in multiple recurrent Clostridium difficile infection. Ann Intern Med. 2016 Nov 1;165(9):609-16.
7. Gerding DN et al. Bezlotoxumab for prevention of recurrent Clostridium difficile infection in patients at increased risk for recurrence. Clin Infect Dis. 2018 Aug 16;67(5):649-56.
8. Wilcox M et al. Bezlotoxumab for prevention of recurrent Clostridium difficile infection. N Engl J Med. 2017 Jan 26;376(4):305-17.
The case
A 67-year-old woman with a past medical history significant for diabetes mellitus type 2 and chronic kidney disease stage 3 was recently hospitalized for a community acquired pneumonia and treated for 5 days with moxifloxacin. In the week following this hospitalization, she began to have watery diarrhea and was found to have Clostridioides difficile diarrhea. She was treated with 10 days of oral vancomycin for her C. difficile infection (CDI). Approximately 3 weeks later, she again developed watery diarrhea with some abdominal cramping and has a leukocyte count of 22.4.
Key clinical questions
When is C. difficile considered recurrent?
C. difficile is considered recurrent when a patient experiences symptom onset and has a positive test in the 2-8 week period following the resolution of symptoms from the previous episode that had been confirmed with a positive test.1
What is the recurrence rate for C. difficile?
Of patients who are initially diagnosed with C. difficile, about 20%-35% develop recurrence of their infection, and of those who experience recurrence, roughly 40%-60% will experience a second recurrence.2
What are the risk factors for recurrent C. difficile?
Risk factors for recurrence of C. difficile include older age (older than 65 years), female sex, Caucasian ethnicity, ongoing antibiotic use, concurrent proton pump inhibitor use, and more severe initial disease.
Also, receiving antineoplastic chemotherapy, being an organ transplant recipient, chronic kidney disease, inflammatory bowel disease, hypogammaglobulinemia, or other immunodeficiency, as well as having exposure to infected adult or infant carrier of C. difficile have all been risk factors for recurrent disease. There is still some degree of ongoing controversy over the role of proton pump inhibitors as a risk factor.2
What are the treatment options for initial C. difficile infection?
The recent Infectious Diseases Society of America (IDSA) guidelines recommend treating for an initial CDI with a 10-day course of oral vancomycin or fidaxomicin instead of metronidazole. This change is based on a combined analysis of two large randomized controlled trials that demonstrated better clinical response rates with vancomycin, compared with metronidazole (81.1% vs. 72.7%; P = .002).1,3
What are the treatment options for first recurrence?
The data is overall limited in treatment of first recurrence of CDI. The IDSA guidelines recommend that a first recurrence of CDI may be treated with oral vancomycin followed by a tapered and pulsed regimen or with a 10-day course of fidaxomicin. If metronidazole was used for the first episode, a 10-day course of vancomycin can be used.1
What are the treatment options for second and subsequent recurrences?
Second or subsequent CDI recurrences may be treated with oral vancomycin as a tapered and pulsed-dose regimen or with fidaxomicin as described above, but this is based on low quality of evidence.
The IDSA guidelines strongly recommend fecal microbiota transplantation (FMT) for patients who have two or more C. difficile recurrences and in whom standard antibiotic treatment has not been successful. FMT has demonstrated high efficacy rates of 80%-90% for clinical remission of recurrent CDI.
FMT can be administered through various routes. The choice of delivery depends in part on local expertise, patient preference, cost, and risk of the procedure.1,4,5,6
What new therapies exist for reducing recurrence?
Bezlotoxumab is a humanized monoclonal antibody directed against C. difficile toxin B that was approved by the Food and Drug Administration in 2016 for prevention of recurrent CDI. Randomized placebo-controlled trials demonstrated that a single infusion of bezlotoxumab, given in combination with usual antibiotics for CDI in adults, was effective in reducing CDI recurrence within 12 weeks (rate of recurrent infection in both trials was 16.5% in the bezlotoxumab groups and 26.6% in the placebo groups).
In a post hoc analysis, the highest benefit was in patients with three or more risk factors: older than 65 years, history of CDI, immunocompromised status, or severe CDI. Although the best strategy for prevention of CDI recurrence remains to be determined, bezlotoxumab remains an option.7,8
Back to the case
The patient had a C. difficile polymerase chain reaction test sent that came back positive for C. difficile. Because she had previously been treated with a 10-day course of oral vancomycin, she was started on a tapered and pulsed-dose regimen of oral vancomycin. Five days later her diarrhea resolved, and her leukocyte count returned to normal.
Dr. Bell is associate clinical professor in the division of hospital medicine at the University of California, San Diego, Medical Center. Dr. Farkhondehpour is a hospitalist and assistant clinical professor at UC San Diego Health.
References
1. McDonald L et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar 19;66(7):987-994.
2. Hopkins R and Wilson R. Treatment of recurrent Clostridium difficile colitis: A narrative review. Gastroenterol Rep (Oxf). 2018 Feb;6(1):21-8.
3. Johnson S et al. (2014). Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: Results from two multinational, randomized, controlled trials. Clin Infect Dis. 2014 Aug 1;59(3):345-54.
4. van Nood E et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med. 2013 Jan 31;368(5):407-15.
5. Cammarota G et al. Randomised clinical trial: Faecal microbiota transplantation by colonoscopy vs. vancomycin for the treatment of recurrent Clostridium difficile infection. Aliment Pharmacol Ther. 2015 May;41(9):835-43.
6. Kelly C et al. Effect of fecal microbiota transplantation on recurrence in multiple recurrent Clostridium difficile infection. Ann Intern Med. 2016 Nov 1;165(9):609-16.
7. Gerding DN et al. Bezlotoxumab for prevention of recurrent Clostridium difficile infection in patients at increased risk for recurrence. Clin Infect Dis. 2018 Aug 16;67(5):649-56.
8. Wilcox M et al. Bezlotoxumab for prevention of recurrent Clostridium difficile infection. N Engl J Med. 2017 Jan 26;376(4):305-17.
ICH: Recent NOAC use associated with lower risk of in-hospital mortality, compared with warfarin
Background: Previous studies comparing NOACs with warfarin have demonstrated a lower incidence of ICH in patients receiving NOACs. Data have been limited, though, regarding ICH with recent anticoagulant use and in-hospital mortality.
Study design: Retrospective cohort study.
Setting: More than 1,600 U.S. hospitals that participate in the Get With The Guidelines–Stroke national registry.
Synopsis: Of 141,311 patients admitted with ICH, 10.6% were receiving warfarin and 3.5% were receiving NOACs prior to hospitalization. Prior use of warfarin or NOACs, compared with no anticoagulant use, was associated with higher in-hospital mortality. However, use of NOACs, compared with use of warfarin, was associated with lower in-hospital mortality risk (adjusted risk difference, –5.7%; adjusted odds ratio, 0.75). Among patients with prior NOAC use, 54% of them were using rivaroxaban.
A limitation to this study is that reversal strategies, such as the use of vitamin K, fresh frozen plasma, or intravenous factor concentrates, were not available in the database. In addition, since rivaroxaban accounted for more than half the NOACs used, it may be difficult to apply the overall findings to all other available NOACs.
Bottom line: In patients admitted for ICH, prior use of NOACs, compared with warfarin, was associated with lower risk of in-hospital mortality.
Citation: Inohara T et al. Association of intracerebral hemorrhage among patients taking non–vitamin K antagonist vs. vitamin K antagonist oral anticoagulants with in-hospital mortality. JAMA. 2018 Feb 6;319(5):463-73.
Dr. Farkhondehpour is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.
Background: Previous studies comparing NOACs with warfarin have demonstrated a lower incidence of ICH in patients receiving NOACs. Data have been limited, though, regarding ICH with recent anticoagulant use and in-hospital mortality.
Study design: Retrospective cohort study.
Setting: More than 1,600 U.S. hospitals that participate in the Get With The Guidelines–Stroke national registry.
Synopsis: Of 141,311 patients admitted with ICH, 10.6% were receiving warfarin and 3.5% were receiving NOACs prior to hospitalization. Prior use of warfarin or NOACs, compared with no anticoagulant use, was associated with higher in-hospital mortality. However, use of NOACs, compared with use of warfarin, was associated with lower in-hospital mortality risk (adjusted risk difference, –5.7%; adjusted odds ratio, 0.75). Among patients with prior NOAC use, 54% of them were using rivaroxaban.
A limitation to this study is that reversal strategies, such as the use of vitamin K, fresh frozen plasma, or intravenous factor concentrates, were not available in the database. In addition, since rivaroxaban accounted for more than half the NOACs used, it may be difficult to apply the overall findings to all other available NOACs.
Bottom line: In patients admitted for ICH, prior use of NOACs, compared with warfarin, was associated with lower risk of in-hospital mortality.
Citation: Inohara T et al. Association of intracerebral hemorrhage among patients taking non–vitamin K antagonist vs. vitamin K antagonist oral anticoagulants with in-hospital mortality. JAMA. 2018 Feb 6;319(5):463-73.
Dr. Farkhondehpour is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.
Background: Previous studies comparing NOACs with warfarin have demonstrated a lower incidence of ICH in patients receiving NOACs. Data have been limited, though, regarding ICH with recent anticoagulant use and in-hospital mortality.
Study design: Retrospective cohort study.
Setting: More than 1,600 U.S. hospitals that participate in the Get With The Guidelines–Stroke national registry.
Synopsis: Of 141,311 patients admitted with ICH, 10.6% were receiving warfarin and 3.5% were receiving NOACs prior to hospitalization. Prior use of warfarin or NOACs, compared with no anticoagulant use, was associated with higher in-hospital mortality. However, use of NOACs, compared with use of warfarin, was associated with lower in-hospital mortality risk (adjusted risk difference, –5.7%; adjusted odds ratio, 0.75). Among patients with prior NOAC use, 54% of them were using rivaroxaban.
A limitation to this study is that reversal strategies, such as the use of vitamin K, fresh frozen plasma, or intravenous factor concentrates, were not available in the database. In addition, since rivaroxaban accounted for more than half the NOACs used, it may be difficult to apply the overall findings to all other available NOACs.
Bottom line: In patients admitted for ICH, prior use of NOACs, compared with warfarin, was associated with lower risk of in-hospital mortality.
Citation: Inohara T et al. Association of intracerebral hemorrhage among patients taking non–vitamin K antagonist vs. vitamin K antagonist oral anticoagulants with in-hospital mortality. JAMA. 2018 Feb 6;319(5):463-73.
Dr. Farkhondehpour is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.
EUS and MRCP as complementary studies in the etiologic diagnosis of idiopathic acute pancreatitis
Background: Approximately 10%-30% of patients with acute pancreatitis do not have an established etiology after routine investigation with imaging. These patients are classified as IAP. Less invasive tests, such as EUS, MRCP, and secretin stimulation MRCP (S-MRCP) have been used to further explore IAP, but their comparison in the etiologic diagnosis of idiopathic acute pancreatitis is lacking.
Study design: Meta-analysis involving 34 studies that investigated the etiology of IAP with MRCP and/or S-MRCP and/or EUS.
Setting: Brazil, Canada, China, France, Hong Kong, India, Italy, Korea, Spain, the United Kingdom, and the United States.
Synopsis: When EUS was compared with MRCP, the diagnostic yield of EUS (153/239 patients; 64%) was higher than that of MRCP (82/238 patients; 34%; P less than .01). Specifically, EUS seemed to have a significant benefit in detecting biliary disease, compared with MRCP. In the subgroup analysis, the diagnostic yield of EUS was higher than that of MRCP for detecting parenchymal changes suggestive of chronic pancreatitis (10% vs. 1%). S-MRCP was superior to EUS and MRCP (12% vs. 2% vs. 2%, respectively) in diagnosing pancreatic divisum, a congenital anomaly that is prevalent in 5%-14% of the population and an etiology of IAP.
A limitation in this meta-analysis was that EUS was used in seven times as many studies as was MRCP, which may have influenced the overall results.
Bottom line: Less invasive modalities, such as EUS and S-MRCP, used together could improve the diagnostic yield in evaluating the etiology of AIP.
Citation: Wang J et al. Comparison of EUS with MRCP in idiopathic acute pancreatitis: A systemic review and meta-analysis. Gastrointest Endosc. 2017 Dec 7. doi: 10.1016/j.gie.2017.11.028.
Dr. Farkhondehpour is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.
Background: Approximately 10%-30% of patients with acute pancreatitis do not have an established etiology after routine investigation with imaging. These patients are classified as IAP. Less invasive tests, such as EUS, MRCP, and secretin stimulation MRCP (S-MRCP) have been used to further explore IAP, but their comparison in the etiologic diagnosis of idiopathic acute pancreatitis is lacking.
Study design: Meta-analysis involving 34 studies that investigated the etiology of IAP with MRCP and/or S-MRCP and/or EUS.
Setting: Brazil, Canada, China, France, Hong Kong, India, Italy, Korea, Spain, the United Kingdom, and the United States.
Synopsis: When EUS was compared with MRCP, the diagnostic yield of EUS (153/239 patients; 64%) was higher than that of MRCP (82/238 patients; 34%; P less than .01). Specifically, EUS seemed to have a significant benefit in detecting biliary disease, compared with MRCP. In the subgroup analysis, the diagnostic yield of EUS was higher than that of MRCP for detecting parenchymal changes suggestive of chronic pancreatitis (10% vs. 1%). S-MRCP was superior to EUS and MRCP (12% vs. 2% vs. 2%, respectively) in diagnosing pancreatic divisum, a congenital anomaly that is prevalent in 5%-14% of the population and an etiology of IAP.
A limitation in this meta-analysis was that EUS was used in seven times as many studies as was MRCP, which may have influenced the overall results.
Bottom line: Less invasive modalities, such as EUS and S-MRCP, used together could improve the diagnostic yield in evaluating the etiology of AIP.
Citation: Wang J et al. Comparison of EUS with MRCP in idiopathic acute pancreatitis: A systemic review and meta-analysis. Gastrointest Endosc. 2017 Dec 7. doi: 10.1016/j.gie.2017.11.028.
Dr. Farkhondehpour is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.
Background: Approximately 10%-30% of patients with acute pancreatitis do not have an established etiology after routine investigation with imaging. These patients are classified as IAP. Less invasive tests, such as EUS, MRCP, and secretin stimulation MRCP (S-MRCP) have been used to further explore IAP, but their comparison in the etiologic diagnosis of idiopathic acute pancreatitis is lacking.
Study design: Meta-analysis involving 34 studies that investigated the etiology of IAP with MRCP and/or S-MRCP and/or EUS.
Setting: Brazil, Canada, China, France, Hong Kong, India, Italy, Korea, Spain, the United Kingdom, and the United States.
Synopsis: When EUS was compared with MRCP, the diagnostic yield of EUS (153/239 patients; 64%) was higher than that of MRCP (82/238 patients; 34%; P less than .01). Specifically, EUS seemed to have a significant benefit in detecting biliary disease, compared with MRCP. In the subgroup analysis, the diagnostic yield of EUS was higher than that of MRCP for detecting parenchymal changes suggestive of chronic pancreatitis (10% vs. 1%). S-MRCP was superior to EUS and MRCP (12% vs. 2% vs. 2%, respectively) in diagnosing pancreatic divisum, a congenital anomaly that is prevalent in 5%-14% of the population and an etiology of IAP.
A limitation in this meta-analysis was that EUS was used in seven times as many studies as was MRCP, which may have influenced the overall results.
Bottom line: Less invasive modalities, such as EUS and S-MRCP, used together could improve the diagnostic yield in evaluating the etiology of AIP.
Citation: Wang J et al. Comparison of EUS with MRCP in idiopathic acute pancreatitis: A systemic review and meta-analysis. Gastrointest Endosc. 2017 Dec 7. doi: 10.1016/j.gie.2017.11.028.
Dr. Farkhondehpour is a hospitalist at UC San Diego Health and an assistant clinical professor at the University of California, San Diego.