Aug. 19, 2022
Treatment of flow-limiting biliary strictures with endoscopic retrograde cholangiopancreatography (ERCP) has the potential to resolve jaundice in those with primary sclerosing cholangitis (PSC). However, ERCP has some associated risks, and not all patients with PSC will benefit from undergoing this procedure. Therefore, it is important to identify which patients are more likely to benefit from endoscopic therapy and examine if jaundice resolution is associated with enhanced clinical outcomes. To explore these questions, Mayo Clinic researchers and colleagues conducted a retrospective cohort study of 124 patients with jaundice and PSC. The results of this study were published in Hepatology Communications in 2022.
Study methods
Using clinical databases, the researchers identified a derivation cohort of 124 patients who underwent endoscopic biliary balloon dilation or stent placement or both for the treatment of jaundice at Mayo Clinic's campus in Rochester, Minnesota, between Oct. 23, 1990, and Dec. 5, 2018.
The researchers compared data extracted from the medical records of the derivation cohort with data obtained from a separate validation cohort of 102 patients with PSC who underwent endoscopic treatment for jaundice at several European centers.
Applying the same inclusion and exclusion criteria to both the derivation and validation cohorts, the researchers abstracted multiple data points from the medical records, including age; sex; comorbidities; history of varices, variceal hemorrhage, ascites and encephalopathy symptoms; physical exam findings; laboratory results; and endoscopic interventions. The researchers also calculated the Mayo PSC Risk Score, which is a measure of liver disease severity, for the derivation cohort using the most recent data available before the index ERCP. They also collected follow-up data.
Results and implications for clinical practice
According to the Hepatology Communications article's lead author John E. Eaton, M.D., a gastroenterologist at Mayo Clinic in Rochester, Minnesota, the study yielded some useful information about ERCP, jaundice resolution and related patient outcomes.
"Overall, our study suggests that older age, shorter duration of jaundice, a lower Mayo PSC Risk Score and an extrahepatic location of the most advanced biliary stricture are independent predictors for jaundice resolution after ERCP," explains Dr. Eaton. "Moreover, jaundice resolution after ERCP appears to be associated with decreased risk of death or liver transplant. These factors can provide added guidance to clinicians when determining the need for an ERCP in those with PSC."
Jaundice resolved after ERCP in about half the patients in the derivation cohort. A multivariable analysis demonstrated that resolution of jaundice was associated with a 57% lower likelihood of subsequent death or liver transplantation. Lower Mayo PSC Risk Scores and jaundice resolution after endoscopic treatment were independently associated with better transplant-free survival.
More-detailed data shared by the researchers include the following:
- Jaundice resolved after endoscopic therapy in 52% (n = 64) of patients in the derivation cohort and 72% (n = 73) of patients in the validation cohort (P = 0.002). Median follow-up was 4.8 years.
- Jaundice recurrence was significantly less frequent in the validation cohort than in the derivation cohort (P = 0.005). Recurrences were noted in 43 of the 64 patients who experienced resolution in the derivation cohort, with cumulative incidences of 20%, 46%, 59%, 71%, and 87% after one, two, three, five and 10 years, respectively; and in 39 of the 69 patients in validation cohort, with cumulative incidences of 12%, 26%, 33%, 54%, and 68% after one, two, three, five and 10 years, respectively.
- Predictors of death or transplant included higher Mayo PSC Risk Scores at the time of ERCP (P < 0.0001; hazard ratio, or HR, 2.33 for every one-point increase), lower total serum bilirubin before ERCP (P = 0.031; HR, 0.91 for every 1 mg/dL increase), and persistence of jaundice after endoscopic therapy (P = 0.003; HR, 2.30).
According to Dr. Eaton, conducting a prospective randomized trial of endoscopic therapy in patients with PSC and jaundice would further clarify the role of endoscopic intervention and refine clinicians' ability to predict who will obtain the most therapeutic benefit from this treatment.
For more information
Eaton JE, et al. Predictors of jaundice resolution and survival after endoscopic treatment of primary sclerosing cholangitis. Hepatology Communications. 2022;6:809.
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