Background The use of prophylactic antibiotics before endoscopic retrograde cholangiopancreatography (ERCP) is recommended by all major international gastroenterological societies, especially in the presence of an obstructed biliary system. Their use is intended to decrease or eliminate the incidence of complications following the procedure, namely cholangitis, cholecystitis, septicaemia, and pancreatitis. Objectives To assess the benefits and harms of antibiotics before elective ERCP in patients without evidence of acute or chronic cholecystitis, or acute or chronic cholangitis, or severe acute pancreatitis. Data collection and analysis We audited South African endoscopists who perform ERCPs in the form of a questionnaire. The review was conducted according to the recommendations of The Cochrane Collaboration as well as the Cochrane Hepato-Biliary Group. Review Manager 5 was used employing fixed-effect and random-effects model meta-analyses. Only randomised clinical trials were included in the analyses, irrespective of blinding, language, or publication status. Participants were patients that underwent elective ERCP that were not on antibiotics, without evidence of acute or chronic cholecystitis, cholangitis, or severe acute pancreatitis before the procedure. We compared patients that received prophylactic antibiotics before the procedure with patients that were given placebo or no intervention before the procedure. Results The audit revealed that no specific protocols were being implemented in South Africa, and there was a marked difference in the practice between surgical and medical gastroenterologists, with surgeons using antibiotics more often. There was also a wide spectrum of antibiotic types and combinations being used. Nine randomised clinical trials (1573 patients) were included into the review analyses. The majority of the trials had risks of bias. When all patients providing data for a certain outcome were included, the fixed-effect meta-analyses significantly favoured the use of prophylactic antibiotics in preventing cholangitis (relative risk (RR) 0.54, 95% CI 0.33 to 0.91), septicaemia (RR 0.35, 95% CI 0.11 to 1.11), bacteriaemia (RR 0.50, 95% CI 0.33 to 0.78), and pancreatitis (RR 0.54, 95% CI 0.29 to 1.00). In random-effects meta- analyses, only the effect on bacteriaemia remained significant. Overall mortality was not reduced (RR 1.33, 95% CI 0.32 to 5.44). If one selects patients in whom the ERCP resolved the biliary obstruction at the first procedure, there seem to be no significant benefit in using prophylactic antibiotics to prevent cholangitis (RR 0.98, 95% CI 0.35 to 2.69, only three trials). Conclusions Prophylactic antibiotics reduce bacteriaemia and seem to prevent cholangitis and septicaemia in patients undergoing elective ERCP. In the subgroup of patients with uncomplicated ERCP, the effect of antibiotics may be less evident. Further research is required to determine whether antibiotics can be given during or after an ERCP if it becomes apparent that biliary obstruction cannot be relieved during that procedure.

Acute pancreatitis is the most common serious complication of endoscopic retrograde cholangiopancreatography (ERCP) resulting in significant morbidity and occasional mortality. Post-ERCP pancreatitis (PEP) has been recognized since ERCP was first performed, and many studies have shown a consistent risk that must be balanced against the many benefits of this procedure. This review will discuss the pathogenesis, epidemiology, potential risk factors, and clinical presentation of PEP. Moreover, it will discuss in detail the most recent updates of PEP prevention and management.

Although it is not a new method endoscopy has undergone incredible development in recent years. The examination is however very unpleasant for a patient, which is why health care staff should be well trained, particularly for child patients. The aim of the thesis was to map the specifics of nursing care for children undergoing endoscopic examination of the gastrointestinal tract. We approached the whole issue from the point of view of caring staff ? nurses. In the theoretical part we first described the gastrointestinal tract anatomy, endoscopy development and types of endoscopic examination. Then we dealt with the role of a nurse in the care for child patients undergoing these examinations. We formed three goals for the research. Goal 1: To find out how nurses prepare child patients for the individual endoscopic examinations. Goal 2: To verify whether nurses caring about a child patient undergoing gastrointestinal tract endoscopy are specifically trained. Goal 3 served as the output of the work: To elaborate recommendation for nurses preparing child patients for the individual endoscopic examinations. We chose quantitative research for collection of the necessary information. A questionnaire designed for nurses caring for child patients was the data collection technique. The questionnaire was anonymous, distributed at paediatric clinics of faculty hospitals of Moravian region. 104 questionnaires suitable for processing returned from 140 issued. The research has shown that nurses working at the clinics where the research was performed master the correct nursing care for child patients undergoing endoscopic examination of the gastrointestinal tract. Nevertheless the fact that most information is gained upon practical experience, with low emphasis on initial and repeated training of nurses also results from the research. A recommendation was elaborated upon the gathered information in the form of a standard nursing procedure proposal.

京都大学 / 0048 / 新制・論文博士 / 博士(医学) / 乙第13363号 / 論医博第2205号 / 新制||医||1045(附属図書館) / (主査)教授 妹尾 浩, 教授 今中 雄一, 教授 川上 浩司 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

Hintergrund und Studienziele: Endoskopisch eingebrachte Kunststoffstents, die zur Behandlung von Gallenwegsobstruktionen verwendet werden, okkludieren mit der Zeit infolge einer mikrobiellen Besiedlung und Bildung von Biofilmen. Die antimikrobielle Behandlung der Stent-assoziierten Cholangitis ist unter klinischen Gesichtspunkten oftmals unvollständig, da nicht hinreichend wirksame Substanzen eingesetzt werden oder antimikrobielle Resistenzen vorliegen. Um die aktuelle Ätiologie von Stent-assoziierten Biofilmen in Bezug auf die Stentverweildauer bei Patienten mit endoskopischer Gallenwegsdrainage am Universitätsklinikum Leipzig näher zu charakterisieren, wurde eine prospektive Kohortenstudie durchgeführt. Zusammenfassung: Die vorliegende Arbeit gibt Hinweise darauf, dass die Besiedlung mit Enterokokken und Candida spp. einen relevanten Kofaktor bei der Bildung von Biofilmen auf Gallestents und der nachfolgenden Stentokklusion darstellt. Daher sollte die empirische antibiotische Therapie von Patienten mit Stent-assoziierter Cholangitis Enterokokken, Enterobakterien, Streptokokken, Candida-Spezies und Anaerobier umfassen. Die Betrachtung der Stentverweildauer erbrachte in unserer Arbeit nur für den Nachweis von Staphylokokken und Enterobacterales einen signifikanten Unterschied, sodass dieses Kriterium bei der Auswahl einer empirischen antibiotischen Therapie nur eine untergeordnete Rolle spielt. Die Analyse der klinischen Parameter zeigt jedoch, dass vor Beginn einer empirischen antibiotischen Therapie auf lokale Unterschiede und patientenspezifische Gegebenheiten (vorheriger Einsatz antimikrobieller Substanzen, Immunsuppression, Nieren- und Leberfunktion sowie Arzneimittelallergien) geachtet werden muss, um eine optimale Therapie zu gewährleisten und die Ausbreitung multiresistenter Erreger zu begrenzen. Daher sollte bei der Behandlung ein multidisziplinärer Ansatz unter Einbeziehung von Gastroenterologen, Infektiologen, Mikrobiologen und klinischen Apothekern verfolgt werden. Für den Nachweis von Krankheitserregern ist eine genaue mikrobiologische Analyse der extrahierten Stents inkl. Sonifikation erforderlich.

Background The gallstone prevalence in the western world is 10-20%. Most gallstones are silent, but symptoms and complications appear in 20-40%. The incidence of symptom development in patients with silent gallstones is 2-4% per year. The indication for surgical (including endoscopic) treatment of gallstones is symptoms of certain magnitude, and no contraindications. During the past three decades an intense technical development in imaging (ultrasound, computerised tomography and magnetic resonance imaging), endoscopic therapy, and surgery has taken place. The aim of this thesis is to scrutinize changes in management of complicated gallstone disease on a population-based level, using national register data. Have the new methods improved the treatment of acute pancreatitis, common bile duct stones and acute gallbladder disease? Methods Data is collected from National Patient Register (NPR) run by The Swedish National Board of Health and Welfare. NPR collects discharge data from every admission from every Swedish hospital. Mortality is calculated as standardised mortality ratio (SMR) using age-, gender-, and calendar year specific survival estimates. We have studied both general trends in admissions and treatment alternatives and outcomes in defined patient cohorts. Length of hospital stay, readmission, and mortality has been used as proxy indicators of the effectiveness of treatment strategies used. Results During the study period mortality in acute pancreatitis (SMR within 90 days of admission) improved and hospital stay for all patients with acute pancreatitis decreased. Cholecystectomy rate at or shortly after index stay for mild acute biliary pancreatitis increased from 14.5 % to 22.7 %. Of all patients with acute pancreatitis 68.4 % of the patients had no aetiological diagnosis in the register. The incidence of bile duct interventions increased 27.8% from 1988 through 2006. The favoured treatment of bile duct stones changed from open choledocholithectomy to endoscopic sphincterotomy with stone extraction during the same period. However, in 2006, still 19.6% of bile duct interventions for stones were performed as choledochotomy and in the great majority of these cases as open surgery. This indicates a continuing need of education in open bile duct surgery. Mean hospital stay for treatment of common bile duct stones decreased significantly (4.5 days) during the period studied. The mortality (SMR) diminished although without statistical significance during the time period, and there was no significant difference in SMR between choledochotomy and endoscopic sphincterotomy. For acute gallbladder disease a moderate increase of admissions occurred from 1988 through 2006. The relation between acute cholecystectomies versus all cholecystectomies did not change during this period. Of all patients admitted with acute gallbladder disease 32.3 % were cholecystectomised during their first hospital stay, whereas 20.3 % underwent elective cholecystectomy and 6.1 % emergency cholecystectomy within two years of first admission. 41.4 % of patients were not operated on for gallbladder disease within two years of first admission with this diagnosis. Mortality from first admission and 90 days onwards was elevated three-fold during the entire period without time trend, without statistical difference between age groups, and between patients who had cholecystectomy at first admission or later. Conclusion During the audit period treatment of acute pancreatitis improved. However, etiological classification and timing of cholecystectomy in mild acute biliary pancreatitis fell below accepted guidelines. Interventions on the common bile duct for gallstone disease increased significantly. Common bile duct clearance has been separated from cholecystectomy, and cholecystectomy often not done. Only one third of all patients with acute gallbladder disease underwent cholecystectomy at first admission. There is room for improvement in treatment of complicatedgallstone disease, and, gallstone surgeons still need good knowledge in open biliary surgery.