Endoscopic retrograde cholangiopancreatography in elderly patients

Background: the presentation of common bile duct disease, value of investig ations and treatment outcome in elderly patients undergoing endoscopic retr ograde cholangiopancreatography (ERCP) were assessed. Methodology: the clinical presentation, liver function tests, full blood co unts, abdominal ultrasound and ERCP results were assessed retrospectively i n 101 patients (59 women, 42 men; mean age 83 years, range 75-100) sequenti ally investigated for possible common bile duct disease. Results: 59 patients had common bile duct gallstones, 35 had malignant bili ary obstruction (13 with co-existing common bile duct stones) and seven had other outcomes. In the malignant-alone group 68% of those who had jaundice presented painlessly compared with 24% in the gallstones-alone group; 49% of the gallstones-alone group had pain compared with 28% of the malignant g roup. In the gallstones-alone group 43% had atypical presentations (non-spe cific symptoms or painless jaundice), Non-specific symptoms were found in 1 9% of the gallstones-alone group bur in only 5% of the malignant group. Of the patients who had common bile duct stones, 18% had pancreatic or biliary malignancy The co-existence of gallstones and malignancy was emphasized by eight patients in whom the clinical and ultrasound diagnosis was of common bile duct stones but malignancy was detected by ERCP. The sensitivity of u ltrasound was 86% for detecting dilated common bile ducts was 86%, but only 69% for diagnosing gallstones within the common bile duct and 67% for diag nosing pancreatic masses. Ultrasound and ERCP were in agreement in 60 patie nts (60%). Endoscopic clearance of common bile duct gallstones was successf ul in 53 of 54 attempts (98%), Palliative ERCP treatment was performed in 3 0 patients who had malignant biliary obstruction and was successful in 22 ( 73%); in a further four patients (13%) an endoprothesis was successfully in serted percutaneously. The commonest complication of ERCP was cholangitis ( four patients); pancreatitis and biliary perforation occurred in one patien t each. Twenty-two patients (63%) who had malignancy died during follow-up, the mean survival being 11.3 weeks (range 3 days-2 years), Carcinoma of th e ampulla was associated with a relatively good prognosis (three patients s urvived 18 months or more). Conclusion: in elderly patients, common bile duct stones often present atyp ically and co-existence with malignancy is not unusual; ampullary carcinoma has a relatively good prognosis and ERCP is a safe and effective procedure in the management of biliary obstruction.