Indications and Complications of Ercp

7/31/2019 Indications and Complications of Ercp

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INDICATIONS AND

COMPLICATIONS OF ERCP

DR PG WILSON

City HospitalBirmingham


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ANATOMY


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ERCP ANATOMY


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PHYSIOLOGY

Biliary tree

gallbladder

sphincter of Oddi

Pancreas

endocrine

exocrine


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PHYSIOLOGY II

Gallbladder

stores bile

contracts to release bile (CCK) concentrates bile (water absorption)

Sphincter of Oddi

relaxes to allow bile flow when closed bile goes to gallbladder

Post cholecystectomy

CBD dilates


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PHYSIOLOGY III

Pancreas

secretes potent digestive enzymes

amylase

trypsinogen

lipase / phospholipase

pancreatic juice alkaline secretion mainly under hormonal control

Vagal stimulation less important


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INDICATIONS

?diagnostic

NO! (although it may end up as such!)

Biliary disease Stones

Biliary stenting/biliary cytology

Sphincterotomy

Pancreatic disease

Chronic pancreatitis (stenting/stone removal)

Acute pancreatitis (duct damage/cyst drainage)


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PROCEDURES

Endoscopic sphincterotomy

Biliary stenting

Benign pancreatic disease


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ENDOSCOPIC

SPHINCTEROTOMY Indications

Choledocholithiasis

Acute obstructive cholangitis

Malignant tumours

Sphincter of Oddi dysfunction

Acute biliary pancreatitis


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Choledocholithiasis

ES is treatment of choice

85% complete removal of CBD stones

Critical size ~ 15mm

>15mm - mechanical lithotripsy

68% success for stones > 25mm

ESWL - alternative to mechanical

lithotripsy


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Choledocholithiasis

Reasons for failure

previous surgery eg Billroth II / biliary surgery

large stones

above stenosis

intrahepatic

anatomical variations duodenal diverticulum

papillary stenosis


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Choledocholithiasis

Complete extraction

reduce risk of

stone impaction

cholangitis

Failure to extract laser

electrohydraulic shockwaves

dissolution therpay

percutaneous approach

Stent should be inserted


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Acute Cholangitis

Mortality - reported upto 100% untreated

ERCP

EST performed - 1st line treatment

bile for microbiology

Success in ~80%

Leese et al (BJS 1986)

ES vs surgery: mortality 4.7% vs 21.4%

mostly stone disease


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SOD

ES improves symptoms in 90% if sphincter

pressure

Normal sphincter pressure - no benefit

Complications and mortality of ES higher


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Acute pancreatitis

4 RCT studies of ES in acute pancreatitis

2 showed benefit

1 no benefit

1 reduction in biliary sepsis

ES should be performed in

Predicted severe AP

Associated cholangitis


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Complications

Overall

complications 4-10%

mortality 0-2%

Haemorrhage 2-9%

surgery in ~10%

balloon tamponade

injection


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Complications

Acute pancreatitis

0-39% post diagnostic ERCP

significant pancreatitis ~2%

Acute cholangitis

inadequate duct clearance

occurs in ~1% cases

unaffected by routine antibiotic administration

Perforation in


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Long term results of ES

No significant long term complications

restenosis

93.5% symptom free over 15 years

no evidence of biliary malignancy

Minor alterations of bile composition

Bacterial colonisation increased


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BILIARY STENTING

Indications

malignant obstrutction

ampullary carcinoma

pancreatic carcinoma

cholangiocarcinoma

metastases

benign obstruction chronic pancreatitis

PSC

Failed stone removal


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Prostheses

Polythene, polyurethane, Teflon stents

straight

pigtail

Metal stents

self expanding wall stents

balloon expandable


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Benign strictures

Chronic pancreatitis

poor long term results

Post operative strictures

dilated and stent inserted

success 60-85% cases

Post operative leak

close more quickly if papilla stented

PSC

dominant CBD stricture


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Malignant Strictures

Most studies pancreatic cancer

success ~ 86%

30 d mortality 10-17%

median survival - 5 months

blocked stent 16 -29%

Higher strictures more difficult

70-75% success

in-hospital mortality 20-25%

median survival - 5months


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Malignant Strictures

Good palliation if >25% of parenchyma

drained

antibiotic cover normally try drain both sides

success in only 30%

Multiple strictures no benefit


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BENIGN PANCREATIC

DISEASE

Acute pancreatitis

Chronic pancreatitis Pancreatic pseudocyst

Pancreatic duct disruption

Pancreas divisum


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Chronic Pancreatitis

Pancreatogram

Intraductal secretin test

Pancreatic duct sphincterotomy

Minor papilla sphincterotomy

Stenting

Stone extraction

Balloon dilatation


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Chronic Pancreatitis

Balloon dilatation of strictures success 70-100%

93% have improvement in symptoms

followed by stent insertion complications in ~ 4%

Stones delivered after EPS (50% success)

correlates with symptom improvement

stone removed whole

disrupted (stent insertion/ESWL)

complications in ~ 10% (mostly pain)


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Pseudocyst

Endoscopic cystoenterostomy

recur in ~ 14%

complicated by perforation

bleeding

infection

Transpapillary drainage

cysts communicate with disrupted duct


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Conclusion

ERCP/ES for biliary stone extraction

Stenting of benign/malignant strictures

Pancreatic disease

Documents

Indications and Complications of Ercp