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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