INDICATIONS AND COMPLICATIONS OF ERCP

DR PG WILSON City Hospital Birmingham

ANATOMY

ERCP ANATOMY

PHYSIOLOGY
Biliary tree
gallbladder sphincter of Oddi

Pancreas
endocrine exocrine

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

PHYSIOLOGY III
Pancreas
secretes potent digestive enzymes
amylase trypsinogen lipase / phospholipase

pancreatic juice alkaline secretion mainly under hormonal control Vagal stimulation less important

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)

PROCEDURES
Endoscopic sphincterotomy

Biliary stenting Benign pancreatic disease

ENDOSCOPIC SPHINCTEROTOMY
Indications
Choledocholithiasis Acute obstructive cholangitis Malignant tumours Sphincter of Oddi dysfunction Acute biliary pancreatitis

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

Choledocholithiasis
Reasons for failure
previous surgery eg Billroth II / biliary surgery large stones
above stenosis intrahepatic

anatomical variations
duodenal diverticulum papillary stenosis

Choledocholithiasis
Complete extraction
reduce risk of
stone impaction cholangitis

Failure to extract
laser electrohydraulic shockwaves dissolution therpay percutaneous approach

Stent should be inserted

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

Tumours
Ampullary Ca
ES often not definitive treatment valuable for biopsies Biliary decompression pre-op

SOD
ES improves symptoms in 90% if sphincter pressure Normal sphincter pressure - no benefit Complications and mortality of ES higher

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

Complications
Overall
complications 4-10% mortality 0-2%

Haemorrhage 2-9%
surgery in ~10% balloon tamponade injection

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 <1% of cases

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

BILIARY STENTING
Indications
malignant obstrutction
ampullary carcinoma pancreatic carcinoma cholangiocarcinoma metastases

benign obstruction
chronic pancreatitis PSC

Failed stone removal

Prostheses
Polythene, polyurethane, Teflon stents
straight pigtail

Metal stents
self expanding wall stents balloon expandable

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

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

Malignant Strictures
Good palliation if >25% of parenchyma drained
antibiotic cover normally try drain both sides success in only 30%

Multiple strictures
no benefit

BENIGN PANCREATIC DISEASE

Acute pancreatitis Chronic pancreatitis Pancreatic pseudocyst Pancreatic duct disruption Pancreas divisum

Chronic Pancreatitis
Pancreatogram Intraductal secretin test Pancreatic duct sphincterotomy Minor papilla sphincterotomy Stenting Stone extraction Balloon dilatation

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)

Pseudocyst
Endoscopic cystoenterostomy
recur in ~ 14% complicated by
perforation bleeding infection

Transpapillary drainage
cysts communicate with disrupted duct

Conclusion
ERCP/ES for biliary stone extraction

Stenting of benign/malignant strictures Pancreatic disease