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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
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
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
Acute Cholangitis
Mortality - reported upto 100% untreated ERCP
EST performed - 1st line treatment bile for microbiology
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
BILIARY STENTING
Indications
malignant obstrutction
ampullary carcinoma pancreatic carcinoma cholangiocarcinoma metastases
benign obstruction
chronic pancreatitis PSC
Prostheses
Polythene, polyurethane, Teflon stents
straight pigtail
Metal stents
self expanding wall stents balloon expandable
Benign strictures
Chronic pancreatitis
poor long term results
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%
Malignant Strictures
Good palliation if >25% of parenchyma drained
antibiotic cover normally try drain both sides success in only 30%
Multiple strictures
no benefit
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%
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