ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY ERCP INTRODUCTION Endoscopic retrograde cholangiopancreatography

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of : • the duodenum (the first portion of the small intestine), • the papilla of Vater (a small structure with openings leading to the bile ducts and the pancreatic duct), • the bile ducts, and • the gallbladder and the pancreatic duct.

USES Diagnostic Used when it is suspected a person’s bile or pancreatic ducts may be narrowed or blocked due to: • tumors • gallstones that form in the gallbladder and become stuck in the ducts • inflammation due to trauma or illness, such as pancreatitis • infection • Dysfunction of valves in the ducts, called sphincters, • scarring of the ducts (sclerosis), • Pseudo-cysts—accumulations of fluid and tissue debris

Therapeutic • Sphincterotomy • Stone Removal • Stent Placement • Balloon Dilation • Tissue Sampling

PREPARATION OF PATIENT BEFORE ERCP • The upper GI tract must be empty. Generally, no eating or drinking is allowed 8 hours before ERCP. • Smoking and chewing gum are also prohibited during this time. • Current medications may need to be adjusted or avoided. Most medications can be continued as usual. • Removal of any dentures, jewelry, or contact lenses before having an ERCP.

• Before ERCP, all of the patient’s previous abdominal imaging findings (from CT scans, magnetic resonance imaging [MRI], ultrasonography, and cholangiography or pancreatography) should be reviewed. • Deep sedation is desirable during ERCP because a stable endoscopic position in the duodenum is important for proper cannulation, therapeutic intervention, and avoidance of complications.

PROCEDURE • Patients receive a local anesthetic that is gargled or sprayed on the back of the throat & IV sedatives. • patients lie on their back or side on an x-ray table • Then a flexible camera (endoscope) is inserted through the mouth, down the esophagus, into the stomach, through the pylorus into the duodenum where the ampulla of Vater (the opening of the common bile duct and pancreatic duct) exists. The sphincter of Oddi is a muscular valve that controls the opening of the ampulla. The region can be directly visualized with the endoscopic camera while various procedures are performed.

• A plastic catheter or cannula is inserted through the ampulla, and radiocontrast is injected into the bile ducts and/or pancreatic duct. Fluoroscopy is used to look for blockages, or other lesions such as stones. • When needed, the opening of the ampulla can be enlarged (sphincterotomy) with an electrified wire (sphincterotome) and access into the bile duct obtained so that gallstones may be removed or otherapy performed.

FLUOROSCOPIC IMAGE SHOWING DILATATION OF THE PANCREATIC DUCT DURING ERCP INVESTIGATION. ENDOSCOPE IS VISIBLE.

FLUOROSCOPIC IMAGE OF COMMON BILE DUCT STONE SEEN AT THE TIME OF ERCP. THE STONE IS IMPACTED IN THE DISTAL COMMON BILE DUCT. A NASOBILIARY TUBE HAS BEEN INSERTED.

• Other procedures associated with ERCP include the trawling of the common bile duct with a basket or balloon to remove gallstones and the insertion of a plastic stent to assist the drainage of bile. Also, the pancreatic duct can be cannulated and stents be inserted. The pancreatic duct requires visualization in cases of pancreatitis. • In specific cases, a second camera can be inserted through the channel of the first endoscope. This is termed duodenoscope-assisted cholangiopancreatoscopy (DACP) or mother-daughter ERCP. The daughter scope can be used to administer direct electrohydraulic lithotripsy to break up stones, or to help in diagnosis by directly visualizing the duct.

AFTER THE PROCEDURE • Patients are monitored in the endoscopy area for 1 -2 hours until the effects of the sedatives have worn off & observed for complications. • Eating or drinking is allowed if the throat is no longer numb and are able to swallow without choking. • If a gallstone was removed or placed a stent during the test, the patient is made to stay in the hospital overnight.

AN EXAMPLE (BILE DUCT CANCER (CHOLANGIOCARCINOMA) • Cholangiocarcinoma is a cancer that arises from the cells within the bile ducts; both inside and outside the liver. tumors arise along the bile ducts that enter the liver, the tumors are smaller than those which arise from within.

COMPARISON OF RADIOGRAPHIC IMAGES SHOWING CHOLANGIOCARCINOMA; A, COMPUTED TOMOGRAPHY (CT) IMAGE; B, CHOLANGIOGRAM (ERCP) IMAGE. ARROWS DESIGNATE THE TUMOR

A, B, POSITION OF THE ENDOSCOPE IN THE DUODENUM DURING ERCP

A, TECHNIQUE OF TRANSHEPATIC PERCUTANEOUS CHOLANGIOGRAPHY; B, CORRESPONDING PERCUTANEOUS

COMPLICATIONS • ERCP is a highly specialized procedure which requires a lot of experience and skill. • The procedure is quite safe and is associated with a very low risk when it is performed by experienced physicians. • The success rate in performing this procedure varies from 70% to 95% depending on the experience of the physician. • Complications can occur in approximately one to five percent depending on the skill of the physician and the underlying disorder.

Significant risks associated with ERCP include • Infection • Pancreatitis • Allergic reaction to sedatives • Excessive bleeding, called hemorrhage • Puncture of the GI tract or ducts • Tissue damage from radiation exposure • Death, in rare circumstances

DUODENOSCOPE REPROCESSING

DUODENOSCOPES AND THE “SUPERBUG”

CURRENT FDA RECOMMENDATIONS • Beyond strict adherence to the manufacturer’s recommended cleaning protocol, facilities should conside at least one of the following • Microbiologic culturing • Ethyelene oxide sterilization • Use of a liquid chemical sterilant processing system; and/or • Repeat high-level disinfection

WHAT TO DO IN YOUR PRACTICE? • While the risk of infection transmission cannot be completely eliminated, the benefits of these devices continue to outweigh the risks in appropriately selected patients. FDA Communication, August 4, 2015 • Reasonable to advise patients on the low risk of infection transmission associated with ERCP • Advocate for appropriate use ERCP • Work with hospital infection preventionists on optimizing endoscope reprocessing to make infection transmission a “never” event

PREVENTING POST-ERCP PANCREATITIS STENTING THE PANCREAS DUCT • Pancreatitis may occur in up to 15% of patients after ERCP and may in part be due to • Papillary swelling after ERCP (possibly as a delayed result of sphincterotomy) • Contrast injection into pancreas duct which independently increases the risk of pancreatitis

PREVENTING POST-ERCP PANCREATITIS STENTING THE PANCREAS DUCT • Multiple studies have shown that placement of a small pancreatic stent in at risk patients reduces the risk of post. ERCP pancreatitis

RECTAL INDOMETHACIN REDUCES RISK OF POST-ERCP PANCREATITIS Elmunzer BJ, NEJM, 2012

INDOMETHACIN PROTECTIVE ACROSS ENTIRE RANGE OF PANCREATITIS RISK Elmunzer BJ, NEJM, 2012

AGGRESSIVE IV HYDRATION AFTER ERCP MAY REDUCE POST-ERCP PANCREATITIS • 60 patients randomized 2: 1 to aggressive vs standard hydration. Buxbaum J et al, CGH, 2014

CANNULATION SUCCESS RATES VARY WIDELY Williams EJ, Gut, 2007

AS ERCP HAS BECOME MORE COMPLEX, ARE WE STILL COMFORTABLE WITH IT? • ERCP is becoming technically more complex and training is no longer typically obtained in a standard GI fellowship • Thus, it is unclear whether these advances are translated to the general gastroenterologist or whether this has resulted in physicians performing procedures they do not feel comfortable with

CONTRAINDICATIONS • Unstable cardiopulmonary, neurologic, or cardiovascular status; and existing bowel perforation. • Structural abnormalities of the esophagus, stomach, or small intestine may be relative contraindications for ERCP. • An altered surgical anatomy. • ERCP with sphincterotomy or ampullectomy is relatively contraindicated in coagulopathic patients.

THE INTERSECTION OF EUS AND ERCP EUS has supplemented and supplanted ERCP for many indications including • Patients with low-moderate risk of bile duct stones • Exclusion and evaluation of biliary strictures • Tissue diagnosis of pancreas neoplasms • Evaluation of pancreas cystic lesions

ERCP VS EUS VS MRCP