This lecture is about the common mistakes in ERCP

1. PROF. DR. MOHAMED-NAGUIB WIFI
PROFESSOR OF MEDICINE AND
HAPATOGASTROENTEROLOGY
CAIRO UNIVERSITY
Where Did I Go Wrong?
5 mistake-scenarios from our common GI practice

2. CASE ONE
 A 47-year-old woman, known to have gall stones
presented to the OPD with jaundice.
 Her total Bilirubin level is 4.9 mg/dL.
 She complains of nausea, easy fatigability and
occasional vomiting.

3. What is your next step of management?
A. Do abdominal US examination
B. Hepatitis Markers.
C. Perform an ERCP
D. Perform upper GI endoscopy
E. Start Ursodeoxycholic acid

4. What is your next step of management?
A. Do abdominal US examination
B. Hepatitis Markers.
C. Perform an ERCP
D. Perform upper GI endoscopy
E. Start Ursodeoxycholic acid

5. Unfortunately….
 The physician performed
ERCP for the patient and
was completely normal.
 Fortunately, the procedure
passed without
complications apart from
performing an unnecessary
procedure.
 WHY THIS CHOICE WAS
WRONG?

6. Abdominal US should be the initial
diagnostic procedure for any case
of jaundice.
If CBD is not clearly dilated, ERCP
should never be used a diagnostic
investigation.
ERCP is should be strictly limited
to therapeutic situations, such as
stone extraction and stenting.

7. ERCP is not a good procedure to
diagnose stones in the common bile
duct, with only 70% sensitivity,
whereas EUS has a sensitivity of 95%.
ERCP complications are not low, so
EUS and/or MRCP be used for
diagnosis and then ERCP performed
only when treatment is needed.
Even the Only diagnostic role of ERCP
which is to acquire tissue sampling in
cases of CBD stricture can be replaced
sometimes by EUS

8. Mistake # 1
Performing an ERCP
without having a precise
therapeutic aim

9. CASE TWO
 A 20-year-old woman, with recurrent right
hypochondrial pains.
 Her total Bilirubin level is 0.82 mg/dL, ALT is 95
u/l, and AST 84 u/l.
 Abdominal US shows dilated CBD of 12 mm.

10. What is your probable diagnosis?
A. Achalcular cholecystitis
B. CBD stone
C. Pancreatic head mass
D. Spastic colon
E. Sphincter of Oddi Dysfunction

11. What is your probable diagnosis?
A. Achalcular cholecystitis
B. CBD stone
C. Pancreatic head mass
D. Spastic colon
E. Sphincter of Oddi Dysfunction

12. Unfortunately….
 The physician told the patient
that she needs another Imaging
technique, instead he
performed an ERCP for the
patient.
 After the procedure the patient
developed post-ERCP
pancreatitis and her relatives
had a big fight with the doctor.
 WHAT WAS WRONG?

13. Endoscopic cannulation of the bile
duct, with sphincterotomy, can
induce:
Acute pancreatitis in approximately 5%
Bleeding in 4.5%
Perforation in 0.1% of cases.
ERCP comes with complications

14. Main risk factors for pancreatitis

15. It is essential to give a clear
explanation to the patient of the
benefits and risks of the procedure.
This must be recorded in the
patient medical file in order to limit
the potential for medicolegal issues
in case an adverse event occurs.
Recommendations

16. Mistake # 2
Beginning an ERCP
procedure without
informing the patient about
the possible complications,
such as pancreatitis,
bleeding and perforation

17. CASE THREE
 A 28-year-old woman, with
calcular GB and obstructive
jaundice.
 Her total Bilirubin level is 8.9
mg/dL, and CBD is dilated
measuring 15 mm with stone
inside.
 ERCP is done, cannulation 
large CBD stone.

18. What is your choice?
A.Balloon Sphinctroplasty
B.Fistuolotomy with a knife.
C.Sphinctrotomy with a
sphinctrotome.

19. Every doctor’s wish about the opening

20. Recommendations
 The ESGE does not recommend endoscopic
papillary balloon dilation as an alternative to
sphincterotomy in routine ERCP due to the risk of
pancreatitis.
 Endoscopic papillary balloon dilation may be
advantageous in selected patients:
 Who are taking anticoagulant drugs without
acute possible reversion
 Who need an emergency ERCP (i.e. due to septic
shock).

21. Mistake # 3
Systematically preferring
sphincter dilation with a
balloon to sphincterotomy to
avoid bleeding

22. CASE FOUR
 A 27-year-old woman, with
calcular GB and obstructive
jaundice.
 Her total Bilirubin level is 9.5
mg/dL, and CBD is dilated
measuring 14 mm with stone
inside.
 ERCP is done, attempt of
cannulation failed.

23. What is your choice?
A.Defer the patient.
B.Fistuolotomy with a knife.
C.Repeat cannulation till
success.
D.Refer the patient to another
doctor.

24. Recommendations
 In case of cannulation failure, the ESGE suggests
changing the technique to reduce the number of
cannulations as much as possible to reduce the risk of
pancreatitis.
 The ESGE also suggests restricting the use of a
pancreatic guidewire as a backup technique for biliary
cannulation to cases in which there is repeated
cannulation of the pancreatic duct
 If this method is used, deep biliary cannulation should
be attempted using a guidewire rather than the
contrast-assisted method and a prophylactic
pancreatic stent should beplaced.

25. Recommendations
 Needle-knife fistulotomy should be the preferred
precut technique in patients who have a bile duct
dilated down to the papilla.
 Conventional precut and transpancreatic
sphincterotomy have similar success and complication
rates; if the conventional precut is selected and
pancreatic cannulation is easily achieved, the ESGE
advises attempting to place a small-diameter (3-Fr or
5-Fr) pancreatic stent to guide the cut and leaving the
pancreatic stent in place at the end of ERCP for a
minimum of 12–24 hours.

26. Recommendations
 Many studies showed the benefits of administering
a rectal NSAID, such as diclofenac, for the
prevention of acute pancreatitis post ERCP
 The ESGE guidelines also recommend pancreatic
stenting in high-risk patients (i.e. those with
Sphincter of Oddi dysfunction, multiple pancreatic
cannulations, young women etc.) with a 3-Fr or 5-
Fr stent.

27. Mistake # 4
Attempting cannulation
repeatedly without changing the
technique when the bile duct is
not easily accessible and
forgetting to prevent post-ERCP
acute pancreatitis associated with
pancreatic duct stenting by rectal
administration of a nonsteroidal
anti-inflammatory drug

28. CASE FIVE
 A 47-year-old man,
with obstructive
jaundice following
Liver
Transplantation.
 ERCP is done, CBD
only is visualized.
 WHAT TO DO?

29. Recommendations
 Except in cases of hilar stenosis (risk of
cholangitis), complete mapping of the intrahepatic
biliary tree is advised to detect additional diseases,
such as intrahepatic stones or stenosis, which
could explain the occurrence of recurrent
cholangitis.
 Opacification should be conducted with a certain
pressure, using, for example, an extraction balloon
to avoid contrast leakage in the duodenum.

30. Recommendations
 Different pictures taken from different axes are
needed to understand bile duct insertion and to
avoid structure superposition.
 All the segmental intrahepatic bile ducts should be
visible and analysed one by one.
 MRCP is also effective and combining MRI with
ERCP is another option to reduce the opacification
of the bile tract and exposure of the patient to X-
rays.

31. Mistake # 5
Not obtaining complete
opacification of the bile tract
(complete mapping) and
especially of the intrahepatic
bile ducts to diagnose
intrahepatic stones or
stenosis

32. CASE SIX
 A 67-year-old man,
with hilar stricture.
 ERCP is done,
cholangitis followed.
 WHAT WENT
WRONG?

33. Recommendations
 Opacification of occluded bile ducts may
lead to cholangitis if this duct cannot be
drained with a stent.
 Prior ERCP, precise mapping and a precise
drainage strategy are needed.
 Which technique should be used (ERCP,
percutaneous drainage or immediate
surgical resection)?

34. Recommendations
 Which duct should be drained?
 How many ducts should be drained?
 Having a strategy allows the
catheterization and injection of only
those areas that have to be drained.

35. Mistake # 6
In case of hilar stenosis,
beginning an ERCP for
drainage without MRI
mapping of the obstructed
bile ducts (MRCP)

36. CASE SEVEN
 A 37-year-old man, with hilar stricture.
 Metal Stent inserted.
 WHAT WAS THE DIAGNOSIS?

37. Can you tell the difference?
Sclerosing Cholangitis Klatskin Tumour

38. The Lesson
 The differential diagnosis between cholangitis
and cholangiocarcinoma is challenging and
may require histological analysis of several
brushing or biopsy samples.
 Inserting one or more metal stents in case of
primary sclerosing cholangitis or in case of
neoplastic disease that is reversible by
chemotherapy is a mistake because stent
removal is usually impossible.

39. Mistake # 7
Inserting one or several
non-covered metal stents in
cases of hilar disease
without having a histological
diagnosis

40. CASE EIGHT
 A 35-year-old woman, with history of
laparoscopic cholecystectomy.
 Post-operative drains continued to be filled
with bile, leakage is suspected.
 ERCP was done, sphincterotomy was done
before visualization of the leakage, stent
inserted, patient then developed post-ERCP
acute pancreatitis!
 WHAT WAS WRONG?

41. Recommendations
 ECRP can be very effective at stopping a
biliary post-surgical leakage.
 Depending the location and the associated
biliary lesions, different options (e.g.
papillotomy alone, nasobiliary drainage,
stenting, stone removal) can to be used.
 The first step must be to demonstrate the
leakage by ERCP.

42. The Lesson
 It is a mistake to perform any therapeutic
manoeuvre without such a demonstration.
 So, Sphincterotomy is not justified while the
leakage is not clearly seen, because it adds
risk of acute pancreatitis without any benefit
for the patient.
 If not demonstrated at the time of the first
contrast injection  inject under pressure,
e.g. occluding balloon

43. Mistake # 8
In cases of biliary leakage,
performing a
sphincterotomy without
having clear visualization of
the fistula

44. CASE NINE
 A 27-year-old woman  Lap-chole.
 After which she developed OJ.
 ERCP done, CHD stricture is suspected,
several trials to pass a guidewire.
 The patient after which presented again,
now with a leak.
 WHAT WENT WRONG?

45. The Lesson
 Biliary stenosis following a difficult
cholecystectomy is usually located at the level
of the common hepatic duct.
 The stenosis is frequently complete and
difficult to pass even with a hydrophilic
guidewire.
 A frequent mistake is to mix up the cystic duct
stump and the occluded common hepatic duct
and to repeatedly push the guidewire into the
cystic duct stump.

46. The Pitfall
 The two channels superimpose on
fluoroscopy, but there are two possible
solutions:
1. First, to always think that the cystic duct
stump can superimpose and mimic the
stenotic common hepatic duct.
2. Second, to change the radiological
exposure in order to separate both ducts on
imaging.

47. Mistake # 9
Mixing up the cystic duct
stump and hepatic bile duct
in cases of post-
cholecystectomy biliary
stenosis

48. CASE TEN
 A 57-year-old man, with
Obstructive Jaundice.
 ERCP was done.
 WHAT IS YOUR
DIAGNOSIS?

49. The Lesson
 Mirizzi syndrome type I is a common bile
duct compression that is caused by a stone
impacted at the neck of the gallbladder or at
the cystic duct.
 The compression induces obstructive
jaundice and its diagnosis and treatment are
challenging (endoscopic / surgical).

50. The Lesson
 It has been reported that there is an
association with gallbladder cancer in one
third of Mirizzi cases and Mirizzi can also
masquerade as cholangiocarcinoma.
 Thickening of the gallbladder or the cystic
duct wall is not specific enough to rule out or
confirm the presence of associated
cholangiocarcinoma.

51. Mistake # 10
Ignoring the fact that Mirizzi
syndrome can mimic or be
associated with
cholangiocarcinoma

53. TOP 10 Mistakes in ERCP
 Mistake 1 | Performing an ERCP without
having a precise therapeutic aim
 Mistake 2 | Beginning an ERCP procedure
without informing the patient about the
possible complications, such as pancreatitis,
bleeding and perforation
 Mistake 3 | Systematically preferring
sphincter dilation with a balloon to
sphincterotomy to avoid bleeding

54. TOP 10 Mistakes in ERCP
 Mistake 4 | Attempting cannulation repeatedly
without changing the technique when the bile duct
is not easily accessible and forgetting to prevent
post-ERCP acute pancreatitis associated with
pancreatic duct stenting by rectal administration of
a nonsteroidal anti-inflammatory drug
 Mistake 5 | Not obtaining complete opacification of
the bile tract (complete mapping) and especially of
the intrahepatic bile ducts to diagnose intrahepatic
stones or stenosis

55. TOP 10 Mistakes in ERCP
 Mistake 6 | In case of hilar stenosis,
beginning an ERCP for drainage without
MRI mapping of the obstructed bile ducts
(MRCP)
 Mistake 7 | Inserting one or several non-
covered metal stents in cases of hilar disease
without having a histological diagnosis

56. TOP 10 Mistakes in ERCP
 Mistake 8 | In cases of biliary leakage,
performing a sphincterotomy without
having clear visualization of the fistula
 Mistake 9 | Mixing up the cystic duct stump
and hepatic bile duct in cases of post-
cholecystectomy biliary stenosis
 Mistake 10 | Ignoring the fact that Mirizzi
syndrome can mimic or be associated with
cholangiocarcinoma

58. THANK YOU