understanding ERCP, indications and risks

1. Ramez Antakia
General Surgery

2. ERCP
 What does it stand for?
 Endoscopic Retrograde Cholangiopancreatography
 It is radiological procedure
 Why perform it?
 Diagnostic, Therapeutic & Follow-up
 Informed consent is required

3. Anatomy

4. Indications
 Gall stones in the Common Bile Duct (CBD)
 Benign or Malignant CBD obstruction
 Biliary leak post-cholecystectomy
 Tissue sampling in suspected pancreatic/biliary cancer
 Sphincter of Oddi Dysfunction
 Selected patients with Pancreatic pseudocyst

5. Contra-indications
 Uncooperative patient
 Coagulopathy
 Patient physically unable to tolerate the procedure
 Recent Myocardial Infarction
 Presence of Barium/contrast in the GI tract

6. Clinical Presentations for ERCP
Painful Jaundice
Murphy’s sign +ve
Painless Jaundice
Courvoisier’s sign +ve

7. Pre-ERCP investigations
 FBC
 LFTs
 Coagulation profile
 Imaging:
 USS
 MRCP
 CT
 Endoscopic USS

8. How is it performed?
Similarity to Gastroscopy Difference to Gastroscopy
 NBM 6 hours prior
 IV sedation
 Left lateral position
 Not sterile
 Side viewing endoscope
 Portable image intensifier
 Longer duration
 Requires more training

10. ERCP equipment

11. Sphincterotomy
 Sphincter of Oddi acts like a valve
 Needs to be cut to allow stone removal & relieve biliary
obstruction
 Increases the risk of complications as opposed to
standard ERCP

12. Stents
Plastic Metal
 Biliary
 7 or 10 FG
 Need to be
removed/replaced within 3
months
 Pancreatic
 5 FG
 Need to be removed within
2-4 weeks
 10 mm
 Usually not removable

13. Stents continued
Plastic Metal

14. Complications of ERCP
 Failure 5-10%
 Pancreatitis 4%
 Sepsis/Cholangitis 1.5%
 Haemorrhage/Bleeding 1.5%
 Perforation 0.5%

15. Risk Factors
 Sphincter of Oddi Dysfunction (SOD)
 Biliary sphincterotomy
 Previous post-ERCP pancreatitis
 Female gender
 Obesity
 Difficult duct cannulation/small-diameter CBD
 Low case volume centres
 Bleeding coagulopathy, anticoagulation, cholangitis

16. RCT of rectal indomethacin to prevent
post-ERCP pancreatitis
 Elmunzer BJ et al. N Engl J Med. 2012 Apr
12;366(15):1414-1422.
 602 pts, 3x amylase, 2 day stay, high risk patients
 Among patients at high risk for post-
ERCP pancreatitis, rectal indomethacin significantly
reduced the incidence of the condition.

17. Guide wire-assisted vs conventional contrast-assisted
cannulation in prevention of Post-ERCP pancreatitis
 Compared with contrast-assisted cannulation
technique, guide wire-assisted cannulation increases
the primary cannulation rate and reduces the risk of
PEP, and therefore appears to be the most appropriate
first-line cannulation technique.
 Tse F et al. Endoscopy 2013 Aug; 45(8):605-618.
 Tse F et al. Cochrane Database Syst Rev. 2012 Dec
12;12:CD009662

18. Prophylactic stent placement in patients with
difficult biliary cannulation to prevent PEP
 Mazaki T et al. J Gastroenterol 2014 Feb;49(2):343-55.
updated meta-analysis
 Lee TH et al. Gastrointest Endosc 2012 Sep;76(3):578-85.
mutlicentre RCT
 The meta-analysis showed that pancreatic stent placement
after ERCP vs no stent placement reduces the risk of PEP.
 Prophylactic temporary 3F PS placement in patients with a
difficult biliary cannulation during ERCP seems to be a
safe and effective method for reducing PEP.

19. Algorithm for management of post-
ERCP gastric perforation

21. Algorithm for management of post-
ERCP ductal perforation

22. Algorithm for management of post-
ERCP duodenal perforation

23. Summary
 Familiarise oneself with anatomy, indications &
contra-indications of ERCP
 Close observation post-ERCP
 Abdominal pain
 Blood tests: FBC, LFTs, Coagulation profile, Amylase

24. References
 American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice
Committee. (2012). Complications of ERCP. Gastrointestinal Endoscopy Journal, 75(3).
467-473.
 AORN Recommended Practices Committee. (2005, March). Recommended practices for
electrosurgery. AORN Journal81(3):616-618, 621-626, 629-632
 Aquino, A,C. (Ed.). 2008). Gastroenterology Nursing, A Core Curriculum. (4th ed.). Liver.
(pp. 203-218). Mosby.
 Dai, H. F., Wang, X. W., & Zhao, K. (2009). Role of nonsteroidal anti-inflammatory drugs
in the prevention of post-ERCP pancreatitis: a meta-analysis. 8(1):11-16.
 Ding X, Chen M, Huang S, Zhang S, Zou X. (2012). Nonsteroidal anti-inflammatory drugs
for prevention of post-ERCP pancreatitis: a meta-analysis. Gastrointestinal Endoscopy,
76(6):1152-1159.
 Elmunzer, B. J. , Scheiman, J. M., Lehman, G. A., Chak, A., Mosler, P., Higgins, P. D.R. et
al. (2012). A Randomized Trial of Rectal Indomethacin to Prevent Post-ERCP
Pancreatitis. The New England Journal of Medicine, 366, 1414-1422.
 Tse F et al. Guide wire-assisted cannulation for the prevention of post-ERCP pancreatitis:
a systematic review and meta-analysis. Endoscopy 2013 Aug; 45(8):605-618.

25. References continued
 Elmunzer B. J., Waljee, A. K., Elta, G.H., Taylor, J.R., Fehmi S.M., & Higgins PD. (2008). A
meta-analysis of rectal NSAIDs in the prevention of post-ERCP pancreatitis. Gut, 57(9).
1262-1267.
 Pagana, E., & Pagana, T. (2009) Mosby’s Diagnostic and Laboratory Test Reference. (9th
ed.). St. Louis, MO: Mosby.
 http://www.google.com/imgres?imgurl=http://bbsimg.ngfiles.com/1/22845000/ngbbs4d
e33e3e41bcf.jpg&imgrefurl=http://www.newgrounds.com/bbs/topic/1223426&h=600
 Paspatis GA, Dumonceau JM et al. Diagnosis and management of iatrogenic endoscopic
perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position
Statement. Endoscpy 2014 Aug;46(8):693-711.
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