Approaches to Difficult ERCP Cannulation, Part 1 of 3
Kaveh Mojtahed, MDGI Fellow
The biliary tree and most things internal medicine doctor need to know
Kaveh Mojtahed, MD
Objectives• Common terminology
• Gallstone diseases
• ERCP indications and complications
• Brief review of pancreatic cysts
• Biliary malignancies
• Topics not covered: biliary cysts, chronic gallbladder dysfunction, biliary atresia, gallbladder polyps, HIV cholangiopathy
Chole-what
• Cholelithiasis• Cholecystitis• Choledocholithiasis• Cholangitis• Cholecystectomy• Cholangiocarcinoma
Charcot’s triad vs Raynaud’s Pentad
Fever RUQ painJaundice
HypotensionAltered mental status
Only 50-70% develop all Charcot’s triad
Case #1
• 34 year old male presents to general clinic with episodes of severe epigastric and RUQ abdominal pain
H&P
• Starts 30 minutes after eating, lasts for 4 hrs, then resolves, refers to scapula and right upper back
• Exam: anicteric sclera, no Murphy’s sign
Jaundice
• Scleral icterus and sublingual, total bili 2-2.5• Cutaneous jaundice, total bili 5• Tympanic membrane, total bili 10
• Hemolysis does not increase total bili > 5
• Clay-colored stools = obstructive jaundice • Occult blood in clay colored stool suggests
pancreatic or ampullary CA
Murphy’s sign
65% sensitivity, 88% specificity
Pain and arrested inspiration when the examiners fingers are hooked under right costal margin at mid-clavicular line
Labs/imaging
• CBC and LFTs- normal
What’s the diagnosis?
• Biliary colic
• He decides to defer cholecystectomy for now
Is this a good idea?
• ~60% of symptomatic gallstone patients continue to have symptoms
• 90% of complications (eg cholecystitis) preceded by uncomplicated biliary colic
3 months later
Constant RUQ pain for 24 hrs
T 39, HR 105, BP 110/53Exam: + Murphy’s
WBC 15, Hgb 15, Plt 210, INR 1.1AST 120, ALT 145, AlkP 290, Total bili 4.9, Lipase 200
Differential
• What disease process is occuring?
• Acute cholecystitis• Cholangitis• Gallstone pancreatitis• Choledocholithiasis• Biliary Colic
Cholangitis
• Early antibiotic use
• Biliary decompression
• **Elderly, diabetics, immunocompromised do not have typical presentation**
Antibiotic coverage: 3 most common GN bacteria implicated in cholangitis?
• E. Coli• Klebsiella• Enterobacter
What is the most common GP bacteria• Enterococcus
• Anaerobes
Antibiotics
• GNR- ampicillin/sulbactam, piperacillin-tazobactam, ceftriaxone, levofloxacin, ciprofloxacin, carbapenems
• Anaerobes- Zosyn/Unasyn, metronidazole
Biliary decompression
• Urgent ERCP <24hrs if obstructive biliary stones associated with mod-severe cholangitis [sepsis, total bili > 5, age >75, etc* (refer Tokyo 2013 guidelines)]
• Early ERCP <72hrs with mild cholangitis responding to medical therapy
• Cholecystectomy once clinically stable
ERCP
• Endoscopic retrograde cholangiopancreatography
• Indications: stone disease, malignancy, stricture, recurrent/chronic pancreatitis
• Contraindications: abnormal anatomy, pancreatitis (unless need to remove gallstone)
• What’s an esophageal abnormality that would be a high risk situation for perforation with passing a side viewing scope?
Zenker’s diverticulum
Successful stone extraction
Post-ERCP patient starts to eat and develops severe epigastric pain
Lipase is 1900
What are the main complications of ERCP?
• Perforation (esophageal/duodenal/biliary)
• Post-ERCP pancreatitis (2-10%)- costs healthcare system $150 million/year
• Post-sphincterotomy bleed
How do you diagnose post-ERCP pancreatitis?
1. New or increased abdominal pain 2. Pancreatic enzymes 3x ULN 24 hrs post ERCP3. Resultant hospitalization more than a night
RF: any injection, probing or manipulation of pancreas or its duct, sphincterotomy
Reducing post-ERCP pancreatitis
• Prophylactic pancreatic STENT placement (18 trials have shown reduces risk of PEP by 70%, NNT 8)
• PR INDOMETHACIN immediately after procedure (meta-analysis of 912 pateints, 64% reduction in PEP)
A few other important things
• Acalculous cholecystitisRisk factors: sepsis, TPN, prolonged fasting, sickle cell disease, Salmonella infections, diabetes mellitus, cytomegalovirus, cryptosporidiosis, microsporidiosis
• Antibiotics, percutaneous drain, cholecystectomy
HIDA
Gallstone disease key points
• Asymptomatic gallstone disease has a benign course and can be managed with observation.
• Biliary colic is the most common clinical presentation in patients with symptomatic gallstones.
• Laparoscopic cholecystectomy is the treatment of choice for biliary colic and acute cholecystitis.
A few other biliary diseases
• 1. Spinchter of Oddi dysfunction
• 2. Recurrent pyogenic cholangitis
• 3. Primary sclerosing cholangitis
Spinchter of Oddi dysfunction
• Manometry • Nifedipine for Type 3 and
mild 2• ERCP for Type 1 with
spinchterotomy
Recurrent pyogenic cholangitis
• Intrabiliary pigment stone formation resulting in stricture and obstruction leading to recurrent cholangitis
• Stone formation thought to be instigated by parasite (Clonorchis sinesis) or bacterial infection
• Exclusively SE Asians
https://www.youtube.com/watch?v=g18B2rm78E4
PSC• intra/extrahepatic bile duct
inflammation/fibrosis• Alk phos 3-5 x ULN• Ulcerative colitis• ERCP/MRCP• Cholangiocarcinoma
• Treatment: Ursodeoxycholic acid 13-15 mg/kg/day- no change in survival but improves LFTs
Demographic lesson
• Who gets PSC?middle aged men, 70% of PSC patients are men average age 40
• Who gets PBC?middle aged woman, 10 times more than men. Incidence in US women 1/1000 over age 45
Pancreatic cysts
Complete list of pancreatic cystsWidespread use of CT and MRI = 13.5% prevalence of incidental cysts
Epidermoid Cyst in Intrapancreatic SpleenIntraductal Oncocytic Papillary Neoplasm
1. Intraductal Papillary Mucinous Neoplasm (IPMN)Intraductal Tubular AdenomaIntraductal Tubular CarcinomaLymphoepithelial CystMucinous Cystic NeoplasmPancreatic Intraepithelial NeoplasiaParaduodenal Wall Cyst
2. PseudocystSerous CystadenocarcinomaSerous Macrocystic / Oligocystic AdenomaSerous Microcystic AdenomaSolid and Cystic Hamartoma of the PancreasSolid Pseudopapillary NeoplasmSolid Serous AdenomaSquamoid Cyst of Pancreatic Ductsvon Hippel Lindau Pancreatic Lesions
IPMN
• Main vs side branch intrapapillary mucinous neoplasm
• Risk of carcinoma 70% in main branch IPMN >3 cm
• Recurrent pancreatitis
• Increased risk of extra-pancreatic malignancies
Pseudocyst or “walled off pancreatic fluid collection”
• Non-epithelial lined lesion formed from resorption of fat necrosis
• Pseudoaneursym
• 40% resolve on their own
• If symptomatic can undergo drainage procedure
Biliary malignancies
• Cholangiocarcinoma
• Ampullary adenocarcinoma
CholangiocarcinomaRisk factors: PSC, biliary atresia, chronic infection with liver flukes, and biliary cysts
60-70%- Klatskin tumor or more distal = complete obstruction
Symptoms: painless jaundice, right upper quadrant pain, and weight loss
CA 19-9, CEA, AFP
MRCP/ERCP
Ampullary adenocarcinoma
• familial adenomatous polyposis or Peutz-Jeghers syndrome
• pancreaticoduodenectomy (Whipple procedure)
Summary
• Common terminology
• Gallstone diseases
• ERCP indications and complications
• Brief review of pancreatic cysts
• Biliary malignancies
Question
• 85 year old diabetic male in ER for 2 days confusion and poor appetite. He is cool, clammy, no fever, BP 90/70, HR 110, RR 32, nontender abdomen.
• WBC 7, ALKP 550, ALT 120, AST 190, Total bili 3, U/S normal liver, gallstones present, no duct dilatation.
• What’s the next step in management?• A) HIDA• B) ERCP• C) MRCP• D) cholecystectomy
Key point
• In severely ill patients with hypotension and sepsis and a high clinical suspicion for acute cholangitis with or without confirmatory imaging studies
• Preferred next diagnostic test is ERCP
• Diabetics and elderly do not have typical presentations!
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