ERCP

1. ERCP Dr David Scott Gastroenterologist Tamworth Base Hospital

2. ERCP What is it? When is it recommended? How is it performed? What are the complications? What’s new in ERCP?

3. What is ERCP? Endoscopic Retrograde Cholangiopancreatogram Essentially it is a radiological procedure performed via an endoscope to diagnose and treat conditions of the bile and pancreatic ducts

5. When is it recommended? Gall stones in the bile duct Malignant bile duct obstruction Bile duct leak post cholecystectomy Benign bile duct obstructions Tissue sampling of bile duct lesion Sphincter of Oddi Dysfunction (type 1) Pancreatic duct stones and obstruction Pancreatic pseudocysts Others…

6. Complications Of Gall Stones Biliary colic (pain but normal BR) Cholecystitis (pain and fever but normal BR) Biliary colic (pain and raised BR) Cholangitis (pain and fever and raised BR) Pancreatitis (pain +/- raised BR)

7. Malignant Bile Duct Obstruction Bile duct cancer Pancreatic cancer

8. Clinical Presentations for ERCP Gall stones: PAIN AND JAUNDICE Malignant obstruction: PAINLESS JAUNDICE

9. Special Situations • Gallstone Pancreatitis • <24 hours if persisting bile duct obstruction and severe pancreatitis • Otherwise avoid • Gall bladder in situ • Depends on the surgeon

10. Pre-procedure investigations Liver tests Platelet count and coagulation profile Imaging Ultrasound CT CT cholangiogram MRCP Endoscopic Ultrasound

11. Pre-procedure Imaging Transabdominal Ultrasound MRCP Endoscopic Ultrasound Sens 25-82% Spec 50-85% Sens 81-91% Spec 100% Sens 84-100% Spec 87-100% CT Cholangiogram Pre-procedure imaging has revolutionised ERCP

12. How is it performed? Similar to a Gastroscopy NBM for 6 hours prior (no bowel prep) IV sedation (not usually intubated) Left lateral position (sometimes prone) NOT sterile – just clean Different to a Gastroscopy Side viewing endoscope Portable image intensifier used Diagnostic and therapeutic equipment About 30 minutes

16. Cannulation of the Bile Duct

18. Common channel Common bile duct Pancreatic duct Major Papilla Anatomy Image property of Marco Bruno, AMC Amsterdam, From: Atlas of human anatomy. Gosling et al. Gower Medical Publishing Ltd. 1985

30. Sphincterotomy

31. Sphincterotomy Biliary sphincter is like a valve Needs to be cut to allow most interventions to relieve biliary obstruction Highest risk part of standard ERCP Perforation Bleeding Pancreatitis

35. Stents • Plastic • Biliary • 7 or 10 FG • Need to be removed/replaced within 3 months • Pancreatic • 5 FG • Need to be removed within 2-4 weeks • Metal • 10mm • Not removable (usually)

36. Cardiologists and ERCP • Aspirin • OK • Clopidogrel / Warfarin / Enoxaparin • No sphincterotomy • Stent can solve acute problem and allow definitive treatment to be deferred • Implantable defibrillator • No sphincterotomy without local technician • Need to go to tertiary centre

37. Complications of ERCP • Failure 5 - 10% • Pancreatitis 5% (severe in 0.5%) • Bleeding 1% • Perforation 0.1% • Anaesthetic complications

38. Predicting Post ERCP Pancreatitis • Doctor Factors • Low case volume, trainee • Procedure Factors • Difficult cannulation, pancreatic injection, precut • Patient Factors • Young, female, normal BR, previous pancreatitis

39. Reducing the Risks of ERCP • Patient selection • Patient selection • Patient selection • Wire guided technique • Pancreatic stents • Don’t persist indefinitely

41. Teamwork Radiographer Nursing Assistant * VERY IMPORTANT ROLE * 2nd Assistant Anaesthetics / Recovery Medical Endoscopist Anaesthetist

42. ERCP Set up Anaesthetic Nurse Anaesthetist ‘Scout’ nurse Anaesthetic Stuff ‘Scrub’ nurse Equipment Video Assistant’s Table XRay viewer Processor XRay Machine Diathermy Machine Radiographer Endoscopist

43. What’s new in ERCP?

44. Spyglass®IntraductalEndoscopy

49. Summary More like interventional radiology than endoscopy Patient selection important Needs Teamwork and Communication