ERCP and Cholangioscopy

1. ERCP and Cholangioscopy Lisa M. Gangarosa MD Associate Professor of Medicine Resident�s Conference September 30, 2008

4. 1. What is the role of ERCP in gallstone disease?

5. Tests to detect CBD stones In decreasing order of sensitivity ERCP ~ EUS ~MRCP CT abd US

6. Pre-test probability of CBD stones important Jaundice abnormal liver enzymes ductal dilation on imaging

7. Patients undergoing cholecystectomy

8. Acute Cholangitis Bacterial infection superimposed on obstruction of biliary tree The most common organisms cultured in cholangitis are Escherichia coli (39%), Klebsiella (54%) and Enterobacter (34%) species, enterococci (34%), and group D streptococci. The infection may also be polymicrobial Mortality ranges from 7-40% Elderly patients are more likely to progress from asymptomatic gallstones to serious complications of gallstones and cholangitis without gallbladder colic. Suspect cholangitis in older patients presenting with sepsis and mental status changes. Elderly patients are more prone to gallstones and CBD stones and, therefore, cholangitis.

9. Risk Factors for higher morbidity and mortality Hypotension Acute renal failure Liver abscess Cirrhosis Inflammatory bowel disease High malignant strictures Radiologic cholangitis � Post percutaneous transhepatic cholangiography or post ERCP Female gender Age older than 50 years Failure to respond to antibiotics and conservative therapy

10. Eponyms Charcot triad of fever, RUQ pain, and jaundice (first described 1877) is found in 50-70% of patients presenting with cholangitis Patients present with altered mental status 10-20% of the time and hypotension approximately 30% of the time. These signs combined with Charcot triad constitute Reynold�s pentad.

11. Cholangitis ERCP with sphincterotomy is also the primary treatment for patients with cholangitis secondary to common bile duct stones. These patients require immediate resuscitation with intravenous fluids and antibiotics. For those patients who do not improve promptly, ERCP with sphincterotomy and duct drainage is indicated as soon as possible. In contrast, for those patients who improve, urgent (within 24 hours) ERCP and sphincterotomy are indicated.

12. 2. What is the role of ERCP in pancreatic and biliary malignancy? Approximately 30,000 new cases of pancreatic cancer and 7,000 biliary tract cancers are diagnosed annually in the United States. Few of these patients will survive 5 years, and most will succumb in less than 2 years. CT scanning is the principal means for initial diagnosis and staging of these neoplasms. The detection and staging of pancreatic and biliary tract cancers are best accomplished with contrast-enhanced CT scanning, MRCP, or EUS, but not ERCP.

13. 2. What is the role of ERCP in pancreatic and biliary malignancy?

14. 3. What is the role of ERCP in pancreatitis? ERCP has no role in the diagnosis of acute pancreatitis except when biliary pancreatitis is suspected. In patients with severe biliary pancreatitis, early intervention with ERCP reduces morbidity and mortality compared with delayed ERCP. ERCP with appropriate therapy is beneficial in selected patients who have either recurrent pancreatitis or pancreatic pseudocysts.

15. 4. What is the role of ERCP in abdominal pain of possible pancreatic or biliary origin? The recommendations concerning this topic were the most difficult to derive. The validity of sphincter of Oddi dysfunction (SOD), especially types II and III, as a diagnostic entity has been questioned largely because, in contrast to the other topics, SOD lacks concrete pathological findings. SOD refers to an abnormality in sphincter of Oddi contractility. This benign, noncalculous, obstructive disorder may be responsible for recurrent abdominal pain of a biliary or pancreatic pattern for which an anatomic or structural lesion cannot be found. One classification system proposed for this elusive diagnosis follows. Type I biliary SOD includes all of the following: typical biliary-type pain (lasting 30 minutes and occurring at least once a year), elevated alanine transaminase and aspartate transaminase on two occasions, dilated common bile duct (>12 mm) or delayed biliary drainage (>45 min). Type II biliary SOD requires biliary-type pain and at least one additional criterion, while type III SOD is defined by pain alone and may represent part of the spectrum of functional abdominal pain.

16. 4. What is the role of ERCP in abdominal pain of possible pancreatic or biliary origin? Patients with type I sphincter of Oddi dysfunction (SOD) respond to endoscopic sphincterotomy (ES). Patients with type II SOD should not undergo diagnostic ERCP alone. If sphincter of Oddi manometer pressures are >40 mmHg, ES is beneficial in some patients. (Note: UNC does not perform Sphincter of Oddi manometry)

17. 5. What are the factors determining adverse events or success? The main complication of ERCP is pancreatitis. Other complications include hemorrhage, perforation, cholangitis, stent-related complications, and cardiopulmonary complications. Pancreatitis occurs in about 5 to 7 percent of patients undergoing ERCP, whether for diagnosis or therapy. Avoidance of unnecessary ERCP is the best way to reduce the number of complications. ERCP should be avoided if there is a low likelihood of biliary stone or stricture, especially in women with recurrent pain, a normal bilirubin, and no other objective sign of biliary disease. Endoscopists performing ERCP should have appropriate training and expertise before performing advanced procedures.

18. Cholangioscopy and Related Therapeutics

19. Issues with ERCP Recognized Early

20. Early Reports of Cholangioscopy

21. Early Reports

22. Early Reports

23. First Report of EHL

24. Mother-Daughter Scope System

25. 1999 Review of Miniscopes

26. A summary of two recent papers illustrating the significant difference between ERCP and cholangioscopy sensitivity Improved sensitivity achieved thru direct visualization A summary of two recent papers illustrating the significant difference between ERCP and cholangioscopy sensitivity Improved sensitivity achieved thru direct visualization

27. Malignant Stricture

28. Benign Stricture

29. So why haven�t baby scopes been adopted by more endoscopists? (read lines & ask for own experience) provide this context: 2 operators because 2 way steering requires duodenoscope manipulation One channel for both accessories & irrigation make clearing the field and EHL difficult Compensating for 2 way steering by torquing scope can break fiber bundles So why haven�t baby scopes been adopted by more endoscopists? (read lines & ask for own experience) provide this context: 2 operators because 2 way steering requires duodenoscope manipulation One channel for both accessories & irrigation make clearing the field and EHL difficult Compensating for 2 way steering by torquing scope can break fiber bundles

30. Single operator system � no need for duodenoscope manipulation because of four way steering � no need to schedule a special procedure with 2 MDs present Independent irrigation channels designed to provide optimal visual clearing and conductivity for EHL purposes Diagnostic & Tx capabilities � this is BSCs core competency � advanced Dx & Tx catheters Disposable & multi-use components � helps avoid costly capital expense due to repairs, should be available every time you need it Single operator system � no need for duodenoscope manipulation because of four way steering � no need to schedule a special procedure with 2 MDs present Independent irrigation channels designed to provide optimal visual clearing and conductivity for EHL purposes Diagnostic & Tx capabilities � this is BSCs core competency � advanced Dx & Tx catheters Disposable & multi-use components � helps avoid costly capital expense due to repairs, should be available every time you need it

31. Allow me to highlight the key components of the systemAllow me to highlight the key components of the system

32. There are 4 guidewires in the internal construction of the SpyScope Access & Delivery Catheter that facilitate steering as well as 4 open lumens; 2 for irrigation, one for devices, & one for visualization Show demo sample of SpyScope Access & Delivery Catheter if available Discuss single use advantage � protection for visualization probe and first time use performance There are 4 guidewires in the internal construction of the SpyScope Access & Delivery Catheter that facilitate steering as well as 4 open lumens; 2 for irrigation, one for devices, & one for visualization Show demo sample of SpyScope Access & Delivery Catheter if available Discuss single use advantage � protection for visualization probe and first time use performance

33. Probe Compare the size of the SpyGlass Probe to the size of a guidewire Cross section of probe � around the diameter there are about 250 fibers delivering light, in the center there is a 6000 pixel bundle connected to the lens at the tip to carry the image back to camera. All the size of .035 guidewire Forceps Micro-engineered Designed to provide histology sampling Very different jaw design, spike on side jaw designed to facilitate tissue capture & retention Probe Compare the size of the SpyGlass Probe to the size of a guidewire Cross section of probe � around the diameter there are about 250 fibers delivering light, in the center there is a 6000 pixel bundle connected to the lens at the tip to carry the image back to camera. All the size of .035 guidewire Forceps Micro-engineered Designed to provide histology sampling Very different jaw design, spike on side jaw designed to facilitate tissue capture & retention

34. Electrohydraulic Lithotripsy Equipment

35. Illustrative video