Post ERCP Pancreatitis

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Post ERCP Pancreatitis

• John M. Coleman
• Gen Med 3A
• 5/16/07

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What is ERCP?

• Endoscopic Retrograde Cholangiopancreatography
  An endoscopic technique in which an endoscope is
  guided into the Duodenum allowing instruements to
  be passed into the Bile or Pancreatic ducts
• Indications
• Diagnosis of Choledocholithiasis
• Palliation of Biliary obstruction in pts with
  Pancreatic or Biliary cancer
• Tissue sampling
• Diagnosis of Ampullary cancers
• Recurrent Pancreatitis or Pancreatic Pseudocyst
• Sphincter of Oddi Dysfunction
• Postop Biliary leaks or strictures
• NO ROLE IN DIAGNOSING ACUTE PANCREATITIS (except
  in biliary pancreatitis)

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Sphincter of Oddi Dysfunction

• Muscular structure that encompasses the distal
  bile duct and pancreatic duct as they enter the
  wall of the Duodenum
• Sphincter of Oddi Dysfunction describes a
  clinical syndrome of biliary or pancreatic
  obstruction related to mechanical or functional
  abnormalities of the Sphincter of Oddi
• Associated with post-cholecystectomy biliary pain

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Sphincter of Dysfunction

• Diagnosis is made by manometry, during ERCP,
  pressures greater than 40mm Hg
• Rome III Criteria
• Type I Biliary-type pain, abnormal
  transaminases, Bilirubin or Alk Phos gt2 times
  normal on 2 or more occasions. 65-95 evidence
  of Dysfunction
• Type II Biliary-type pain and ONE abnormal lab
  value. 50-63 evidence of Dysfunction
• Type III Recurrent Biliary-type pain and NO
  abnormal lab values. 12-59 evidence of
  Dysfunction

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Treatment for Dysfunction

• Pharmological Calcium Channel Blockers and
  Nitrates smooth muscle relaxation
• Endoscopic Sphincterotomy has the greatest
  benefits when pressures gt 40mm Hg
• Surgical Decreases the risk of recurrent
  stenosis from scarring and less risk of Duodenal
  Perferation

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Complications of ERCP

• Pancreatitis most common
• Hemorrhage
• Perforation
• Cholangitis
• Medications Sedatives and Contrast allergy
• Infection
• Rare Complications Duodenal Pneumatosis, Bilioma

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Post-ERCP Pancreatitis

• Risk Factors Younger Age, Females, prior-ERCP
  induced Pancreatitis, Sphincter of Oddi
  Dysfunction, small bile duct, pancreatic divisum
• Pathogenesis Mechanical injury from
  instrumentation of pancreatic duct, chemical
  reaction to contrast medium

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Treatment of Pancreatitis

• IVF Hydration
• Bowel Rest
• ICU Monitoring
• Antibiotics
• Pain Control (Demerol less Sphincter of Oddi
  spasm

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Effectiveness of the Treatment

• Sphincterotomy is only successful in 30 of
  patients in relieving symptoms longterm
• There is a five fold risk of repeat Pancreatitis
  after ERCP.