ERCP and Sphincterotomy

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ERCP and Sphincterotomy

• Raika Jamali M.D.
• Gastroenterologist and hepatologist
• Tehran University of Medical Sciences

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Case 1

• An 74 year man came to ER with RUQ pain, fever,
  and icterus.
• He uses ASA, and warfarin for IHD and heart
  failure.

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LAB DATA

• AST 230 U/L ALT 256 U/L
• Bili total 7.8 mg/dl Bili direct 2.6 mg/dl
• ALP 640 U/L

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IMAGING

• Ultrasonography of biliary tree shows dilation of
  CBD with stone.

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• What is your recommendation for anticoagulation
  in this patient before ERCP?

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• 1.stop warfarin 10 days before endoscopy
• 2.stop warfarin 5 days before endoscopy
• 3.stop warfarin between 5-10 days before
  endoscopy

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Case 2

• A 65 year old diabetic woman on insulin admited
  for the evaluation of RUQ pain and icterus.

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LAB DATA

• AST 230 U/L ALT 256 U/L
• Bili total 7.8 mg/dl Bili direct 2.6 mg/dl
• ALP 640 U/L

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IMAGING

• Ultrsonography of biliary tree shows dilation of
  CBD without stone.
• MRCP showed 9 mm stone in distal CBD.

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• What is your recommendation on prophylactic
  antibiotic for this patient before ERCP?

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• 1.Antibiotic prophylaxis should be considered
  before ERCP
• 2. Antibiotic prophylaxis is not recommended
  before ERCP

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RECOMMENDATION

• Antibiotic prophylaxis should be considered
  before an ERCP in patients with known or
  suspected biliary obstruction, in which there is
  a possibility that complete drainage may not be
  achieved at the ERCP, such as in patients with a
  hilar stricture and primary sclerosing
  cholangitis (PSC) (Grade 2C).

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RECOMMENDATION

• Antibiotic prophylaxis is not recommended in
  patients with biliary obstruction when it is
  likely that an ERCP will accomplish complete
  biliary drainage (Grade 1C).

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RECOMMENDATION

• Antibiotic prophylaxis is not recommended before
  an ERCP when obstructive biliary-tract disease is
  not suspected (Grade 1C).

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RECOMMENDATION

• Antibiotic prophylaxis is recommended before an
  ERCP in patients with communicating pancreatic
  cysts or pseudocysts and before transpapillary or
  transmural drainage of pseudocysts (Grade 3).

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Case 3

• A 68 year old man presented with RUQ pain, fever,
  and icterus.

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LAB DATA

• AST 230 U/L ALT 256 U/L
• Bili total 7.8 mg/dl Bili direct 2.6 mg/dl
• ALP 640 U/L

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• You see the ERCP of the patient. What is the best
  treatment plan for this patient?

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Common bile duct stone
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• 1.ANTIBIOTICS is mandataory
• 2.Percutaneous drainage
• 3.ERCPand sphinctrotomy
• 4.Surgery

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Case 4

• An old man presented with RUQ pain, fever, and
  ichterus 3 months after cholecystectomy .
• AST 230 U/L ALT 256 U/L
• Bili total 7.8 mg/dl Bili direct 2.6 mg/dl
• ALP 640 U/L
• You see the ERCP of the patient.

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Common bile duct stricture
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• What is the best treatment plan for this patient?

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• 1.ANTIBIOTICS is mandataory
• 2.ERCPand Biliary stenting
• 3.Percutaneous drainage
• 4.Surgery

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Case 5

• An old man presented with progressive icterus and
  significant weight loss.

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LAB DATA

• AST 30 U/L ALT 56 U/L
• Bili total 17.8 mg/dl Bili direct 10.6 mg/dl
• ALP 640 U/L

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Common bile duct stricture
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• What is the best treatment plan for this patient?

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• 1.ANTIBIOTICS is mandataory
• 2.ERCP and Metalic Biliary stenting
• 3.ERCP and plastic Biliary stenting
• 4.Percutaneous drainage

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Case 6

• An opium addict 57 year old man presented with
  icterus and RUQ pain.

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LAB DATA

• In admition AST 30 U/L ALT 56 U/L Bili
  total 1.8 mg/dl Bili direct 0.6 mg/dlALP
  640 U/L
• 3 days later AST35 ALT69 Bili total2 D0.7
  ALP666

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IMAGING

• Ultrasonography of biliary tree shows dilation of
  CBD without stone.
• MRCP Only dilated CBD. No stone or mass

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• What is the best diagnostic plan for this
  patient?

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Sphincter of Oddi manometry
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• What is the best management plan for this
  patient?

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• 1.Nitrates
• 2.ERCP and Biliary stenting
• 3.ERCP and sphincterotomy
• 4.Percutaneous drainage

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Whats your diagnosis?
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• 1.Bilary leak
• 2.Mirrizi Syndrome
• 3.Choledochal cyst
• 4.PSC

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Indications for sphincterotomy

• Common bile duct stone
• Common bile duct stricture
• Post cholecystectomy (benign)
• Cholangiocarcinoma (malignant)
• Bile leak
• Sphincter of oddi dysfunction (SOD)

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Periampullary vs ampulary diverticulum

• Is it a cause or an effect?

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• 1.Both conditions are associated with
  pancreatitis
• 2.Periampulary diverticula is associated with
  pancreatitis
• 3. Ampulary diverticula is associated with
  pancreatitis

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• While ampullary duodenal diverticula can cause
  chronic pancreatitis, periampullary duodenal
  diverticula are no etiologic factor.
• Naranjo-Chavez J, Schwarz M, Leder G, Beger HG.
  Ampullary but not periampullary duodenal
  diverticula are an etiologic factor for chronic
  pancreatitis. Dig Surg. 200017(4)358-63.

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• Choledocholithiasis is considered to be strongly
  associated with JPD, but the role of JPD in the
  development of cholecystolithiasis and
  pancreatitis is still disputable.

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• The ERCP procedure can be hampered by JPD,
  although recent papers have reported no
  difference in the successful cannulation rate or
  complications between patients with JPD and those
  without JPD.

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Case 7

• A man presented with RUQ pain and fever 12 hours
  after ERCP.
• The abdominal CT scan is shown in the next slide.

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• What is the best treatment plan for this patient?

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• 1. Conservative management
• 2. Surgery

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