ERCP (Endoscopic Retrograde Cholangiopancreatography): Who needs it and who doesn’t?
ERCP is essentially a therapeutic procedure for the management of mainly biliary and to a lesser extent pancreatic disorders. ERCP mostly involves a sphincterotomy ( a cut ) to open the duodenal ampulla to remove stones from the bile duct, stenting of bile duct to relieve obstruction from inoperable cholangiocarcinoma , pancreatic cancer or metastatic tumour, removal of pancreatic duct stone, obtain brush cytology from probable malignant stricture of the bile duct and pancreatic duct stenting following sphincterotomy for type 2 sphincter of Oddi dysfunction.
These patients, by and large, present with abnormal liver tests (LFTs), sometimes with pancreatitis or both and almost always with dilated bile and or pancreatic ducts. Clinical features include signs of sepsis as in cholangitis, painless jaundice, abdominal pain and or wt loss. So, how should one proceed with a patient who presents with abnormal LFTs with or without symptoms? Clearly there are two broad possibilities:
- Parenchymal liver disorders
e.g.,viral hepatidis (A,B,C,CMV,EBV), autoimmune disorders (autoimmune hepatitis, primary biliary cirrhosis), metal storage diseases (haemochromatosis , Wilson’s disease) and alfa -one antitrypsin deficiency. These can be addressed with serology for viral hepatidis, anti-smooth muscle antibody, antimitochondrial antibody, iron studies, caeruloplasmin, alfa-one antitrypsin level and remember to add on an alfa-fetoprotein: broadly referred to as liver screen tests. - Obstruction of biliary tree and or pancreatic disorder from stone in the bile duct (figure 1), cancer of the bile duct (cholangiocarcinoma) (fig2), external compression of the bile ducts by tumour or known metastatic disease, carcinoma of the head of the pancreas (fig.3), stricture of the distal bile duct from chronic pancreatitis or from sclerosing cholangitis, type 1 sphincter of Oddi dysfunction and stone in the pancreatic duct in symptomatic patients. These disorders are best defined initially with CT of the abdomen with or without an US.
So , how do we proceed to investigate?
I prefer to request liver screen tests and CT of the abdomen at the initial consultation. I attach little importance to whether the abnormal LFTs are hepatitic or cholestatic which can be misleading and can cause loss of precious time. However, in some viral hepatidis, prodorm and symptoms can be quite characteristic. For the purpose of this article, we are only interested in patients whose liver screen tests are normal (excluding parenchymal liver disorders) but their CT scan demonstrates dilated biliary tree, bile duct stone, pancreatic head tumour or metastatic tumour around the extra hepatic biliary tree or portahepatis and pancreatic duct obstruction from stones. Further details can be obtained from an MRCP (magnetic resonance cholangiopancreatog- raphy) which I often employ to obtain confirmation and details for a road map prior to proceeding with an ERCP.
Complications of ERCP: Mortality rates of 0.33% and 0.34% respectively were reported in a North American summary of prospective studies (1) of 16,855 patients and in two prospective series of 7252 patients (2,3). My mortality rates of 0.03% in the 3,457 ERCPs ( data 1 June,2010) compares favourably with the above studies which are the largest series to date. The larger series (1) referred to above also reported perforation rates of 0.6% in 16,855 patients compared to 0.08% for my ERCPs for 3,457 patients. Commonest complications of ERCP is mild to moderate pancreatitis. Martin Freedman reported 5.4% for his series (4) of 2,347 patients compared to 3.8% for my 3,457 patients.
Summary:
- For patients presenting with febrile illness/cholangitis, painless jaundice or simply pain with abnormal LFTs, in the interest of time, please request liver screen tests and a CT abdomen at the initial consultation.
- If the liver screen tests are normal and CT scan shows dilated bili- ary tree, pancreatic tumour, biliary or pancreatic duct stones or metastatic tumour encasing the biliary tree, then please refer to a gastroenterologist for ERCP.
I am available at 07 5531 7809 to dicuss your case. If I am in the middle of a procedure, please leave a telephone number such that I can call you back directly between cases or after hours if that suits better.
References
1.Andriulli A et al, Am . J. Gastroenterol 2007;1002:1781
2.William E.J et al.,Endoscopy 2007; 39,793
3 Wang P et al.,Am. J. Gastroenterol 2009 ;104,31
4.Freedman M L et al.,N.Eng.J. Med 1996;335,909.
Further reading:
Loperfido S et al., Overview of indications for and complications of ERCP and endoscopic biliary sphincterotoy, UpToDate, version 17.3:sept 2009
Update on Eosinophilic Oesophagitis
Eosinophilic oesophagitis is a common cause of long standing intermittent dysphagia and food bolus obstruction of allergic diathesis mainly in the Caucasian male. These patients have history of allergic rhinitis, asthma , eczema and other skin atopy. Endoscopic features of fine longitudinal and circumferential rings and furrows and fine nodular appearance of the oesophageal mucosa (due to exudates) are readily recognizable. Biopsies from the proximal oesophagus demonstrating more than 15 eosinophils per high power field is considered diagnostic. Some patients have peripheral eosinophilia.
Treatment with fluticasone aerosol 500 micrograms swallowed twice daily for 3 months , on an average, induces remission for 7 months. Treatment can be repeated. Australian patients seem to do very well with single course of fluticasone and rarely return for a further course. Exclusion of milk, egg, wheat, soy, nuts and shell fish helps. Persistence of dysphagia, despite medical treatment, indicates reduced compliance of the oesophagus and can be treated with careful oesophageal dilatation.
Further Reading
Hirano,I: Oesinophilic oesophagitis :what do we know after 15 years.?:AGA post graduate course. May 2010.