ERCP & Fluoro Quiz

1. ERCP & Fluoro Quiz Willis Parsons, M.D. Medical Director of GI Center Northwest Community Hospital Arlington Heights, IL Center for Advanced Therapeutic Endoscopy

2. Outline ERCP indications, pancreaticobiliary tract diseases and terminology Patient preparation Stone, stricture, and leak management Minimizing post-ERCP pancreatitis Fluoroscopy quiz

3. Common Indications for Biliary ERCP • Bile duct stones +/- cholangitis • Obstructive jaundice • Malignant & benign strictures • Pancreatitis • Severe acute gallstone pancreatitis • Management of post-op complications • Bile leaks, injuries/strictures

4. Less Common Indications for ERCP • Pancreatitis • Acute recurrent • Pseudocyst drainage & pancreatic endotherapy • Management of post-op complications • Post-liver transplant • Sphincter of Oddi dysfunction • Ampullectomy for adenoma

5. Abdominal U/S Gallstone Gallbladder stones = Cholelithiasis

6. Bile Duct Stone = Choledocholithiasis MRCP • May present incidentally, or with biliary colic, jaundice, cholangitis, gallstone pancreatitis • Role of U/S, MRCP, EUS • ERCP sensitive, therapeutic, operator-dependent, and potentially morbid CBD

7. Left Hepatic Duct Right Hepatic Duct Confluence CHD . … Cystic Duct CD Origin CBD Biliary Sph. Gallbladder

8. Proximal . Distal

9. Hilum of Liver Porta Hepatis .

10. Normal Pancreaticobiliary Anatomy • Normal bile duct diameter <7 mm • Causes of Duct Dilation • Disease • Functional • Post-cholecystectomy (CCY) • Peri-ampullarydiverticulae • Aging

11. ERCP X-Ray of CBD Stones on Left/Endo Photo of Impacted Stone on Right

12. Bile Duct Infection = Cholangitis Presents as RUQ pain, fever, chills, jaundice/elevated LFTs, shock, mental status changes Rx: IV fluids, broad spectrum antibiotics, biliary tract drainage (ERCP with stone extraction/stent or PTC/PTB)

13. Video of Suppurative Cholangitis

14. Bile Duct Cancer = Cholangiocarcinoma • Risk factors: PSC, choledochocysts, parasites • 5th-7th decades • M>F • Painless jaundice + weight loss • Curative surgery uncommon CHD stricture

15. Primary Sclerosing CholangitisChronic, progressive, fibrosing inflammatory disease of bile ducts • 70% of PSC pts have IBD • 15% will develop cholangiocarcinoma • Dx: ERCP or MRCP • Rx: Actigall, treat dominant strictures, liver transplant

16. Sphincter of Oddi Dysfunction • Biliary-type pain • Females>males, children and adults <60 yr • Stenosisvs Spasm • Dx: ERCP with manometry • Risk of post-ERCP pancreatitis much greater

17. Normal Pancreatogram Accessory Duct Main Pancreatic Duct

18. Normal Pancreatogram Duct of Santorini Duct of Wirsung

19. Pancreatic Terminology Tail Minor papilla Body Head Major papilla

20. Pancreatic Terminology Distal Pancreas Proximal Pancreas

21. Acute Pancreatitis • Inflammation of pancreas due to “auto-digestion” • Presents as acute onset of severe epigastric pain radiating to back, N/V with associated elevations in serum lipase • Ranges from mild to severe (pancreatic necrosis & MSOF) • CT+IV ctx distinguishes interstitial from necrotizing • Treatment: NPO, aggressive IVF resuscitation, pain control, nutritional support • ERCP for selected patients

22. Acute Pancreatitis • 80% of all pancreatitis related to alcohol or gallstones

23. Other Causes of Acute Pancreatitis Pancreas divisum Tumors including cancers Drugs Post-ERCP Sphincter of Oddi Dysfunction Autoimmune Miscellaneous – scorpion bite, choledochocele, hereditary, viral infections, trauma Idiopathic – less than 10%

24. CT of Acute Pancreatitis Gallbladder w/ cholelithiasis Pancreas Liver Spleen

25. Normal MRCP Bile duct Pancreas duct Major Papilla/ Ampulla of Vater

26. Pancreas Divisum Minor papilla Ampulla of Vater (Major Papilla)

27. Chronic Pancreatitis • Fibrosis & atrophy of gland • 70% alcohol related • Pain, steatorrhea, weight loss, diabetes • Rx: pain management, pancreatic enzymes, ERCP/pancreatic endotherapy, surgery Pancreas Duct

28. Pancreas Cancer • 60-75% occur in head • Few early symptoms • Rx: Whipple for the 15% that appear resectable after staging; palliative stenting, chemoXRT, pain Rx for the remainder CBD stricture PD stricture

29. Patient Preparation

30. Patient Preparation – At Home • Fast for >8 hours • Hold anti-platelet meds • Coumadin, Plavix, Lovenox/Heparin, ASA • Correct platelets to >60K and INR to <1.6 • Continue cardiac & BP meds • Adjust diabetes meds

31. Patient Preparation – In GI Lab • Place IV - 20 ga or larger • Check FS glucose in diabetic patients • Obtain urine hCG in ovulating females • Give antibiotics to select patients • Deactivate AICD • Answer questions & complete consent form

32. Endoscopic Photo of Ampulla of Vater 12 The “5 to 11 O’Clock Angle” 9 Glucagon 0.3 mg IV increments 6 Gentle Touch & Communicate

33. Guidewire Cannulation *Cennamo V et al. Am J Gastroenterol 2009; 104:2343-2350 Katsinelos P et al. Endoscopy 2008; 40:302-307 Mariani A et al. GIE 2012; 5:339-346 Tse F et al. Cochrane Database 12:CD009662 Kawakami H et al. Gastrointest Endosc 2012; 75(2):362 • Increases primary cannulation rate • Likely reduces risk of post-ERCP pancreatitis* • Sphincterotomes pre-loaded with hydrophilic straight-tipped guidewires are ideal

34. Short vs Long Wire : Fusion & Rx SHORT WIRE LONG WIRE V- Lock is built into the Olympus duodenoscope elevator and allows for short wire techniques without using Fusion or Rx products Less expensive More X-ray exposure Training needed for smooth exchanges More expensive Less X-ray exposure ?Faster Gives the doctor more guide-wire control

35. Biliary Stone Extraction – Balloon or Basket? BALLOON BASKET Must have emergency lithotriptor available Cannot provide high quality cholangiogram Works well for almost all size stones Can be used either as open or closed basket sweep • No entrapment risk • Allows for occlusion cholangiogram • Good for sludge • Often fails with stones >8 mm diameter • Often fails with small stones in dilated duct

36. The “Flip Down” Maneuver Prevents balloon breakage and aids in stone extraction One stone is pulled down above sphincterotomy, balloon size matched to CBD diameter, then stone is extracted by simultaneously gently pulling on balloon andturning the big wheel forward

37. Video of Flip Down Maneuver

38. Fusion/Trapezoid Basket & Handle • Fusion (Cook) • Trapezoid (BSC)

39. Video of Trapezoid Basket Lithotripsy

40. Endoscopic Papillary Balloon Dilation (EPBD) for Stones *Freeman et al. Gastrointest Endosc 2010; 72:1163-1166 • Early data suggested high risk of pancreatitis • Very helpful after sphincterotomy for extraction of large stones; 6-18mm diam balloons – choose size based upon duct diameter*

41. EPBD

42. Extraction of Large Bile Duct Stones Usually Requires Lithotripsy • Mechanical lithotripsy should be available in your lab! • Conquest TTC, Lithocrush, Soehendra • Fusion or Trapezoid lithotripsy basket • Refractory stones usually amenable to electro-hydraulic lithotripsy (EHL) or laser lithotripsy via cholangioscopy

43. Soft Wire Basket Capturing Distal Stone Proximal Stone Distal Stone

44. Soehendra Lithotripsy: Removal of Scope after Closing Basket

45. Placement of Soehendra Lithotriptor Cable over Basket and Sheath Soehendra Cable Basket around Stone

46. Soehendra Lithotriptor Handle

47. Lithocrush TTS Lithotripsy

48. Lithocrush TTS Lithotripsy

49. Spyglass Cholangioscopy (BSC) Single-operator, disposable, steerable, POC catheter with 2 dedicated irrigation channels, 1 channel for optical probe, 1 working channel, and disposable SpyBite biopsy forceps

50. Spyscope