Endoscopic Retrograde Cholangiopancreatography (EPCR)

Abstract: Objective: Endoscopic retrograde cholangiopancreatography (ERCP) is widely used for the diagnosis and treatment of pancreatobiliary disease but requires a high level of endoscopic techniques, especially cannulation of the common bile duct (CBD). Peppermint oil has been reported to inhibit the contraction of smooth muscle. We hypothesized that spray of peppermint oil on papilla can shorten the cannulation time of ERCP. Methods: 160 pa- tients suspected of pancreatobiliary disease were randomly assigned to Peppermint oil group (group PO, n = 80) and Normal saline group (group NS, n = 80). After insertion of the duodenoscope and find the duodenal papilla, 20 mL of 1.6% peppermint oil solution (group PO) or Normal saline (group NS) was sprayed on the papilla by syringe via the working channel. The Deep CBD cannulation time, success rate of biliary cannulation and the incidence rate of adverse events were assessed. Results: The average cannulation time for the first 5 minutes was 189.7 (2-300) seconds in group PO and 237.8 (2-300) seconds in group NS (P = 0.03). The final success rate of biliary cannulation was 98.8% in group PO and 100.0% in group NS. The incidence rate of post-ERCP pancreatitis was 2.5% (2/80) in group PO and 6.3% (5/80) in group NS (P = 0.44). The mean amylase concentration was 177.4 (range 36-1067) IU/L in group PO and 267.5 (range 42-1733) IU/L in group NS (P = 0.04). Conclusion: Peppermint oil helps us to cannulate the papilla, shorten the time of cannulation, and reduce the incidence of hyperamylasemia after ERCP.

Abstract: Background: Endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal perforation is a serious complication associated with high mortality. We aimed to characterize and define improvements for ERCP through a retrospective review of ERCP-related perforations in our institution. Methods: The review of our medi- cal records identified six cases of ERCP-related perforations between March 2003 and March 2013. Associated clinical manifestations and outcomes, perforation types, imaging ERCP-related findings and treatment modalities were analyzed. Results: Between March 2003 and March 2013, 2071 ERCPs were performed, 6 (0.29%) of which resulted in ERCP-related perforations. The perforations localized in one instance to the horizontal part of duode- num, in one case to the bile duct, in one patient to the hepatic duct, and two times a periampullary perforation occurred. Perforation was suspected in 2 patients during the ERCP because of specific radiological findings, and in four patients after ERCP because of subsequent clinical behavior. The latter four perforations were confirmed by computed tomography (CT). The perforation of the horizontal part of duodenum was managed surgically, whereas the remaining five cases were managed conservatively. Conclusion: Successful management of ERCP-related per- foration requires a timely diagnosis and vigilant clinical and radiographic monitoring. CT is an important diagnostic modality in ERCP-related perforations.

times is followed by complications like biliary cutaneous fistula, biloma and bile peritonitis in the frequency (4% - 28%) [5]. With the introduction of endoscopic retrograde pancreatico-cholangiography (ERCP) pre- or post-operatively, these complications were greatly reduced [2]. The RECP interventions include sphincterotomy with or without stenting, nasobiliary drainage and balloon dilatation followed by evacuation making ERCP to play a pivotal role in the diagnosis and therapeutic treatment of IBRH [1] [5]. Until recently, ERCP is used as adjunct to surgery pre- or post-operatively to reduce surgical complication and the role of ERCP in the non- operative management was described only in case reports or small case series [1] [2] [5] [11] [12]. The aim of this study is to evaluate the role of ERCP in IHRH in the largest case series studied till now [11] [12].

Each patient or his/her relatives provided written informed con- sent after receiving verbal and written explanations of ERCP and possible post-procedure complications. The inclusion cri- teria: patients with age over 18 years old; underwent elective ERCP, the conditions of patients were informed. The exclusion cri- teria were an age of <18 years, pregnancy or breastfeeding, up- per gastrointestinal obstruction, Billroth II operation, severe hypo- xemia with ventilation/perfusion imbalance, acute myocardial in- farction within 3 months before the procedure, coagulopathy, and refusal to participate in the study. All patients’ medical his- tory was recorded, including the indications for ERCP, the pres- ence of concomitant diseases, and current medications. Endoscopic procedure

In conclusion, the incidence of post-ERCP bleeding in pa- tients with liver cirrhosis is remarkably high after diagnostic and therapeutic ERCP. CP classification can be a valuable pre- dictive factor for ERCP-related adverse events, especially in terms of bleeding. Bleeding problems may be related to the formation of a powerful collateral vascular bed in the area of the duodenum due to portal hypertension. In this regard, ther- apeutic ERCP in patients with liver cirrhosis should be used according to absolute indications and with high caution. For diagnostic purposes, minimally invasive methods, such as mag- netic resonance cholangiopancreatography, endoscopic ultra- sound, etc., may be more appropriate.

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved into a complex procedure involving spe- cialized operators, equipment and supporting personnel. ERCP was first described in 1965 as a novel method for imaging the pancreatic duct and biliary tree [1]. Successful management of choledocholithiasis with biliary sphincterotomy was described in 1974 by Classen [2] in Germany and Kawai [3] in Japan. Advances in compu- terized axial tomography (CT) body imaging, endoscopic ultrasound (EUS), and magnetic resonance cholan- giopancreatography (MRCP) have been essential in the evolution of ERCP applications from diagnostic to the- rapeutic. By 2007, estimated 500,000 ERCPs were performed annually in the US. ERCP utilization has steadily increased over time [4], with current annual US ERCP volumes expected to exceed those published in 2007 [5]. Analysis of the 2006 National Inpatient Sample Database for US ERCPs found that 90 percent were performed in centers with volumes of less than 200 per year, suggesting a large portion of ERCPs during the study period were performed in a community setting [6].

Introduction: Common bile duct stone (CBDS) is a common clinical problem that can cause serious complications, such as acute cholangitis and pancreatitis. It is im- portant to have an accurate, safe, and reliable method for the definitive diagnosis of CBDS before proceeding to therapeutic endoscopic retrograde cholangiopancreato- graphy (ERCP). Objective: To compare the accuracy of trans-abdominal ultrasound (TAUS) as a diagnostic tool at our institution—Kurdistan Centre for Gastroenterol- ogy & Hepatology (KCGH)—with invasive tool like ERCP in the diagnosis of bile duct stones, using specificity, sensitivity, and positive and negative predictive values. Pa- tient and Method: After obtaining ethical committee approval & informed consent from every patient. This was a prospective study conducted on 71 patients (24 male patients and 47 females patients) where suspected to have CBDS depending on his- tory, clinical suspicion and blood tests. Their ages range between (2 - 88 years). Both TAUS and ERCP were performed. Final diagnosis was confirmed depending on ERCP as it served as a diagnostic standard in diagnosing CBDS. Result: In 71 patients sus- pected to have CBDS by TAUS, only 46 patients had stone (65%), and 55 patients had stone by ERCP (77%). In our result, sensitivity, specificity, positive predictive value and negative predictive value for TAUS were 80%, 87.5%, 65.5% and 56%, respec- tively. Conclusion: TAUS can play an important role as an initial screening proce- dure for CBDS detection because of the various advantages like easy availability, cost effectiveness, no requirement of contrast material and lack of ionizing radiation but should done with other imaging modality to avoid serious complication of ERCP. How to cite this paper: Alkarboly, T.A.M.,

Since its first reported application in 1968, endoscopic retrograde cholangiopancreatography (ERCP) has be- come a valuable procedure for examination and treat- ment of pancreaticobiliary diseases [1]. One of the most serious complications of (ERCP) is acute pancreatitis. The reported incidence varies from 1.3% to 24.4% [2]. Measurement of serum amylase and lipase levels after the procedure may have a possible role for early recog- nition of post-ERCP pancreatitis [3]. Asymptomatic ele- vation in serum amylase and lipase activities after ERCP is common, occurring in approximately 25% to 75% of all patients, owing to the lack of specificity of pancreatic enzymes [4]. Reports indicate that serum and urinary trypsinogen-2 concentrations increase in patients with acute pancreatitis and that trypsinogen-2 levels can ser- ve as a more sensitive diagnostic marker for pancreatitis relative to amylase or lipase [1,5]. A rapid test strip has been developed for the detection of trypsinogen-2 in urine (The urinary trypsinogen-2 dipstick test—UT2DST- actim pancreatitis) which is based on the immunochro- matography principle and shows a good sensitivity and specificity in diagnosing acute pancreatitis [6].

cystic lesion in the pancreatic head. They showed the dila- tation of the MPD from the body to the tail of her pan- creas. We could not identify a connection between the cystic lesion and the MPD. EUS showed the cystic lesion more clearly than other modalities. EUS revealed that the cystic lesion consisted of both solid and cystic lesions. The solid area was shown as a hypoechoic and heterogeneous tumor, and the cystic area was shown as an anechoic le- sion. The EUS also showed that the MPD was dilated to 5 mm, and it was cut off around the mass in the pancreatic head. Endoscopic retrograde cholangiopancreatography (ERCP) showed > 12-mm-long stenosis of the MPD in the pancreatic head. The stenosis prevented a brush for cytology passing the stricture, and it was not possible to obtain a cytology specimen.

While most gastroenterologists are aware of the more common complications of endoscopy such as bleeding, infection and perforation, air embolism remains an under-recognised and difficult to diagnose problem due to its varying modes of presentation. This is the case of a 55-year-old man with right upper quadrant pain and imaging notable for cholecystitis and choledocholithiasis, who underwent endoscopic retrograde cholangiopancreatography (ERCP). During the ERCP, and shortly after a sphincterotomy was performed, he became hypotensive and hypoxic, quickly decompensating into pulseless electrical activity. While advanced cardiac life support was initiated, the patient passed away. Autopsy revealed air in the pulmonary artery suggestive of a pulmonary embolism. While air embolism remains a rare

Endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for evaluation of the pancreati- cobiliary tree. The major drawback of this invasive proce- dure is the potential for serious complications. The most common serious and potentially life-threatening complica- tions of ERCP are pancreatitis and cholangitis, which occur respectively in 5.4% and 1.0% of patients undergoing biliary sphincterotomy, even in expert centers (1). Although pancre- atitis risk is increased with therapeutic ERCP, it may also occur in the setting of diagnostic procedures. Although the therapeu- tic potential of ERCP is unsurpassed by alternative imaging procedures, less invasive diagnostic alternatives with similar capabilities, such as endoscopic ultrasound (EUS) and mag- netic resonance cholangiopancreatography (MRCP), can be considered potential alternative imaging techniques.

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique developed by McCune et al. in 1968 and Takagi et al. and Ohi in 1969 and subsequently became widely used worldwide [15]. Since then, as an ex- tension of this technique, various treatment methodologies have been developed and evolved. However, adverse outcomes, such as pancreatitis, are not rare, and measures to reduce these complications remain challenging. As to the complications of ERCP, pancreatitis, hemorrhage and gastrointestinal perforation are the primary exam- ples, among which pancreatitis may be severe and/or fatal. Various reports of high-risk groups regarding the development of ERCP-induced pancreatitis have been published. Fisk factors include a young age, female gender, normal pancreatogram findings, previous history of ERCP-induced pancreatitis, recurrent acute pancrea- titis and sphincter of Oddi dysfunction (SOD), etc., while operative risk factors involve the level of experience of the physician performing the operation, frequent pancreatography, precut EST, endoscopic papillary balloon dilatation (EPBD) and difficult intubation [1] [16]-[20]. Currently, treatment protocols for the treatment of acute pancreatitis based on evidence-based medicine comprise the use of massive transfusions at the early stage of onset and the administration of prophylactic antibiotics only. Furthermore, evidence regarding the efficacy of protease inhibitor therapy does not support the use of continuous arterial drop therapy. Although identifying high-risk groups and administering treatments such as preventive medications and pancreatic duct stent place- ment have been attempted as preventive measures for reducing the incidence of ERCP-induced pancreatitis, no effective strategies have been confirmed [21]-[27]. Therefore, providing sufficient hydration to prevent the onset of dehydration around the time of testing due to the effects of fasting is more critical in patients undergoing en- doscopic screening than in other cases. However, patients undergoing ERCP are normally instructed to fast starting the night before the procedure, similar to that required for normal endoscopy. Therefore, patients fre- quently complain of thirst and hunger at the time of testing and are often dehydrated, raising concern about the potential development of pancreatitis, a common ERCP complication, as well as the vasovagal reflex.

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive proced ure for diagnosis and treatment of biliary and pancreatic diseases. Even in the best hands, complications may occur in 2% - 10% of the cases, pancreatitis, cholangitis, perforation, and bleeding from papillotomy being the most frequent ones [1]. The overall mortality rate after a diagnostic ERCP is approximately 0.5%, while death rates after therapeutic ERCP are twice as high, and may occur from any of the complications described previously [4].

In the diagnosis of bile duct pathologies, clinical labora- tory findings and imaging studies play important roles. Frequently used imaging techniques are ultrasonography (USG), magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancrea- tography (ERCP). Abdominal USG is useful in detecting bile duct morphology; however, its sensitivity in detect- ing the ethiology of bile duct obstruction is low. In the diagnosis of bile duct stones, USG must be combined with other imaging methods [1]. The advantages of MRCP are it is not invasive or radionuclear and provides 3D images [2]. ERCP is another way of detecting those pathologies. Although it is an invasive method, some therapeutic investigations like sphincterotomy, stone extraction and stent placement can be performed while performing a diagnostic study [3]. According to some authors, 10% of MRCP and 5% of ERCP performed in

Background: Pancreatic extracorporeal shock wave lithotripsy (P-ESWL) is the first-line therapy for large pancreatic duct stones. Although it is a highly effective and safe procedure for the fragmentation of pancreatic stones, it is still not complication-free. Just like endoscopic retrograde cholangiopancreatography (ERCP), pancreatitis is the most common complication. To date, nonsteroidal anti-inflammatory drugs (NSAIDs) have proven to be the only effective prophylactic medication for post-ERCP pancreatitis and the European, American and Japanese Society for Gastrointestinal Endoscopy guidelines have recommended prophylactic rectally administered indomethacin for all patients undergoing ERCP. Given the little research about effective prevention for post P-ESWL pancreatitis, we aim to determine whether rectally administered indomethacin can reduce post-ESWL-pancreatitis.

versus Drotaverine Hydrochloride versus Hyoscine-N-Butylbromide for Duodenal Antimotility and ease of cannulation During Endoscopic Retrograde Cholangiopancreatography (ERCP)", is a bonafide work done by Dr.VADIVEL KUMARAN.S., Post-Graduate in Medical Gastroenterology, Madras Medical College, in partial fulfillment of the university rules and regulations for award of “D.M. IN MEDICAL GASTROENTEROLOGY” under my guidance and supervision during the academic year June 2013 to March 2014.

All ERCP procedures were done by experienced endoscopists who car- ried out > 200 ERCP procedures per year. The procedures were performed with Side-viewing duodenoscopes (TJF-240/260V, Olympus). The precut technique was carried out in difficult case of biliary cannulation. Endo- scopic sphincterotomy was carried out if necessary. Endoscopic papillary balloon dilation (EPBD) using a dilator balloon (COOK) was carried out in patients who required anti-thrombot- ic drugs or a stricture in the pancrea- tobiliary system. Endoscopic mechan- ical lithotripsy (EML) was carried out in patients with stones more than 12 mm in dimension. Standard tech- niques, such as basket or extraction balloon or both were used for bile duct stone removal. Patients with pancreatobiliary stricture were biop- sied during the procedure. After the procedure, stents or nasobiliary cath- eters were used as appropriate for duct drainage. Most of the treatments were carried out for up to 30 min after inserting an endoscope. All the patients were hospitalized before the procedure. In the postprocedure recovery period, an endoscopy nurse written the clinical observation and then patients were hospitalized for additional 72 h to assess any post- ERCP complications.

The patient was anesthetized with general or spinal anesthesia, and placed in lithotomy position. After cystoscopy, a hydro- philic guidewire (Roadrunner Wire Guide, Cook Medical, Bloom- ington, IN, USA) was inserted into the ureter. If pre-stenting was performed, using a ureteral stent, a hydrophilic guidewire was installed to the renal pelvis. A dual-lumen catheter was in- serted through the hydrophilic guidewire, and retrograde py- elography was performed. Using the dual-lumen catheter, an- other guidewire (Amplatz Superstiff Guidewire; Boston Scientific, Marlborough, MA, USA) was inserted, and an 11/13 or 12/14 Fr ureteral access sheath (Uropass, Olympus) was in- serted into the level of ureteropelvic junction. A flexible ure- teroreno-videoscope was inserted through the ureteral access sheath. Lithotripsy was performed with a laser lithotripter (Ver- saPulse Powersuite 100W, Lumenis, Tel Aviv, Israel) and 200 micron laser fibers. Large fragmented stones were extracted using a 1.9 Fr (Zero-tip, Boston Scientific) or a 1.3 Fr (OptiFlex, Boston Scientific) nitinol stone basket. Dusted particles were not removed to allow for natural drainage. At the end of the procedure, fluoroscopy was performed to evaluate stone clearance. A 6 Fr ureteral stent (Polaris Ultra or Polaris Loop, Boston Scientific) was routinely placed and maintained for 1 to 2 weeks in all patients.

flexible oesophagoscope. The port also facilitates gastric insufflation with carbon dioxide, in addition to the endo- scopic gas insufflation, for better visualization and nego- tiation of the gastro-oesophageal junction. The flexible oesophagoscope is advanced up the oesophagus until the lower aspect of the occlusion is encountered. Once the antegrade pharyngoscope and the retrograde flexible oe- sophagoscope are in place an image intensifier is posi- tioned for lateral fluoroscopy of the cervical region. Fluoroscopy is employed to gauge the length of the oc- cluded segment. An interventional radiologist then uses a long needle and co-axial catheter assembly (Rosch-Uchi- da Transjugular Liver Access Set, Cook Medical, Amer- sham, UK) to puncture across the occlusion from the upper end, using a combination of direct visualization and fluoroscopy for needle guidance. Entry into the distal oesophageal lumen is confirmed by watching the flexible oesophagoscope images from below the occlusion. After the co-axial needle and catheter assembly has been ad- vanced into the oesophageal lumen below the occlusion the needle component is withdrawn and a 260 cm stiff radiological guidewire (Amplatz, Boston Scientific, Na- tick, MA, USA) passed down the catheter into the distal oesophageal lumen where it is grasped via the flexible oesophagoscope, thus achieving “rendezvous” between the patent lumen above and below the occlusion. The guidewire is then withdrawn down through the distal oe- sophagus and out through the mini-laparotomy, thereby creating through-and-through guidewire access across the occlusion.

Both percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiography (ERC) are accepted approaches in the management of pa- tients with malignant obstruction at the liver hilum. In routine clinical practice, ERC is generally favored on the basis of: (1) high technical and clinical suc- cess rates for other (non-hilar) indications; (2) the perceived safety of ERC relative to PTBD; (3) the perceived ability to perform more comprehensive tis- sue sampling at the time of ERC compared to PTBD; (4) the avoidance of external tubes which are often needed for PTBD; and (5) because patients with sus- pected malignant hilar obstruction (MHO) typically present to, and are managed by, gastroenterologists.