ERCP
and
Sphincterotomy
Raika Jamali M.D.
Gastroenterologist and hepatologist
Tehran University of Medical Sciences
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.
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
IMAGING
• Ultrasonography of biliary tree shows
dilation of CBD with stone.
• What is your recommendation for
anticoagulation in this patient before
ERCP?
• 1.stop warfarin 10 days before endoscopy
• 2.stop warfarin 5 days before endoscopy
• 3.stop warfarin between 5-10 days before
endoscopy
Case 2
• A 65 year old diabetic woman on
insulin admited for the evaluation of
RUQ pain and icterus.
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
IMAGING
• Ultrsonography of biliary tree shows
dilation of CBD without stone.
• MRCP showed 9 mm stone in distal CBD.
• What is your recommendation on
prophylactic antibiotic for this patient
before ERCP?
• 1.Antibiotic prophylaxis should be
considered before ERCP
• 2. Antibiotic prophylaxis is not
recommended before ERCP
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).
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).
RECOMMENDATION
• Antibiotic prophylaxis is not recommended
before an ERCP when obstructive biliarytract disease is not suspected (Grade 1C).
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).
Case 3
• A 68 year old man presented with
RUQ pain, fever, and icterus.
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
• You see the ERCP of the patient.
What is the best treatment plan
for this patient?
Common bile duct stone
• 1.ANTIBIOTICS is mandataory
• 2.Percutaneous drainage
• 3.ERCPand sphinctrotomy
• 4.Surgery
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.
Common bile duct stricture
• What is the best treatment plan
for this patient?
• 1.ANTIBIOTICS is mandataory
• 2.ERCPand Biliary stenting
• 3.Percutaneous drainage
• 4.Surgery
Case 5
• An old man presented with
progressive icterus and significant
weight loss.
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
Common bile duct stricture
• What is the best treatment plan
for this patient?
• 1.ANTIBIOTICS is mandataory
• 2.ERCP and Metalic Biliary stenting
• 3.ERCP and plastic Biliary stenting
• 4.Percutaneous drainage
Case 6
• An opium addict 57 year old man
presented with icterus and RUQ pain.
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: AST=35 ALT=69 Bili total=2
D=0.7 ALP=666
IMAGING
• Ultrasonography of biliary tree shows
dilation of CBD without stone.
• MRCP: Only dilated CBD. No stone
or mass
• What is the best diagnostic plan for
this patient?
Sphincter of Oddi manometry
• What is the best management plan
for this patient?
• 1.Nitrates
• 2.ERCP and Biliary stenting
• 3.ERCP and sphincterotomy
• 4.Percutaneous drainage
What’s your diagnosis?
• 1.Bilary leak
• 2.Mirrizi Syndrome
• 3.Choledochal cyst
• 4.PSC
Indications for sphincterotomy
• Common bile duct stone
• Common bile duct stricture
– Post cholecystectomy (benign)
– Cholangiocarcinoma (malignant)
• Bile leak
• Sphincter of oddi dysfunction (SOD)
Periampullary vs ampulary
diverticulum
• Is it a cause or an effect?
• 1.Both conditions are associated with
pancreatitis
• 2.Periampulary diverticula is
associated with pancreatitis
• 3. Ampulary diverticula is associated
with pancreatitis
• 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. 2000;17(4):358-63.
• Choledocholithiasis is considered to be
strongly associated with JPD, but the role
of JPD in the development of
cholecystolithiasis and pancreatitis is still
disputable.
• 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.
Case 7
• A man presented with RUQ pain and
fever 12 hours after ERCP.
• The abdominal CT scan is shown in
the next slide.
• What is the best treatment plan for
this patient?
• 1. Conservative management
• 2. Surgery