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 Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)

Chapter

VII

Endoscopic Retrogerade
Cholangiopancreatography (ERCP)

Waseem Hamoudi M.D

Consultant Gastroenterology & Hepatology

Amman-Jordan

247
 Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)
1. Introduction
Endoscopic retrograde cholangio-pancrea-
tography (ERCP) is an endoscopic technique
in which a side-viewing duodenoscope is
guided into the duodenum, allowing for differ-
ent instruments to be passed into the biliary
and pancreatic ducts. The procedure is done
by injection of a contrast medium in order to
permit radiologic visualization of biliary and
pancreatic ducts. It was first described by Mc-
Cune in 19681
The success and safety of the procedure
depends on proper indication, sedation
and monitoring of the patient during
and after the procedure, equipment and
procedural accessories and training of
the endoscopist and endoscopic team . 2
At least 180 procedures are required for
a trainee to acquire a level of competence
Figure 1: Cannulation of Common bile duct through a lateral view endoscope
in diagnostic and therapeutic ERCP,
defined by deep cannulation of the bile
duct in 70 to 80 percent of cases3, 4. For
experts the optimal standard requirement
for deep cannulation is 90 to 95 percent5.
To maintain proficiency it is recommended
to perform more than 40 endoscopic
sphincterotomies per year6 or at least
one per week7.
2. Indications
ERCP should be done for clear
indications, by trained endoscopists
using standard techniques, with well-
documented patient-informed consent,
and communication before and after the
procedure8,9. Complications should be
recognized and managed early, and there
should be honest and compassionate
communication with the family and
patient. (figure 1).
249
Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)
ERCP is generally indicated in10, 11:
• Suspected obstructive jaundiced
patient (painful or painless) with clinical
and biochemical or imaging data
suggest pancreatic duct or biliary tract
disease.
• Acute biliary pancreatitis with concomitant
cholangitis or biliary obstruction.
• Evaluation of pancreatitis of unknown
etiology.
• Preoperative evaluation of the patient
with chronic pancreatitis.
• Evaluation of the sphincter of Oddi by
manometry in patients with suspected
type II SOD.
• Endoscopic sphincterotomy for:
Choledocholithiasis, sphincter of Oddi
dysfunction type I, Sump syndrome,
papillary stenosis, stricture therapy
and facilitating stent introduction or to
facilitate access to the pancreatic duct.
• Stent placement for benign or malig-
nant strictures, fistulae, postoperative
bile leak, or in high-risk patients with
large difficult to remove common duct
stones.
• Dilation of intra-biliary strictures.
• Balloon dilation of the papilla (sphinc-
teroplasty).
• Pancreatic pseudocyst drainage in
some cases.
• Tissue sampling from pancreatic or bile
ducts.
250
• Ampullectomy of adenomatous lesions
of the major papilla.
• Facilitation of cholangioscopy and or pan-
creatoscopy.
3. Complications
Complications could be general similar
to all endoscopic procedures (medica-
tion reactions, oxygen desaturation,
cardiopulmonary accidents, and bleed-
ing or perforation induced by the en-
doscope), and selective complications
related to the procedure (pancreatitis,
sepsis, and bleeding or retroperitoneal
duodenal perforation following thera-
peutic procedures)
Early complications occur within the
first 30 days after the procedure while
late complications after 30 days12. The
severity of complications can be assessed
in terms of the length of hospital stay;
the need for transfusions; intensive care
unit assistance; surgical, radiologic or
endoscopic interventions, any resulting
permanent; and death12,13,14.
4. Specific complications
4.1. Pancreatitis
The most frequent complication of ERCP
is pancreatitis, it occurs between 0.4 to
5.4% of cases and may reach 15%.
4.2. Bleeding
Bleeding during ERCP typically develops
after sphincterotomy. It occurs between
 Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)
1.2 and 1.5% of the cases. As for all
endoscopic procedures, patients should
be screened for a history of excessive
bleeding and the use of anticoagulants or
antiplatelet agents. A platelet count and
prothrombin time should be checked in
patients undergoing ERCP.
4.3. Infection
Infections occurring after ERCP are most
often due to manipulation of an obstructed
biliary or pancreatic system, thus it is
important to achieve effective drainage in
patients with biliary obstruction 15
. Less
commonly, infection can be introduced
by contaminated endoscopic equipment
(unlikely if proper disinfection methods
have been used). It occurs in less than
1% of cases.
4.4. Perforation
Retroperitoneal duodenal perforation
can occur, usually secondary to
sphincterotomy. ERCP may rarely
be complicated by perforation of the
esophagus, stomach, duodenum, or
jejunum (risk is increased in patients with
stenosis of any of these segments and
in patients who have undergone gastric
resection). It occurs between 0.1-0.6% of
cases.
5. Nonspecific complications
5.1. Conscious sedation-related complications
With intravenous benzodiazepines and
analgesic opiates, may induce respiratory
incidences16. Thus, all patients should be
carefully monitored, and flumazenil and
naloxone should always be available.
Propofol needs to be administered by
specially trained personnel who are not
directly involved in the procedure17, 18.
5.2. Anticholinergic side effects
Anticholinergics are used to inhibit motor
and secretory activity of the intestinal tract.
They can have effects on cardiac function
that require monitoring. Glucagon is a
safe alternative to anticholinergic agents.
5.3. Contrast allergy
May induce rarely anaphylactic reactions
during ERCP, thus a history of sensitivity
to iodine contrast or drug should always
be considered in the preprocedure
assessment and in the informed consent
process. In patients with prior allergy to
contrast media, prophylactic measures
must be adopted and those include19:
Use of nonionic/low-osmolarity contrast
media (ex: Gadolinium)20, and
premedication with oral steroids starting
the day before ERCP or intravenous
steroids when an allergy is discovered
just before the procedure. Addition of
intravenous antihistamine in combination
with the steroids is warranted also.
6. Informed consent
Patients should be made aware of the
risks associated with the procedure
during procurement of informed consent.
251
Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)
The informed consent content varies
according to the ethics of the medical
profession and the rules of each country,
but it typically requires that the patient
has adequate awareness of his operator,
the specific benefits and risks of the
procedure, and possible alternatives.
7. Preprocedure evaluation
Should be used selectively based on the
patient’s medical history, physical exam-
ination findings, and procedural risk fac-
tors. General basic tests for therapeutic
endoscopic procedure such as complete
blood count and prothrombin time/inter-
national normalized ratio are important
prior to procedure. coagulation studies
for patients with coagulopathy; chest ra-
diograph for patients with new respira-
tory symptoms or decompensated heart
failure. Patients who are receiving anti-
coagulants should hold their medication
for an appropriate time prior to the pro-
cedure.
8. Monitoring during and after ERCP
Electronic monitoring devices such as
pulse oximetry enhance the safety of
conscious sedation and are commonly
used. After the procedure, patients of
moderate and high risk of complications
are advised to continue fasting for 12
hours with strict monitoring for eventual
complications. Patients who are at low
risk of complications can have their
diet advanced gradually over four to
six hours. Serum pancreatic enzymes
252
prior to the procedure and later for early
detection of post-ERCP pancreatitis are
recommended since this complication is
the most frequent serious complication
of ERCP. Patients should be carefully
monitored during the recovery phase
after ERCP (6-8 hours after procedure)
to detect symptoms or signs suggestive
of adverse events.
9. ERCP; Procedural techniques
Identification and cannulation
9.1. Procedural techniques
When the side view doudenoscope
reaches the first part of the duodenum,
and the tip is angled to the right and
slightly upward. The scope is then
carefully withdrawn with slight clockwise
torque applied to bring the endoscope
into the “short position.” This maneuver
should advance the endoscope to the
second part of the duodenum and permit
visualization of the major duodenal
papilla, which appears as a small, pink
colored protuberance at the junction of
the horizontal and vertical duodenal folds.
9.2 Positioning
Proper positioning of the doudenoscope is
the key of cannulation of the pancreatic or
common bile duct.
Of the pancreatic or common bile duct.
To canulate common bile duct, the scope
should be positioned so that the image
of the papilla is in the upper part of the
video monitor, this allows an upward
approach to the papilla, which results in
easy cannulation of CBD. Cannulation of
 Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)

the pancreatic duct is easily achieved by using the wire guided approach ease the
an approach that is more perpendicular cannulation in such cases (figure 2 & 3).
to the duodenal wall.

For cannulation of the CBD, the cannula-

tion device should be aimed in a slightly
tangential direction to the 11 o’clock po-
sition. For cannulation of the pancreatic
duct, the device should be pointed to the
1 o’clock position.

There are two methods of cannulation,

the contrast guided cannulation which
involves passage of the cannulation
device tip into the papillary orifice, followed
by injection of contrast material to confirm
Figure 2: Guide wire inserted in the
proper positioning, and the wire guided common bile duct – Fluoroscopic image.
approach, which involves a passage of a
guide wire under fluoroscopy into either Once cannulation obtained a cholangiogram
the pancreatic duct or the CBD before the or pancreatogram is performed by injection
injection of contrast (less complication of a contrast media in the desired ducts,
method). this will give details upon the biliary tree
or pancreatic duct pathology and will
Few anatomical abnormalities could
permit therapeutic procedures by passing
make the cannulation challenging. A
periampullary diverticulum, which occurs accessories over the guide wire into the
in approximately 7.5% of patients 21 is the desired duct under fluoroscopy.
most common abnormality.

When the ampulla is located outside the

diverticulum, the natural course of the
CBD is often unaltered, but when it is
located inside the sac, proper alignment
of the duodenoscope can be very
challenging (risk of bowel perforation),
so considerable care should be taken
in repositioning the duodenoscope in
the presence of a diverticulum. Distal
ductal defects (impacted stone, distal Figure 3: Fluoroscopic image of biliary tree
CBD tumor or stenosis) may make the after injection of contrast media. Image
cannulation of the papilla difficult but representing Mirizzi syndrome type IV

253
Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)
The most common therapeutic procedures
are those dealing with biliary or pancreatic
duct stones, malignant or benign strictures
or stenosis, leaks, and tissue sampling.
10. Endoscopic sphincterotomy and
its variants.
10.1. Sphincterotomy
The goal of the sphincterotomy is to cut the
biliary sphincter after deep cannulation in
order to eliminate the principal anatomic
barrier impeding stone passage and
facilitating stone extraction.
Standard sphincterotomy involves the
application of electrocautery to create
an incision through the musculature
of the biliary portion of the sphincter of
Oddi. This is done by of different devices
(sphincterotome) that vary in design
to facilitate the procedure depending
upon specific anatomic considerations.
In expert hands, a sphincterotomy is
possible in 95 to 100 percent of patients
(Figure 4).
Figure 4: Endoscopic sphicterotomy
254
The length of the sphincterotomy should
be tailored to the size of the stone
and papilla. It is preferred to create a
sphincterotomy that completely unroofs
the papilla, since this maximizes access to
the common bile duct and decreases the
risk of developing papillary stenosis. The
current used for cutting is preferred to be
a mixed current (coagulation and cut 1:2
ratio) in order to minimize complications
of sphincterotomy. Sphincterotomy for
common bile duct that is not dilated may
result in retroperitoneal perforation.
10.2. Complications
The most common short term
complication associated with endoscopic
sphincterotomy is pancreatitis, which
can also occur during ERCP without
sphincterotomy. Other complications
are perforation of the duodenum or bile
duct, bleeding, and infection. Long-term
complications following endoscopic
sphincterotomy include stone recurrence,
papillary stenosis, and cholangitis, which
occur in approximately 6 to 24 percent
of patients 22, 23
. In difficult cannulation, a
needle-knife fistulotomy can be created
with subsequent antegrade passage of
a guide wire across the ampulla. The
fistulotomy can then be extended using a
wire guided sphincterotome.
10.3. Billroth II
Sphincterotomy in patients who have
undergone a partial gastrectomy with
Billroth II anastomosis and the papilla is
 Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)

upside down, the bile duct is cannulated 5). It is associated with higher incidence
by orienting the catheter downwards of pancreatitis (it is believed to be due to
in the six o’clock position. Two major a compartment syndrome at the level of
techniques for performing sphincterotomy the ampulla that results in significant lo-
in this situation, the first involves stenting cal edema and compression). Combining
the bile duct and then using a needle- large balloon dilation with small sphinc-
knife to cut over the stent. The incision terotomy appears to be safe and permits
stone extraction while avoiding the need
is continued along the stent towards the
for mechanical lithotripsy.
junction of the intramural segment and the
duodenal wall (in the six o’clock position).
The other method uses the reverse
sphincterotomes which are sigmoid
loop sphincterotomes that are designed
so that the diathermy wire is oriented
towards the six o’clock position.24, 25

10.4. High-risk patients

Patients with comorbid illness are at

greater risk for complications. Those
are patients who have had a recent
myocardial infarction and patients with Figure 5: Balloon dilatation of the ampul-
cirrhosis, so care must be taken in la of Vater (sphincteroplasty)
addition to alternative methods of ES.

10.5. Papillary balloon dilatation

(sphincteroplasty)

This method involves dilation of the am-

pulla with a balloon followed by stone
extraction. The balloonThe balloon (spe-
cial balloon under controlled pressure) is
positioned within the ampulla (alone or
after small sphincterotomy) then it is in-
flated up to 10 mm for 20 to 60 seconds
26
. This method is used for patients with
Figure 6A: Common hepatic duct
high risk of bleeding or to avoid lithotripsy dilatation with inflated balloon-
and patients with a periampullary diver- Fluoroscopic image.
ticulum or Billroth II gastrectomy (Figure

255
Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)
11. Choledocholithiasis management
Presence of gallstones within the common
bile duct (migration of gallbladder stones)
is called secondary choledocholithiasis
while primary choledocholithiasis (for-
mation of stones within the common bile
duct due to bile stasis) is less common.
Primary choledocholithiasis occurs in the
setting of bile stasis (patients with cystic
fibrosis, older adults with large bile ducts
and periampullary diverticula and patients
Figure 6B: CBD stone
Figure 6D: IHBRs stones
256
with recurrent or persistent infection in-
volving the biliary system (populations
from East Asia)) (Figure 6A,B,C,D,E).
The two major complications associated
with choledocholithiasis are pancreatitis
and acute cholangitis, patients with biliary
pancreatitis typically present with nausea,
vomiting, elevations in serum amylase
and lipase (more than three times the
upper limit of normal), and/or imaging
findings suggestive of acute pancreatitis.
Figure 6C: CBD dilated due lower end stone
Figure 6E: Dilated CBD without stones
 Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)
Patients with acute cholangitis often
present with Charcot’s triad (fever, right
upper quadrant pain, and jaundice) and
leukocytosis. In severe cases, bacteremia
and sepsis may lead to hypotension and
altered mental status (Reynolds’ pentad).
Confirmation of choledocholithiasis can
be obtained using ERCP, MRCP, EUS
and trans-abdominal US. It is preferred
to perform noninvasive procedure to
diagnose choledocholithiasis (such
as MRCP). ERCP is reserved for
interventional purposes.
Endoscopic management of choledocho-
lithiasis implies identification of ampulla
of Oddi, cannulation and opacification of
the biliary ducts with identification of bil-
iary stones. Sphincterotomy is the most
commonly used therapy for treatment
of choledocholithiasis. The goal of the
sphincterotomy is to cut the biliary sphinc-
ter with the use of electrocautery to cre-
ate an incision through the musculature
of the biliary portion of the sphincter of
Oddi thereby eliminating the principal an-
atomic barrier impeding stone passage
and facilitating stone extraction. Stan-
dard sphincterotomy involves the use of
sphincterotomes (long or short nose) and
basket or extraction balloons. The use of
basket is generally indicated when the
duct is dilated or multiple large stones are
present, the use of balloon is warranted
when the duct is not dilated or if there is
a single free-floating stone , also balloons
are useful when multiple small stones are
present or when a larger stone has been
crushed. . The balloon must be larger
than the diameter of the duct. Once a
stone has been grasped within a basket
or a balloon has been advanced proxi-
mal to the stone, pulling the stone/bal-
loon or stone/basket apparatus is often
sufficient to extract the stone.
One risk of basket extraction is impaction
of the basket within the bile duct. This
results from imbedding of the basket’s
wires within the stone surface. Mechan-
ical lithotripsy is often helpful in these cir-
cumstances. Mechanical lithotriptors are
devices that are designed to break stones
that have been captured within a basket.
The risk of impaction can be reduced by
extraction of the most distal stone first
when multiple stones are present. The
risk of impaction can also be reduced by
gently pulling the basket and stone to the
preampullary level without closing the
basket tightly against the stone (Figure
7&8).
Alternative methods to sphincterotomy
are sphincteroplasty (Endoscopic papil-
lary balloon dilatation) and combination
of biliary sphincterotomy and balloon di-
lation especially for larger stones and in
patients with an associated suprapapil-
lary stricture27,28.
257
Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)

Figure 7: Lithotripsy (Courtesy of Prof. Ahmed Hashem & Cairo University Endoscopy
Unit)

Figure 8: CBD stone in dormia basket (Courtesy of Cairo University Endoscopy Unit)

258
 Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)

12. Endoscopic stenting and double-pigtail. Straight stents have

one, two, or four flaps at each end to
Biliary stents are used to relieve
help anchor the stent. Available stent
obstruction in patients with both benign
diameters include 7, 8.5, 10, and 11.5 Fr
and malignant disease.
with lengths ranging between 5 and 15
The use of stents for the treatment of cm. The duration of function of plastic

benign disease (strictures of biliary biliary stents is variable, with stent

tree, stones, post-surgical leaks) or for patency typically ranging between 60 and

the prevention of post ERCP induced 200 days. Metalic stents: Self-expanding

pancreatitis. In the setting of malignant metal stents (SEMS) can be uncovered,

pancreatic and biliary obstruction, stents partially covered, or fully covered. The

may be used as a bridge to surgery or metal component can be stainless steel,

for palliation in patients with unresectable nitinol (nickel and titanium), or Platinum

terminal disease. (platinum core with nitinol encasement)

Nitinol has traditionally been the preferred
Malignant conditions in which stenting metal due to its ability to maintain the
is usually indicated are: Distal malignant shape of a curved lumen30 . (Figures
biliary obstruction (often due to pancreat- 9,10,11&12).
ic cancer, cholangiocarcinoma, or exter-
Metal biliary stents are cylindrical in
nal compression from lymph node metas-
shape and made by interwoven alloy
tases). Hilar obstruction may result from
wires, with some stents having proximal
cholangiocarcinoma (Klatskin tumor),
and distal flaring to reduce migration.
gallbladder carcinoma, hepatoma, lo-
Biliary SEMS are deployed with through-
cal extension of pancreatic cancer, solid
the-scope (TTS) delivery systems that
metastases, or compression from lymph
have diameters ranging from 6 to 8.5 Fr.
nodes29 .
They are pre-constrained within delivery
Types of stents: Plastic stents: They catheters and deployed via the removal or
can be made from multiple materials withdrawal of an outer restraining sheath.
including Teflon, polyurethane, and After deployment, the stent material
polyethylene. Stent shapes include embeds into both the tumor and normal
straight (Amsterdam), single-pigtail, tissue by expansible, radial pressure.

259
Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)

Difficult cannulation due to presence of Divertuculae

Extracted stones from CBD

Successful drainage Insertion of two plastic stents

Figure 9&10: Cannulation, stones extracion & stent insertion (Courtesy of Prof.
Ahmed Hashem)
260
 Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)
12.1. Uncovered metal stents
The advantage of using them anywhere
in the biliary tree (including the hilum).
In addition, they have low rates of
stent migration. The disadvantages
of uncovered metal stents are limited
removability and higher rates of tumor
ingrowth (Figure 11).
Figure 11: An uncovered Self Expandable
Metal Stent for a case of cancer head of
pancreas (Courtesy of Prof. Ayman Yousry)
Figure 12: Metallic stent deployed in the ampulla of Vater.
12.2. Covered metal stents
They have advantages of potential
reduction of tumor ingrowth and are
potential removable. The disadvantages
of covered metal stents include potentially
increased rates of stent migration, an
inability to use the stents at the level of
the hilum, and the possibility of stent-
induced cholecystitis (Figure 12).
It is indicated that patients with unresect-
able disease who are expected to survive
more than three to six months be treat-
ed with metal stents. For a patient with
a distal malignant biliary obstruction due
to potentially resectable disease, the
placement of plastic stent or a short distal
metal stent should be considered. Also,
patients with extrinsic compression may
be adequately treated with an uncovered
stent, while those with intraluminal
261
Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)

tumors may benefit from a covered stent

to minimize tumor ingrowth.

Placing of covered metal stents in prox-

imal biliary strictures must be avoided
because it could block the left or right he-
patic duct. For patients with hilar obstruc-
tions, stenting of both the right and left
systems with either plastic stents or un-
covered SEMS is indicated to decrease
the risk of cholangitis.
Figure 13: Common bile duct stricture-
Fluoroscopic image.
The most common complications of bil-
iary stent placement include stent oc-
clusion and stent migration. Less com-
mon complications include cholecystitis,
cholangitis, pancreatitis, perforation, and
bleeding31.

13. Stricture dilatation

Biliary tree strictures can be treated

by using dilating catheters (up to 11.5
French) and Gruntzg type balloon (up to
30 French = 10mm which is performed at
4 to 6 atm pressure). With inflation, the
waist of the balloon disappears. Following Figure 14: Hilar stricture with dilated
dilatation, the stricture may be stented intrahepatic biliary radicles

temporally with a stent having a diameter (Courtesy of Prof. Ahmed Hashem,

smaller than the maximum diameter of Cairo University Endoscopy Unit)

the balloon32, 33 (Figure 13& 14).

262
 Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)
14. Postoperative complications
Include strictures, bile leaks and sump
syndrome. After recognition of bile duct
injury by diagnostic means, the type and
extent of endoscopic intervention will be
determined by the anatomic site of bile
injury.
14.1. Strictures
Previous biliary tract surgery is the most
common cause of benign biliary strictures.
Jaundice and symptoms of cholangitis
usually occurs within 2 years of surgery
and imaging studies prove the presence
of stricture. Endoscopic treatment of
postsurgical strictures consists of balloon
dilatation and stenting with plastic or
metalic stents. Balloon dilatation and
stricture stenting may be repeated
many times when surgical definitive
management is contraindicated.
14.2. Fistulas
Post-surgical complications may result
in fistulas or biloma. After recognition of
the site of leak, sphincterotomy may be
sufficient to seal the leak. If extrahepatic
leak is detected a nasobiliary catheter or
a plastic stent may be placed across the
disruption to divert bile temporarily from
the site of injury and allow time for the
injury to heal 34, 35
. al abnormality that could lead to these
14.3. Sump syndrome
Rare complication of a side to side
choledochoduodenostomy which include
stenosis of the surgical anastomosis
with accumulation of debris, stones,
food particles in the common bile duct
proximal to the papilla and distal to
the stenotic anastomosis which will be
complicated with bacterial overgrowth
and cholangitis. Treatment of Sump
syndrome consists of combination of
endoscopic sphincterotomy and balloon
passage through the CBD and sweeping
the debris out of the duct.
15. Sphincter of Oddi dysfunction
The pathogenesis of this condition is
recognized to encompass stenosis
or dyskinesia of the sphincter of Oddi
(especially after cholecystectomy);
consequently the terms biliary dyski-
nesia, papillary stenosis, and post cho-
lecystectomy syndrome have all been
used to describe this condition. The
pathogenesis is unclear; one hypothe-
sis is that denervation of the common
bile duct in the ampullary region (sec-
ondary to surgical intervention) leads
to the development of a hypertonic
sphincter, causing dilated ducts and
cholestasis36.Abdominal pain in the
right upper quadrant area that persists
more than 30 minutes without structur-
263
Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)
symptoms. This condition can be pre-
cipitated by gall bladder surgery or bar-
iatric surgery and may be precipitated
by opioids. The Milwaukee classifica-
tion of biliary sphincter of Oddi dysfunc-
tion (SOD) further divides the condition
into three subtypes:37 Type I biliary:
biliary-type abdominal pain, with all of
the following: altered liver enzymes on
blood testing, dilated biliary ducts on
ultrasound or ERCP, and delayed bile
clearance on HIDA scan. Type II biliary:
biliary-type abdominal pain associated
with one or two of the following: altered
liver enzymes on blood testing, dilat-
ed biliary ducts on imaging tests, and
delayed bile clearance on HIDA scan.
Type III biliary: biliary-type abdominal
pain with none of the following: altered
liver enzymes on blood testing, dilat-
ed biliary ducts on imaging tests, and
delayed bile clearance on HIDA scan.
Sphincter of Oddi dysfunction is best di-
agnosed using manometry to measure
the pressures within sphincter of Oddi.
Endoscopic sphincterotomy may be the
treatment.
16. Malignant diseases
Endoscopic management of malignant
non operative tumors of biliary tree with
the aim of palliation is to relieve jaundice,
pruritus and sepsis. This is obtained by
stenting of the biliary tree with plastic or
metalic self-expandable stents. Plastic
264
stenting has a success rate comparable
with palliative surgical bypass with lower
complication rates and lower hospital stay.
The disadvantage is stent obstruction
for patients with a longer survival. Metal
self-expandable stents occlude less
frequently, with patency that exceeds
9 months which means lower rates
to repeat ERCP and hospitalizations.
Occluded stents may be treated by re-
stenting with plastic or metalic stent or
mechanical cleaning of the occluded
stent. Removal of metalic stents is
possible for covered stents only38, 39. For
distal CBD lesions (pancreatic carcinoma,
ampulla carcinoma and peripancreatic
lymph nodes enlargement that obstruct
the distal CBD) stenting with biliary
plastic or metalic stents is preferred. In
cases of distorted ampulla area, supra-
ampullary precut needle approach with
stenting can be the solution and if not
possible, stenting with percutaneous
trans-hepatic approach. Proximal CBD
lesions (cholangiocarcinoma, external
compression and gall bladder carcinoma)
are treated with long plastic stents or self-
expandable metalic uncovered stents. In
hilar and intrahepatic lesions relieving
jaundice can be obtained by draining one
single system, but to relieve cholangitis, it
is important to drain both biliary systems.
Using metalic and plastic stent to relieve
both systems can be used40,41. (Figure
15&16)
 Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)

Figure 15: GB cancer

Figure 16: A.Cancer Pancreas B.Cancer Pancreas with stent

Figure 17: Primary sclerosing cholangitis

(Courtesy of Prof. Ahmed Hashem, Cairo University Endoscopy Unit)
265
Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)

17. Treatment of ampullary adenomas polyps, which are frequently numerous

and also have malignant potential44,45
Ampullary Adenoma is a benign neoplasms
of the ampulla of Vater and represent less Patients diagnosed with an ampullary
than 10 percent of periampullary neoplasms, adenoma have three options for polyp
The most common benign lesions are removal: pancreaticoduodenectomy
villous and tubulovillous adenomas; others (Whipple procedure), surgical local
include hemangiomas, leiomyomas, excision (surgical ampullectomy), or
leiomyofibromas, lipomas, lymphangiomas, endoscopic ampullectomy. Surgical
and neurogenic tumors .
42,43
Although excision is typically recommended for
classified as benign, ampullary adenomas patients with larger lesions, lesions that
have the potential to undergo malignant contain carcinoma or lesions with lymph
transformation to ampullary carcinomas
node involvement on preprocedure
(Figure 18).
imaging. Endoscopic ampullectomy may
be considered in patients with smaller
lesions (2-3 cm diameter) that do not
contain carcinoma and in patients who
are poor surgical candidates.

Success rates for endoscopic removal of

Figure 18: Ampullary adenoma – Endo-
scopic image.
They can occur sporadically or in the
setting of familial polyposis syndromes,
such as familial adenomatous polyposis
(FAP) and its related conditions. Around
40-100 percent of patients with FAP
who have ampullary adenomas also
have coexisting duodenal adenomatous
ampullary adenomas range from 46 to 92
percent, with recurrence rates of 0 to 33
percent46 . Complications after endoscopic
ampullectomy include pancreatitis (8 to
15 percent), perforation (0 to 4 percent),
bleeding (2 to 13 percent), cholangitis (0
to 2 percent), and papillary stenosis (0 to
8 percent)47,48,49,50 .
Endoscopic ampullectomy is typically
performed with the standard monopolar
diathermic snare used in colonoscopic
polypectomy through lateral view
duodenoscope, removal of the adenoma
can be performed en block (one piece)
or by piece meal resection. Biliary or
pancreatic sphincterotomy prior to

266
 Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)

procedure may enhance the outcome of 18. AIDS Cholangiopathy

procedure and decrease complications;
AIDS Cholangiopathy is an uncommon
similarly pancreatic stent insertion after
manifestation of advanced AIDS that was
the procedure may decrease pancreatitis
associated with a poor prognosis prior to
as a complication. Local saline injection
the era of effective antiretroviral therapy.
may increase technical success and
AIDS cholangiopathy occurred in as many
decrease complications49, 50 .The injection
prevents a deeper burn into the duodenal as 26 percent of AIDS patients prior to the

wall. Removal of residual marginal tissue
after the procedure by thermal ablation
(ex. Argon plasma ablation, using a 7 Fr
probe at a setting of 50 to 60 watts) paying
careful attention to avoid aggressive
tissue destruction around the biliary or
pancreatic orifices (Figure 19) .
advent of highly active antiretroviral ther-
apy (HAART)51,52 ; the current incidence
of cholangiopathy is not known, but has
decreased in the era of potent antiretro-
viral therapy (ART)52 . Almost all patients
have CD4 cell counts of <100 × 106/L and
many have counts of <50 × 106/L. The

A: Ampullary mass (endoscopic picture) B: Echoendoscopic image of

T1N0 papillary mass

C: Enbloc papillary resection.

Figure 19: Ampullary tumour (EUS diagnosis and endoscopic ampullectomy)

(Courtesy of Prof. Jean Escourrou and Prof. Hany Shehab) .

267
Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)

most common presenting symptom is needle aspiration (FNA)

that of biliary-type pain. Jaundice is un- •Tumor ablation
common but most patients show changes
•Cystgastrostomy
in liver enzymes, typically a mild to mod-
erate elevation of alkaline phosphatase. •Ampullary resection

Abnormalities at cholangiography can in- 19.2. Low-risk procedures (bleeding risk

clude bile duct dilatation associated with <1 percent) include:
papillary stenosis, widespread changes
•Diagnostic endoscopic retrograde
similar to sclerosing cholangitis and ex- cholangiopancreatography (with or
trahepatic strictures53.These changes are without biopsy)
usually due to opportunistic infections in
•Biliary stent insertion without endoscopic
the biliary system with Cryptosporidium,
sphincterotomy
cytomegalovirus or Mycobacterium avi-
um-intracellulare54,55. Although antimicro- •Papillary balloon dilation (without sphinc-
terotomy)
bial therapy for AIDS cholangiopathy is
often ineffective, most patients improve •EUS without FNA
after the introduction of antiretroviral ther-
•Argon plasma coagulation
apy. Endoscopic sphincterotomy (or en-
doscopic stenting) is helpful for pain as- For low-risk procedures, the American
Society of Gastrointestinal Endoscopy
sociated with papillary stenosis but only
guidelines suggest making no changes
results in improvement in liver function
in anticoagulation but for elective pro-
tests in a minority of patients56.
cedures it is preferable to be delayed if
19. Management of anticoagulants in the international normalized ratio or pro-
patients undergoing ERCP thrombin time is in the supratherapeutic

The risk of bleeding from endoscopic range 57.

procedures can be classified as high or In patients undergoing high-risk

low. In general, diagnostic procedures are
low risk, whereas therapeutic procedures
are high risk.
19.1. High-risk procedures (risk
bleeding 1 to 6 percent) include:
•Biliary or pancreatic sphincterotomy
•Endoscopic ultrasound (EUS) with fine-
endoscopic procedures, discontinuing
vitamin K antagonists (e.g, warfarin)
five days before the procedure and
of discontinuing direct oral anticoagulants
(e.g, dabigatran, rivaroxaban, apixaban,
or edoxaban) one to two days before the
procedure in patients with normal renal
function.

268
 Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)
• Bridge therapy is not required for pa-
tients at low risk for thromboembolism.
• Bridge therapy may be required for pa-
tients at high risk for thromboembolism.
Patients who resume warfarin will require
several days to achieve therapeutic levels
of anticoagulation. Oral direct thrombin or
factor Xa inhibitors (dabigatran,rivaroxaban,
and apixaban) will achieve therapeutic
levels of anticoagulation within hours of
administration 58.
19.3. Reversing anticoagulation in acute
hemorrhage
Fresh frozen plasma and unactivated
prothrombin complex concentrate (PCC)
can be used to correct a supratherapeutic
international normalized ratio (INR).
Vitamin K is less useful than fresh frozen
plasma or PCC in the acute setting
because of its delayed onset of action
(12 to 24 hours) and the prolonged
time required to reestablish therapeutic
anticoagulation after its use59
Disorders of hemostasis that may
require treatment prior to gastrointestinal
procedures include von Willebrand
disease, hemophilia A and B, renal failure,
liver failure, and thrombocytopenia and
are corrected by giving desmopressin,
Von Willebrand factor, factor VII, fresh
frozen plasma and others.
20. Complications related to liver
transplantation (Figure 20 A,B,C&D)
Biliary tract complications are an import-
ant cause of morbidity and mortality in
liver transplantation (LT) recipients. The
most frequent are biliary tract strictures,
bile leaks, and bile duct stones. The
estimated incidence of these complica-
tions ranges between 10 and 25 percent
in various reports, although rates have
been decreasing over time60,61. Most
can be managed successfully with en-
doscopic retrograde cholangiography if
there is a duct-to-duct anastomosis. Bil-
iary complications following LT can be
categorized as early (within four weeks)
or late62. Biliary strictures can be further
divided into anastomotic, nonanasto-
motic, and diffuse intrahepatic strictures.
Other complications such as bile casts,
sphincter of Oddi dysfunction, mucocele,
and hemobilia are rare and also can be
managed endoscopically. Risk factors
for the development of biliary complica-
tions after LT (particularly strictures) are
acute hepatic artery thrombosis, hepatic
artery stenosis, bile leak, technical fac-
tors during surgery (excessive dissection
of periductal tissue during procurement,
excessive use of electrocautery for biliary
duct bleeding control in both donor and
recipient, and tension of the duct anas-
tomosis), small caliber of the bile duct
and mismatched size between donor and
269
Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)
recipient bile ducts, ischemia/reperfu-
sion injury, pre-LT diagnosis of cytomeg-
alovirus infection, donation after cardiac
death, ABO blood group mismatch, older
age of donor, prolonged cold and warm
ischemia times, and primary sclerosing
cholangitis62,63,64,65.
20.1. Diagnosis
A biliary complication is
first suspected in asymptomatic LT
recipients who have elevations of serum
aminotransferases, bilirubin,
phosphatase, and/or gamma-glutamyl
transferase levels. Occasionally, patients
have nonspecific symptoms (such as
fever and anorexia), right upper quadrant
abdominal pain (especially with bile
leaks), pruritus, jaundice,
ascites. Exposure of the peritoneum and
other visceral structures to bile usually
results in abdominal pain. However,
pain may be absent in the transplant
setting because of immunosuppression
and hepatic denervation 62, 63, 65
abdominal ultrasound, angio-computer
tomography and hepatic angiography
must be obtained. Liver biopsy is often
performed to exclude rejection. If there is
a strong clinical suspicion and an US that
indicates a bile duct obstruction with or
without stones or bile leak, it is mandatory
to perform ERC, MRCP or percutaneous
transhepatic cholangiography (PTC) (for
patients with patients with a Roux-en-Y
choledochojejunostomy).
270
20.2. Strictures
Bile duct strictures account for
approximately 40 percent of all biliary
complications after LT63. The incidence
in various reports ranges between 4
and 16 percent. Strictures that occur
early after LT are due mostly to technical
usually problems, whereas late strictures are
mainly due to vascular insufficiency,
ischemia, and problems with healing and
alkaline fibrosis63, 66. Bile leak is an independent
risk factor for the development of
anastomotic strictures67,68. Strictures
can occur with either type of biliary
anastomosis, but are more common
with Roux-en-Y choledochojejunostomy
and bile
reconstruction69,70 .
20.3. Anastomotic strictures (AS)
AS occur within the first 12 months after
LT. AS identified within six months after
. Doppler LT usually have a good response to short-
term stenting (three to six months) 71
but
they have recurrence rate of 18-34%.
Treatment is done by ERCP with balloon
dilation (with 6 to 8 mm) and plastic
stents. Endoscopic imaging will show a
thin narrowing in the area of the biliary
anastomosis. Most patients with an AS
require ongoing ERC sessions (every
three months) with balloon dilation and
long-term stenting (for 12 to 24 months).
 Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)

A.The anterior system is cannulated and B. A stent inserted into the anterior
is mildly dilated. There is partial filling of system. Balloon dilation of the posterior
the anastomosis of the posterior system. system “note the waist “.

C.Dilation of the posterior system accom- D.A stent in the anterior system and
plished “disappearance of the waist”. another in the posterior system: “drainage
accomplished “.

Figure 20 A,B,C&D : ERCP for a jaundiced patient post living donor liver transplantation:
two donor bile ducts anastomosed to one recipient CBD. (Courtesy of Prof. Ayman
Yousry)

271
Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)
20.4. Nonanastomotic strictures (NAS)
NAS result mainly from hepatic artery
thrombosis or other forms of ischemia.
Less commonly, they can be due to
recurrence of the underlying disease
such as primary sclerosing cholangitis.
They account for 10 to 25 percent of all
stricture complications after LT, with an
incidence in the range of 0.5 to 10 percent
72,73,74,75
. Impaired blood supply as a result
of vascular ischemia may cause injury
to the peribiliary glands and vascular
plexus. Damage to these structures
is associated with the development of
NAS after transplantation76. NAS can
occur proximal to the anastomosis in the
extra- or intrahepatic bile duct. There
may be multiple strictures involving the
hilum and intrahepatic ducts, causing
a cholangiographic appearance that
resembles primary sclerosing cholangitis.
Biliary sludge can accumulate proximal
to the strictures, leading to the formation
of casts77 which predispose the patient to
develop recurrent episodes of cholangitis.
NAS tend to occur earlier than AS, with
a mean time to stricture development
of three to six months, though they
can occur up to one year following
LT73,74. Endoscopic therapy of NAS
typically consists of 4 to 6 mm balloon
dilation followed by sphincterotomy and
placement of 10 to 11.5 Fr plastic stents
272
with replacement every three months,
similar to the management of AS43.
Only 50 percent of patients have a long-
term response with endoscopic therapy
with dilation and stent placement73 and
up to 50 percent of patients undergo
retransplantation or die as a consequence
of this complication despite endoscopic
therapy73. Generally, ischemic events
that lead to diffuse intrahepatic bile duct
strictures are associated with poor graft
survival and in most instances will require
retransplantation in suitable candidates.
Surgical revision may ultimately be
required in patients with strictures
that are refractory to endoscopic or
percutaneous treatment. A Roux-en-Y
choledochojejunostomy is usually
performed in patients with duct-to-duct
anastomosis. In those who already have
a Roux-en-Y anastomosis, repositioning
the bile duct of the graft to a better
vascularized area may be required.
20.5. Bile leaks
Occur following LT with an incidence that
ranges between 2 and 25 percent62, 78, 79.
Leakage can occur from the anastomosis,
the cystic duct, the T-tube tract, or (in the
case of living donor or split liver LT) from
the cut surface of the liver. Many bile leaks
can be resolved nonoperatively with early
intervention. Early bile leaks usually
occur at the anastomotic site and are
often related to technical issues. Bile
leaks are suspected in patients with
 Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)

peritonitis or fluid collections seen on Large bilomas not communicating with

imaging tests. In cases where a T-tube is the bile ducts should be treated with
in place, small anastomotic leaks can be percutaneous drainage and antibiotics.
diagnosed with a T-tube cholangiogram Surgery is indicated when the bile leak
and be managed by leaving the tube cannot be effectively controlled with
open without further intervention. In nonsurgical methods.
patients without a T-tube, ERC is the gold
In patients with common bile duct filling
standard diagnostic method in detecting
defects (such as gallstones, sludge,
bile leaks. Placement of a plastic biliary
blood clots, casts, and migrated stents),
stent (for 2-4 weeks), with or without
treatment should be done by ERC and
biliary sphincterotomy is successful in
sphincterotomy with extraction of the
treating 90 to 95 percent of early bile
filling defect. In patients with suspected
leaks. Small leaks can be managed with
sphincter of Oddi dysfunction, biliary
biliary sphincterotomy alone. Bile leaks in
sphincterotomy is indicated80.
patients with Roux-en-Y anatomy more
often require surgical management.
Late bile leaks usually related to the
removal of the T-tube, resulting from
delay in T-tube tract maturation due to
immunosuppression. A bile leak should
be suspected in patients who develop
pain when the T-tube is removed. ERC
(with or without sphincterotomy) with
placement of transpapillary stents is
indicated. Surgery or a percutaneous
transhepatic approach is reserved
for patients in whom the endoscopic
approach is unsuccessful.

20.6. Biloma

In patients with bile duct necrosis

secondary to hepatic artery thrombosis,
bilomas can occur due to bile duct
rupture and extravasation of bile into the
hepatic parenchyma or the abdominal
cavity. Management of small bilomas is
ERC with trans-papillary plastic stent.

273
Chapter VII: Endoscopic Retrogerade Cholangiopancreatography (ERCP)

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