ERCP Diagnosis and Treatment

 ERCP Diagnosis and Treatment

n Common questions from ERCP academic forum

(Reference from Chinese Practical Internal Medicine Magazine)

The below questions and experience are from ERCP “academic contention” in China, focusing on the high forum opinions of ERCP technology and technique.

Some experience come from Prof. LingHuEnqiang, the leading professor in Chief Army Hospital of People’s Republic of China.

1. Should the patients stay in hospital after ERCP operation?

In most developed countries, the community hospitals have good facilities for after operation observation and treatments. While in China, the community hospital is not that well equipped with medical facilities. The patients after ERCP operation are not suggested to be located out of the hospital. ERCP patients in China should have the whole process from diagnosis to after operation treatment in hospital.

2. The steps of biliary duct intubation choices

Presently in China, the intubation successful rate of ERCP is 80% ~97%.

In order to raise the successful rate of endoscopic intubation, we normally follow these steps.

Firstly, insert the contrast media tube. If it fails, but the patients have clear indicationsof performing ERCP, make EST and do the intubation again. If intubation still fails in this circumstance, make percutaneous puncture and load the guide wire to connect with endoscope.

It needs to be mentioned that if the percutaneous puncture is performed, high rate of complicationsis indicated.

3. EST or balloon dilation?

EST is accompanied by 10% complications.

﹒For the patients of EST high risk or young patients, balloon dilation at the papilla is suggested.

﹒When the stone diameter issmaller than 1CM, balloon dilation is suggested.

Clinical experience proves that the rate of pancreatitis shall not decrease due toballoon dilation.

4. Endoscopic stone retrieval and extraction

Firstly, compare the diameter of the stone and the diameter of the cutting opening.

﹒If the stone diameter is smaller than the cutting opening diameter, and the stone diameter is below 8mm, use stone extraction balloon catheter firstly. If it fails, apply stone retrieval basket and clean the bile duct with extraction balloons.

﹒If the stone diameter is larger than the cutting opening diameter, use lithotripter. Mechanical way of stone breaking is the first choice. If lithotripter is not available, use biliary duct drainage tube or nasal biliary tube.

5. What is the difference in treatment for benign stricture or malignant stricture?

Benign stricture of bile duct is mainly caused by operational injury. In some cases, it is caused by chronic pancreatic disease.

In the strictures that are caused by chronic pancreatitis,short-term treatment is suggested to use retrievable metal stent. If it is indwelled with plastic stents, multiple stents implantation should be suggested to make sure sufficient expanding force. Stent could reach satisfying drainage effect. But in the long-term, open surgery operation is often required.

In the case of biliary fistula caused by operation, indwelling plastic stent is suggested. Normally, the stent is implanted for 4-6 weeks to have good curative effect. 80% patients could be cured by endoscopic stent treatment.

Malignant bile duct stricture could be diagnosed by ERCP for stricture length, position and nature. Pathological examination could be made by cytological brush inspection, biopsy forceps inspection, or needle aspiration by ultrasound. The application of choledochoscopecould raise the precise rate of pathological examination.  

Open surgery still is the first choice. Indwelling stent should be placed before the surgery to alleviate the jaundice.

If the patents loose the opportunity of open surgery, metal stent or plastic stents are recommended.  For patients with bile duct stricture at the hilushepatis, place at least two stents. For the cases that stents fail to succeed with drainage, PTCD operation should be performed.