Endoscope and Endoscopic accessories’ roles in the diagnosis and treatment of primary sclerosing cholangitis

Endoscope and Endoscopic accessories’ roles in the diagnosis and treatment of primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC for short) is a disease chronic bile duct disease. The occurrence rate is from 1 in 100,000 people to 16 in 100,000 people. It has geographic features in Europe. The main challenge in clinical management of this disease is the rising risk of bile duct malignant tumor and the unpredictability.

This article is an excerpt of role of endoscopy in primary sclerosing cholangitis: European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) clinical guideline (2017).

ESGE/EASL suggests that if apparent stenosis is suspected after MRC examination, and the symptoms might get improved after endoscopic treatment, these PSC patients shall be treated with endoscopic therapy and pathological sampling shall be taken by cytology brush or biliary tract biopsy. (Highly recommended, low quality evidence)

ESGE/EASL suggests that the choice between stent placement and balloon dilation should be decided by endoscopic physicians. (Weak recommendation, low quality evidence)

ESGE/EASL recommends comparing the expected benefits of biliary papillotomy/sphincterotomy with its risks according to the specific condition. (Highly recommended, medium quality evidence)

Biliary papillotomy/sphincterotomy should be considered especially after difficult intubation. ESGE/EASL recommends choosing the diameter of the balloon according to the maximum diameter restricted by the stricture of the bile duct. (Weak recommendation, low quality evidence)

ESGE/EASL suggests repeatedly expanding the dominant stricture: (1) dominant stenosis is considered to be the cause of recurrent symptoms (cholangitis, pruritus) or cholestasis; patient's response to the previous expansion was satisfactory. (Weak recommendation, very low quality evidence)

ESGE/EASL recommends 1 piece single 10fr stent for dominant extra hepatic duct stenosis and 2 pieces 7Fr stents for hilar stenosis extending to the left or right hepatic duct (stent diameter is determined by stepwise implantation). (Weak recommendation, very low quality evidence)

ESGE/EASL suggests that the stent for treatment of dominant stenosis should be removed 1 to 2 weeks after implantation. (Weak recommendation, low quality evidence)

ESGE/EASL suggests that ERCP in PSC patients should be performed by experienced cholangiopancreatography physicians. (Highly recommended, very low quality evidence)

ESGE/EASL suggests immediate administration of 100 mg diclofenac or indomethacin before and after ERCP in all patients without contraindication. In addition, in ERCP postoperative pancreatitis (post ERCP pancreatitis, PEP) under the condition of high risk, to install 5Fr prophylactic pancreatic duct stent should be considered. (Highly recommended, high quality evidence)

ESGE/EASL suggests routine prophylactic antibiotics before ERCP in PSC patients. (Highly recommended, low quality evidence)