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Sunguk Jang, M.D. Cleveland Clinic Digestive Disease Institute

Role of ERCP in patients with PSC. Sunguk Jang, M.D. Cleveland Clinic Digestive Disease Institute. Objectives. Technical aspects of ERCP Indications Role of ERCP in PSC? What questions should be asked before and after the procedure?. PSC. Systemic IBD: UC > Crohn’s Skeletal: Osteopenia

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Sunguk Jang, M.D. Cleveland Clinic Digestive Disease Institute

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  1. Role of ERCP in patients with PSC Sunguk Jang, M.D. Cleveland Clinic Digestive Disease Institute

  2. Objectives • Technical aspects of ERCP • Indications • Role of ERCP in PSC? • What questions should be asked before and after the procedure?

  3. PSC • Systemic • IBD: UC > Crohn’s • Skeletal: Osteopenia • Autoimmune • Inflammation and fibrosis (onion skin) • No cure

  4. ERCP: Endoscopic Retrograde Cholangiopancreatography • Special endoscopic procedure • Side-viewing duodenoscope • Targets bile and pancreatic duct • To assess the status • Invasive and technically challenging

  5. EGD scope vs. ERCP scope

  6. ERCP • Performed by gastroenterologists with additional training • Diagnostic and therapeutic • Indications • Symptoms or signs suggestive of biliary or pancreatic duct disease • Jaundice, established stone or stricture Ampulla of Vater

  7. ERCP: Steps • Identify • Ampulla of Vater • Located in duodenum (proximal small bowel) • Access • Cannulate using catheter (sphinctertome or balloon) • Take a look • Inject contrast dye and obtain fluoroscopy (X-ray) • Treat • Incision to gain bigger opening and resolve the issue

  8. ERCP: Steps 1. Identify 2. Access

  9. ERCP: Steps 3. Take a look: Fluoroscopy 4. Treat: Sphincterotomy

  10. ERCP in PSC Multi-focal annular stricture “ Beads on string” • In Diagnosis of PSC • Historic “gold standard” • MRCP has largely replaced ERCP as initial choice • Highly sensitive and specific • MRCP is non-invasive

  11. ERCP in PSC: Losing Ground MRCP ERCP

  12. How good is MRCP? • MRCP vs. ERCP • Sensitivity: 86% (MRCP) vs. 89-90% (ERCP) • Specificity: 94% (MRCP) vs. 96% (ERCP) • In cirrhotic patients and early PSC, accuracy of MRCP suffer

  13. ERCP: Complications • Pancreatitis • 3-5 % • Infection • Cholangitis: 1 % • Bleeding • 2 % • Majority: non-life threatening • But severity can be compounded in patients with autoimmune issues (such as PSC)

  14. Role of ERCP in PSC • When MRCP imaging is not clear • When intervention is contemplated • When progression to dysplastic (malignant) process is suspected

  15. Diagnostic Approach

  16. PSC: Endoscopic Intervention • 25-50% develop bile duct obstruction • Bile duct obstruction leads to potentially life threatening infection (sepsis) • Endscopic relief can be life saving

  17. ERCP in PSC: Intervention • Goal • To look for treatable, “dominant” stricture • Up to 50% of PSC patients • At “big” trunk (CBD, CHD) • Single or few strictures only • Intrahepatics are not routinely treated

  18. ERCP in PSC: Therapy • Biliary sphincterotomy (incision) • Stricture dilation (dominant strictures) • Balloon dilation • Catheter dilation • Stent placement • Plastic tube that augments bile drainage • Temporary and eventually needs removal • 8 – 12 weeks interval

  19. ERCP with stent placement

  20. Balloon Dilation + Stenting

  21. Benefits of Treating Dominant Stricture in PSC • Symptoms improvement • Pruritus • Reduced risk of recurrent cholangitis • Reduction ins rate of disease progression? • Improvements in LFTs • Dominant stricture • Associated with reduced survival free of liver transplant • Improved survival? • Controversial

  22. ERCP in PSC patients: Complication • Retrospective study in Mayo Clinic • Comparable rates of bleeding, pancreatitis and perofration • Significantly higher risk of infection (Cholangitis) • Antibiotic is a MUST

  23. Role of ERCP in PSC: Detection of Disease Progression Cholangiocarcinoma from PSC

  24. Detection of Cholangiocarcinoma • Commonly arise from dominant stricture • 0.6% annual risk among PSC patients • ERCP is the most sensitive and accurate

  25. Suspicious Strictures • Laboratory (LFT, CA 19-9, IgG4) • Routine imaging (US, CT) • MRCP, EUS • ERCP Sensitivity Specificity • Brush cytology ~50% >95% • Intraductal biopsy ~60% >95% • Cholangioscopy ~80% ~80%

  26. Conclusion • ERCP • Technically challenging endoscopic test to assess status of bile duct • Largely replaced by MRCP as the initial imaging choice • Specific roles remain • Ambiguous diagnosis by MRCP • Therapy of certain stricture • Early detection of disease progression to CCA

  27. Conclusion • Ask physicians • What do you hope to gain? • Is benefit/risk ratio worth it? • If treatment is a part of the procedure, what should be expected in terms of follow up?

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