1. ERCP for the Diagnosis and Management of PSC
Vinay Chandrasekhara, M.D.
June 21, 2019

2. Endoscopic Retrograde Cholangio-Pancreatography

3.
applications/gastroenterology_1/endoscopic_retrograde_chloangiopancreatography__
ercp_/endoscopic_retrograde_cholangiopancreatography__ercp_.html

6. Role of ERCP in PSC Diagnosis Tissue sampling Treatment
Treatment of strictures
Removal of stones
Treatment of cholangitis (infection of the bile duct)

7. ERCP for diagnosing PSC

8. MRCP
ERCP

9. ERCP for tissue sampling
Brushing
Cytology
Fluorescent in situ hybridization (FISH)
Forceps biopsy
Cholangioscopy-guided biopsies

10. Brushing
Biopsy

11. Cholangioscopy

13. SINGLE OPERATOR CHOLANGIOSCOPY-DIRECTED BIOPSIES IMPROVES DIAGNOSTIC YIELD FOR CHOLANGIOCARCINOMA AND IS SAFE IN PATIENTS WITH PRIMARY SCLEROSING CHOLANGITIS
Karan Kaura, MBBS, Tarek Sawas, MD, Fateh Bazerbachi, MD, Mark D. Topazian, MD, John A. Martin, MD, Barham K. Abu Dayyeh, MD, Michael J. Levy, MD, Andrew C. Storm, MD, Gregory J. Gores, MD, Bret T. Petersen, MD, Vinay Chandrasekhara, MD
Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
Background
Baseline Characteristics
Procedural Characteristics
Parallel comparison in patients who received all modalities of tissue acquisition, n=49
Single operator cholangioscopy (SOC) has been suggested to improve sensitivity and diagnostic accuracy in for the detection of malignancy in patients with primary sclerosing cholangitis (PSC), yet data are limited.
Reported rates of high diagnostic accuracy for SOC have been due to the visual impression with cholangioscopy rather than based on tissue acquired during the procedure.
PATIENT CHARACTERISTICS
PSC (n=36)
Non PSC (n=56)
Mean age ± SD, years
61 ± 11
54 ± 14
Male sex
 22 (61%)
 30 (54%)
Biliary Stricture
Anatomical location
Extra-hepatic duct
Peri-hilar/Intrahepatic
Multiple segments
13 (36.1%)
14 (38.8%)
9 (25%)
20 (35.7%)
14 (25%)
22 (39%)
Mass seen on CT/MRI
7 (19%)
17 (30%)
Cholangiocarcinoma
17 (47%)
24 (43%)
Median follow up after SOC, months (IQR)
32 (9.5 – 82.3)
11.56 (6.7 – 26.9)
PROCEDURE CHARACTERISTICS
(n=36)
PSC
Non PSC (n=56)
P value
Performance of stricture dilation
13 (36%)
14 (25%)
Peri-procedural Antibiotics
23 (64%)
37 (66%)
Post- procedure antibiotics
26 (72%)
36 (64%)
Indomethacin suppository
1 (3%)
8 (14%)
 0.06
Procedural related adverse events
Post-ERCP Pancreatitis
Post-ERCP pain
Upper GI Bleeding
Wire Perforation
Infection within 30 days
5 (14%)
0 (0%)
3 (8%)
13 (23.2%)
2 (4%)
7 (12%)
1 (2%)
0.27 
Sensitivity
(95% CI)
Specificity
PPV
NPV
Cytology
46.2%
(26.6% %)
82.6%
(61.2% %)
75.0%
(47.6% -92.7%)
57.6%
(39.2% %)
Cytology + FISH
57.7%
(36.9% %)
78.9%
(54.4% %)
63.3%
(43.9% %)
Cytology + FISH + SOC-guided biopsy
69.2%
(48.2% %)
81.8%
(59.7% %)
70.4%
(49.8% %)
Cytology + FISH + Transpapillary biopsy
Cytology + FISH+ SOC-guided biopsy + transpapillary biopsy
(61.2% %)
Aims
Primary aim was to compare the performance characteristics of SOC- guided biopsies and/or endoscopic transpapillary forceps biopsies in addition to conventional brush cytology and FISH for diagnosing cholangiocarcinoma (CCA) in patients with and without PSC.
Secondary aim was to assess the safety profile of SOC in patients with PSC.
Methods
The study analyzed consecutive patients who underwent ERCP with SOC from January 2007 to November 2018 at a single institution.
Procedural outcomes, pathology reports, and postprocedural adverse outcomes were recorded.
The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated in reference to the final clinical and pathologic diagnosis of CCA using the exact binomial test. Sensitivity was compared using exact McNemar test exclusively among patients with CCA.
All statistical analyses were performed using STATA 14.0 (StataCorp, College Station, TX).
Performance characteristics of tissue sampling techniques for the detection of cholangiocarcinoma
Overall Patients, n=92
Sensitivity (95% CI)
Specificity (95% CI)
PPV (95% CI)
NPV (95% CI)
Cytology, n=85
44.7%
(28.6% %)
89.4%
(76.9% %)
77.3%
(54.6% %)
66.7%
(53.7% %)
Cytology + FISH, n=85
56.8%
(39.5% %)
80.8%
(60.6% %)
72.4%
(59.1% %)
Cytology + FISH + SOC-guided biopsy, n=58
71.4%
(51.3% %)
86.7%
(69.3% %)
83.3%
(62.6% %)
76.5%
(58.8% %)
Cytology + FISH + Transpapillary biopsy, n=64
64.5%
(45.4% %)
84.8%
(68.1% %)
80.0%
(59.3% %)
71.8%
(55.1% %)
Cytology + FISH + SOC-guided biopsy + Transpapillary biopsy, n=49
69.2%
(48.2% %)
82.6%
(61.2% %)
81.8%
(59.7% %)
70.4%
(49.8% %)
Patients with Primary Sclerosing Cholangitis, n=36
Cytology, n=35
50.0%
(24.7% %)
89.5%
(66.9% %)
(44.4% %)
68.0%
(46.5% %)
Cytology + FISH, n=35
62.5%
(35.4% %)
(51.6% %)
73.9%
(51.6% %)
Cytology + FISH + SOC-guided biopsy, n=23
63.6%
(30.8% %)
77.8%
(40.0% -97.2%)
(41.9% %)
Cytology + FISH + Transpapillary biopsy, n=24
58.3%
(27.7% %)
(51.6% -97.9%)
(40.0% %)
(30.8% % )
Cytology + FISH + SOC-guided biopsy + Transpapillary biopsy, n=19
60.0%
(26.2% %)
75.0%
(34.9% %)
Conclusions
SOC-guided biopsy and transpapillary biopsy improved sensitivity for the detection of malignancy in the overall patient cohort. However, in patients with PSC, SOC-guided biopsy and transpapillary biopsy did not improve diagnostic sensitivity for the detection of cholangiocarcinoma.
SOC is safe in patients with PSC. There were no increased rates of post-ERCP pancreatitis, pain, or infection noted in patients with PSC compared to those without PSC.
Further prospective studies are needed to determine the role of targeted SOC-guided biopsies and/or transpapillary biopsies for sampling of strictures in patients with PSC.
Results
The study cohort included 92 patients with indeterminate biliary strictures.
36 with PSC, 56 without PSC.
In the overall study cohort, SOC-guided biopsies improved sensitivity in combination with brush cytology and FISH for the detection of CCA compared to brush cytology + FISH (71.4% vs 56.8%; p=0.03).
In the overall study cohort, transpapillary biopsies improved sensitivity in combination with brush cytology and FISH for the detection of CCA compared to brush cytology + FISH (64.5% vs 56.8%; p=0.01).
In patients with PSC, SOC-guided biopsies in combination with brush cytology and FISH did not improve sensitivity for the detection of CCA compared to brush cytology + FISH (63.6% vs 62.5%, p=NS),
In patients with PSC, transpapillary biopsies in combination with brush cytology and FISH did not improve sensitivity for the detection of CCA compared to brush cytology + FISH (58.3% vs 62.5%; p=NS)
SOC is safe in patients with PSC with a nonsignificant trend towards lower rates of pancreatitis, pain and infection.

14. ERCP with dilation for treatment of strictures
Balloon Dilation

15. ERCP with stenting for treatment of strictures

17. ERCP for removal of stones

18. ERCP for treatment of cholangitis

20. Risks of ERCP in PSC Pancreatitis Bleeding Infection Perforation
5% - 10%
Bleeding
1% - 3%
Infection
Perforation
< 1%