1. ERCP and Sphincterotomy Raika Jamali M.D. Gastroenterologist and hepatologist Tehran University of Medical Sciences

2. Case 1 An 74 year man came to ER with RUQ pain, fever, and icterus. He uses ASA, and warfarin for IHD and heart failure.

3. LAB DATA AST: 230 U/L ALT: 256 U/L Bili total: 7.8 mg/dl Bili direct: 2.6 mg/dl ALP: 640 U/L

4. IMAGING Ultrasonography of biliary tree shows dilation of CBD with stone.

5. What is your recommendation for anticoagulation in this patient before ERCP?

6. 1.stop warfarin 10 days before endoscopy 2.stop warfarin 5 days before endoscopy 3.stop warfarin between 5-10 days before endoscopy

8. Case 2 A 65 year old diabetic woman on insulin admited for the evaluation of RUQ pain and icterus.

9. LAB DATA AST: 230 U/L ALT: 256 U/L Bili total: 7.8 mg/dl Bili direct: 2.6 mg/dl ALP: 640 U/L

10. IMAGING Ultrsonography of biliary tree shows dilation of CBD without stone. MRCP showed 9 mm stone in distal CBD.

11. What is your recommendation on prophylactic antibiotic for this patient before ERCP?

12. 1.Antibiotic prophylaxis should be considered before ERCP 2. Antibiotic prophylaxis is not recommended before ERCP

13. RECOMMENDATION Antibiotic prophylaxis should be considered before an ERCP in patients with known or suspected biliary obstruction, in which there is a possibility that complete drainage may not be achieved at the ERCP, such as in patients with a hilar stricture and primary sclerosing cholangitis (PSC) (Grade 2C).

14. RECOMMENDATION Antibiotic prophylaxis is not recommended in patients with biliary obstruction when it is likely that an ERCP will accomplish complete biliary drainage (Grade 1C).

15. RECOMMENDATION Antibiotic prophylaxis is not recommended before an ERCP when obstructive biliary- tract disease is not suspected (Grade 1C).

16. RECOMMENDATION Antibiotic prophylaxis is recommended before an ERCP in patients with communicating pancreatic cysts or pseudocysts and before transpapillary or transmural drainage of pseudocysts (Grade 3).

17. Case 3 A 68 year old man presented with RUQ pain, fever, and icterus.

18. LAB DATA AST: 230 U/L ALT: 256 U/L Bili total: 7.8 mg/dl Bili direct: 2.6 mg/dl ALP: 640 U/L

19. You see the ERCP of the patient. What is the best treatment plan for this patient?

20. Common bile duct stone

21. 1.ANTIBIOTICS is mandataory 2.Percutaneous drainage 3.ERCPand sphinctrotomy 4.Surgery

22. Case 4 An old man presented with RUQ pain, fever, and ichterus 3 months after cholecystectomy. AST: 230 U/L ALT: 256 U/L Bili total: 7.8 mg/dl Bili direct: 2.6 mg/dl ALP: 640 U/L You see the ERCP of the patient.

23. Common bile duct stricture

24. What is the best treatment plan for this patient?

25. 1.ANTIBIOTICS is mandataory 2.ERCPand Biliary stenting 3.Percutaneous drainage 4.Surgery

26. Case 5 An old man presented with progressive icterus and significant weight loss.

27. LAB DATA AST: 30 U/L ALT: 56 U/L Bili total: 17.8 mg/dl Bili direct: 10.6 mg/dl ALP: 640 U/L

28. Common bile duct stricture

29. What is the best treatment plan for this patient?

30. 1.ANTIBIOTICS is mandataory 2.ERCP and Metalic Biliary stenting 3.ERCP and plastic Biliary stenting 4.Percutaneous drainage

31. Case 6 An opium addict 57 year old man presented with icterus and RUQ pain.

32. LAB DATA In admition : AST: 30 U/L ALT: 56 U/L Bili total: 1.8 mg/dl Bili direct: 0.6 mg/dlALP: 640 U/L 3 days later: AST=35 ALT=69 Bili total=2 D=0.7 ALP=666

33. IMAGING Ultrasonography of biliary tree shows dilation of CBD without stone. MRCP: Only dilated CBD. No stone or mass

34. What is the best diagnostic plan for this patient?

35. Sphincter of Oddi manometry

36. What is the best management plan for this patient?

37. 1.Nitrates 2.ERCP and Biliary stenting 3.ERCP and sphincterotomy 4.Percutaneous drainage

39. What’s your diagnosis?

40. 1.Bilary leak 2.Mirrizi Syndrome 3.Choledochal cyst 4.PSC

41. Indications for sphincterotomy Common bile duct stone Common bile duct stricture –Post cholecystectomy (benign) –Cholangiocarcinoma (malignant) Bile leak Sphincter of oddi dysfunction (SOD)

42. Periampullary vs ampulary diverticulum Is it a cause or an effect?

43. 1.Both conditions are associated with pancreatitis 2.Periampulary diverticula is associated with pancreatitis 3. Ampulary diverticula is associated with pancreatitis

44. While ampullary duodenal diverticula can cause chronic pancreatitis, periampullary duodenal diverticula are no etiologic factor. Naranjo-Chavez J, Schwarz M, Leder G, Beger HG. Ampullary but not periampullary duodenal diverticula are an etiologic factor for chronic pancreatitis. Dig Surg. 2000;17(4):358-63.Naranjo-Chavez JSchwarz MLeder GBeger HG

45. Choledocholithiasis is considered to be strongly associated with JPD, but the role of JPD in the development of cholecystolithiasis and pancreatitis is still disputable.

46. The ERCP procedure can be hampered by JPD, although recent papers have reported no difference in the successful cannulation rate or complications between patients with JPD and those without JPD.

47. Case 7 A man presented with RUQ pain and fever 12 hours after ERCP. The abdominal CT scan is shown in the next slide.

48. What is the best treatment plan for this patient?

50. 1. Conservative management 2. Surgery