Endoscopic retrograde cholangiopancreatography in the diagnosis and management of pancreatic diseases

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) has been used for diagnosis and treatment of pancreatic diseases for over 20 years. ERCP has been most intensely investigated for acute biliary pancreatitis. Randomized trials have proven that its use will decrease morbidity and have suggested a decrease in mortality for patients with severe gallstone pancreatitis. ERCP is also valuable in detecting and treating main pancreatic duct leaks with transpapillary stenting. Symptomatic pseudocysts, which may be seen in either acute or chronic pancreatitis, can be drained via the papilla or through creation of a cystogastrostomy or cystoduodenostomy with a needle-knife sphincterotome. Endoscopic treatment of patients with recurrent acute pancreatitis presumed due to pancreas divisum and sphincter of Oddi dysfunction remains controversial. Dominant pancreatic strictures or calculi in the setting of chronic pancreatitis may be treated with stenting and removal of calculi to improve abdominal pain. Finally, diagnosis of pancreatic cancer by brush cytology and palliative management of biliary obstruction with various plastic and expandable metal sents have simplified management of this difficult problem.

Pancreatic Cancer in Hereditary Pancreatitis: Consensus Guidelines for Prevention, Screening and Treatment

“…Certain investigators argue that ERCP facilitates the detection and sampling of ductal pancreatic dysplasia/malignancy while allowing optimal collection of pancreatic juice [51,52]. Other investigators feel that the same objectives can be accomplished with lower morbidity and mortality through EUS with needle biopsy of suspicious lesions and aspiration of duodenal contents following secretin stimulation [42,43,50,53]. Similar arguments can be made in favor of multiphasic CT or MRI/ MRCP when performed in conjunction with duodenal tube placement and aspiration of intestinal contents following secretin stimulation.…”

“…HP and hereditary pancreatic cancer) [41]; (2) the lack of tumor markers (serum, pancreatic juice or stool) alone or in combination with sufficient sensitivity, specificity, positive predictive value and negative predictive value to alter management independent of radiologic imaging [42,43], and (3) the assumed inefficiency of radiologic imaging techniques [e.g. multiphasic helical computed tomography (CT), endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP)] in detecting tumors at a resectable stage [44][45][46][47][48][49][50].…”

“…The assumed inefficiency of these modalities in the screening of HP patients has been based on the highly metastatic nature of even small tumors, the detection limits in the setting of chronic pancreatitis and cost [42][43][44][45][46][47][48][49][50].…”

“…Ideally, screening should be performed yearly and within the context of multicenter protocols assessing the efficacy of EUS or multiphasic helical CT or MRI/MRCP in conjunction with standardized collection and storage of blood/serum and pancreatic juice for future analysis. Despite the logical appeal of EUS, the consensus conference agreed that all of these imaging modalities exhibit limitations in the setting of chronic pancreatitis [42][43][44][45][46][47][48][49][50]. Therefore, definitive statements cannot be made at this time favoring one over the other.…”

Recurrent acute pancreatitis

“…If the results of ERCP are normal or demonstrate choledocholithiasis or ampullary stenosis, we advocate biliary sphincterotomy with subsequent balloon sweep. Empiric biliary sphincterotomy in patients with a normal ERCP addresses inter-institutional variation in the availability and quality of microcrystal analysis of bile duct aspirates and eliminates the enhanced risk of pancreatitis imposed by SOM in patients with suspected SOD [14][15][16][17][18]47]. Cholecystectomy should be performed at some point subsequent to biliary sphincterotomy.…”