Download An Atlas of Complications of ERCP

Grant Smith, HMS III
Gillian Lieberman, MD
March 2012
An Atlas of
Complications of
ERCP
Grant Smith, HMS Year III
Dr. Gillian Lieberman, MD
Brunicardi FC, Andersen DK, Biliar TR, Dunn DL, Hunter JG, Matthews JB,
Polluck, RE: Schwartz’s Principles of Surgery, 9th Edition:
http://www.accessmedicine.com
Grant Smith, HMS III
Gillian Lieberman, MD
Teaching Goals
1)
2)
3)
4)
Understand how ERCP is performed.
Become familiar with the indications for ERCP.
Know the common complications of ERCP.
Identify the menu of radiologic tests used to
diagnose complications of ERCP.
5) Recognize radiologic findings of ERCP
complications.
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Grant Smith, HMS III
Gillian Lieberman, MD
Endoscopic Retrograde
Cholangiopancreatography (ERCP)
• ERCP is an endoscopic
procedure, in which a
specialized side-viewing
upper endoscope is guided
into the duodenum.
• ERCP provides an opportunity
for instrumentation to:
1.
2.
Perform procedures such as
brush cytology, biopsy,
sphincterotomy, and stone
removal
Visualize the biliary tree and
pancreatic ducts
Brunicardi FC, Andersen DK, Biliar TR, Dunn DL, Hunter JG, Matthews JB, Polluck, RE:
Schwartz’s Principles of Surgery, 9th Edition: http://www.accessmedicine.com
Abdominal Fluoroscopy during ERCP
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Grant Smith, HMS III
Gillian Lieberman, MD
Anatomy of ERCP: Diagram
Chandrasoma P, Taylor CR: “Anatomy of the biliary system,” Concise Pathology, 3rd Edition: http://www.accessmedicine.com
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Grant Smith, HMS III
Gillian Lieberman, MD
Anatomy of ERCP: Fluoroscopy
Endoscope
Common Hepatic Duct
Gallbladder
Cystic Duct
Common Bile Duct
Pancreatic Duct
2nd Part of
Duodenum
Ampulla/
Sphincter of Oddi
Guntau J. (2006). ERCP: Unauffälliger Gallen- und Pankreasgang, mehrere unterschiedlich große Gallensteine in der
Gallenblase und im Gallenblasengang. Endoskopiebilder.de. http://en.wikipedia.org/wiki/File:ERCP_Roentgen .jpgA
Abdominal Fluoroscopy during ERCP
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Grant Smith, HMS III
Gillian Lieberman, MD
Indications for ERCP
NIH Consensus Guidelines & American Society for
Gastrointestinal Endoscopy Guidelines
–
–
–
–
–
–
–
–
Diagnosis and treatment of choledocholithiasis
Common bile duct (CBD) stone removal after cholecystectomy
Pancreatitis or cholangitis secondary to CBD stones
Biopsies/Brushings/FNA of suspicious pancreatic masses for tissue
diagnosis to initiate chemotherapy and/or radiation
Visualization and biopsy of ampullary malignancies
Stent placement for bile duct strictures
ERCP with sphincter of Oddi manometry for recurrent pancreatitis
Drainage of pancreatic pseudocysts
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Grant Smith, HMS III
Gillian Lieberman, MD
When ERCP is NOT Appropriate
• Asymptomatic cholelithiasis
• Acute pancreatitis (unless
gallstone pancreatitis is
suspected)
• Exploration for CBD stones
prior to cholecystectomy
(when there is a low suspicion
for choledocholithiasis)
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Grant Smith, HMS III
Gillian Lieberman, MD
Changing Role for ERCP
• ERCP has become a
modality primarily used for
treatment and procedures
rather than diagnosis.
• Magnetic Resonance
Cholangiopancreatography
(MRCP) is a non-invasive
technique that does not
require contrast material to
be injected into the biliary
tree or pancreatic duct.
Greenberger NJ, Blumberg RS, Burakoff R: CURRENT Diagnosis & Treatment: Gastroenterology,
Hepatology, & Endoscopy: http://www.accessmedicine.com
Abdominal MRI, coronal, heavily-weighted T2
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Grant Smith, HMS III
Gillian Lieberman, MD
COMPLICATIONS OF ERCP
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Grant Smith, HMS III
Gillian Lieberman, MD
ERCP Complications: A Framework
Classification of site, timing, and severity of complications related to ERCP
Site
Specific
Occurring at the point of endoscopic contact or cannulation
Nonspecific
Occurring in organs not transversed or treated
Timing
Immediate
Occurring during ERCP
Early
Evident within the recovery period
Delayed
Specific (occurring within 30 days), Nonspecific (1st symptom within 3
days)
Late
Evident after months or years
Criteria for Severity
Mild
< or equal to 3 night inpatient stay
Moderate
4-10 night inpatient stay
Severe
> 10 nights, ICU admission, or surgery
Fatal
Death attributable to procedure within 30 days
Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointestinal endoscopy 1991;37(3):383-93.
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Grant Smith, HMS III
Gillian Lieberman, MD
Complication Rates
Specific complications (pancreatitis, bleeding, sepsis, and
perforation) occur in approximately 5.3-6.9% of patients with
mortality rate of 0.33-0.34%.
Non-specific complications occur in approximately 0.87-1.3% of
patients with mortality rate of 0.07%.
Specific Complications
–
–
–
–
–
Pancreatitis (4%)
Hemorrhage (1%)
Cholangitis (1%)
Perforation (0.5%)
Death (0.1%)
Non-Specific Complications
– Medication reactions
– Oxygen desaturation
– Cardiopulmonary events
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Grant Smith, HMS III
Gillian Lieberman, MD
Index Patient: Clinical Presentation
• 58 year old female presents from OSH 1 day s/p ERCP for
choledocholithiasis.
• Stones were extracted from the common bile duct and a
biliary stent was placed.
• A few hours after ERCP, the patient presented with facial
swelling, thought to be an allergic reaction.
• Later, the patient was noted to have subcutaneous
emphysema and transferred to BIDMC for further
management.
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Grant Smith, HMS III
Gillian Lieberman, MD
Index Patient: Initial CXR
Subcutaneous
air in cervical
area
“Gingko Sign”
Air between
muscle fibers of
pectoralis
major
indicating
subcutaneous
emphysema
Pneumomediastinum
BIDMC, PACS
Chest X-ray, Portable
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Grant Smith, HMS III
Gillian Lieberman, MD
Companion Patient: “Gingko Sign”
37-year-old man 2 weeks after knife wound to chest.
“Gingko Sign”
seen as air
between the
muscle fibers of
pectoralis major
(arrows and stars)
indicating
subcutaneous
emphysema
©2009 by American Roentgen Ray Society
Ho M , Gutierrez F R AJR 2009;192:599-612
Chest X-ray, Portable
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Grant Smith, HMS III
Gillian Lieberman, MD
Index Patient: Plain Abdominal Film
Streaky air
surrounding T10, T11,
T12, and L1 indicating
free air in the
abdomen
Subcutaneous
emphysema
Rigler’s Sign (Box) bowel wall etched in
white with adjacent
lucent line indicating
free air in the
abdomen
(pneumoperitoneum)
BIDMC, PACS
Abdominal X-ray, Portable, Supine
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Grant Smith, HMS III
Gillian Lieberman, MD
Index Patient: Chest CT - Pneumomediastinum
and “Ginko Sign”
“Ginko Sign”
Air separating
muscle fibers
of pectoralis
major
Aberrant air in
mediastinum
indicating
pneumomediastinum
BIDMC, PACS
Chest CT with contrast, axial, lung windows
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Grant Smith, HMS III
Gillian Lieberman, MD
Index Patient: Chest CT - Pneumothorax
“Ginko Sign”
showing air
separating
muscle
fibers of
pectoralis
major
Small
pneumothorax
Pneumomediastinum
BIDMC, PACS
Chest CT with contrast, axial, lung windows
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Grant Smith, HMS III
Gillian Lieberman, MD
Index Patient: Abdominal CT Pneumoretroperitoneum and Pneumomperitoneum
Pneumoperitoneum
Subcutaneous
Air
Pneumoretroperitoneum
BIDMC, PACS
Abdominal CT with contrast, axial, lung windows
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Grant Smith, HMS III
Gillian Lieberman, MD
Index Patient: Abdominal CT Duodenal Diverticulum
Duodenal
diverticulum
Stent
BIDMC, PACS
Abdominal CT with contrast, axial, abdominal windows
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Grant Smith, HMS III
Gillian Lieberman, MD
Index Patient: Abdominal CT - Perforation
Extraluminal
contrast
suggestive of
perforation
BIDMC, PACS
Abdominal CT with contrast, axial, abdominal windows
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Grant Smith, HMS III
Gillian Lieberman, MD
Perforation: Overview
• Incidence – Approx. 1.3% of cases
• Clinical Manifestations
– Abdominal pain
– Elevated serum amylase
• Risk Factors
–
–
–
–
–
–
–
–
Sphincterotomy
Sphincter of Oddi dysfunction
Dilated CBD
Long procedure
Biliary stricture dilatation
Duodenal diverticula
Aberrant biliary anatomy
Post-surgical anatomy (Roux-en-Y gastric bypass)
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Grant Smith, HMS III
Gillian Lieberman, MD
Perforation: Radiologic Findings
• Menu of Radiologic Tests
– Plain Abdominal Film
• Free air seen as “Rigler’s Sign” (bowel wall outlined by air) or
the “Football Sign” (central lucency with visualization of
falciform and medial umbilical ligaments).
– Free air is best seen on upright films or left lateral decubitus (if
unable to stand) or cross-table lateral view.
– Computed Tomography
• Ability to see tiny foci of free air not seen on plain films.
• Recommended if patient has increase WBC count or pain
and fever.
• Bile infection and bile leakage through a perforation seen on
CT correlates with increased mortality.
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Grant Smith, HMS III
Gillian Lieberman, MD
Perforation: Companion Patient
• 49 year old female
• ERCP performed for
evaluation of RUQ found to
have acute cholecystitis
• The patient had pain
immediately after the
procedure and a significant
amount of free air.
• Subcutaneous free air
• Pneumoperitoneum
• Pneumoretroperitoneum
• Pneumomediastinum
Pannu HK, Fishman EK. Complications of endoscopic retrograde cholangiopancreatography: spectrum of
abnormalities demonstrated with CT. Radiographics 2001;21(6):1441-53.
Abdominal CT without contrast, axial, abdominal windows
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Grant Smith, HMS III
Gillian Lieberman, MD
Pancreatitis: Overview
• Incidence – Approx. 5% of diagnostic cases and 10% of
therapeutic cases
• Clinical Manifestations
– Abdominal pain for >24hrs s/p ERCP
• Often epigastric or back pain with nausea
– Elevated serum amylase and lipase (3x normal)
• Risk Factors
– Operator-Related: inadequate training, lack of experience, low case
volume
– Patient-Related: younger age, females, recurrent pancreatitis, history
of post-ERCP pancreatitis, Sphincter of Oddi dysfunction
– Procedure-Related factors: difficulty with cannulation, pancreatic duct
infection, precut/pancreatic/minor papilla sphincterotomy, or biliary
balloon sphincteroplasty.
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Grant Smith, HMS III
Gillian Lieberman, MD
Pancreatitis: Radiologic Findings
• Menu of Radiologic Tests
– Computed Tomography
• Heterogeneous enhancement and gland enlargement.
• Peripancreatic fat has increased attenuation due to
extravasation of pancreatic secretions.
• Glandular necrosis appears as hypoattenuation.
• Infected necrosis appears as bubbles of gas in
devitalized parenchyma.
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Grant Smith, HMS III
Gillian Lieberman, MD
Pancreatitis: Companion Patient
• 50-year-old man s/p ERCP for
a mass in the pancreatic tail
• The patient was readmitted 3
days after ERCP with
abdominal pain and low-grade
fever.
• Heterogeneous attenuation of
the pancreas.
• Low-attenuation areas (*)
suggest necrosis.
• Thickening of the wall of the
antrum of the stomach (arrow)
secondary to local
inflammation.
• Stranding of the peripancreatic
fat.
Pannu HK, Fishman EK. Complications of endoscopic retrograde cholangiopancreatography:
spectrum of abnormalities demonstrated with CT. Radiographics 2001;21(6):1441-53.
Abdominal CT with contrast, axial, abdominal windows
26
Grant Smith, HMS III
Gillian Lieberman, MD
Pancreatitis: Companion Patient –
Fat Stranding
Fat stranding
around the
pancreas
Pannu HK, Fishman EK. Complications of endoscopic retrograde cholangiopancreatography: spectrum of abnormalities
demonstrated with CT. Radiographics 2001;21(6):1441-53
Abdominal CT with contrast, axial, abdominal windows
27
Grant Smith, HMS III
Gillian Lieberman, MD
Pancreatitis: Index Patient
Infected
pancreatic
necrosis with
gas
BIDMC, PACS
Abdominal CT with contrast, axial, abdominal windows
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Grant Smith, HMS III
Gillian Lieberman, MD
Hemorrhage: Overview
• Incidence – Approx. 1.3% (with about 29% of bleeds requiring >5
units of transfusions or intervention)
• Clinical Manifestations
– Drop in hemoglobin/hematocrit
– Melena or hematemesis
• Risk Factors
–
–
–
–
–
–
Sphincterotomy
Evidence of bleeding at time of sphincterotomy
Prior sphincterotomy
Prolonged PTT (at least 2x above normal)
Periampullary diverticulum
Cholangitis
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Grant Smith, HMS III
Gillian Lieberman, MD
Hemorrhage: Radiologic Findings
• Menu of Radiologic Tests and Findings
– Computed Tomography (CT)
• Typically not performed to diagnose hemorrhage; but bleeding
may be detected if CT is performed.
• Acute hemorrhage is hyperattenuating on noncontrast CT,
which can become iso/hypoattenuating in later stages.
• Non-contrast CT is used to assess for hematoma, while
contrast-enhanced CT angiography is used to assess for site of
active extravasation.
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Grant Smith, HMS III
Gillian Lieberman, MD
Hemorrhage: Companion Patient #1
• 67-year-old woman s/p
ERCP with unsuccessful
cannulation of the
common bile duct
• The patient experienced
pain after the
procedure.
• High attenuation area
between the duodenum
and pancreas (arrow)
representing bleeding
Pannu HK, Fishman EK. Complications of endoscopic retrograde cholangiopancreatography: spectrum of
abnormalities demonstrated with CT. Radiographics 2001;21(6):1441-53
Abdominal CT with contrast, axial, abdominal windows
31
Grant Smith, HMS III
Gillian Lieberman, MD
Hemorrhage: Companion Patient #2
• High-attenuation
mass (arrow) that
appears to be
abutting the lumen
of the duodenum, a
finding compatible
with intramural
bleeding.
Pannu HK, Fishman EK. Complications of endoscopic retrograde cholangiopancreatography: spectrum of
abnormalities demonstrated with CT. Radiographics 2001;21(6):1441-53
Abdominal CT with contrast, axial, abdominal windows
32
Grant Smith, HMS III
Gillian Lieberman, MD
Infection/Cholangitis: Overview
• Infection can include many complications
• Ascending cholangitis is the most frequent infectious complication of
ERCP
• Incidence – Approx 1.4% (with range of 0.4-10% depending on the study)
• Clinical Manifestations
–
–
–
–
–
–
Typically occur 24-72 hours after ERCP
Fever
Jaundice
Charcot’s Triad
Abdominal pain (RUQ)
May develop confusion and hypotension
Elevated WBC count
Reynold’s Pentad
• Risk Factors
– Biliary stents
– Combined percutaneous and endoscopic procedures
– Unsuccessful drainage of the biliary system (retained stones)
33
Grant Smith, HMS III
Gillian Lieberman, MD
Infection/Cholangitis: Radiologic Findings
• Menu of Radiologic Tests
– Computed Tomography (CT)
• Bile ducts may appear dilated and bile itself may appear
hyperattenuated due to increased debris.
• Thickening of wall of ducts and pneumobilia.
• Peri-biliary hyperattenuation.
• Abscesses may also appear with enhancing capsules.
34
Grant Smith, HMS III
Gillian Lieberman, MD
Infection/Cholangitis: Companion Patient
• 67 year old man with
common bile duct
stones
• In this case, has not
undergone ERCP but
demonstrates findings
of biliary obstruction
• Diffuse, mottled
enhancement of the
liver parenchyma
• Dilatation of the
intrahepatic bile ducts
(arrows)
Kim SW, Shin HC, Kim HC, Hong MJ, Kim IY. Diagnostic performance of multidetector CT for acute
cholangitis: evaluation of a CT scoring method. The British journal of radiology.
Abdominal CT with contrast, axial, abdominal windows
35
Grant Smith, HMS III
Gillian Lieberman, MD
Summary
• ERCP is an endoscopic procedure primary used for
therapeutic intervention.
• ERCP is appropriately used to remove stones from the
CBD, assist in diagnosis of pancreatic/ampullary
masses, and stent placement for biliary obstruction.
• The main complications of ERCP include perforation,
pancreatitis, hemorrhage, and infection.
• Computed tomography is a good first choice for
investigating for complications of ERCP when patients
become acutely ill within 24-48 hours after ERCP.
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Grant Smith, HMS III
Gillian Lieberman, MD
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References
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diagnosis and therapy, January 14-16, 2002. Gastrointestinal endoscopy 2002;56(6):803-9.
Adler DG, Baron TH, Davila RE, et al. ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas.
Gastrointestinal endoscopy 2005;62(1):1-8.
Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at
consensus. Gastrointestinal endoscopy 1991;37(3):383-93.
Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: a systematic survey of
prospective studies. The American journal of gastroenterology 2007;102(8):1781-8.
Williams EJ, Taylor S, Fairclough P, et al. Risk factors for complication following ERCP; results of a large-scale, prospective
multicenter study. Endoscopy 2007;39(9):793-801.
Wang P, Li ZS, Liu F, et al. Risk factors for ERCP-related complications: a prospective multicenter study. The American
journal of gastroenterology 2009;104(1):31-40.
Zissin R, Shapiro-Feinberg M, Oscadchy A, Pomeranz I, Leichtmann G, Novis B. Retroperitoneal perforation during
endoscopic sphincterotomy: imaging findings. Abdominal imaging 2000;25(3):279-82.
Cohen SA, Siegel JH, Kasmin FE. Complications of diagnostic and therapeutic ERCP. Abdominal imaging 1996;21(5):38594.
Scarlett PY, Falk GL. The management of perforation of the duodenum following endoscopic sphincterotomy: a proposal
for selective therapy. The Australian and New Zealand journal of surgery 1994;64(12):843-6.
Pannu HK, Fishman EK. Complications of endoscopic retrograde cholangiopancreatography: spectrum of abnormalities
demonstrated with CT. Radiographics 2001;21(6):1441-53
Balthazar EJ. CT diagnosis and staging of acute pancreatitis. Radiologic clinics of North America 1989;27(1):19-37.
Balthazar EJ, Freeny PC, vanSonnenberg E. Imaging and intervention in acute pancreatitis. Radiology 1994;193(2):297306.
Testoni PA, Mariani A, Giussani A, et al. Risk factors for post-ERCP pancreatitis in high- and low-volume centers and
among expert and non-expert operators: a prospective multicenter study. The American journal of
gastroenterology;105(8):1753-61
Kim SW, Shin HC, Kim HC, Hong MJ, Kim IY. Diagnostic performance of multidetector CT for acute cholangitis: evaluation
of a CT scoring method. The British journal of radiology.
Carr-Locke DL. Therapeutic role of ERCP in the management of suspected common bile duct stones. Gastrointestinal
endoscopy 2002;56(6 Suppl):S170-4.
Ho ML, Gutierrez FR. Chest radiography in thoracic polytrauma. Ajr 2009;192(3):599-612.
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Special Thanks To:
• Dr. Gillian Lieberman
• Dr. Mai-Lan Ho
• Dr. Mark Ashkan
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