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 Autoimmune IBD: UC > Crohn’s Skeletal: Osteopenia Inflammation and fibrosis (onion skin) No cure

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

EGD scope vs. ERCP scope

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

ERCP: Steps Identify Access Take a look Treat 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

ERCP: Steps 1. Identify 2. Access

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

ERCP in PSC In Diagnosis of 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

ERCP in PSC: Losing Ground MRCP ERCP

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

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

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

Diagnostic Approach

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

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

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

ERCP with stent placement

Balloon Dilation + Stenting

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

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

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

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

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%

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

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?