1. Role of ERCP in patients with PSC
Sunguk Jang, M.D.
Cleveland Clinic
Digestive Disease Institute

2. Objectives Technical aspects of ERCP Indications Role of ERCP in PSC?
What questions should be asked before and after the procedure?

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

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

5. EGD scope vs. ERCP scope

6. 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

7. 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

8. ERCP: Steps
1. Identify
2. Access

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

10. 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

11. ERCP in PSC: Losing Ground
MRCP
ERCP

12. How good is MRCP? MRCP vs. ERCP
Sensitivity: 86% (MRCP) vs % (ERCP)
Specificity: 94% (MRCP) vs. 96% (ERCP)
In cirrhotic patients and early PSC, accuracy of MRCP suffer

13. 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)

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

15. Diagnostic Approach

16. 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

17. 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

18. 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

19. ERCP with stent placement

20. Balloon Dilation + Stenting

21. 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

22. 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

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

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

25. 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%

26. 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

27. 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?