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Dilated Bile Duct and Pneumobilia

Dilated Bile Duct Defining Dilated Bile Ducts There is no consensus definition for what constitutes a dilated bile duct. Rather, it is important to understand that the definition is contextual and depends on the site of measurement, the imaging modality used, and the clinical scenario. Even with parameters such as these, definitions can vary widely based on individual patient characteristics and imaging study characteristics. Dilation may…

Pancreas Divisum, Biliary Cysts, and Other Congenital Anomalies

Anomalies of the biliary and pancreatic ducts are commonly encountered during endoscopic retrograde cholangiopancreatography (ERCP) and are important to both surgeons and gastroenterologists. This chapter reviews the diagnosis, clinical relevance, and therapy of these variants. Ampullary Anomalies Ectopic Major Papilla The major papilla, which is typically located in the mid-duodenum or distal second duodenum, is occasionally located in the third duodenum. Ectopic distal location of the…

Pancreaticobiliary Disorders: What Are the Roles of CT, MRCP, and EUS Relative to ERCP?

Endoscopic retrograde cholangiopancreatography (ERCP) was first described in 1968 (see Chapter 1 ). Despite being technically challenging because of the limited range of available endoscopes and accessories at that time, it became an important modality for diagnostic evaluation of the pancreaticobiliary system in Japan and Europe. The therapeutic role of ERCP was recognized and developed after the introduction of sphincterotomy in 1972 by Classen and Demling…

Endoscopic Ultrasound and EUS-Guided Endotherapy

Overview Endoscopic ultrasonography (EUS) was first introduced in the 1980s and has since become a cornerstone of endoscopic diagnosis of pancreaticobiliary disease, tissue acquisition via fine-needle aspiration (FNA), and staging of gastrointestinal malignancy. As experience with directed needle access into adjacent organ systems increased, endoscopists were able to expand the utility of EUS to therapeutic interventions. This evolution includes EUS-guided drainage of pancreatic fluid collections, abscesses,…

Endoscopic Ultrasonography–Guided Biliary Drainage

Endoscopic ultrasonography (EUS) has gradually replaced many percutaneous image-guided interventions, such as tissue sampling of pancreatic tumors. Similarly, EUS-guided biliary therapeutics mirror percutaneous intervention on the biliary tract. Three anatomic structures can be targeted for biliary drainage under EUS guidance: the bile duct, the gallbladder, and the gastrointestinal (GI) tract, giving rise to three distinct procedures, EUS-guided biliary drainage (EUS-BD), EUS-guided gallbladder drainage (EUS-GBD), and EUS-guided…

ERCP in Surgically Altered Anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) is generally considered the technically most difficult procedure in gastrointestinal (GI) endoscopy because of the complex maneuvers necessary to gain ductal access and perform therapies within the bile duct or pancreas. Altering the upper GI tract or pancreaticobiliary anatomy invariably adds to procedure complexity and technical challenges. Thorough understanding of surgically altered anatomy is essential to ensure technical success and minimize procedure-related…

ERCP in Pregnancy

Pancreaticobiliary diseases such as choledocholithiasis and gallstone pancreatitis during pregnancy are challenging to manage because of increased risk to both the mother and fetus. Physiologic alterations during pregnancy, such as weight gain and hormonal changes, increase the risk of cholelithiasis. Elevated estrogen levels are believed to enhance biliary saturation, increasing bile lithogenicity, whereas a rise in progesterone causes smooth muscle relaxation and bile stasis, reducing gallbladder…

ERCP in Children

Endoscopic retrograde cholangiopancreatography (ERCP) was introduced into pediatric medicine in the late 1970s and is now routinely used for the diagnosis and treatment of biliary tract and pancreatic diseases in children throughout the world. With the advent of high-quality magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) (see Chapter 33 ), ERCP in children is now predominantly used for anticipated therapeutic interventions. This parallels practice in…

Endomicroscopy in the Pancreaticobiliary Tree

The concept of confocal microscopy was first patented in 1957. Since then, this technology has been used with much success in the laboratory, and more recently this has translated into use in various clinical settings, first described in the field of gastroenterology in 2004 for diagnosing colorectal lesions. Confocal laser endomicroscopy (CLE) combines the principles of confocal laser microscopy with the endoscope to allow high-resolution images…

Cholangioscopy

Historically, cholangioscopy was performed with a fiberoptic mother (large-caliber duodenoscope) and daughter (cholangioscope) system requiring two endoscopists, two light sources, and two video monitors, if the endoscopy unit was fortunate enough to have two video cameras to interface with the respective endoscopes. The development of a video mother endoscope made the endoscopy suite a bit less cluttered, although even after video daughter endoscopes were markedly improved…

Pancreatoscopy

Peroral pancreatoscopy, in which a small-caliber fiberscope (“baby scope”) is inserted into the pancreatic duct from the papilla through the working channel of a duodenoscope (“mother scope”), was first described by Japanese investigators Takagi and Takegoshi in 1974. Although the idea was very attractive and several investigators studied its feasibility, pancreatoscopy was not widely adopted because of poor visibility and instrument fragility, as well as the…

Papillectomy and Ampullectomy

Ampullary neoplasms (see Chapter 38 ) are rare, with an annual incidence of 3000 in the United States and a reported prevalence of 0.04% to 0.12% in autopsy series. Endoscopically the papilla can appear enlarged and abnormal because of various tumors (benign or malignant) and other etiologies such as papillitis, gastric foveolar metaplasia, or pancreatic acinar hyperplasia ( Fig. 25.1 ). Ampullary tumors can be classified…

Pancreaticobiliary Stent Retrieval

Pancreaticobiliary stenting is an efficacious and safe method to address biliary manifestations of benign and malignant disease. At present, indications for stent placement include palliative biliary decompression, adjunctive preoperative decompression, treatment of benign biliary and pancreatic strictures, refractory lithiasis, bile leaks, pancreatic ductal disruption, transpapillary gallbladder decompression, prophylaxis of post–endoscopic retrograde cholangiopancreatography (ERCP), pancreatitis (PEP), and treatment of postsphincterotomy-related bleeding. The advent of lumen-apposing self-expandable metal…

Biliary Metal Stent Insertion: Indications and Insertion Techniques

Self-expandable metal stents (SEMS), classified as uncovered (uSEMS), partially covered (pcSEMS), or fully covered (fcSEMS), offer a more durable means to overcome biliary stenosis compared with fixed-diameter plastic stents (PS), which occlude in 30% and 50% of patients within 3 and 6 months, respectively. The outer diameter of PS is limited by the duodenoscope accessory channel diameter to 12 Fr (4 mm). In contrast, SEMS are constrained…

Plastic Pancreaticobiliary Stents and Nasopancreaticobiliary Tubes: Concepts and Insertion Techniques

The use of plastic pancreaticobiliary stents for drainage of the bile duct was described more than 3 decades ago. These stents are used for a variety of indications, including malignant and benign conditions, and have proven reliable and safe for decompression of the biliary tree. Palliative insertion of biliary stents relieves distal biliary obstruction as effectively as surgical bypass. Although the use of expandable metal stents…

Minor Papilla Cannulation and Sphincterotomy

Pancreas divisum (literally “divided pancreas”) is a congenital anatomic variant in which the dorsal and ventral pancreatic ducts completely or partially fail to fuse, and drain separately into the medial wall of the duodenum. Thus in most patients with pancreas divisum the vast majority of the pancreatic ductal system drains via the dorsal duct through the minor papilla. This is the most common pancreatic anomaly, occurring…

Pancreatic Sphincterotomy

Since its initial application in 1974, endoscopic biliary sphincterotomy (see Chapter 17 ) has revolutionized the approach to patients with biliary tract diseases. Biliary sphincterotomy has been used in conjunction with other techniques such as stent placement, balloon and basket extraction of stones, and stricture dilatation, and it has become the standard of care for problems that were once remedied only by surgical procedures. Endoscopic therapy…

Stone Extraction

Introduction and Scientific Basis Biliary stone disease is the most common reason for undertaking therapeutic endoscopic retrograde cholangiopancreatography (ERCP). In Western countries, choledocholithiasis is primarily related to passage of gallstones from the gallbladder into the common bile duct. The clinical presentation of choledocholithiasis varies from no symptoms to biliary colic, jaundice, cholangitis, and/or acute biliary pancreatitis. ERCP plays an important role in managing or preventing biliary…

Balloon Dilation of the Native and Postsphincterotomy Papilla

Endoscopic sphincterotomy (EST; see Chapter 17 ) has become the procedure of choice for removal of stones from the bile duct, especially in postcholecystectomy patients. The procedure is successful in 90% to 98% of patients, and 86% to 91% of all bile duct stones can be extracted using EST and balloon/basket extraction. In this chapter, we will discuss endoscopic balloon dilation with and without sphincterotomy. Small-diameter…

Biliary Sphincterotomy

Diagnostic endoscopic retrograde cholangiopancreatography (ERCP) has been widely replaced by computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and endoscopic ultrasonography (EUS) as noninvasive or less invasive imaging techniques. Indications for diagnostic ERCP should be limited to selected patients with indeterminate biliary strictures or filling defects for evaluation by tissue acquisition with or without cholangioscopic guidance. ERCP is mainly performed for therapeutic biliopancreatic interventions. Endoscopic sphincterotomy (EST)…