Between 7972 and /977, 440 patients underwent endoscopic retrograde cholangiopancreatography (FRCP) at Henry Ford Hospital. The procedure was found to be most useful for identifying the site and nature of an extrahepatic obstruction, the diagnosis of pancreatic cancer, and the preoperative evaluation of chronic pancreatitis. One death occurred as a result of cholangitis in a patient with cancer of the pancreas. Review of the data has led us to refine our indications for FRCP. It has been shown to be a valuable technique with a low incidence of complications in evaluating pancreaticobiliary disease. Based on our study, it would be indicated for jaundiced patients without dilated ducts by echogram or with failure of or contraindication to percutaneous transhepatic cholangiography (PTC), carefully selected patients with unexplained abdominal pain, preoperative evaluation of patients with chronic pancreatitis, and in patients with presumed primary biliary cirrhosis

Adham, A. N.

Salimi, R.

Schuman, Bernard M.

Wong, Kian H.

English

Henry Ford Health System Scholarly Commons

Henry Ford Hosp Med Journal Vol 26, No 4, 1978 Endoscopic Retrograde Cholangiopancreatography at Henry Ford Hospital: 1972-1977 Bernard M. Schuman, MD,* Kian H. Wong, MD,* R. Salimi, MD,* and A. N. Adham, MD* Between 7972 and /977, 440 patients underwent endo-scopic retrograde cholangiopancreatography (FRCP) at Henry Ford Hospital. The procedure was found to be most useful for identifying the site and nature of an extrahepatic obstruction, the diagnosis of pancreatic cancer, and the preoperative evaluation of chronic pancreatitis. One death occurred as a resultof cholangitis in a patient with cancer of the pancreas. Review of the data has led us to refine our indications for FRCP. It has been shown to be a valuable technique with a low incidence of complications in evaluat-ing pancreaticobiliary disease. Based on our study, it would be indicated for jaundiced patients without dilated ducts by echogram or with failure of or contraindication to per-cutaneous transhepatic cholangiography (PTC), carefully selected patients with unexplained abdominal pain, pre-operative evaluation of patients with chronic pancreatitis, and in patients with presumed primary biliary cirrhosis. Submitted for publication: August 28, 1978 Accepted for publication: September 27, 1978 'Department of Internal Medicine, Division of Gastroenterology, Henry Ford Hospital Address reprint requests to Dr. Schuman, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, Ml 48202 Endoscopic cannulation of the ampulla of Vater was first described in 1968 by McCune.'' Since the development of new duodenoscopes in Japan in 1970, the technique has been widely employed and carefully described.^"" Endo-scopic retrograde cholangiopancreatography (FRCP) per-mits excel lent visualization ofthe pancreatic duct as well as intra- and extrahepatic biliary ducts, whatever the level of serum bilirubin. Materials and Methods These studies were performed with a duodenoscope man-ufactured by Olympus Corporation, Patients fast from the night before. Intravenous dextrose is given duringthe pro-cedure. Patients receive intravenous diazepam (Valium) to tolerance and when the duodenum is intubated, tridihex-ethyl chloride (Pathilon) is administered intravenously for anticholinergic effect. In most cases, after the ampulla of Vater has been located, 0 .2-0.5 mg of glucagon is given intravenously to reduce duodenal motility and to relax the ampulla. Four hundred and forty-four patients between 23 and 85 years of age (female to male ratio — 1:1.2) underwent FRCP at Henry Ford Hospital between 1972 and 1977. The procedure was successful in 313 (71.1%) patients. Patients were divided into three groups (Table I). The largest category contained 271 patients with unexplained abdomi-nal pain who were further subdivided into three groups: 115 patients with suspected pancreatic carcinoma, 97 with suspected pancreatitis, and 59 with suspected biliary tract d isease. The second category consisted of 121 patients who had unexplained jaundice. In the third group, 48 patients were examined for preoperative evaluation of chronic pancreatitis. Results of the ERCP procedure are shown in Table I. Schuman, Wong, Salimi, and Adham Group I: Unexplained Abdominal Pain (271 cases) Suspected Pancreatic Cancer (115) Normal ERCP 58 Abnormal Pancreatic Duct 23 a) Cancer (18) b) Pancreatitis (5) Ampullary Cancer 1 Cholelithiasis 1 Unsuccessful ERCP 32 Suspected Pancreatitis (97) Normal ERCP 55 Abnormal Pancreatic Duct 11 Biliary Tract Disease 5 Unsuccessful ERCP 26 Suspected Biliary Tract Disease (59) CBD Stones 6 Gallbladder Stones 2 Stricture 1 Normal 22 Pancreatic Duct Only 20 Unsuccessful ERCP 8 TABLE I ERCP Evaluation Group II: Unexplained Jaundice (121 cases) CBD Stones 13 CBD Stricture 4 Biliary Tract Cancer 3 Choledochal Cyst 1 Pancreatic Cancer 11 Normal CBD and/or PD 52 Unsuccessful ERCP 29 Case Reports Case 1 A 50-year-old man came to the hospital with a history of recurrent epigastric pain radiating to his back since 1966. He was an occasional beer drinker. In 1967, he was treated for mumps with orchitis and questionable pancreatitis. In 1970, he developed diabetes mellitus, which was controlled by diet. Four years later, steatorrhea was documented. On upper gastrointestinal series, compression of the duodenal sweep and calcification within the pancreas was noted, ERCP showed dilatation and tortuosity ofthe pancreatic duct and its radicals (Figure 1), The patient underwent distal pancreatectomy with a Roux-en-Y pancreatico-jejunostomy. The pathologic examination of the tissue confirmed the diagnosis of chronic pancreatitis. Case 2 A45-year-old man with a long history of ethanol ingestion had had several hospital admissions for recurrent abdominal pain. Upper gastrointestinal and gallbladder series and barium enema were within normal limits. His amylase on the last admission was markedly elevated, ERCP revealed a pancreatic duct with multiple strictures (Figure 2), After subtotal pancreatectomy, microscopic study showed severe fibrotic replacement of pancreatic tissue. Group III: Preoperative Evaluation of Chronic Pancreatitis (48 cases) Normal 8 Dilatation and/or Stricture 25 Pseudocyst Unsuccessful ERCP 4 11 Fig. 1: Case 1 Dilated pancreatic duct crosses the spine. The common bile duct is also opacified parallel to the spine. Case 3 A 66-year-old man came tothe hospital with a three-month history of abdominal pain and weight loss. Physical examination was unrevealing. All biochemical and radiological tests were unre-markable except for an elevated alkaline phosphatase. On ERCP the pancreatic duct was "cut off", presumably due to obstruction by a mass. A cut-off sign ofthe right hepatic duct was also noted and was thought to be due to metastatic obstruction of the duct (Figure 3), Atoperation, there was adenocarcinoma of the pancreatic head metastatic to the liver. Case 4 A 66-year-old woman was transferred to Henry Ford Hospital because of obstructive jaundice. She had had a cholecystectomy six years earlier. She continued to have some nonspecific right-upper quadrant pain and indigestion. Three weeks before admis-sion, she noted yellow eyes along with acholic stool and choluria. ERCP showed a dilated common bile duct with multiple stones (Figure 4), Endoscopic Retrograde Cholangiopancreatography Fig. 2: Case 2 Arrows identify points of stricture in the pancreatic duct. Fig. 3: Case 3 Pancreatic duct iscut off in the proximal body. Right hepatic duct also fails to fill. Contrast material fills the bowel loops below. Fig. 4: Case 4 Markedly dilated common bile duct filled with stones. Postoperative stone collection overlaps the x-ray film. Discussion Pancreatitis In our study, cases of pancreatitis had abnormalities that included diffuse narrowing, discrete stenosis, dilatation, tortuosity, biliary and pancreatic duct calculi, pseudocysts and narrowing of the distal common bile duct (CBD). However, there were a few patients whose pancreatic ducts were normal but were proven at surgery to have chronic pancreatitis. Parenchymal disease of the pancreas does not necessarily correspond with ductal alterations"; in eight cases of chronic pancreatitis ERCP showed normal or min imal changes in the pancreatic duct. Pancreatic pseudocyst communicates with the duct system in 60% of the cases.' Its most common site is the head, and single pseudocysts are seen more often than multiple cysts.' In all of our cases, the abdominal echogram preceded ERCP. If cystic changes were suspected in the pancreas, we avoided the injection of excessive contrast because of the danger of infect ing a pseudocyst. ERCP in cases w i th defini te pseudocyst was done only if the patient was scheduled for surgery and ERCP was required for preoperative evaluation. Preoperative evaluation of the pancreatic duct allows the surgeon to design the surgical procedure. The severity of major PD pathology depends on the number of attacks and the destructive effects of the inflammation. The surgical lesion, be it obstruction, stricture or pseudocyst, has been found in different stages of chronic pancreatitis, isolated or combined in the same case.^"^^ ERCP not only provides a basis for selecting a drainage procedure or resection of the pancreas,^^"'^but is also useful for postoperative assessment of a prior drainage procedure.^''^' Schuman, Wong, Salimi, and Adham Pancreatic cancer Differentiating pancreatitis from pancreatic cancer by ERCP is sometimes difficuk. The duct could be completely normal in the presence of parenchymal pancreatic carcinoma; however, when the major pancreatic duct is involved, characteristic configurations have been reported,'^ The two most common radiologic features in pancreatic carcinoma are obstruction, the so-called cut-off sign, and tapered stricture ofthe duct, a "rat-tai l" configuration. However, a false-positive diagnosis could occur ifthe pancreatic duct is blocked by a pseudocyst or is incompletely filled. Freeny et a/^' found that in 11 cases in which ERCP findings were reviewed blindly, the diagnosis of pancreatic cancer was correct and that PD encasement or obstruction occurred exclusively in carcinoma. Our study tends to support that conclusion although the diagnosis wil l always be difficult in patients who have pancreatitis complicated by cancer. Patients with jaundice In our study of 115 icteric cases, we found that 52 had normal CBD and/or PD. In most, a liver biopsy was performed thereafter and revealed evidence of liver cir-rhosis, chronic active hepatitis with cholestasis, or primary biliary cirrhosis (three cases). The demonstration ofa patent normal biliary duct in these cases of prolonged jaundice is very val uable because it reduces the risk from needle biopsy of the liver, excludes other causes of jaundice in liver disease, and avoids laparotomy in cases of primary biliary cirrhosis. In 32 patients with obstructive jaundice, pancreatic head carcinoma was found in 11 cases. Stones in the CBD have been cited as the most frequent cause of extrahepatic biliary obstruction,^^ which was found in 13 of our cases. Carcinoma of the bil iary tract, although not very common, should be part of the differential diagnosis for jaundice.^" Radiologic features encountered by ERCP are: 1) stenosis of the bile duct system with dilatation ofthe upperduct system and its branches and a normal appearance of the duct below the site of obstruction; 2) abrupt blockage of the common bileductwith irregular ragged contour; 3) complete stenosis of the hepatic duct without fill ing of its branches. All three features have occurred in our experience." Ste-nosis of the CB can also be caused by extrinsic compression or by a stricture or scarring of inflammatory origin, and differentiation may be difficult, particularly in patients with sclerosing cholangitis.^' ERCP avoids the prolonged period of observation usually necessary before deciding upon laparotomy in jaundiced patients.^^'"'^^ Problems after biliary surgery Fifty-nine of our cases complained of persistent epigastric or right-upper quadrant pain. Most of these had had a cho-lecystectomy inthe past. In all cases, intravenous cholangio-grams were normal or inconclusive. ERCP revealed abnormalities in 9 cases including CBD stones, gallbladder stones, and stricture (Table I). In cases in which the ERCP was normal, follow-up has not revealed pancreatic or biliary tract disease. Complications A variety of complications after ERCP have been reported (Table 11).^ '"^ ^ A recent study by the Research Committee of the American Society for Gastrointestinal Endoscopy^^ found a complication rate of 21.6/1000 in the reported examinations obtained by survey. Most of these complica-tions were minor. Respiratory depression may be acompi ication of diazepam, although the incidence is very low. Slow intravenous injec-tion of the agent, and a lower dose in the elderly and in patients with chronic obstructive lung disease wil l prevent this problem. We did not encounter this compi ication, but four patients had a paradoxical reaction to diazepam and became hyperactive. Acute pancreatitis follows 1 % of ERCP examinations.^^ Most ofthese patients have a history of chronic or acute relapsing pancreatitis. Pressure, speed and volume of contrast injec-tion into the pancreatic duct are predisposing factors for this complication. The amount of injected contrast should be small although pancreatitis has been reported after injection of as little contrast as 2 ml.^° Pancreatic pseudocyst infection has also been reported after ERCP,^ ^ and the presence o fa pseudocyst contraindicates ERCP except as a preoperative maneuver. In our series, two patients had severe and three patients had moderate pancreatitis, none of whom required surgery. All had had prior episodes of pancreatitis. TABLE 11 Reported Complications of ERCP^"'^' Premedications Diazepam; Apnea Anticholinergics: Tachycardia Pancreatitis Hyperamylasemia (asymptomatic) Sepsis Cholangitis Infected Pseudocyst Possible transmission of hepatitis Instrumentation Submucosal injection of the contrast Injury to the papilla of Vater IV. V VI. In our series, one death occurred due to cholangitis and septic shock. This patient was found to have obstructive jaundice due to pancreatic head carcinoma. Three other Endoscopic Retrograde Cholangiopancreatography cases of cholangitis were successfully treated with antibiot-ics. We now routinely give patients with obstructive jaun-dice intravenous antibiotics (Cephazolin, 1.0 gm every 6 house), starting a few hours before the procedure. Although there is little evidence that bacteria are introduced into the duct system by cannulation, the possibility cannot be dismissed. ERCP failures There were several reasons for failure to accomplish a satisfactory study in 28.9% of our cases. First, our early experience had a high failure rate, a factor reflected in our data. Patients with Billroth-ll type gastrectomies were suc-cessfully cannulated in only 50% of cases. Patients with chronic pancreatitis are difficult to cannulate in some cases because of severe obstructive changes at the ampulla. A malignant obstructive lesion atthe pancreatic head may also interfere with cannulation. A few patients had pyloric narrowing, and we could not intubate the pylorus. How-ever, in our last 200 cases the failure rate was reduced to 20%, a rate which is generally accepted as reasonable. 10 Schuman, Wong, Salimi and Adham References 1. McCune WS, Shorb PE, and Moscowitz H: Endoscopic cannulation of the ampulla of Vater, a preliminary report, Ann Surg 167:752,1968. 2. Vennes jA and Silvis SE: Endoscopic visualization of bile and pancrea-tic ducts, Castro/ntest Endose 18:149-152, 1972, 3. Kasugai T, et a l : Endoscopic pancreatocholangiography I, The normal endoscopic pancreatocholangiograph, Castroentero/ogy 63: 217-226, 1972. 4. KasugalT,eta/: Endoscopic pancreatocholangiography II. The patho-logical endoscopic pancreatocholangiogram, Castroentero/ogy 63:227-234, 1972, 5. Silvis SE and Rahrmann CA: Endoscopic pancreatography in the evaluation of patients with suspected pancreatic pseudocysts. Am / Castroentero/ 61:452-459, 1974. 6. Robbins AH, Messian RA, et a l : Endoscopic pancreatography: An analysis of the rad io log ic f indings in pancreat i t is . Radiology 113:293-296, 1974, 7. Salmon PR: Endoscopic retrograde choledochopancreatography in the diagnosis of pancreatic disease. Cut 16:658-663, 1975, 8. Katsusuke S, Kaoru J, et a l : An eva luat ion of endoscopic pan-creatocholangiography in surgical patients. Surg Cynecol Obstet 140:349-354, 1975. 9. Weiss HD, Anacker H, et at: The diagnosis of necrotizing pancreatic lesions by means of duodenoscopic pancreatography Am / Castroen-tero/ 64:26-33, 1975. 10, Seifert E and Stender H St: X-ray findings of pancreatic cyst diagnosed by endoscopic pancreatocholangiography. Endoscopy 6:77-83, 1974, 11, Zimmon DS and Falkenstein DB, ef at: Endoscopic retrograde cho-langiopancreatography (ERCP) in the diagnosis of pancreatic inflamma-tory disease. Radiology 113: 287-292, 1974. 12, Cotton PB and BealesJS: Endoscopic pancreatography in management of relapsing acute pancreatitis, Brit M 1:608-611,1974, 13, Sugawa, C, et at: Peroral endoscopic cholangiography and pan-creatography, the surgeon's helper. Arch Surg 109:231-237, 1974. 14, Grodsinsky C, Schuman B, and Brush BE: Endoscopic retrograde pancreatic duct cannulation (ERCP). HFH Med I 24:9-18, 1976. 15, Cooperman AM, et at: Endoscopic pancreatography. Its value in preoperative and postoperative assessment of pancreatic disease. A m / Surg 129:38-43, 1975. 16, Braasch JW and Gregg JA: Surgical uses of peroral retrograde pan-creatography and cholangiography. Am / Surg 125:432-436, 1973, 17, Grodsinsky C, Schuman BM, and Block MA: Absence of pancreatic duct dilation in chronic pancreatitis. Arch Surg 111:444-449, 1976, 18. Kugelberg CH and Wehlin L, et at: Endoscopic pancreatography in evaluating results of pancreaticojejunostomy Cut 17:267-272,1976. 19. Feeeny PC, Bilbao MK, et at: "B l i nd " evaluation of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of pan-creatic carcinoma. The "double duct" and other signs. Radiology 119:271-274, 1976, 20. Ayoola EA and Vennes JA, et at: Endoscopic retrograde intrahepatic cholangiography in liver disease. Castro/ntest Endose 22:156-159, 1976, 21. Vennes J A, Jacobson JR, et at: Endoscopic cholangiography for biliary system diagnosis. Ann Intern Med 80:61-64, 1974. 22. Blumgart LH, Cotton PB,et at: Endoscopy and retrograde choledocho-pancreatography in the diagnosis of the jaundiced patient, /.ance! 2:1269-1273, 1972, 23. Blumgart LH, Salmon PR, et at: Endoscopy and retrograde choledocho-pancreatography in the diagnosis of the patient with jaundice, Surg Cynecot Obst 138:565-570, 1974. 24. Seifert E and Safrany, et at: Identification of bile duct tumors by means of endoscopic retrograde pancreatocholangiography (ERCP), Endo-scopy 6:156-162, 1974. 25. Zonca MC, Schuman BM, and Wong KH: The diagnosis of cancer of the biliary tract and pancreas by endoscopic retrograde cannulation, Castro/ntest Endose 21: 129-132, 1975. 26. Abbruzzese AA: Retrograde cholangiography and sclerosing cho-langitis. Digest Dis 19:571-574, 1974. 27. Wong K and Schuman BM: The value of endoscopic study of the bile ducts and the pancreas in the elderly. Geriatrics 7:61-67, 1976. 28. Zimman DS, et at: Complication of endoscopic retrograde cholangio-pancreatography Analysisof 300 consecutive cases, Castroentero/ogy 69:303-309, 1975, 29. Bilbao MK, Dotter CT, et a/: Complications of endoscopic retrograde cholangiopancreatography (ERCP). A study of 10,000 cases. Castroen-tero/ogy 70:314-320, 1976. 30. B lackwood W D , et a t : Post-endoscopy pancreat i t is and hyper-amylasuria. Castro/ntest Endose 20:56-58, 1973, 31 . Elson CO and Hattor K, et at : Po lymicrob ia l sepsis f o l l o w i n g endoscopic retrograde cholangiopancreatography Castroentero/ogy 69:507-510, 1975, 32. McDonald GB and Silverstein FE: Can gastrointestinal endoscopy transmit hepatitis B to patients?Castro/ntest Endose 22:168-170,1976. 1 1 

Endoscopic Retrograde Cholangiopancreatography at Henry Ford Hospital: 1972-1977

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Endoscopic Retrograde Cholangiopancreatography at Henry Ford Hospital: 1972-1977

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