Since the introduction of endoscopic retrograde cholangiopancreatoscopy (ERCP) in 1968 and endoscopic sphincterotomy in 1974, the management of various biliary and pancreatic illnesses has evolved from surgical to endoscopic methods with substantial improvements in patient outcomes. Additionally, development of custom accessories has improved procedural efficiency and success rates; these include balloons and baskets for stone extraction, lithotripsy devices, stents, drains, and duodenoscope-assisted cholangiopancreatoscopy. In expert centers success rates for many therapeutic endoscopic interventions exceed 90%.
Several acute biliary and pancreatic conditions are amenable to endoscopic diagnosis and therapy. ERCP has been shown to have better outcomes than surgery when dealing with most ductal obstructions and leaks. Additionally, ERCP may have a limited role in the diagnosis of bleeding conditions and the treatment of associated complications. This chapter details endoscopic treatment options for these conditions.
ESSENTIALS OF DIAGNOSIS
Diagnosis of acute biliary obstruction with cholangitis relies on clinical findings, blood counts, blood chemistries, biochemical profile, and imaging studies such as magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP).
Endoscopic biliary drainage is the standard of care, with emergent drainage for patients not responding to antibiotics and supportive measures or showing signs of clinical deterioration (ie, hypotension, altered mental states, and signs of continuing infection such as persistent fever).
Acute cholangitis is characterized by biliary stasis and infection of the bile ducts. In 1877, Charcot defined the clinical triad of fever, right upper quadrant pain, and jaundice that is present in up to 70% of patients with acute cholangitis. The spectrum of clinical presentation ranges from mild pain and low-grade fever, to a fulminate course with hypotensive sepsis. In 1959, the Charcot triad was modified to include hypotension and mental status changes, subsequently known as the Reynolds pentad. Clinical presentation is, however, not useful in differentiating between suppurative and nonsuppurative cholangitis, which can only be determined at the time of therapy. In the latter form, bacteria are still present in bile, but without the formation of pus. Suppurative cholangitis has a more acute course and is less likely to respond to antibiotics; however, either form is potentially life threatening, and when acute cholangitis is suspected urgent diagnosis and treatment are critical.
Bile duct obstruction and infection are requisite for the development of cholangitis. Over 90% of cases are attributed to common bile duct stones. Other causes of obstruction include iatrogenic biliary instrumentation and endoprostheses. Less common causes include malignant biliary obstruction, benign bile duct strictures, ampullary adenomas, periductal adenopathy, choledochal cysts, parasites, and blood clots.
Following bile duct obstruction and biliary stasis, infection may occur either by direct ascent from the bowel, or via the lymphatics or portal vein. The latter assumes translocation of bacteria from the bowel into the portal circulation and subsequent clearance of bacteria by the reticuloendothelial system ...