47 2
THE CLINICAL VALUE OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY* DAVID S. ZIMMON, M.D. Department of Medicine, Gastroenterology Section Veterans Administration Hospital New York, N.Y.
ENDOSCOPIc retrograde cholangiopancreatography (ERCP) is a combined endoscopic and radiologic procedure that utilizes a specialized fiberoptic endoscope to identify the papilla of Vater and visually cannulate the pancreatic or biliary duct systems for retrograde injection of radiopaque contrast media. METHOD The endoscope used for this procedure (Olympus JFB or JFB-2) is a lateral viewing instrument with optical characteristics that allow excellent visualization of close-up mucosal detail. Not only can the papilla of Vater (5 mm. in diameter) be identified, but its orifice, which has a diameter of less than I mm., can be visualized clearly. Identification of these small structures and their cannulation is predicated upon sedation of the patient, absence of duodenal peristalsis, and relaxation of the ampullary sphincter. Duodenal motion must be reduced to the minimum produced by respiration and vascular pulsation. Diazepam and meperidine are the preferred sedatives. Anticholinergics were used initially for duodenal relaxation. Since these drugs must be administered by rapid intravenous injection and are a potential source of complications in the period of recovery, they have been replaced by glucagon. By positioning the endoscope and directing the cannula, either the pancreatic or biliary duct systems may be entered. With the endoscopic head above or at the level of the papilla and the catheter introduced perpendicular to the duodenal wall the pancreatic duct system is cannulated. To cannulate the bile duct the endoscope is positioned *Presented as part of A Day on the Liver held by the New York Academy of Medicine and the International Association for the Study of the Liver at the Academy, March 7, 1974.
Bull. N. Y. Acad. Med.
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
47 3
Fig. 1. This endoscopic retrograde cholangiogram was performed on a 28-year-old woman six weeks after cholecystectomy and common duct exploration for cholelithiasis and choledocholithiasis. At the time of T-tube cholangiography a stricture of the hepatic duct was noted. After withdrawal of the T-tube the patient had no symptoms; liver function tests were normal. This retrograde cholangiogram was performed to ascertain the extent of the stricture and determine if repair was necessary. The endoscope is seen placed in the duodenum beyond the papilla of Vater. In this position the catheter passes upward, avoiding the pancreatic duct, and contrast material is injected directly into the common bile duct. The small arrow marks the catheter within the papilla of Vater and the terminal common bile duct. The large arrow points to the stricture in the hepatic duct. The narrowed segment is 3 mm. in diameter and appears adequate to provide drainage for the liver. The intrahepatic bile ducts are normal and testify to the absence of increased pressure within the liver.
474
D. S. ZIMMON
Fig. 2. This retrograde cholangiogram was performed because an elevated level of serum amylase had been found in a patient who was receiving chronic hemodialysis for renal failure. The pancreatogram was normal. The retrograde cholangiogram demonstrates a dilated common bile duct with a large intraluminal filling defect (single small arrow). The intrahepatic bile ducts are dilated and contain many similar filling defects (two small arrows). At endoscopy blood was seen coming from the papilla of Vater. The cystic duct (single large arrow) appears to be blocked and also shows multiple filling defects. The single large filling defect at the point of the large arrow was thought to be a stone in the cystic duct. On surgical exploration this mass proved to be a papillary carcinoma of the cystic duct. Ulceration in the tumor had produced hemobilia. Blood clots accounted for multiple filling defects seen in the biliary tree. The gallbladder was normal, although the cystic duct was obstructed by the tumor mass.
farther distally in the duodenum and the cannula is passed cephalad into the papilla parallel to the duodenal wall (Figure I). Injection of the pancreatic duct must be monitored carefully through the fluoroscope since much pressure is required to inject contrast media through the long narrow catheter. This force is magnified hydraulically at the outlet of the catheter. High pressures may be produced in the pancreatic duct system if leakage back through the papilla of Vater or through the accessory duct of Santorini does not occur. Excessive intraductal pressure may cause damage and may induce pancreatitis. Infection, the major cholangiographic complication, occurs almost exclusively when the ducts are obstructed. This danger has been markedly reduced by the addition Bull. N. Y. Acad. Med.
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
47 5
Fig. 3. This retrograde cholangiogram was performed in a patient with jaundice, right upper quadrant pain, and a history of excessive alcohol intake. The gallbladder demonstrates the presence of small radiolucent stones (large arrow). The common bile duct and cystic duct are normal. The small defect in the terminal common bile duct represents the normal terminal sphincter. The intrahepatic bile ducts (small arrow) are stretched and attenuated; this is compatible with fatty infiltration or cirrhosis. Both conditions were documented by liver biopsy.
Vol. 51, No. 4, April 1975
47 6
D. S. ZIMMON
Fig. 4. This retrograde cholangiogram and pancreatogram were performed in a patient with history of excessive alcohol intake and jaundice. The pancreatogram was normal. The proximal pancreatic duct is seen at the lower right-hand portion of the figure. The common bile duct, cystic duct, and gallbladder are normal. Tihe intrahepatic bile ducts appear compressed and poorly filled, suggesting the presence of cirrhosis. The left lateral hepatic duct (arrow) is distorted with areas of narrowing and dilatation and the medial branch of the left hepatic duct is abruptly shortened and dilated. These findings raised the question of a mass lesion within a cirrhotic liver. Laparoscopy demonstrated micronodular cirrhosis without evidence of hepatorna or large regenerating nodules. A cholangiogram six months later demonstrated identical configuration of the intrahepatic ducts, suggesting that the process was due entirely to cirrhosis.
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
47 7
Fig. 5. This endoscopic cholangiogram and pancreatogram were performed in a patient who had had recurrent attacks of pancreatitis. The cholangiogram demonstrates a small shrunken gallbladder with multiple radiolucent stones (single large arrow). The common duct is slightly dilated and tapers within the pancreas, indicating extrinsic compression. The pancreatic duct is irregular with dilated and clubbed secondary pancreatic radicles suggesting the presence of acute or early chronic pancreatitis. An area of ductal disruption and pseudocyst formation is seen in the midportion of the pancreas (two small arrows). This is an example of pancreatitis associated with gallstones where disruption of the pancreatic duct and pseudocyst formation have taken place.
of antibiotics to the inj ectate and by prompt surgical intervention to establish drainage when necessary. ENDOSCOPY The Olympus JFB and JFB-2 are superior endoscopic instruments and allow a complete examination of the upper gastrointestinal tract, target biopsy, and collection of cytologic or biliary samples. Therefore, in patients suspected of biliary or pancreatic disease, it is feasible to bypass many preliminary studies and to combine endoscopy with ERCP in a single diagnostic procedure. This speeds the diagnostic study. Even if other modalities such as barium radiography have preceded ERCP, the endoscopic portion of the procedure may yield important information because of its precision in identifying consequences of the primary disease process (e.g., esophageal varices, gastric cancer) or secondary Vol. 51, No. 4, April 1975
47 8 478
ZIMMON D. S. ZIMMON D.
5.
Fig. 6. This is an example of chronic pancreatitis with a dilated irregular pancreatic duct and irregularity of the secondary duct radicles in the head of the pancreas. A small pseudocyst at the junction of the major and minor pancreatic ducts is marked by the arrow. The resolution of this pseudocyst and the potential for stricture formation at the site can be judged only by subsequent pancreatography.
conditions such as hiatus hernia, esophagitis, gastritis, and peptic ulcer. These secondary conditions may be unsuspected, their symptoms overshadowed by the primary disease, although their presence can influence management. CHOLANGIOGRAPHY Retrograde cholangiography permits visualization of both the extrahepatic and intrahepatic biliary tree. By this method, in contrast to cholecystography or intravenous cholangiography, the duct system is forcefully filled with dense contrast media. Thus radiography of high quality can be combined with fluoroscopic study of biliary distensibility and emptying (Figure i). It becomes possible to differentiate failure of the concentrating function of the gallbladder from cholelithiasis and from obstruction of the cystic duct (Figure 2). The anatomy of the individual cystic duct can be studied and the presence of a cystic duct Bull. N. Y. Acad. Med.
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
479
Fig. 7. This retrograde pancreatogram shows chronic pancreatitis with a moderately dilated main pancreatic duct and dilated secondary radicles extending laterally from it. An area of ductal stricture is seen in the head of the pancreas adjacent to the tip of the endoscope (white arrow). Contrast medium has been forced through this blocked segment. The terminal pancreatic duct is narrowed, with two areas of stricture. The black arrow on the right marks the site of a pancreaticojunostomy performed at the time of a previous pancreatic resection. This operation was performed because an earlier pancreatogram had shown the obstruction in the head of the pancreas demonstrated here. This anastomosis is not considered adequate for drainage of the pancreas since a stricture has formed at the anastomosis. Delayed films, prepared after withdrawal of the endoscope, demonstrated extremely slow emptying of the dye from the pancreatic duct system. This surgical attempt to relieve pancreatic duct obstruction and preserve the function of the gland must be considered a technical failure.
segment combined with the common bile duct in a common sheath can be established. The value of precise preoperative diagnosis and exclusion of choledocholithiasis need not be emphasized (Figure 3). Visualization of the intrahepatic biliary radicles is accomplished by increasing the volume of contrast medium injected and lowering the patient's head 20°. The bile ducts within the portal triad are subject to the same influences as the hepatic artery and the portal vein. Radiographic analysis of the intrahepatic cholangiogram provides information similar to that acquired by hepatic angiography or venography and permits the diagnosis of hepatic mass lesions (tumor, abscess), infiltrative diseases (fatty liver, lymphoma), and cirrhosis (Figures 3 and 4). PANCREATOGRAPHY Retrograde pancreatography routinely opacifies the main and secondary pancreatic ducts. If the injection pressure is increased and the period of opacification is prolonged, the pancreatic acini become opaciVol. 51, No. 4, April 1975
480
480
-
D. S. ZIMM\ON
fied and the entire gland is outlined as in a nephrogram. The majority of pathological processes in the pancreas are easily identified during visualization of the duct system alone. The classification of pancreatic inflammatory disease (Figure 5), the identification of duct stricture and obstruction (Figure 6), the appraisal of pancreatic operative procedures (Figure 7), and the diagnosis of pancreatic neoplasia are facilitated by endoscopic retrograde pancreatography. Undoubtedly this diagnostic advance will be reflected in improved surgical therapy for pancreatic disease and will allow the postoperative evaluation of the efficacy of surgical efforts to establish continuity between the diseased pancreas and the gastrointestinal tract. In the past, pancreatic surgery was delayed until extensive lesions or intolerable symptoms developed. Only the operative pancreatogram performed at laparotomy could establish the presence of ductal obstruction and determine the type of operation to be performed. With the use of endoscopic retrograde pancreatography, lesions amenable to surgical management can be diagnosed early and the appropriate procedure planned prior to laparotomy. This will undoubtedly reduce the operative morbidity and encourage early surgical intervention. Postoperative retrograde pancreatograms will allow the assessment of operative results and differentiate failure to relieve the disease state from primary technical failure of the operative procedure (Figure 7). SUMMARY
Endoscopic retrograde cholangiopancreatography is a demanding and complex technique requiring the coordinate use of endoscopy and radiography. The great expense and effort required to exhibit this technique must be weighed against its rapid and precise ability to define or exclude disease of the upper gastrointestinal tract, pancreas, and biliary tree. Initial experience suggests that ERCP will find wide usefulness in the early diagnosis of a wide range of gastrointestinal diseases.
Bull. N. Y. Acad. Med.
THE CLINICAL VALUE OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY* DAVID S. ZIMMON, M.D. Department of Medicine, Gastroenterology Section Veterans Administration Hospital New York, N.Y.
ENDOSCOPIc retrograde cholangiopancreatography (ERCP) is a combined endoscopic and radiologic procedure that utilizes a specialized fiberoptic endoscope to identify the papilla of Vater and visually cannulate the pancreatic or biliary duct systems for retrograde injection of radiopaque contrast media. METHOD The endoscope used for this procedure (Olympus JFB or JFB-2) is a lateral viewing instrument with optical characteristics that allow excellent visualization of close-up mucosal detail. Not only can the papilla of Vater (5 mm. in diameter) be identified, but its orifice, which has a diameter of less than I mm., can be visualized clearly. Identification of these small structures and their cannulation is predicated upon sedation of the patient, absence of duodenal peristalsis, and relaxation of the ampullary sphincter. Duodenal motion must be reduced to the minimum produced by respiration and vascular pulsation. Diazepam and meperidine are the preferred sedatives. Anticholinergics were used initially for duodenal relaxation. Since these drugs must be administered by rapid intravenous injection and are a potential source of complications in the period of recovery, they have been replaced by glucagon. By positioning the endoscope and directing the cannula, either the pancreatic or biliary duct systems may be entered. With the endoscopic head above or at the level of the papilla and the catheter introduced perpendicular to the duodenal wall the pancreatic duct system is cannulated. To cannulate the bile duct the endoscope is positioned *Presented as part of A Day on the Liver held by the New York Academy of Medicine and the International Association for the Study of the Liver at the Academy, March 7, 1974.
Bull. N. Y. Acad. Med.
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
47 3
Fig. 1. This endoscopic retrograde cholangiogram was performed on a 28-year-old woman six weeks after cholecystectomy and common duct exploration for cholelithiasis and choledocholithiasis. At the time of T-tube cholangiography a stricture of the hepatic duct was noted. After withdrawal of the T-tube the patient had no symptoms; liver function tests were normal. This retrograde cholangiogram was performed to ascertain the extent of the stricture and determine if repair was necessary. The endoscope is seen placed in the duodenum beyond the papilla of Vater. In this position the catheter passes upward, avoiding the pancreatic duct, and contrast material is injected directly into the common bile duct. The small arrow marks the catheter within the papilla of Vater and the terminal common bile duct. The large arrow points to the stricture in the hepatic duct. The narrowed segment is 3 mm. in diameter and appears adequate to provide drainage for the liver. The intrahepatic bile ducts are normal and testify to the absence of increased pressure within the liver.
474
D. S. ZIMMON
Fig. 2. This retrograde cholangiogram was performed because an elevated level of serum amylase had been found in a patient who was receiving chronic hemodialysis for renal failure. The pancreatogram was normal. The retrograde cholangiogram demonstrates a dilated common bile duct with a large intraluminal filling defect (single small arrow). The intrahepatic bile ducts are dilated and contain many similar filling defects (two small arrows). At endoscopy blood was seen coming from the papilla of Vater. The cystic duct (single large arrow) appears to be blocked and also shows multiple filling defects. The single large filling defect at the point of the large arrow was thought to be a stone in the cystic duct. On surgical exploration this mass proved to be a papillary carcinoma of the cystic duct. Ulceration in the tumor had produced hemobilia. Blood clots accounted for multiple filling defects seen in the biliary tree. The gallbladder was normal, although the cystic duct was obstructed by the tumor mass.
farther distally in the duodenum and the cannula is passed cephalad into the papilla parallel to the duodenal wall (Figure I). Injection of the pancreatic duct must be monitored carefully through the fluoroscope since much pressure is required to inject contrast media through the long narrow catheter. This force is magnified hydraulically at the outlet of the catheter. High pressures may be produced in the pancreatic duct system if leakage back through the papilla of Vater or through the accessory duct of Santorini does not occur. Excessive intraductal pressure may cause damage and may induce pancreatitis. Infection, the major cholangiographic complication, occurs almost exclusively when the ducts are obstructed. This danger has been markedly reduced by the addition Bull. N. Y. Acad. Med.
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
47 5
Fig. 3. This retrograde cholangiogram was performed in a patient with jaundice, right upper quadrant pain, and a history of excessive alcohol intake. The gallbladder demonstrates the presence of small radiolucent stones (large arrow). The common bile duct and cystic duct are normal. The small defect in the terminal common bile duct represents the normal terminal sphincter. The intrahepatic bile ducts (small arrow) are stretched and attenuated; this is compatible with fatty infiltration or cirrhosis. Both conditions were documented by liver biopsy.
Vol. 51, No. 4, April 1975
47 6
D. S. ZIMMON
Fig. 4. This retrograde cholangiogram and pancreatogram were performed in a patient with history of excessive alcohol intake and jaundice. The pancreatogram was normal. The proximal pancreatic duct is seen at the lower right-hand portion of the figure. The common bile duct, cystic duct, and gallbladder are normal. Tihe intrahepatic bile ducts appear compressed and poorly filled, suggesting the presence of cirrhosis. The left lateral hepatic duct (arrow) is distorted with areas of narrowing and dilatation and the medial branch of the left hepatic duct is abruptly shortened and dilated. These findings raised the question of a mass lesion within a cirrhotic liver. Laparoscopy demonstrated micronodular cirrhosis without evidence of hepatorna or large regenerating nodules. A cholangiogram six months later demonstrated identical configuration of the intrahepatic ducts, suggesting that the process was due entirely to cirrhosis.
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
47 7
Fig. 5. This endoscopic cholangiogram and pancreatogram were performed in a patient who had had recurrent attacks of pancreatitis. The cholangiogram demonstrates a small shrunken gallbladder with multiple radiolucent stones (single large arrow). The common duct is slightly dilated and tapers within the pancreas, indicating extrinsic compression. The pancreatic duct is irregular with dilated and clubbed secondary pancreatic radicles suggesting the presence of acute or early chronic pancreatitis. An area of ductal disruption and pseudocyst formation is seen in the midportion of the pancreas (two small arrows). This is an example of pancreatitis associated with gallstones where disruption of the pancreatic duct and pseudocyst formation have taken place.
of antibiotics to the inj ectate and by prompt surgical intervention to establish drainage when necessary. ENDOSCOPY The Olympus JFB and JFB-2 are superior endoscopic instruments and allow a complete examination of the upper gastrointestinal tract, target biopsy, and collection of cytologic or biliary samples. Therefore, in patients suspected of biliary or pancreatic disease, it is feasible to bypass many preliminary studies and to combine endoscopy with ERCP in a single diagnostic procedure. This speeds the diagnostic study. Even if other modalities such as barium radiography have preceded ERCP, the endoscopic portion of the procedure may yield important information because of its precision in identifying consequences of the primary disease process (e.g., esophageal varices, gastric cancer) or secondary Vol. 51, No. 4, April 1975
47 8 478
ZIMMON D. S. ZIMMON D.
5.
Fig. 6. This is an example of chronic pancreatitis with a dilated irregular pancreatic duct and irregularity of the secondary duct radicles in the head of the pancreas. A small pseudocyst at the junction of the major and minor pancreatic ducts is marked by the arrow. The resolution of this pseudocyst and the potential for stricture formation at the site can be judged only by subsequent pancreatography.
conditions such as hiatus hernia, esophagitis, gastritis, and peptic ulcer. These secondary conditions may be unsuspected, their symptoms overshadowed by the primary disease, although their presence can influence management. CHOLANGIOGRAPHY Retrograde cholangiography permits visualization of both the extrahepatic and intrahepatic biliary tree. By this method, in contrast to cholecystography or intravenous cholangiography, the duct system is forcefully filled with dense contrast media. Thus radiography of high quality can be combined with fluoroscopic study of biliary distensibility and emptying (Figure i). It becomes possible to differentiate failure of the concentrating function of the gallbladder from cholelithiasis and from obstruction of the cystic duct (Figure 2). The anatomy of the individual cystic duct can be studied and the presence of a cystic duct Bull. N. Y. Acad. Med.
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
479
Fig. 7. This retrograde pancreatogram shows chronic pancreatitis with a moderately dilated main pancreatic duct and dilated secondary radicles extending laterally from it. An area of ductal stricture is seen in the head of the pancreas adjacent to the tip of the endoscope (white arrow). Contrast medium has been forced through this blocked segment. The terminal pancreatic duct is narrowed, with two areas of stricture. The black arrow on the right marks the site of a pancreaticojunostomy performed at the time of a previous pancreatic resection. This operation was performed because an earlier pancreatogram had shown the obstruction in the head of the pancreas demonstrated here. This anastomosis is not considered adequate for drainage of the pancreas since a stricture has formed at the anastomosis. Delayed films, prepared after withdrawal of the endoscope, demonstrated extremely slow emptying of the dye from the pancreatic duct system. This surgical attempt to relieve pancreatic duct obstruction and preserve the function of the gland must be considered a technical failure.
segment combined with the common bile duct in a common sheath can be established. The value of precise preoperative diagnosis and exclusion of choledocholithiasis need not be emphasized (Figure 3). Visualization of the intrahepatic biliary radicles is accomplished by increasing the volume of contrast medium injected and lowering the patient's head 20°. The bile ducts within the portal triad are subject to the same influences as the hepatic artery and the portal vein. Radiographic analysis of the intrahepatic cholangiogram provides information similar to that acquired by hepatic angiography or venography and permits the diagnosis of hepatic mass lesions (tumor, abscess), infiltrative diseases (fatty liver, lymphoma), and cirrhosis (Figures 3 and 4). PANCREATOGRAPHY Retrograde pancreatography routinely opacifies the main and secondary pancreatic ducts. If the injection pressure is increased and the period of opacification is prolonged, the pancreatic acini become opaciVol. 51, No. 4, April 1975
480
480
-
D. S. ZIMM\ON
fied and the entire gland is outlined as in a nephrogram. The majority of pathological processes in the pancreas are easily identified during visualization of the duct system alone. The classification of pancreatic inflammatory disease (Figure 5), the identification of duct stricture and obstruction (Figure 6), the appraisal of pancreatic operative procedures (Figure 7), and the diagnosis of pancreatic neoplasia are facilitated by endoscopic retrograde pancreatography. Undoubtedly this diagnostic advance will be reflected in improved surgical therapy for pancreatic disease and will allow the postoperative evaluation of the efficacy of surgical efforts to establish continuity between the diseased pancreas and the gastrointestinal tract. In the past, pancreatic surgery was delayed until extensive lesions or intolerable symptoms developed. Only the operative pancreatogram performed at laparotomy could establish the presence of ductal obstruction and determine the type of operation to be performed. With the use of endoscopic retrograde pancreatography, lesions amenable to surgical management can be diagnosed early and the appropriate procedure planned prior to laparotomy. This will undoubtedly reduce the operative morbidity and encourage early surgical intervention. Postoperative retrograde pancreatograms will allow the assessment of operative results and differentiate failure to relieve the disease state from primary technical failure of the operative procedure (Figure 7). SUMMARY
Endoscopic retrograde cholangiopancreatography is a demanding and complex technique requiring the coordinate use of endoscopy and radiography. The great expense and effort required to exhibit this technique must be weighed against its rapid and precise ability to define or exclude disease of the upper gastrointestinal tract, pancreas, and biliary tree. Initial experience suggests that ERCP will find wide usefulness in the early diagnosis of a wide range of gastrointestinal diseases.
Bull. N. Y. Acad. Med.
