For this test, you will have a narrow tube put through your mouth and throat into your small intestine. Endoscopic retrograde cholangiopancreatography ercp related perforation, is a rare complication with a high morbidity and mortality. Endoscopic retrograde cholangiopancreatography ercp niddk. Duodenal perforation is an uncommon complication of endoscopic retrograde cholangiopancreatography ercp and a rare complication of upper gastrointestinal endoscopy. Perforations are one of the most feared complications because early diagnosis is very difficult and because they. Sphincterotomy billroth ii anatomy the intramural injection of contrast prolonged duration of procedure biliary stricture dilation sod malignancy precut access complications of ercp 3. Ercp is attended with certain complications, the majority of which are well known to the medical community. The decision to close a perforation surgically is usually made immediately.
Ercp short for endoscopic retrograde cholangiopancreatography is a procedure used to diagnose diseases of the gallbladder, biliary system, pancreas, and liver. Algorithm for the management of endoscopic perforations. Furthermore, such a plan demonstrates preparedness on the part of the gastroenterologist. Perforation is a rare complication of it, but it is associated with high rate of mortality, an overall. Classification and management of perforations complicating. Most are minor perforations that settle with conservative management.
Epidemiology perforation rates with ercp range from 0. Perforation related to endoscopic retrograde cholangiopancreatography ercp is a rare complication associated with significant morbidity and mortality. The most common complication is post ercp pancreatitis, which occurs in approximately 5% to 15% of patients and is the subject of a significant amount of research, including identifying risk. Ercp with sphincterotomy is commonly performed to treat hepatopancreato biliary disease. Many previo us reports have described the management of perforation inju ries associated with ercp.
Endoscopic retrograde cholangiopancreatography, or ercp, is a specialized technique used to study the bile ducts, pancreatic duct and gallbladder. In total, 15 of 29 patients with ercp perforation were operated on. Some advocate a nonsurgical approach to management in certain select patients. If a perforation is not recognized or suspected during ercp, it would be difficult to make the diagnosis early i. Endoscopic retrograde cholangiopancreatography ercp is a procedure used to get pictures of the digestive tract, including the pancreas. Endoscopic retrograde cholangiopancreatography ercp is a procedure that combines upper gastrointestinal gi endoscopy and xrays to treat problems of the bile and pancreatic ducts. A few perforations however result in lifethreatening retroperitoneal necrosis and require surgical intervention. The perforation is usually diagnosed with xray or ct scan after the patients pain persists.
Evidencebased strategies are lacking regarding the appropriate management of duodenal perforations complicating endoscopic retrograde cholangiopancreatography ercp combined with endoscopic sphincterotomy es. Ercp is a procedure that physicians use to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. Although endoscopic sphincterotomy with eplbd and complete endoscopic sphincterotomy alone are risk factors for ercprelated perforation, there is a lower. Iatrogenic duodenal perforations caused by endoscopic. Institutional algorithm used for the management of ercprelated perforation. Management of perforation after endoscopic retrograde. Duodenal perforations caused during stenting and stent migration are rare but lifethreatening. Endoscopic retrograde cholangiopancreatographyrelated perforation 18144 int j clin exp med 2016. Perforation of approximately 1 cm is evident in the duodenal wall contralateral to the papilla over a duodenal diverticulum.
It is typically performed by doctors with endoscopic qualifications e. Duodenal perforation after endoscopic procedure federal. Acute perforations are one of the recognised complications of both diagnostic and therapeutic gastrointestinal gi endoscopy. Depending on the individual situation, perforations can sometimes be treated with antibiotics and extra days in the hospital. Patients lie in the left lateral decubitus position for introduction of the endoscope into the duodenum and are then turned into the prone oblique position, 16.
We developed an endoscopic perforation management strategy based on the best available scientific evidence and our specific. Although complications requiring hospitalization can occur, they are uncommon. Adverse events of endoscopic interventions adverse events of ugi dilation data from randomized trials and large case series suggest that the overall rate of dilation adverse events is between 0. Epub ahead of print, v kumbhari, a sinha, a reddy, e afghani, d cotsalas, ya patel, ac storm, ma khashab, an kalloo, vk singh from medlinepubmed, a database of the u. Depending on your age, your other medical problems, what therapy is. Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Fifteen patients 50 % were successfully treated conservatively. Sphincterotomy billroth ii anatomy the intramural injection of contrast prolonged. Here, a case of massive subcutaneous emphysema following ercp was re. We report two cases of duodenal perforations following endoscopic sphincterotomy.
Ercp procedure indications, recovery, complications. Early management experience of perforation after ercp. Diagnosis and management of iatrogenic endoscopic perforations. Endoscopic retrograde cholangio pancreatography ercp. Algorithm for the management of ercprelated perforations.
A case report of nonsurgical duodenal perforation following ercp. Perforation, endoscopic retrograde cholangiopancreatography, ercp. Clips for managing perforation and bleeding after colorectal endoscopic mucosal resection a. N2 iatrogenic duodenal and pancreaticobiliary perforations associated with endoscopic retrograde cholangiopancreatography ercp are rare but associated with a significant morbidity and mortality. Endoscopic retrograde cholangiopancreatography ercp information for patients you have been advised to have an ercp endoscopic retrograde cholangiopancreatography. Ercp subsequent to retroperitoneal perforation caused by. The mortality rate in perforated patients is as high as 25% 4. Ercp endoscopic retrograde cholangiopancreatography this information was developed by the publications committee of the american society for gastrointestinal endoscopy asge. Ercp in one case and, in the second case, perforation was evident during ercp and a biliary stent was inserted. Endoscopic retrograde cholangiopancreatography ercp is a technique that uses xray to view the patients bile and pancreatic ducts. The frequency of ercp perforation was higher in the studies with a lower number of ercps carried out and lower in the studies with a high number of ercps. Ercp endoscopic retrograde cholangiopancreatography ercp is a test of the ducts of your gallbladder and pancreas.
Having an ercp endoscopic retrograde cholangio pancreatogram this leaflet explains more about having an ercp, including the benefits, risks and any alternatives and what you can expect when you come to hospital. Akira tsuji, daisuke hashimoto, tetsu ozaki, akira chikamoto, toru beppu, hideo baba subject. Endoscopic retrograde cholangiopancreatography ercp is widely used for the diagnosis and treatment of biliary and pancreatic tract disease. Percutaneous treatment of endoscopic sphincterotomyrelated. Nevertheless, because of its risks, it has been used only for therapeutic. The management of perforation of the duodenum following ercp. Pdf management of duodenal perforation after endoscopic. The diagnosis of perforation was made during the ercp in 111 patients 36. Vs the risk of a perforation occurring during an ercp is fairly uncommon.
Management of ercprelated small bowel perforations. An elevation in the serum amylase concentration is common after endoscopic retrograde cholangiopancreatography ercp, occurring in up to 75 percent of patients. Seven patients underwent ercp at another institution, and 23 patients underwent an endoscopic procedure at our hospital. A tailored approach to the management of perforations. Sepsis may occur in patients with partial obstruction of common bile duct. What is endoscopic retrograde cholangiopancreatography ercp. The size, location and seriousness of such a perforation or hole can vary along with the treatment choices for such an injury. Between november 2003 and december 2011, a total of 8504 ercps were performed at our regional endoscopy center.
Endoscopic retrograde cholangio pancreatography, or ercp, is a specialized. The functions of the common bile duct and the pancreatic duct are to drain the gallbladder, liver, and pancreas. An ercp is an xray examination which uses an endoscope to examine the. Iatrogenic perforations related to endoscopic retrograde cholangiopancreatography ercp are an uncommon adverse event, occurring in 0.
The aim of this study was to determine the timing and the outcome of ercp after retroperitoneal perforation caused by endoscopic sphincterotomy when the initial ercp was incomplete. Management of endoscopic complications, in particular. Nine 60% of those who underwent surgery were discharged uneventful, but 6 40% patients died due to postoperative complications andor associated comorbidities. Nih stateofthescience conference on endoscopic retrograde. T ension pneumoperitoneum tpp, also known as hyperacute abdominal compartment syndrome or abdominal tamponade, is a rare condition most commonly associated with gastrointestinal gi perforation during endoscopy and iatrogenic insufflation of gas into the peritoneal cavity. Ercp endoscopic retrograde cholangiopancreatography. This study evaluated the early management experience of these perforations. Ercp can provide important information that cannot be obtained by other diagnostic examinations, for example. Endoscopic retrograde cholangiopancreatography ercp. The national institutes of health nih is convening a stateofthescience conference on endoscopic retrograde cholangiopancreatography ercp for diagnosis and therapy on january 1416, 2002. Materials and methods between march 2003 and march 20, 2,071 ercps were performed in our hospital.
Endoscopic treatment for duodenal perforation during ercp. The overall ercp complication rate requiring hospitalization is 610%. If cannulation of the biliary tree is difficult, a flexible. Common bile duct perforation by biliary stents postercp. The majority are caused during the procedure due to guidewire insertion. Perforation of the duodenum during the retrograde cholangiopancreatography treated without surgery author. As an improvement of endoscopic devices, endoscopic treatment may replace the role of surgical management in near future. If you have any further questions, please speak to a doctor or nurse caring for you. In 2011, kim et al14 proposed a new classification based on the instrument that caused the perforation. A complication to take into account 1 gast r 16111 1 abstract when it was introduced 40 years ago, endoscopic retrograde cholangiopancreatography ercp was used to diagnose biliopancreatic diseases. This has led some authors to recommended early operation in all duodenal perforations. A small number are caused at the time of stent placement or its subsequent migration. Ercp endoscopic retrograde cholangiopancreatography, duodenal perforation, biliary stent.
Management of duodenal perforation after endoscopic. Perforation after endoscopic retrograde cholangiopancreatography ercp is a rare complication, but it is associated with significant mortality. Endoscopic retrograde cholangiopancreatographyrelated. Successful closure of lateral duodenal perforation by endoscopic band ligation after endoscopic clipping failure. It takes xray pictures after a dye is injected through a thin tube. Endoscopic retrograde cholangiopancreatography ercp test. Perforation related to endoscopic retrograde cholangiopancreatography ercp. Successful endoscopic vacuum therapy with new openpore film drainage in a case of iatrogenic duodenal perforation during ercp. Your bile ducts are tubes that carry bile from your liver to your.
Ercp is a diagnostic procedure designed to examine diseases of the liver, bile ducts and pancreas. Endoscopic retrograde cholangiopancreatography ercp is a diagnostic and interventional procedure technique using both endoscopy and fluoroscopy for examination and intervention of the biliary tree and pancreatic ducts. Ercp is usually best performed under general anesthesia. An overview of the complications of ercp and detailed discussions of other individual complications are presented separately. Patients routinely undergo intravenous sedation, which increases the risk of cardiopulmonary complications, 6, 15. Duodenal perforation post ercp is rare, occurring in 1% range 0. Since the initial reports, endoscopic retrograde cholangiopancreatography ercp and endoscopic sphincterotomy es have become a standard procedure for treating a broad spectrum of diseases of the biliary and pancreatic ducts. Since perforations are uncommon, a predetermined plan of action can streamline patient management. An algorithm for the management of ercprelated perforations. For decades, surgical treatment has been the standard of care, but endoscopic closure has become a more popular approach, due to feasibility and the. For more information about asge, visit what is ercp. Some recommend surgery, while others recommend conservative treatment. Management of endoscopic retrograde cholangiopancreatography ercp associated duodenal perforation remains controversial.
Endoscopic biliary stenting is the preferred method of decompression in obstructive jaundice. An algorithm for the management of ercprelated perforations gastrointest. In addition, they must understand and attempt to follow maneuvers that reduce the risk of adverse events. Paspatis1, jeanmarc dumonceau2, marc barthet3, soren meisner4, alessandro repici5, brian p.
Perforation is a rare complication of it, but it is associated with high rate of mortality, an overall mortality rate of 1. From january 1999 to december 2011, 30 perforations after ercp were observed. Endoscopy is the examination of an internal body part with an instrument called an endoscope. Perforation ercprelated perforations were previously classified into 34 types, regardless of the site of perforation12, table 1. Ducts are small tubes that let fluid pass from one place to another. Surgical management of duodenal perforations after ercp.
Imaging findings of complications after endoscopic. The major findings of this study are a perforation rate lower than that reported recently in the literature, 4, 11 the recent sight decrease in the use of ercp and the pivotal role of surgical assessment and tailored treatment of patients with duodenal perforation after ercp. The management of endoscopic retrograde cholangiopancreatography ercprelated perforations remains controversial. Endoscopic retrograde cholangiopancreatography radiology. Siersema department of gastroenterology and hepatology, radboud university medical centre, the netherlands abstract introduction. Jan 01, 2016 epidemiology perforation rates with ercp range from 0. Perforation after endoscopic retrograde cholan giopancreatography ercp. However, it is rare for an endoscopic attempt to appear successful only for a patient to later undergo surgery for an incomplete closure or fallen clip. Sutherland1 1department of surgery, university of calgary and 2department of medicine, university of toronto, canada abstract background. There have been patients in whom an endoscopic attempt is made but fails, and they go directly into surgery. This procedure allows the doctor to take detailed xrays of the bile duct andor pancreas. Ercp is a welltolerated procedure when performed by doctors who are specially trained and experienced in the technique.
In this report, we present the clinical course of three patients who sustained guidewire perforation of the. Guidewire injury to the hepatic or pancreatic parenchyma represents one of the much less appreciated, albeit preventable, complications. European society of gastrointestinal endoscopy esge position statement authors gregorios a. Pneumoretroperitoneum secondary to duodenal perforation. Saunders6, antonios vezakis7, jean michel gonzalez3, stine ydegaard turino4, zacharias p. Clinical manifestations are similar to those that appear in pancreatitis i. Infection cholangitis the rate of post ercp cholangitis is 1% or less. Jan 24, 2014 duodenal perforation is an uncommon complication of endoscopic retrograde cholangiopancreatography ercp and a rare complication of upper gastrointestinal endoscopy.
The most commonly used treatment for advanced colorectal adenomas is. Cbd perforation by stents could be speculated to be caused by the nature and type of stent or the duration between ercp and laparoscopic cholecystectomy when left insitu. Perforation is a rare but serious adverse event of ercp. The expected rate of ercp induced pancreatitis is generally between 1% and 7%. Perforation is one of the most feared complications of endoscopic retrograde cholangiopancreatography ercp. Management of ercp related small bowel perforations. May 31, 2016 our results support the belief that stapfer type ii perforations should be managed medically and this will likely have tremendous clinical relevance to those that perform ercp andor manage patients postercp. Paspatis1, jeanmarc dumonceau2, marc barthet3, soren meisner4, alessandro repici5. Some have characterized treatment strategies according to. Perforation ercp related perforations were previously classified into 34 types, regardless of the site of perforation 12, table 1. An immediate diagnosis and early management of ercp related perforation are key factors to minimize mortality. Managing perforations related to endoscopic retrograde.
Pdf periampullary diverticulum perforation following. Perforation related to endoscopic retrograde cholangiopancreatography ercp is a rare complication associated with. Diagnosis of perforation was both clinical and instrumental. Conservative management of duodenal perforation following. There is no consensus to guide the clinician on the management of ercp related perforations, with particular controversy surrounding the immediate surgical management of postprocedurally detected duodenal perforation because of overextension of a sphincterotomy. Management of duodenopancreatobiliary perforations after. Management of endoscopic retrograde cholangiopancreatography ercpassociated duodenal perforation remains controversial. The incidence rate varies according to the type of procedure and the anatomical location within the gi tract. Endoscopic retrograde cholangiopancreatography ercp is a commonly used method in the diagnosis and treatment of biliary and pancreatic duct diseases.
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