radiologic findings of complications of ercp -...

An Atlas of Complications of

ERCP Grant Smith, HMS Year III

Dr. Gillian Lieberman, MD

March 2012 Grant Smith, HMS III Gillian Lieberman, MD

Brunicardi FC, Andersen DK, Biliar TR, Dunn DL, Hunter JG, Matthews JB, Polluck, RE: Schwartz’s Principles of Surgery, 9th Edition: http://www.accessmedicine.com

Teaching Goals

1) Understand how ERCP is performed.

2) Become familiar with the indications for ERCP.

3) Know the common complications of ERCP.

4) Identify the menu of radiologic tests used to diagnose complications of ERCP.

5) Recognize radiologic findings of ERCP complications.

Grant Smith, HMS III Gillian Lieberman, MD

2

Endoscopic Retrograde Cholangiopancreatography (ERCP)

• ERCP is an endoscopic procedure, in which a specialized side-viewing upper endoscope is guided into the duodenum.

• ERCP provides an opportunity

for instrumentation to: 1. Perform procedures such as

brush cytology, biopsy, sphincterotomy, and stone removal

2. Visualize the biliary tree and pancreatic ducts


Brunicardi FC, Andersen DK, Biliar TR, Dunn DL, Hunter JG, Matthews JB, Polluck, RE: Schwartz’s Principles of Surgery, 9th Edition: http://www.accessmedicine.com Abdominal Fluoroscopy during ERCP 3

http://www.accessmedicine.com/

Anatomy of ERCP: Diagram


Chandrasoma P, Taylor CR: “Anatomy of the biliary system,” Concise Pathology, 3rd Edition: http://www.accessmedicine.com 4

Anatomy of ERCP: Fluoroscopy


Guntau J. (2006). ERCP: Unauffälliger Gallen- und Pankreasgang, mehrere unterschiedlich große Gallensteine in der Gallenblase und im Gallenblasengang. Endoskopiebilder.de. http://en.wikipedia.org/wiki/File:ERCP_Roentgen .jpgA Abdominal Fluoroscopy during ERCP

Endoscope

Pancreatic Duct

2nd Part of Duodenum

Cystic Duct

Common Bile Duct

Gallbladder

Ampulla/ Sphincter of Oddi

Common Hepatic Duct

5

Indications for ERCP NIH Consensus Guidelines & American Society for Gastrointestinal Endoscopy Guidelines

– Diagnosis and treatment of choledocholithiasis

– Common bile duct (CBD) stone removal after cholecystectomy

– Pancreatitis or cholangitis secondary to CBD stones

– Biopsies/Brushings/FNA of suspicious pancreatic masses for tissue diagnosis to initiate chemotherapy and/or radiation

– Visualization and biopsy of ampullary malignancies

– Stent placement for bile duct strictures

– ERCP with sphincter of Oddi manometry for recurrent pancreatitis

– Drainage of pancreatic pseudocysts


6

When ERCP is NOT Appropriate

• Asymptomatic cholelithiasis

• Acute pancreatitis (unless gallstone pancreatitis is suspected)

• Exploration for CBD stones prior to cholecystectomy (when there is a low suspicion for choledocholithiasis)

7


Changing Role for ERCP

• ERCP has become a modality primarily used for treatment and procedures rather than diagnosis.

• Magnetic Resonance Cholangiopancreatography (MRCP) is a non-invasive technique that does not require contrast material to be injected into the biliary tree or pancreatic duct.

8


Greenberger NJ, Blumberg RS, Burakoff R: CURRENT Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy: http://www.accessmedicine.com Abdominal MRI, coronal, heavily-weighted T2

COMPLICATIONS OF ERCP

9


ERCP Complications: A Framework

10


Classification of site, timing, and severity of complications related to ERCP

Site

Specific Occurring at the point of endoscopic contact or cannulation

Nonspecific Occurring in organs not transversed or treated

Timing

Immediate Occurring during ERCP

Early Evident within the recovery period

Delayed Specific (occurring within 30 days), Nonspecific (1st symptom within 3 days)

Late Evident after months or years

Criteria for Severity

Mild < or equal to 3 night inpatient stay

Moderate 4-10 night inpatient stay

Severe > 10 nights, ICU admission, or surgery

Fatal Death attributable to procedure within 30 days Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointestinal endoscopy 1991;37(3):383-93.

Complication Rates

Specific Complications – Pancreatitis (4%)

– Hemorrhage (1%)

– Cholangitis (1%)

– Perforation (0.5%)

– Death (0.1%)

Non-Specific Complications – Medication reactions

– Oxygen desaturation

– Cardiopulmonary events

11


Specific complications (pancreatitis, bleeding, sepsis, and perforation) occur in approximately 5.3-6.9% of patients with mortality rate of 0.33-0.34%. Non-specific complications occur in approximately 0.87-1.3% of patients with mortality rate of 0.07%.

Index Patient: Clinical Presentation

• 58 year old female presents from OSH 1 day s/p ERCP for choledocholithiasis.

• Stones were extracted from the common bile duct and a biliary stent was placed.

• A few hours after ERCP, the patient presented with facial swelling, thought to be an allergic reaction.

• Later, the patient was noted to have subcutaneous emphysema and transferred to BIDMC for further management.

12


Subcutaneous air in cervical

area

Pneumo-mediastinum

“Gingko Sign” Air between muscle fibers of pectoralis major indicating subcutaneous emphysema

13


Index Patient: Initial CXR

BIDMC, PACS Chest X-ray, Portable

37-year-old man 2 weeks after knife wound to chest.

Ho M , Gutierrez F R AJR 2009;192:599-612 Chest X-ray, Portable ©2009 by American Roentgen Ray Society 14

Companion Patient: “Gingko Sign”


“Gingko Sign” seen as air between the muscle fibers of pectoralis major (arrows and stars) indicating subcutaneous emphysema

15

Subcutaneous emphysema


Index Patient: Plain Abdominal Film

BIDMC, PACS Abdominal X-ray, Portable, Supine

Rigler’s Sign (Box) - bowel wall etched in white with adjacent lucent line indicating free air in the abdomen (pneumoperitoneum)

Streaky air surrounding T10, T11, T12, and L1 indicating

free air in the abdomen

16


Index Patient: Chest CT - Pneumomediastinum and “Ginko Sign”

Aberrant air in mediastinum

indicating pneumo-

mediastinum

“Ginko Sign” Air separating muscle fibers of pectoralis major

BIDMC, PACS Chest CT with contrast, axial, lung windows

17


Index Patient: Chest CT - Pneumothorax

Small pneumothorax

“Ginko Sign” showing air separating muscle fibers of pectoralis major

Pneumo-mediastinum

BIDMC, PACS Chest CT with contrast, axial, lung windows

18


Index Patient: Abdominal CT - Pneumoretroperitoneum and Pneumomperitoneum

Subcutaneous Air

Pneumo-retroperitoneum

Pneumoperitoneum

BIDMC, PACS Abdominal CT with contrast, axial, lung windows

Duodenal diverticulum

19


Index Patient: Abdominal CT - Duodenal Diverticulum

Stent

BIDMC, PACS Abdominal CT with contrast, axial, abdominal windows

Extraluminal contrast

suggestive of perforation

20


Index Patient: Abdominal CT - Perforation

BIDMC, PACS Abdominal CT with contrast, axial, abdominal windows

Perforation: Overview • Incidence – Approx. 1.3% of cases

• Clinical Manifestations

– Abdominal pain – Elevated serum amylase

• Risk Factors – Sphincterotomy – Sphincter of Oddi dysfunction – Dilated CBD – Long procedure – Biliary stricture dilatation – Duodenal diverticula – Aberrant biliary anatomy – Post-surgical anatomy (Roux-en-Y gastric bypass) 21


22

• Menu of Radiologic Tests – Plain Abdominal Film

• Free air seen as “Rigler’s Sign” (bowel wall outlined by air) or the “Football Sign” (central lucency with visualization of falciform and medial umbilical ligaments). – Free air is best seen on upright films or left lateral decubitus (if

unable to stand) or cross-table lateral view.

– Computed Tomography

• Ability to see tiny foci of free air not seen on plain films. • Recommended if patient has increase WBC count or pain

and fever. • Bile infection and bile leakage through a perforation seen on

CT correlates with increased mortality.

Perforation: Radiologic Findings


Perforation: Companion Patient

• 49 year old female

• ERCP performed for evaluation of RUQ found to have acute cholecystitis

• The patient had pain immediately after the procedure and a significant amount of free air.

• Subcutaneous free air

• Pneumoperitoneum

• Pneumoretroperitoneum

• Pneumomediastinum

23


Pannu HK, Fishman EK. Complications of endoscopic retrograde cholangiopancreatography: spectrum of abnormalities demonstrated with CT. Radiographics 2001;21(6):1441-53. Abdominal CT without contrast, axial, abdominal windows

Pancreatitis: Overview • Incidence – Approx. 5% of diagnostic cases and 10% of

therapeutic cases • Clinical Manifestations

– Abdominal pain for >24hrs s/p ERCP • Often epigastric or back pain with nausea

– Elevated serum amylase and lipase (3x normal)

• Risk Factors – Operator-Related: inadequate training, lack of experience, low case

volume – Patient-Related: younger age, females, recurrent pancreatitis, history

of post-ERCP pancreatitis, Sphincter of Oddi dysfunction – Procedure-Related factors: difficulty with cannulation, pancreatic duct

infection, precut/pancreatic/minor papilla sphincterotomy, or biliary balloon sphincteroplasty.

24


25

• Menu of Radiologic Tests

– Computed Tomography

• Heterogeneous enhancement and gland enlargement.

• Peripancreatic fat has increased attenuation due to extravasation of pancreatic secretions.

• Glandular necrosis appears as hypoattenuation.

• Infected necrosis appears as bubbles of gas in devitalized parenchyma.

Pancreatitis: Radiologic Findings


Pancreatitis: Companion Patient

26


Pannu HK, Fishman EK. Complications of endoscopic retrograde cholangiopancreatography: spectrum of abnormalities demonstrated with CT. Radiographics 2001;21(6):1441-53. Abdominal CT with contrast, axial, abdominal windows

• 50-year-old man s/p ERCP for a mass in the pancreatic tail

• The patient was readmitted 3 days after ERCP with abdominal pain and low-grade fever.

• Heterogeneous attenuation of the pancreas.

• Low-attenuation areas (*) suggest necrosis.

• Thickening of the wall of the antrum of the stomach (arrow) secondary to local inflammation.

• Stranding of the peripancreatic fat.

27

Pancreatitis: Companion Patient – Fat Stranding


Fat stranding around the

pancreas

Pannu HK, Fishman EK. Complications of endoscopic retrograde cholangiopancreatography: spectrum of abnormalities demonstrated with CT. Radiographics 2001;21(6):1441-53 Abdominal CT with contrast, axial, abdominal windows

Pancreatitis: Index Patient


Infected pancreatic necrosis with gas

28 BIDMC, PACS Abdominal CT with contrast, axial, abdominal windows

Hemorrhage: Overview • Incidence – Approx. 1.3% (with about 29% of bleeds requiring >5

units of transfusions or intervention)

• Clinical Manifestations – Drop in hemoglobin/hematocrit – Melena or hematemesis

• Risk Factors

– Sphincterotomy – Evidence of bleeding at time of sphincterotomy – Prior sphincterotomy – Prolonged PTT (at least 2x above normal) – Periampullary diverticulum – Cholangitis

29


Hemorrhage: Radiologic Findings

• Menu of Radiologic Tests and Findings

– Computed Tomography (CT) • Typically not performed to diagnose hemorrhage; but bleeding

may be detected if CT is performed.

• Acute hemorrhage is hyperattenuating on noncontrast CT, which can become iso/hypoattenuating in later stages.

• Non-contrast CT is used to assess for hematoma, while contrast-enhanced CT angiography is used to assess for site of active extravasation.

30


• 67-year-old woman s/p ERCP with unsuccessful cannulation of the common bile duct

• The patient experienced pain after the procedure.

• High attenuation area between the duodenum and pancreas (arrow) representing bleeding

31

Hemorrhage: Companion Patient #1



• High-attenuation mass (arrow) that appears to be abutting the lumen of the duodenum, a finding compatible with intramural bleeding.

32

Hemorrhage: Companion Patient #2



Infection/Cholangitis: Overview

33


• Infection can include many complications • Ascending cholangitis is the most frequent infectious complication of

ERCP

• Incidence – Approx 1.4% (with range of 0.4-10% depending on the study)

• Clinical Manifestations – Typically occur 24-72 hours after ERCP – Fever – Jaundice – Abdominal pain (RUQ) – May develop confusion and hypotension – Elevated WBC count

• Risk Factors – Biliary stents – Combined percutaneous and endoscopic procedures – Unsuccessful drainage of the biliary system (retained stones)

Charcot’s Triad Reynold’s Pentad

Infection/Cholangitis: Radiologic Findings

34


• Menu of Radiologic Tests

– Computed Tomography (CT) • Bile ducts may appear dilated and bile itself may appear

hyperattenuated due to increased debris.

• Thickening of wall of ducts and pneumobilia.

• Peri-biliary hyperattenuation.

• Abscesses may also appear with enhancing capsules.

• 67 year old man with common bile duct stones

• In this case, has not undergone ERCP but demonstrates findings of biliary obstruction

• Diffuse, mottled enhancement of the liver parenchyma

• Dilatation of the intrahepatic bile ducts (arrows)

35

Infection/Cholangitis: Companion Patient


Kim SW, Shin HC, Kim HC, Hong MJ, Kim IY. Diagnostic performance of multidetector CT for acute cholangitis: evaluation of a CT scoring method. The British journal of radiology. Abdominal CT with contrast, axial, abdominal windows

Summary

• ERCP is an endoscopic procedure primary used for therapeutic intervention.

• ERCP is appropriately used to remove stones from the CBD, assist in diagnosis of pancreatic/ampullary masses, and stent placement for biliary obstruction.

• The main complications of ERCP include perforation, pancreatitis, hemorrhage, and infection.

• Computed tomography is a good first choice for investigating for complications of ERCP when patients become acutely ill within 24-48 hours after ERCP.

36


References 1. Cohen S, Bacon BR, Berlin JA, et al. National Institutes of Health State-of-the-Science Conference Statement: ERCP for

diagnosis and therapy, January 14-16, 2002. Gastrointestinal endoscopy 2002;56(6):803-9. 2. Adler DG, Baron TH, Davila RE, et al. ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas.

Gastrointestinal endoscopy 2005;62(1):1-8. 3. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at

consensus. Gastrointestinal endoscopy 1991;37(3):383-93. 4. Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: a systematic survey of

prospective studies. The American journal of gastroenterology 2007;102(8):1781-8. 5. Williams EJ, Taylor S, Fairclough P, et al. Risk factors for complication following ERCP; results of a large-scale, prospective

multicenter study. Endoscopy 2007;39(9):793-801. 6. Wang P, Li ZS, Liu F, et al. Risk factors for ERCP-related complications: a prospective multicenter study. The American

journal of gastroenterology 2009;104(1):31-40. 7. Zissin R, Shapiro-Feinberg M, Oscadchy A, Pomeranz I, Leichtmann G, Novis B. Retroperitoneal perforation during

endoscopic sphincterotomy: imaging findings. Abdominal imaging 2000;25(3):279-82. 8. Cohen SA, Siegel JH, Kasmin FE. Complications of diagnostic and therapeutic ERCP. Abdominal imaging 1996;21(5):385-

94. 9. Scarlett PY, Falk GL. The management of perforation of the duodenum following endoscopic sphincterotomy: a proposal

for selective therapy. The Australian and New Zealand journal of surgery 1994;64(12):843-6. 10. Pannu HK, Fishman EK. Complications of endoscopic retrograde cholangiopancreatography: spectrum of abnormalities

demonstrated with CT. Radiographics 2001;21(6):1441-53 11. Balthazar EJ. CT diagnosis and staging of acute pancreatitis. Radiologic clinics of North America 1989;27(1):19-37. 12. Balthazar EJ, Freeny PC, vanSonnenberg E. Imaging and intervention in acute pancreatitis. Radiology 1994;193(2):297-

306. 13. Testoni PA, Mariani A, Giussani A, et al. Risk factors for post-ERCP pancreatitis in high- and low-volume centers and

among expert and non-expert operators: a prospective multicenter study. The American journal of gastroenterology;105(8):1753-61

14. Kim SW, Shin HC, Kim HC, Hong MJ, Kim IY. Diagnostic performance of multidetector CT for acute cholangitis: evaluation of a CT scoring method. The British journal of radiology.

15. Carr-Locke DL. Therapeutic role of ERCP in the management of suspected common bile duct stones. Gastrointestinal endoscopy 2002;56(6 Suppl):S170-4.

16. Ho ML, Gutierrez FR. Chest radiography in thoracic polytrauma. Ajr 2009;192(3):599-612.

37


Special Thanks To:

• Dr. Gillian Lieberman

• Dr. Mai-Lan Ho

• Dr. Mark Ashkan

38

radiologic findings of complications of ercp -...

Documents