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Endoscopic retrograde cholangiopancreatography in the diagnosis of jaundice
Endoscopic Retrograde Cholangiopancreatography in the Diagnosis of Jaundice Walter D. Gaisford, MD, Salt Lake City, Utah
To avoid unnecessary risk to the patient with medical jaundice an accurate diagnosis of the cause of jaundice is essential to the surgeon before operative surgical exploration is considered. However, delay in surgical decompression of obstructive jaundice may result in deterioration of liver function and increased risk of operation. Excretion cholangiocholecystography is not helpful in the evaluation of the jaundiced patient. Early experience with endoscopic cannulation of the papilla of Vater and endoscopic retrograde cholangiopancreatography (ERCP) in evaluating patients with biliary-pancreatic disease was encouraging [I]. ERCP in the diagnosis of jaundice provides: (1) a direct view of the papilla of Vater with tissue biopsy when needed; (2) safe retrograde cholangiography with fluoroscopic observation of filling-drainage characteristics and spot filming in various patient positions; (3) retrograde pancreatography to evaluate associated pancreatic diseases; and (4) endoscopic diagnoses of associated diseases of the esophagus, stomach, and duodenum. Material and Methods
Endoscopic cannulation of the papilla of Vater has been performed in 407 patients ranging in age from fifteen to eighty-five years. Of these patients, 157 had jaundice that could not be diagnosed by history, physical examination, blood chemistry studies, or excretion cholangiography. Transduodenal endoscopic retrograde cholangiograms were obtained in 145 patients with jaundice. There were seventy-nine females and seventy-eight males with jaundice with serum bilirubin levels of 2.0 to 41 mg/lOO ml. Forty-six patients had had cholecystectomy, six had biliary-enteric anastomoses, ten had sphincteroplasty, and five had gastrojejunostomy reconstructions after gastrectomy. All examinations were performed in a radiology department where fluoroscopic image intensification and spot filming devices were used. A side-viewing Olympus fiberFrom the Department of Surgery, Latter-day Saints Hospital, Salt Lake City, Utah. Reprint requests should be aMmssed to Walter D. Gaisford, MD, 508 East South Temple, Salt Lake City, Utah 84102. Presented at the Twenty-Eighth Annual Meeting of the Southwestern Surgical Congress, Houston, Texas, May 3-6. 1976.
Volume 132, December 1976
scope (JF-B) was used for all examinations. The endoscopic technic used has been previously reported [f ] . In five patients with Billroth II gastrojejunostomies, cholangiography was performed through the afferent loop [I-3]. In six patients with biliary-enteric anastomoses, the biliary ducts were filled through the stoma [4,5]. Results
Cannulation of the papilla of Vater was attempted in 407 patients and successful in 395 for an overall success rate of 97 per cent. Forty-four patients had selective cholangiography, 111 had selective pancreatography, and 240 patients had combined cholangiopancreatography. Therefore, a total of 284 cholangiograms and 351 pancreatograms were obtained. In the group of 157 patients with jaundice, retrograde cholangiography or combined cholangiopancreatography was successfully accomplished in 145 patients (92 per cent of jaundiced patients). Failure to cannulate and obtain satisfactory cholangiograms in twelve patients was attributed to respiratory arrest in one, submucosal injection of contrast in one, uncooperativeness in one, selective fill of pancreatic ductal system only in five, papillary orifice in a duodenal diverticulum in two, tumor mass in duodenum without identifiable orifice in one, and obstruction. of the duodenum preventing intubation in one. Of five jaundiced patients with a Billroth II gastrojejunostomy, the afferent limb was intubated and successful cholangiograms obtained in four patients. Under fluoroscopic control, valuable information could be obtained during injection of contrast medium and as the ducts would spontaneously empty. However, the final diagnoses were based on serial spot filming radiographs taken during the procedure. The results of 145 endoscopic retrograde cholangiograms in jaundiced patients are summarized and classified according to the diagnosis in Table I. Selected radiographs from each category of diagnoses are shown in Figures 1 through 10. There were thirty-eight patients in whom esophagogastroduodenoscopy at the time of duct cannulation revealed significant pathologic changes in
699
Gaisford
TABLE
I Classification according
of 157 Jaundiced to ERCP Diagnosis
Diagnosis Normal
biliary
system
Hepatic cirrhosis Hepatic metastasis Stones in bile ducts Stones in gallbladder Benign strictures of bile ducts Primary sclerosing cholangitis Cancer of the head of the pancreas Cancer of the bile ducts Cancer of the ampulla of vater Pancreatic fibrosis Ampullary stenosis No cholangiogram obtained Total
Patients
Number of Patients 31 17 1 37 4 13 4 13 10 2 7 6 12 157
Figure 1. Normal intrahepatic and extraftepatlc blltary tree in a deeply jaundiced patient with drug hepatitls.
Figure 2. Several calculi in dilated common bile duct.
Figure 4. Gallstones are demonstrated in this retrograde cholangiogram in a patient who reportedly had cfwlecystectomy ten years earlier.
700
Figure 3. Layered calculi in gallbladder demonstrated by this retrograde cholangiogram. Two previous oral cholecystograms had visual/red but failed to show stones.
the upper gastrointestinal tract and pancreas. These are summarized in Table II. In the 157patients with jaundice only one endoscopic complication occurred: a momentary respiratory arrest secondary to intravenous meperidine in a sixty-nine year old woman with cardiac failure and emphysema. A second examination later in this patient demonstrated common bile duct stones. No incidence of cholangitis or sepsis occurred in any of the 395 patients having ERCP. Postcannulation pancreatitis of a mild brief type occurred in four patients after pancreatography but these were nonjaundiced patients. Three of the four had had previous spontaneous episodes of acute pancreatitis
ThsAmerican
Journal of Surgery
Cholangiopancreatography
Figure 6. Carcinoma of the common bile duct. Gallbladder had been removed several years previously.
Figure 5. Primary scierosing choiangitis was demonstrated in this young man with painless jaundice. The retrograde choiangiogram demonstrated a patent cystic duct and satisfactory gallbladder for biiiary-enteric decompression.
[6,7]. Ten retrograde ductograms were performed in patients known to be allergic to iodine-containing contrast agents and no allergic complications occurred [S]. Comments
The most significant finding in this series of patients with cholestatic jaundice is the high number of normal extrahepatic biliary ductograms which excluded the diagnosis of ductal obstruction and saved forty-nine patients (and surgeons) from unnecessary surgical exploration. Patients with cirrhosis of the liver and normal extrahepatic biliary ducts frequently showed abnormalities of intrahepatic ducts such as segmental ductular narrowing and “pruning” as described by Vennes et al [9]. In patients with abnormal ductograms, the site and probable cause of bile duct obstruction was delineated, providing the surgeon with clear indication for exploration and focusing the surgical plan of operation. The finding of significant additional upper gastrointestinal disease in 25 per cent of the patients having ERCP confirms the advantage and the importance of a careful endoscopic survey at the time of ductal cannulation.
Figure 7. Cancer in the head of the pancreas with obstruction of bile and pancreatic ducts.
Figure 6, Cancer of the ampuiia of Vater with obstruction and dilatation of pancreatic and bile ducts. Endoscopic biopsy proved the diagnosis preoperativeiy.
701
Gaisford
Figure 10. Retrograde jejunoscopy and chotangiography in a patient eight years after a Whipple procedure for ampullary carcinoma. The biliary-jejunal anastomosis is narrowed without significant ductal dilatation.
Figure 9. Top, extrinsic narrowing of bile duct wtth jaundice in patlent with recurrent pancreatitis. Bottom, selective pancreatic ductography in same patient shows advanced chronic pancreatitis.
TABLE I I
Associated Upper Gastrointestinal Disease Diagnosed by Endoscopy in 157 Jaundiced Patients during ERCP
Diagnosis Reflux esophagitis Esophageal varices Gastric ulcer Gastritis Gastric carcinoma Duodenal ulcer Duodenal carcinoma Chronic pancreatitis Pancreatic cyst or abscess Total
Number of Patients 3 5 5 4 1 9 3 38
Summary
Endoscopic retrograde cholangiopancreatography (ERCP) was successfully accomplished in 395 patients or 97 per cent of the patients in whom it was attempted. Of 157 patients with cholestatic type
702
jaundice, satisfactory endoscopic retrograde cholangiography or cholangiopancreatography was accomplished in 145 (92 per cent), with only one complication. ERCP excluded extrahepatic biliary ductal obstruction and thus avoided unnecessary surgical exploration in forty-nine patients with cholestatic jaundice. ERCP established the diagnosis of obstructive jaundice in ninety-six patients and delineated the site of ductal obstruction and probable cause. ERCP revealed additional significant previously undiagnosed upper gastrointestinal pathologic changes in 25 per cent of jaundiced patients. References 1. Gaisford WD: Endoscopic cannulation of the papilla of Vater. Arch Surg 108: 519, 1974. 2. Safrany L, et al: Endoscopic retrograde cholangiography. GasfroinfesfEndosc 19: 163, 1973. 3. Katon RM, Bilbao MK, Parent JA, Smith FW: Endoscopic retrograde cholangiopancreatography in patients with gastrectomy and gastrojejunoscopy (Billroth II). A case for the forward Iti. Gasfrointest Endosc 21: 164, 1975. 4. Safrany L: Endoscopy and retrcgrade cholangiopancreatography after Billroth II operation. Endoscopy 4: 198, 1972. 5. Safrany L: Ertdoscopic visualization of bile flow using indocyanine green. Endoscopy5: 18, 1973. 6. Nebel OT, Silvis SE, Rogers C, Sugawa C, Mandelstram P: Complications associated with endoscopic retrograde cholangiopancreatography. Results of the 1974 A/S/G/E/Survey. Gastrointest Endosc 22: 34, 1975. 7. Blackwood WD, Vennes JH, Silvis SE: Post-endoscopy pancreatitis and hyperamylasuria. Gastrointest Endosc 20: 56, 1973. 8. Kaufman B, Gambescia R, Maldonado A, Raskin JB: Systemic absorption of contrast agent during endoscopic retrograde cholangiography. Gastrointest Endosc 22: 175, 1976. 9. Ayoola EA, Vennes JA, Silvis SE, Rohrmann CA, Ansel HJ: Endoscopic retrograde intrahepatic cholangiography in liver diseases. Gasfrointest Endosc 22: 156, 1976.
The American Journal 01Surgery
To avoid unnecessary risk to the patient with medical jaundice an accurate diagnosis of the cause of jaundice is essential to the surgeon before operative surgical exploration is considered. However, delay in surgical decompression of obstructive jaundice may result in deterioration of liver function and increased risk of operation. Excretion cholangiocholecystography is not helpful in the evaluation of the jaundiced patient. Early experience with endoscopic cannulation of the papilla of Vater and endoscopic retrograde cholangiopancreatography (ERCP) in evaluating patients with biliary-pancreatic disease was encouraging [I]. ERCP in the diagnosis of jaundice provides: (1) a direct view of the papilla of Vater with tissue biopsy when needed; (2) safe retrograde cholangiography with fluoroscopic observation of filling-drainage characteristics and spot filming in various patient positions; (3) retrograde pancreatography to evaluate associated pancreatic diseases; and (4) endoscopic diagnoses of associated diseases of the esophagus, stomach, and duodenum. Material and Methods
Endoscopic cannulation of the papilla of Vater has been performed in 407 patients ranging in age from fifteen to eighty-five years. Of these patients, 157 had jaundice that could not be diagnosed by history, physical examination, blood chemistry studies, or excretion cholangiography. Transduodenal endoscopic retrograde cholangiograms were obtained in 145 patients with jaundice. There were seventy-nine females and seventy-eight males with jaundice with serum bilirubin levels of 2.0 to 41 mg/lOO ml. Forty-six patients had had cholecystectomy, six had biliary-enteric anastomoses, ten had sphincteroplasty, and five had gastrojejunostomy reconstructions after gastrectomy. All examinations were performed in a radiology department where fluoroscopic image intensification and spot filming devices were used. A side-viewing Olympus fiberFrom the Department of Surgery, Latter-day Saints Hospital, Salt Lake City, Utah. Reprint requests should be aMmssed to Walter D. Gaisford, MD, 508 East South Temple, Salt Lake City, Utah 84102. Presented at the Twenty-Eighth Annual Meeting of the Southwestern Surgical Congress, Houston, Texas, May 3-6. 1976.
Volume 132, December 1976
scope (JF-B) was used for all examinations. The endoscopic technic used has been previously reported [f ] . In five patients with Billroth II gastrojejunostomies, cholangiography was performed through the afferent loop [I-3]. In six patients with biliary-enteric anastomoses, the biliary ducts were filled through the stoma [4,5]. Results
Cannulation of the papilla of Vater was attempted in 407 patients and successful in 395 for an overall success rate of 97 per cent. Forty-four patients had selective cholangiography, 111 had selective pancreatography, and 240 patients had combined cholangiopancreatography. Therefore, a total of 284 cholangiograms and 351 pancreatograms were obtained. In the group of 157 patients with jaundice, retrograde cholangiography or combined cholangiopancreatography was successfully accomplished in 145 patients (92 per cent of jaundiced patients). Failure to cannulate and obtain satisfactory cholangiograms in twelve patients was attributed to respiratory arrest in one, submucosal injection of contrast in one, uncooperativeness in one, selective fill of pancreatic ductal system only in five, papillary orifice in a duodenal diverticulum in two, tumor mass in duodenum without identifiable orifice in one, and obstruction. of the duodenum preventing intubation in one. Of five jaundiced patients with a Billroth II gastrojejunostomy, the afferent limb was intubated and successful cholangiograms obtained in four patients. Under fluoroscopic control, valuable information could be obtained during injection of contrast medium and as the ducts would spontaneously empty. However, the final diagnoses were based on serial spot filming radiographs taken during the procedure. The results of 145 endoscopic retrograde cholangiograms in jaundiced patients are summarized and classified according to the diagnosis in Table I. Selected radiographs from each category of diagnoses are shown in Figures 1 through 10. There were thirty-eight patients in whom esophagogastroduodenoscopy at the time of duct cannulation revealed significant pathologic changes in
699
Gaisford
TABLE
I Classification according
of 157 Jaundiced to ERCP Diagnosis
Diagnosis Normal
biliary
system
Hepatic cirrhosis Hepatic metastasis Stones in bile ducts Stones in gallbladder Benign strictures of bile ducts Primary sclerosing cholangitis Cancer of the head of the pancreas Cancer of the bile ducts Cancer of the ampulla of vater Pancreatic fibrosis Ampullary stenosis No cholangiogram obtained Total
Patients
Number of Patients 31 17 1 37 4 13 4 13 10 2 7 6 12 157
Figure 1. Normal intrahepatic and extraftepatlc blltary tree in a deeply jaundiced patient with drug hepatitls.
Figure 2. Several calculi in dilated common bile duct.
Figure 4. Gallstones are demonstrated in this retrograde cholangiogram in a patient who reportedly had cfwlecystectomy ten years earlier.
700
Figure 3. Layered calculi in gallbladder demonstrated by this retrograde cholangiogram. Two previous oral cholecystograms had visual/red but failed to show stones.
the upper gastrointestinal tract and pancreas. These are summarized in Table II. In the 157patients with jaundice only one endoscopic complication occurred: a momentary respiratory arrest secondary to intravenous meperidine in a sixty-nine year old woman with cardiac failure and emphysema. A second examination later in this patient demonstrated common bile duct stones. No incidence of cholangitis or sepsis occurred in any of the 395 patients having ERCP. Postcannulation pancreatitis of a mild brief type occurred in four patients after pancreatography but these were nonjaundiced patients. Three of the four had had previous spontaneous episodes of acute pancreatitis
ThsAmerican
Journal of Surgery
Cholangiopancreatography
Figure 6. Carcinoma of the common bile duct. Gallbladder had been removed several years previously.
Figure 5. Primary scierosing choiangitis was demonstrated in this young man with painless jaundice. The retrograde choiangiogram demonstrated a patent cystic duct and satisfactory gallbladder for biiiary-enteric decompression.
[6,7]. Ten retrograde ductograms were performed in patients known to be allergic to iodine-containing contrast agents and no allergic complications occurred [S]. Comments
The most significant finding in this series of patients with cholestatic jaundice is the high number of normal extrahepatic biliary ductograms which excluded the diagnosis of ductal obstruction and saved forty-nine patients (and surgeons) from unnecessary surgical exploration. Patients with cirrhosis of the liver and normal extrahepatic biliary ducts frequently showed abnormalities of intrahepatic ducts such as segmental ductular narrowing and “pruning” as described by Vennes et al [9]. In patients with abnormal ductograms, the site and probable cause of bile duct obstruction was delineated, providing the surgeon with clear indication for exploration and focusing the surgical plan of operation. The finding of significant additional upper gastrointestinal disease in 25 per cent of the patients having ERCP confirms the advantage and the importance of a careful endoscopic survey at the time of ductal cannulation.
Figure 7. Cancer in the head of the pancreas with obstruction of bile and pancreatic ducts.
Figure 6, Cancer of the ampuiia of Vater with obstruction and dilatation of pancreatic and bile ducts. Endoscopic biopsy proved the diagnosis preoperativeiy.
701
Gaisford
Figure 10. Retrograde jejunoscopy and chotangiography in a patient eight years after a Whipple procedure for ampullary carcinoma. The biliary-jejunal anastomosis is narrowed without significant ductal dilatation.
Figure 9. Top, extrinsic narrowing of bile duct wtth jaundice in patlent with recurrent pancreatitis. Bottom, selective pancreatic ductography in same patient shows advanced chronic pancreatitis.
TABLE I I
Associated Upper Gastrointestinal Disease Diagnosed by Endoscopy in 157 Jaundiced Patients during ERCP
Diagnosis Reflux esophagitis Esophageal varices Gastric ulcer Gastritis Gastric carcinoma Duodenal ulcer Duodenal carcinoma Chronic pancreatitis Pancreatic cyst or abscess Total
Number of Patients 3 5 5 4 1 9 3 38
Summary
Endoscopic retrograde cholangiopancreatography (ERCP) was successfully accomplished in 395 patients or 97 per cent of the patients in whom it was attempted. Of 157 patients with cholestatic type
702
jaundice, satisfactory endoscopic retrograde cholangiography or cholangiopancreatography was accomplished in 145 (92 per cent), with only one complication. ERCP excluded extrahepatic biliary ductal obstruction and thus avoided unnecessary surgical exploration in forty-nine patients with cholestatic jaundice. ERCP established the diagnosis of obstructive jaundice in ninety-six patients and delineated the site of ductal obstruction and probable cause. ERCP revealed additional significant previously undiagnosed upper gastrointestinal pathologic changes in 25 per cent of jaundiced patients. References 1. Gaisford WD: Endoscopic cannulation of the papilla of Vater. Arch Surg 108: 519, 1974. 2. Safrany L, et al: Endoscopic retrograde cholangiography. GasfroinfesfEndosc 19: 163, 1973. 3. Katon RM, Bilbao MK, Parent JA, Smith FW: Endoscopic retrograde cholangiopancreatography in patients with gastrectomy and gastrojejunoscopy (Billroth II). A case for the forward Iti. Gasfrointest Endosc 21: 164, 1975. 4. Safrany L: Endoscopy and retrcgrade cholangiopancreatography after Billroth II operation. Endoscopy 4: 198, 1972. 5. Safrany L: Ertdoscopic visualization of bile flow using indocyanine green. Endoscopy5: 18, 1973. 6. Nebel OT, Silvis SE, Rogers C, Sugawa C, Mandelstram P: Complications associated with endoscopic retrograde cholangiopancreatography. Results of the 1974 A/S/G/E/Survey. Gastrointest Endosc 22: 34, 1975. 7. Blackwood WD, Vennes JH, Silvis SE: Post-endoscopy pancreatitis and hyperamylasuria. Gastrointest Endosc 20: 56, 1973. 8. Kaufman B, Gambescia R, Maldonado A, Raskin JB: Systemic absorption of contrast agent during endoscopic retrograde cholangiography. Gastrointest Endosc 22: 175, 1976. 9. Ayoola EA, Vennes JA, Silvis SE, Rohrmann CA, Ansel HJ: Endoscopic retrograde intrahepatic cholangiography in liver diseases. Gasfrointest Endosc 22: 156, 1976.
The American Journal 01Surgery