Common bile duct stones Common bile duct stones are the most common cause of bile duct obstruction. Clinical manifestations are biliary colic, obstructive jaundice, cholangitis or biliary pancreatitis.The sensitivity and specificity of ERCP in the diagnosis of common bile duct stones is more than 95%. Currently in expert hands, the success rate of ERCP papillary sphincterotomy for stone extraction is greater than 90%, with an overall complication rate of 5% and a mortality rate of less than 1%, all of which are superior to surgical treatment. In case of selective bile duct cannulation failure, pre-incision is feasible, but its complication rate is higher than that of conventional methods. In addition to papillary sphincterotomy, balloon dilation of the biliary sphincter is additionally an option. In some special cases, such as those with abnormal coagulation and those at high risk of post-ERC pancreatitis, balloon dilation can be chosen. Removal of stones is usually chosen from balloon or mesh basket, and mechanical lithotripsy can be chosen for large stones or tonal stones, which are more difficult to remove. If stone extraction is unsuccessful, a biliary stent or nasobiliary drainage tube should be placed to drain the stone. Benign and malignant biliary strictures ERCP can be used for the diagnosis and treatment of malignant biliary obstruction. biopsy, brushing and ultrasound endoscopy-mediated puncture can provide a histological diagnosis, but the overall sensitivity is not higher than 62%. erCP is also used for the diagnosis and treatment of benign biliary obstruction, congenital abnormalities of the biliary tract and post-surgical complications, including biliary complications after liver transplantation. Endoscopic dilatation and stent drainage are possible for biliary strictures. The placement of biliary stents can provide effective drainage for benign and malignant biliary obstruction, with metal stents providing twice the patency time of plastic stents and a better cost-benefit ratio. Metal stents are indicated for patients with a long survival expectancy, no distant metastases and a short opening time with plastic stents. Biliary stents are also useful in the treatment of postoperative biliary strictures and biliary fistulas. Oddi’s sphincter dysfunction Oddi’s sphincter dysfunction presents similarly to biliary or pancreatic disease. more than 90% of patients have disappearance of pain after sphincterotomy. Some studies suggest that sphincterotomy is beneficial, but it has not been accepted and should be further studied; patients with sphincter of Oddi dysfunction have a high rate of complications after ERCP and clinical caution should be exercised. Chronic pancreatitis ERCP with pancreatic ductography is feasible for microscopic treatment of symptomatic pancreatic duct stones, pancreatic duct strictures and pseudocysts. Pancreatic duct stenosis can be effectively treated by dilation and stenting. For patients with chronic obstructive pancreatitis with abdominal pain, endoscopic treatment is preferred, and only cases with ineffective endoscopic treatment or recurrence can be considered for surgical treatment. Stones in the pancreatic duct of patients with chronic pancreatitis can induce abdominal pain and acute pancreatitis, because of pancreatic duct stenosis, pancreatic sphincterotomy for stone extraction is more difficult, and often requires extracorporeal shock wave lithotripsy before attempting endoscopic stone extraction
. Pancreatic fistula Rupture of the pancreatic duct or pancreatic fistula is mostly caused by acute pancreatitis, chronic pancreatitis, pancreatic trauma and surgical injury. Pancreatic fistulas can present with pancreatic-derived ascites, pseudocyst formation, or both. Pancreatic duct stenting has become a common treatment for pancreatic fistulas. In most severe pancreatic duct injuries, a bridge-like stent can be placed to re-establish normal pancreatic duct drainage. Pancreatic cysts ERCP can be used to diagnose and treat fluid accumulation in the pancreas, including acute pseudocysts, chronic pseudocysts, and pancreatic necrosis. EUS can be used for pre-puncture positioning to avoid blood vessels.
Fluid accumulation in communication with the pancreatic duct includes cysts in the tail of the pancreas, which can be treated by trans-papillary placement of a pancreatic stent. Drainage of pseudocysts via the stomach or duodenum is technically demanding but still has a success rate of >80% in skilled practitioners. Complications of pseudocyst drainage include pancreatitis, bleeding, perforation, and infection.