Biliary Endoscopy in the Management of Choledocholithiasis CSGNA

Biliary Endoscopy in the Management of Choledocholithiasis CSGNA

Biliary Endoscopy in the Management of Choledocholithiasis CSGNA CONFERENCE 3 November 2018 Calvin W. Parker, III, M.D. Woodholme Gastroenterology Associates

Goals and Outline Recognize the clinical signs and symptoms of biliary pathology. Stratify patients as low risk, intermediate risk, or high risk for biliary pathology based on clinical parameters, serology, and imaging.

Understand the diagnostic tools for evaluating biliary pathology including physical exam, serology, imaging modalities, and endoscopy. Review the therapeutic role of ERCP and the implications for providers as well as nurses for successful outcomes. Case

35 yr old female 5 days MEG/RUQ Pain 5/10 Constant, varying intensity, worse after meals + Nausea; no emesis - Fever/chills Labs

WBCs 9.2 Amylase 44 Lipase 24

TBili 0.4 AP 83 AST 123 ALT 78 Repeat Labs

Tbili 3.6 AP 167 AST 784 ALT 1084 US

Stones in GB No Pericholecystic fluid GB wall 3 mm CBD 8mm w/stones

Choledocholithiasis Stone inside CBD > 20% Americans have gallstones

15% of them have choledocholithiasis 95% of pt.s w/CBD stones have gallstones 700,000 + CCYs/year Stone Make-up West: most are cholesterol stones from GB < 10% form de novo within CBD East: pigmented stones more common (higher incidence of RPC)

Demographics - NA > Hispanics > Whites > African Americans Female > Male Pregnancy Estrogen Progesterone Age 25-30% by age 50 BMI 35% of females with BMI > 32

Wt Loss If rapid 25% get gallstones Drugs = Ceftriaxone, Octreotide, etc. Clinical Manifestations Depends on stone location & presence of bacterial invasion 60-80% are asymptomatic (stones in intrahepatics, size <5mm, spontaneous passage) Biliary Pancreatitis (spontaneous passage 70%)

Distal impaction biliary colic, jaundice, cholangitis, pancreatitis Mirizzi Syndrome Diagnosis of Choledocholithasis

LAEs RUQ US CT Abd MRCP EUS ERCP

RUQ US - RUQ US has poor sensitivity for CBD stones - 22-55% - RUQ US more reliably detects CBD dilation - Sensitivity 77-87% - Normal CBD = 3-6mm - Mild increase with age (1mm/yr after age 50) - CBD dilation > 8mm in pt with GB is abnormal

Choledocholithiasis Clinical Strategies Age over 55 Tbil over 1.5

Tbil below 1.5 cbd dilation + + + + +

- Age under 55 Tbil over 1.5 + + + +

- Tbil below 1.5 - cbd stone u/s prob 94 72

+ 85 50 + 90 61 + 67+ 38

+ + + + - 85 49

69 28 67+ 38 58 19 Ann surg 1994 220:32-39 GIE 2009 69:244-52

Stratifying Patients Low Risk (atypical pain w/normal LAEs) Intermediate Risk (pain & cholestatic LAEs) High Risk (fever,jaundice,pain) Choledocholithiasis Sensitivity Specificity

RUQ US CT Abd MRCP EUS

ERCP 22-55% 65-88% 85-92% 89-94%

89-93% 73-97% 93-97% 94-95%

100% - Intermediate probability patients should have: - EUS, MRCP, or IOC - High probability patients should have: - Preoperative ERCP - Post-Chole with ? CBD stone should have: - EUS or MRCP if labs and US are non-dx - Acute biliary pancreatitis should have:

- Mild = No procedure if no evidence of stone - Cholangitis or obstruction go for ERCP What about cholangitis? Impacted stones biliary stasis When ductal pressure >30 cm H2O, flow stops IgA secretion decreases weakened antibacterial function

Bacteria ascends, invades biliary system cholangitis Culprits: E. Coli, enterococci, klebsiella, proteus, pseudomonas, less commonly anaerobic bugs (bacteroides fragilis or clostridium perfringens) Back to the Case Intermediate risk obese, young, female

Cholestatic pattern/pain US w/CBD stones QUESTIONS?

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