Therapeutic endoscopic intervention, including sphincterotomy, can remove the CBD stone and may be curative when done prior to cholecystectomy (keeping in mind that up to 5% of patients may be recurrent primary CBD stone formers), but it has associated morbidity of up to 10% because of the risk of iatrogenic pancreatitis [53,72]. ERCP is limited in the evaluation of patients with previous gastroenteric anastomoses, as it is technically difficult to advance the endoscope into the biliopancreatic limb of the anastomosis. ERCP also remains the standard procedure for stent placement in cases of obstructive jaundice. When deployed for distal CBD strictures, stenting via ERCP is successful in more than 90% of cases [115]. For diagnostic yield from ERCP-guided FNA of biopsies of solid pancreatic neoplasms, ERCP demonstrated sensitivity between 57.1% (for pancreatic body/tail neoplasms) and 82.4% (for pancreatic head neoplasms) [116]. In patients with suspected sclerosing cholangitis or biliary stricture, ERCP should be performed with caution, as suppurative cholangitis may be induced by endoscopic catheter manipulation of an obstructed biliary system [53]. MRCP findings may guide directed approaches, such as ERCP, with brushing, percutaneous transhepatic biliary stenting, or reconstructive surgery [34,51-53,62,63]. Jaundice Studies from the gastroenterology literature show that ERCP has equivalent or greater sensitivity for tumor detection (provided the tumor is in the pancreatic head/duodenum or CBD), with superior sensitivity particularly for ampullary carcinoma, but it does not provide staging information for operability [76]. Tissue diagnosis can be obtained by endoscopically directed brushing or guided US with FNA [71,76,78,117,118]; however, results of brush cytology for biliary strictures from pancreatic malignancies are inferior (46% sensitive) relative to biliary malignancies (68%) [119].
Jaundice. Therapeutic endoscopic intervention, including sphincterotomy, can remove the CBD stone and may be curative when done prior to cholecystectomy (keeping in mind that up to 5% of patients may be recurrent primary CBD stone formers), but it has associated morbidity of up to 10% because of the risk of iatrogenic pancreatitis [53,72]. ERCP is limited in the evaluation of patients with previous gastroenteric anastomoses, as it is technically difficult to advance the endoscope into the biliopancreatic limb of the anastomosis. ERCP also remains the standard procedure for stent placement in cases of obstructive jaundice. When deployed for distal CBD strictures, stenting via ERCP is successful in more than 90% of cases [115]. For diagnostic yield from ERCP-guided FNA of biopsies of solid pancreatic neoplasms, ERCP demonstrated sensitivity between 57.1% (for pancreatic body/tail neoplasms) and 82.4% (for pancreatic head neoplasms) [116]. In patients with suspected sclerosing cholangitis or biliary stricture, ERCP should be performed with caution, as suppurative cholangitis may be induced by endoscopic catheter manipulation of an obstructed biliary system [53]. MRCP findings may guide directed approaches, such as ERCP, with brushing, percutaneous transhepatic biliary stenting, or reconstructive surgery [34,51-53,62,63]. Jaundice Studies from the gastroenterology literature show that ERCP has equivalent or greater sensitivity for tumor detection (provided the tumor is in the pancreatic head/duodenum or CBD), with superior sensitivity particularly for ampullary carcinoma, but it does not provide staging information for operability [76]. Tissue diagnosis can be obtained by endoscopically directed brushing or guided US with FNA [71,76,78,117,118]; however, results of brush cytology for biliary strictures from pancreatic malignancies are inferior (46% sensitive) relative to biliary malignancies (68%) [119].