ASGE Annual GI Advanced Practice Provider Course (On-Demand) - Onboarding (Day One)

Pdf Summary
ERCP (endoscopic retrograde cholangiopancreatography) is a procedure used for diagnosing and managing pancreatic and biliary diseases. It has evolved from being a diagnostic tool to a therapeutic procedure. However, other less risky procedures like EUS (endoscopic ultrasound), MRCP (magnetic resonance cholangiopancreatography), ultrasound, CT, and intraoperative cholangiogram have replaced diagnostic ERCP.<br /><br />The indications for ERCP include choledocholithiasis with or without cholangitis, malignant biliary obstruction, pancreatic cancer, cholangiocarcinoma, intrahepatic mass, postcholecystectomy bile leak, biliary stricture, chronic pancreatitis, intraductal stones, biliary stricture, and pancreatic duct injury or leak. The role of endoscopy in choledocholithiasis depends on the risk level. High-risk patients should proceed directly to ERCP, while lower-risk patients may undergo MRCP, EUS, or laparoscopic cholecystectomy with intraoperative cholangiogram.<br /><br />In terms of preprocedural assessment for ERCP, the patient's preoperative risk assessment should be reviewed, and a decision on sedation plan should be made. Antibiotics are only needed in certain cases like primary sclerosing cholangitis or when adequate biliary drainage cannot be achieved. Rectal indomethacin may reduce the risk of post-procedure pancreatitis in high-risk patients.<br /><br />The management of anticoagulation varies depending on the risk level of the procedures. Sphincterotomy and dilation are considered high risk, so anticoagulation and antiplatelet agents should be held. For lower-risk procedures like stent placement/removal, brushings, cholangiogram, or pancreatogram, anticoagulation or antiplatelet agents may be continued.<br /><br />EUS is a technique that combines endoscopy with high-frequency ultrasonography. It is used for diagnosing, staging, and managing a broad range of gastrointestinal and non-gastrointestinal diseases. The indications for EUS include diagnostic purposes like evaluating pancreatic cystic/solid lesions, subepithelial lesions, mediastinal mass/adenopathy, liver mass, thickened gastric folds, choledocholithiasis, and staging purposes for esophageal cancer, gastric cancer, pancreatic cancer, lung cancer, ampullary cancer, and rectal cancer. EUS can also be used for therapeutic purposes such as pseudocyst drainage, bile duct/gallbladder drainage, celiac plexus block, glue or coil embolization of varices, and EUS-guided ERCP.<br /><br />The preprocedural assessment and management of anticoagulation for EUS are similar to those of ERCP. The patient's preoperative risk assessment should be reviewed, a decision on sedation plan should be made, and anticoagulation should be managed accordingly.<br /><br />In summary, both ERCP and EUS are important procedures for the management of gastrointestinal and non-gastrointestinal diseases. Patient selection and choosing less invasive/risky tests when possible are crucial. The proper management of anticoagulation and recognizing and managing complications are essential for successful outcomes.
Asset Subtitle
Aaron Shiels, MD, FASGE
Keywords
ERCP
EUS
diagnosis
management
choledocholithiasis
anticoagulation
sedation plan
gastrointestinal diseases
therapeutic purposes
complications management