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Advanced Endoscopy Clinical Care

Faculty physicians in the Division of Gastroenterology-Hepatology who specialize in advanced endoscopy are renowned nationally as leading authorities in the field and are engaged in the comprehensive care of patients with pancreatobiliary disease. These world-class physicians are experts in the area of endoscopic retrograde cholangiopancreatography (ERCP) and have extensive knowledge of the indications, applications and complications of diagnostic and therapeutic ERCP.

This accomplished team is at the forefront of endoscopic research and offers expertise in ERCP as well as endoscopic ultrasound (EUS) and multiple other innovative endoscopic treatments.

ERCP Expertise

The first ERCP at Indiana University School of Medicine was performed in 1974 by Dr. Glen Lehman. Since, this specialty division has been a pioneering team in the field of ERCP, consistently ranking as the highest volume referral center for ERCP in North America, with nearly 3,000 ERCP procedures performed annually.

The ERCP program at IU School of Medicine has internationally recognized leaders in ERCP who see patients with pancreatobiliary disease daily. The ERCP service at IU Health University Hospital in downtown Indianapolis provides comprehensive inpatient and outpatient pancreatobiliary services – offering services to patients and referring physicians from the Midwest and throughout the country.

Endoscopic Ultrasound Expertise

The Endoscopic Ultrasound service by IU School of Medicine faculty physicians was started in 1987, making it the third in the United States to provide this clinical services. Over the years, several prominent national and international leaders in gastrointestinal endoscopy have trained in Endoscopic Ultrasound at this program and subsequently moved on to provide this service around the country and the globe.

The Endoscopic Ultrasound specialists at IU School of Medicine is comprised of thought leaders and experts with significant experience in Endoscopic Ultrasound. The high-volume Endoscopic Ultrasound program offers both outpatient and inpatient services for a variety of diagnostic and therapeutic purposes. Endoscopic Ultrasound is frequently part of a multi-disciplinary medical management strategy for complex medical conditions.

Innovative Endoscopy

The Innovative Endoscopy team at IU School of Medicine offers groundbreaking minimally invasive endoscopic therapeutic options for diseases previously treated definitively only with surgery. Faculty physicians on the Innovative Endoscopy team perform innovative endoscopic procedures, including per-oral endoscopic myotomy (POEM) for achalasia, endoscopic submucosal dissection (ESD) for early GI-based malignancies, submucosal tunneling endoscopic resection (STER) for tumors of the GI luminal wall, gastric per-oral endoscopic myotomy (G-POEM) for refractory gastroparesis and flexible endoscopic Zenker diverticulotomy – all of which were the first procedures of their kind performed in the state of Indiana.

Advanced Endoscopy Treatments

Patient care encompasses treatment and diagnosis of pancreatic pseudocyst, pancreas divisum, pancreatitis, Sphincter of Oddi dysfunction/manometry, biliary disorders-sclerosing cholangitis, biliary strictures and the impact of ERCP on these diseases. If x-rays illustrate a blockage of the papilla or the duct systems, a gastroenterologist could potentially treat the problem immediately. Common treatments would include balloon dilation (stretching), sphincterotomy, stenting and positioning of drainage tubes.

Sphincterotomy is a medical procedure that cuts the muscular sphincter of the bile duct or pancreatic duct. A sphincterotomy is usually performed to assist in bile duct stone removal prior to placement of a stent or drainage tube to treat papillary stenosis and sphincter of Oddi dysfunction and to facilitate stricture dilation and tissue sampling. A small incision (about ¼ – ½ inch long) is made in the papilla to expand the relevant opening. This incision is made with an electrical current that also cauterizes the tissues to prevent bleeding. A special type of sphincterotomy, a precut sphincterotomy, is used as a last resort when a physician experiences difficulty in trying to place the standard sphincterotome completely into the pertinent duct. This type of treatment is deemed somewhat more risky in certain situations.

Stone removal is performed when stones are detected. The most common type of stone requiring removal is bile duct stone. Prior to stone removal, a biliary sphincterotomy (an incision is made to expand the opening of the bile duct) is usually performed. Once the incision is made, a physician can remove the stones with a special “basket” designed for stone removal or (s)he may manipulate the stone by using an inflatable balloon device designed to sweep the duct. Stones sometimes pass (into the duodenum) spontaneously after a sphincterotomy is performed; however, physicians generally attempt removal. Larger stones may need to be crushed before a removal attempt can be successful. This type of procedural technique is called a mechanical lithotripsy. Stones detected in the pancreatic ducts can be successfully removed; however, this type of stone removal is technically more complex.

When unsuccessful attempts at removing a stone occurs, a physician may choose to place a nasobilary drainage tube (NBD). This type of stenting (a long tube is put in the bile duct through the endoscope and comes out through the patient’s nose) is useful in the prevention or treatment of acute cholangitis, biliary decompression of an obstructed common bile duct, treatment of a post-operative biliary leak or when unsuccessful stenting (a plastic stent that stays in the duct) has occurred. Once the tube is in place the patient is generally required to stay in the hospital for monitoring purposes (usually a few days). Although the tube causes some discomfort, a patient can eat and drink while it is in place.

A partial blockage or narrowing of the bile or pancreatic duct can be treated with hydrostatic balloon dilation (similar to that used in the arteries of the heart) during the ERCP procedure. The balloon is used to stretch and expand the duct. Dilation may also be achieved by using a graduated catheter passed over a guidewire.

After successful dilation of a duct narrowing, a physician may insert a small tube called a stent to keep the duct expanded or to aid with any duct drainage. There are plastic (polyethylene) stents and metal (metallic) stents. A plastic stent is most commonly used. Plastic stents are generally trouble-free; however, they tend to clog up, thus requiring an additional ERCP in order to remove the stent and replace it with a fresh stent. This type of stent is easy to use and can pass out of the body on its own through stool, or it may require removal by a physician via another ERCP. Metal stents are permanent and expand to a larger diameter once in place. If this type of stent becomes clogged, a plastic or another metal stent can be placed through the original stent. In expert hands, stent placement is very successful.

Benefits, Risks and Side Effects

Most risks depend on the particular patient, disease and type of ERCP procedure and treatments. Complications occur in 5-20 percent of patients.

Pancreatitis is the most common side effect of an ERCP. It occurs in 10 percent of ERCPs and generally requires hospital admission and generally settles in one to three days in almost all cases. The treatment for mild pancreatitis usually consists of restriction of oral intake to ice chips, intravenous fluids and analgesics (pain medications) as needed. Severe pancreatic damage can result in the formation of pseudocyst or abcesses, which may require a prolonged hospital stay. This occurs in less than one percent of patients. It can occur even in the most expert hands.

Other important complications can occur after treatments such as sphincterotomy. A sphincterotomy can trigger bleeding, which can be controlled by the doctor during the ERCP. It is rare and uncommon for a blood transfusion to be needed. Sphincterotomy may result in a perforation when the cut extends into the tissues behind the duodenum and pancreas. Most perforations can be treated medically (with IV fluids, antibiotics and nasogastric tube). In severe cases, it may require surgery. On very rare occasions, the endoscope itself can cause a perforation (make a hole). This type of perforation usually requires surgical treatment.

Infection can occur in the bile ducts or pancreas after ERCP, especially when there is duct obstruction that cannot be treated by the ERCP procedure. Antibiotics are required and possibly another type of drainage procedure such as surgery.

The fluoroscope involves a small dose of radiation; this is no greater exposure than any other standard x-ray test and is well within the recommended limits. Possible drug reactions could occur with the medications and can cause nausea and skin reactions.

About one percent of ERCP procedures can result in severe complication. These types of complications would require a prolonged hospital stay, treatment in an intensive care unit or surgery. Death rarely occurs.

National Pancreas Foundation Center

IU Health University Hospital has been nationally recognized as a National Pancreas Foundation Center for the care of patients with pancreatitis and pancreatic cancer. Clinical care facilities recognized by this foundation undergo a rigorous audit to ensure a focus on multidisciplinary treatment of pancreatic disease. These centers align their resources to meet every aspect of a patient’s care needs to ensure not only the best possible outcomes but to enhance quality of life. IU Health University Hospital is the only hospital in Indiana to receive this prestigious designation.