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# Endoscopic Retrograde Cholangiopancreatography

*Evidence Reports/Technology Assessments, No. 50*

Naomi Aronson, PhD, Program Director and Carole Redding Flamm, MD, MPH, Project Director. Investigators: David Mark, MD, MPH, Frank Lefevre, MD, Rhonda L Bohn, ScD, MPH, and Beth Finkelstein, PhD, MPH. Research/Editorial Staff: Kathleen M Ziegler, PharmD, Claudia J Bonnell, BSN, MLS, and Maurice Carter.

Agency for Healthcare Research and Quality (US)2002 Jun
Report No.: 02-E0171-58763-102-4

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## Structured Abstract

#### Objectives:

            Diseases of the pancreas and biliary tree are common in the United States. Prevalence of common bile duct stones is estimated at 6 per 100,000. Incidence of pancreaticobiliary malignancy is approximately 57,400 annually, most with poor prognosis. A variety of diagnostic and therapeutic interventions have been developed to manage these conditions. This systematic review of the evidence on the diagnostic and therapeutic effectiveness of endoscopic retrograde pancreatography (ERCP) addresses four clinical conditions: (1) common bile duct stones; (2) pancreaticobiliary malignancy; (3) pancreatitis; and (4) abdominal pain of possible pancreaticobiliary origin. In addition, the evidence on determinants of complications of ERCP and on the prediction of common bile duct stones are reviewed.

#### Search Strategy:

           The PubMed/MEDLINE, BIOSIS, EMBASE, and SCISEARCH databases with a publication date from 1980 through August 13, 2001 were searched for articles indexed to the NLM Medical Subject Heading (MeSH®) "cholangiopancreatography, endoscopic retrograde" and ERCP synonyms and textword combinations. Search was limited to articles on human subjects published in the English language with an online abstract and supplemented by manual searching. Yielded was 5,698 citations.

#### Selection Criteria:

            Inclusion was limited to published reports. For diagnostic and therapeutic effectiveness, inclusion was limited to comparative studies prospectively designed or using appropriate retrospective sampling with a prespecified minimum number of subjects. For prediction studies, 100 subjects were required. There were 789 articles retrieved for review, yielding 149 included studies.

#### Data Collection and Analysis:

           The protocol was designed prospectively to define: study objectives; search strategy; patient populations; study selection criteria; outcomes; data elements and abstraction; and study quality assessment. One reviewer performed primary data abstraction into evidence tables and a second reviewer checked accuracy. Data synthesis was qualitative.

#### Main Results:

                   Most diagnostic studies were small, did not use common reference standards, and many did not report statistical significance; thus, equivalence and difference among tests cannot be quantified. Qualitative assessment of the available evidence suggests that:

Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) provide similar diagnostic performance as ERCP for detecting common bile duct stones or malignant pancreaticobiliary obstruction.

Sensitivity of nonsurgical tissue sampling techniques for detecting malignancy is similar or higher for brush cytology versus bile aspiration cytology, similar for fine-needle aspiration (FNA) cytology versus brush cytology, and similar or higher for forceps biopsy versus brush cytology.

Robust evidence is lacking to compare strategies for treatment of common bile duct stones.

The absence of any risk factors for common bile duct stones (i.e., clinical jaundice or elevated bilirubin, elevated liver function tests, dilation on ultrasound) is a strong predictor of the absence of stones.

For palliation of biliary obstruction of malignancy, outcomes of surgical bypass and ERCP stenting are similar, but major complications are greater for surgery and stent replacement occurs with ERCP. Total resource utilization was reported to be lower with metal than plastic stents. Pre-operative stenting has greater overall complications than surgery alone and does not appear to improve surgical outcomes.

Evidence on treatment of chronic pancreatitis and relapsing or recurrent pancreatitis is sparse.

Endoscopic sphincterotomy appears to relieve pain in patients with pancreaticobiliary pain, sphincter of Oddi dysfunction, and elevated basal sphincter of Oddi pressure on manometry.

Factors associated with complications of ERCP were age 60 years or less, suspected sphincter of Oddi dysfunction, precut endoscopic sphincterotomy, difficulty in cannulation, multiple pancreatic contrast injections, and case volume.

#### Conclusions:

           Rigorous studies are required in order to reliably quantify the relative performance of diagnostic ERCP compared to alternatives. Comparative studies of alternative diagnostic and treatment strategies for common bile duct stones are urgently needed. Interventions intended to reduce complications of ERCP should incorporate prospectively defined studies to evaluate results.

## Contents

                          - Expand All
                          - Collapse All

                        - Preface
                        - Summary
                        - 1. Introduction                           - Scope of Systematic Review
                          - Key Questions for this Systematic Review
                        - 2. Methodology                           - Search Strategy for the Identification of Articles
                          - Study Selection Criteria
                          - Outcomes of Interest
                          - Methods of the Review
                          - Quality Assessment
                          - Technical Assistance and Peer Review
                        - 3. Results and Conclusions                           - Part I: Common Bile Duct Stones
                          - Results and Conclusions, Part II: Pancreaticobiliary Malignancy
                          - Results and Conclusions, Part III: Pancreatitis
                          - Results and Conclusions, Part IV: Abdominal Pain Of Possible Pancreaticobiliary Origin
                          - ERCP Evidence Review Results and Conclusions, Part V: Patient, Procedure or Operator Determinants of ERCP Complications
                        - 4. Future Research
                        - Evidence Tables
                        - Appendix A. All Retrieved, Excluded Publications
                        - Appendix B. Technical Advisory Group (TAG) Members and Affiliations
                        - Appendix C. Abbreviations
                        - References
                        - Bibliography

                          - Expand All
                          - Collapse All

Prepared for: Agency for Healthcare Research and                            Quality, U.S. Department of Health and Human Services.1             Contract No. 290-97-001-5. Prepared by: Technology Evaluation Center, Blue Cross and Blue Shield Association.

#### Suggested citation:

Flamm CR, Aronson N, Mark D, et al. Endoscopic Retrograde Cholangiopancreatography. Evidence Report/Technology Assessment Number 50. (Prepared by Blue Cross and Blue Shield Association under Contract No. 290-97-001-5.) AHRQ Publication No. 02-E017 Rockville, MD: Agency for Healthcare Research and Quality. June 2002.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. Endorsement by the Agency for Healthcare Research and Quality (AHRQ) or the U.S. Department of Health and Human Services (DHHS) of such derivative products may not be stated or implied.

AHRQ is the lead Federal agency charged with supporting research designed to improve the quality of health care, reduce its cost, address patient safety and medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps heath care decisionmakers -- patients and clinicians, health system leaders, and policymakers -- make more informed decisions and improve the quality of health care services.

The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or other clinical service.

                        - 1
                        - 
2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

Copyright Notice

Bookshelf ID: NBK33925

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                    - Cite this Page Aronson N, Flamm CR, Mark D, et al. Endoscopic Retrograde Cholangiopancreatography. Rockville (MD): Agency for Healthcare Research and Quality (US); 2002 Jun. (Evidence Reports/Technology Assessments, No. 50.)

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