Authors' objectives:

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.

Authors' results and conclusions: 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.

Authors' recommendations: 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.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.ahrq.gov/clinic/epcsums/ercpsum.htm

Year Published: 2001

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: United States

Organisation Name: Agency for Healthcare Research and Quality

Contact Address: Center for Outcomes and Evidence Technology Assessment Program, 540 Gaither Road, Rockville, MD 20850, USA. Tel: +1 301 427 1610; Fax: +1 301 427 1639;

Contact Name: martin.erlichman@ahrq.hhs.gov

Contact Email: martin.erlichman@ahrq.hhs.gov

Copyright: Agency for Healthcare Research and Quality (AHRQ)