Freequent ERCPs

[Guest guest]

Re 's question about frequent ERCPs. There was an important discussion about this at the 2nd Partners Seeking a Cure Conference, Pittsburgh, April, 2006.

In Germany Prof. Stiehl is well-known for his approach in doing ERCPs on his patients every year whether there are stricture problems or not and doing baloon endoscopies on strictures even if they are not causing problems. He claims to be altering the course of PSC to some extent and extending time between diagnosis and possible need for a transplant. He claims to have excellent results in his clinic and very low numbers for bile duct cancer.

He was taken to task by Dr Slivka (University of Pittsburgh Medical Center), who questioned his approach and his results and said "If it ain't broke don't fix it." or words to that effect. Prof Stiehl sees strictures as setting us back and worsening progression and he deals with this agressively.

But ERCP may also be used to look for bile duct cancer and there was a discussion on this at the meeting when somebody asked what was the best way of detecting cholangiocarcinoma.

Dr. Slivka:

That's a difficult question. I look at tumor markers every 6 months, (most insurance companies pay for that). I do think that using ERCP as a screening test isn't safe enough and it may not be in everyone's best interest. With ERCP you'll find large bile duct cancers but you won't find peripheral bile duct cancers which are better picked up by CT scans, MRIs etc. So we do look at tumor markers, broad changes in the blood work - as a key to then go on and do another type of screening - ERCP or CT scan. But from a screening point of view we really don't have a good answer. I like to find an excuse to do a CT scan every couple of years on the patients that I follow - I'd like to hear Dr. Londor's approach to screening for CC.

Dr. Lindor:

This is a very difficult issue. I agree that ERCP is not safe used only for screening purposes. I do blood tests every 3 months, then I do an ultrasound - we have resected patients with CC - 4 that I can think of - 3 had live donors - all survived. If the ultrasound shows something equivocal I end up using CT or MRI with Ferodax, an iron contrast agent - may be more specific for CC.

Again, the risk of developing CC once you have PSC is fairly small - one in 200 patients in our experience. That means if I see 200 PSC patients in a year I'll likely find only one person with PSC. This type of screening will allow us to find tumors in people and give them a successful transplant to save their lives.

The conference was fully reported in our "PSC News" No34, Aug. 2006. If that was one of the issues you missed I can send you a copy.

At a more recent PSC conference last year in Oxford Prof Stiehl gave a paper confirming his approach to ERCP for stricturing, with continuing good results.

Ivor

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