Endoscopic Ultrasound with Fine Needle Aspiration is a fantastic way to obtain tissue samples from lesions around the gastrointestinal tract to aid in diagnosis. This procedure is done with the same type of anesthesia as is given for routine colonoscopy. It involves advancing a special endoscope into the stomach or small intestine, and using ultrasound from inside the gastrointestinal lumen to visualize the deep layers of the gastrointestinal walls as well as structures nearby to the lumen including the pancreas, the liver, and lymph nodes. Once visualized, a needle can be advanced from the scope into the desired lesion under direct visualization to obtain cells to be looked at under a microscope.

Endoscopic Retrograde Cholangiopancreatography (ERCP) is a procedure that allows for alleviation of obstruction of the ducts that drain the liver/gallbladder and that drain the pancreas. There are many causes of obstruction of these ducts, including (but not limited to):

• Gallstones (most common)
• Chronic pancreatitis
• Acute pancreatitis
• Primary bile duct cancer (cholangiocarcinoma)
• Pancreatic cancer
• Metastatic cancer invading the bile duct
• Autoimmune pancreatitis
• Primary sclerosing cholangitis
• Ampullary adenoma / Ampullary cancer

During ERCP, we gain access into either the bile duct or the pancreatic duct and enlarge the opening using a technique called a sphincterotomy. We then use a balloon that we inflate high-up in the duct to sweep out anything that is causing obstruction. In some cases where a stricture is present (a narrowing of the duct either from inflammation or cancer), we place a stent which stretches the narrowed area open over time and allows for continued drainage even after the procedure concludes. We can also take biopsies of the bile duct or pancreatic duct whenever necessary.

Some stones in the bile duct or pancreatic duct are too large to be swept out with a balloon. In these cases, we have several novel techniques to facilitate removal. There are special baskets that can be used to surround a stone and crush it into small pieces which can then be removed. Additionally, at RWJUH, we have a special laser that can be advanced into the bile duct or pancreatic duct and used to blast a large stone into small pieces so that it can be removed. This is called laser lithotripsy.

Some stones in the bile duct or pancreatic duct are too large to be swept out with a balloon. In these cases, we have several novel techniques to facilitate removal. There are special baskets that can be used to surround a stone and crush it into small pieces which can then be removed. Additionally, at RWJUH, we have a special laser that can be advanced into the bile duct or pancreatic duct and used to blast a large stone into small pieces so that it can be removed. This is called laser lithotripsy.

Photodynamic Therapy (PDT)

Primary bile duct cancer, also called cholangiocarcinoma, is a cancer with poor survival rates. Surgery is the only cure, but many patient’s disease is too advanced to undergo surgery at the time of diagnosis. PDT is a technology that can be used in conjunction with chemotherapy to prolong survival. This technique involves receiving an infusion of a light-activated medication that is absorbed by bile duct cancer cells. 48 hours later, light is applied to the bile duct during ERCP causing the cancer cell to die. Studies have shown this technology to be safe and to increase survival in patients with cholangiocarcinoma.

Biliary Radiofrequency Ablation (RFA)

In patients with bile duct obstruction from any type of cancer, RFA to the bile duct during ERCP can be used in conjunction with chemotherapy to prolong survival. This technique works by applying thermal energy to the bile duct tissue which results in coagulation necrosis and death of cancer cells. In studies, it has been shown to improve how long the narrowing in the bile duct remains open, decreasing the need for repeat procedures to exchange stents. In addition, it is associated with a survival benefit.

Some patients with pancreatitis have very large and hard stones that cannot be blasted with the special laser during ERCP. For these patients, we offer a unique technology called extra corporeal shock wave lithotripsy. This technology directs shock waves from outside the body directly at the stone, causing it to break into pieces which can then be subsequently removed during endoscopy.

Sometimes, it can be difficult to know if a stricture (narrowing) in the bile duct or pancreatic duct is due to cancer or to inflammation. Biopsies can be helpful, but sometimes they can be negative even in the setting of cancer. Therefore, a variety of imaging techniques have arisen to aid in making the correct diagnosis.

During ERCP, the bile duct is visualized only by XRays – contrast is injected into the bile duct which shows up on XRay, and pathology is diagnosed by areas that don’t fill or are narrowed. Cholangiopancreatoscopy is a novel and exciting technology that allows a small camera to be inserted into the bile duct or pancreatic duct so that the inside of the duct can be examined visually. In addition, biopsies can be targeted to areas that look especially suspicious, increasing the chance of making an accurate diagnosis.