Endoscopy's role in primary sclerosing cholangitis: a clinical guideline

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The ESGE and EASL has released a guideline of practical advice on how to use endoscopic retrograde cholangiopancreatography and colonoscopy in patients with primary sclerosing cholangitis.
The ESGE and EASL has released a guideline of practical advice on how to use endoscopic retrograde cholangiopancreatography and colonoscopy in patients with primary sclerosing cholangitis.

The European Society of Gastrointestinal Endoscopy (ESGE) and the European Association for the Study of the Liver (EASL) has released an evidence- and consensus-based guideline of practical advice on how to use endoscopic retrograde cholangiopancreatography (ERCP) and colonoscopy in patients with primary sclerosing cholangitis (PSC) to maximize their benefit and minimize their burden and adverse events. The guideline was published in the Journal of Hepatology and in Endoscopy.

The following is a summary of the main recommendations. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to define the strength of recommendations and the quality of the evidence.

  • As the primary diagnostic modality for PSC, magnetic resonance cholangiography (MRC) is preferred over ERCP [moderate-quality evidence, strong recommendation].
  • ERCP can be considered if MRC plus liver biopsy is equivocal or contraindicated in patients with persisting clinical suspicion of PSC. The risks of ERCP should be weighed against the potential benefit with regard to surveillance and treatment recommendations [low-quality evidence, weak recommendation].
  • In patients with an established diagnosis of PSC, MRC should be considered before therapeutic ERCP [low-quality evidence, weak recommendation].
  • Performing endoscopic treatment with concomitant ductal sampling (brush cytology, endobiliary biopsies) of suspected significant strictures identified at MRC in PSC patients who present with symptoms is likely to improve following endoscopic treatment [low-quality evidence, strong recommendation].
  • Weigh the anticipated benefits of biliary papillotomy/sphincterotomy against its risks on a case-by-case basis [moderate-quality evidence, strong recommendation].
  • Biliary papillotomy/sphincterotomy should be considered especially after difficult cannulation [low-quality evidence, strong recommendation].
  • Routine administration of prophylactic antibiotics is suggested before ERCP in patients with PSC [low-quality evidence, strong recommendation].
  • Cholangiocarcinoma (CCA) should be suspected in any patient with worsening cholestasis, weight loss, raised serum CA19-9, and/or new or progressive dominant stricture, particularly with an associated enhancing mass lesion [moderate-quality evidence, strong recommendation].
  • Ductal sampling (brush cytology, endobiliary biopsies) is recommended as part of the initial investigation for the diagnosis and staging of suspected CCA in patients with PSC [high-quality evidence, strong recommendation].

References

  1. Aabakken L, Karlsen TH, Albert J,  et al. Role of endoscopy in primary sclerosing cholangitis: European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) Clinical Guideline. Endoscopy. 2017;49(6):588-608. doi: 10.1055/s-0043-107029 
  2. European Society of Gastrointestinal Endoscopy; European Association for the Study of the Liver. Role of endoscopy in primary sclerosing cholangitis: European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) Clinical Guideline. J Hepatol. 2017;66(6):1265-1281. doi: 10.1016/j.jhep.2017.02.013
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