ORIGINAL ARTICLE

The Effectiveness of Endoscopic Retrograde Cholangio-

pancreatography in the Management of Patients with
Jaundice at Cipto Mangunkusumo Hospital, Jakarta

Arman A. Abdullah1, Murdani Abdullah2, Ahmad Fauzi2, Ari F. Syam2,

Marcellus Simadibrata2, Dadang Makmun2
1
Department of Radiology, Faculty of Medicine University of Indonesia - Cipto Mangunkusumo Hospital.
Jl. Diponegoro no. 71, Jakarta Pusat 10430, Indonesia. Correspondence mail: arman3a@yahoo.com.
2
Department of Internal Medicine, Faculty of Medicine University of Indonesia - Cipto Mangunkusumo Hospital.
Jl. Diponegoro no. 71 Jakarta Pusat 10430, Indonesia

ABSTRAK
Tujuan: untuk mengevaluasi manfaat endoscopic retrograde cholangiopancreatography (ERCP) dalam
penanganan pasien yang memiliki gambaran klinis ikterus. Metode: sebuah studi deskriptif retrospektif dilakukan
dengan menganalisa 129 prosedur ERCP yang dilaksanakan untuk 122 pasien di Rumah Sakit Umum Pusat
Cipto Mangunkusumo dari Januari 2008 hingga Desember 2010. Tujuh orang pasien menjalani prosedur ERCP
kedua. Keluhan utama adalah gambaran ikterus pada kulit pasien. ERCP dilaksanakan sesuai indikasi, dengan
catatan lengkap mengenai distribusi penyakit yang diderita, hasil dari prosedur serta komplikasi yang terjadi.
Hasil: subjek pada studi ini terdiri dari 63 pria (52%) dan 59 wanita (48%). Tujuh pasien menjalani ERCP
dua kali. Data menunjukkan bahwa 68 prosedur (pada 63 pasien) diindikasikan oleh batu empedu, 53 prosedur
(pada 52 pasien) diindikasikan oleh tumor atau massa, dan 8 prosedur (pada 7 pasien) dengan indikasi
infeksi. Sepuluh dari 129 prosedur (8%) menunjukkan hasil normal, 96 prosedur (74%) menunjukkan hasil
yang abnormal. Pada 23 kasus (18%), kanulasi yang sulit terjadi selama ERCP dan akses ke duktus koledokus
(common bile duct) tidak tercapai. Dari 53 pasien dengan temuan batu positif, ektraksi berhasil dilakukan pada
43 pasien (81%); termasuk 12 pasien dengan ERCP sulit yang masih menyisakan fragmen-fragmen batu (23%).
Ekstraksi tidak berhasil dilakukan pada 10 pasien (19%). Dari 53 pasien, 51 (96%) diantaranya memiliki batu
radiolusen dan 2 pasien (4%) memiliki batu radioopak. Stent terpasang pada duktus koledokus (30 kasus, 83%),
duktus pankreas (4 kasus, 11%), dan diluar duktus koledokus (2 kasus, 5%). Komplikasi terjadi pada 3 kasus
(2%), termasuk migrasi stent keluar dari duktus koledokus (2 kasus) dan satu kasus dengan basket yang pecah.
Kesimpulan: prosedur ERCP sangat berguna membantu klinisi dalam diagnosa dan tindakan terapi kelainan-
kelainan pankreatobilier yang membutuhkan ektstraksi batu empedu dan pemasangan stent.

Kata kunci: ERCP, ikterus, koledokolithiasis, tumor pankreatobilier.

ABSTRACT
Aim:.to evaluate endoscopic retrograde cholangiopancreatography (ERCP) benefits in treating patients
with clinical appearance of yellowish discoloration. Methods: a descriptive retrospective cross-sectional study
was performed on 122 patients at Cipto Mangunkusumo Hospital from January 2008 to December 2010. The
main complained was yellowish discoloration of the skin. ERCPs were performed as appropriate, and then
the distribution of disease entity, results of procedure and complications were noted. Results: subjects of this
study consist of 63 males (52%) and 59 females (48%), 7 patients have undergone ERCP 2 times. Data showed
63 cases (51%) were indicated by stone and 52 cases (43%) by tumor/mass and 7 cases by infection (6%).
Ten out of 122 cases (7%) showed normal results. Difficult canulation was encountered in 23 cases (18%) as
access to the CBD could not be obtained. From 53 cases with stone, the extraction was successful in 43 (81%)

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Vol 44 • Number 4 • October 2012 The effectiveness of ERCP in treating patients with jaundice in RSCM

including while 12 procedures with high grade of difficult ERCP left stone remnants (23%), and the remaining
10 procedures entailed stones retention (19%). Radioopaque stones found in 2 cases (4%) and radioluscent
in51 cases (96%). Stent placement was done in CBD (30 cases, 83%), pancreatic duct (4 cases, 11%), and
extraneous CBD (2 cases, 5%). Complications found 3 cases (2%) migration stent outside CBD in 2 cases,
1 case with crand radioluscentin 51 acked basket. Conclusion: ERCP procedure is really helpful in assisting
clinicians to diagnose and manage therapeutic measures, especially in pancreaticobilliar tract disorder, while
performing stone extraction and stent placement.

Key words: ERCP, icterus, choledocholithiasis, pancreaticobiliary tumor.

INTRODUCTION by gastroenterologist, Department of Internal

Since its discovery 30 years ago,the use of
endoscopic retrograde cholangiopancreatography
(ERCP) has developed rapidly, not only as a
diagnostic tool but also for therapeutic uses
especially in patients with pancreaticobiliary
diseases. Other diagnostic modalities of these
diseases still could not replace ERCP main role,
this superiority a malgamated by peripherals
development of ERCP such as sphincterectomy
device, stent replacement apparatus, and stone
extraction instruments.
The most frequent abnormality encountered
in pancreaticobiliary tract is obstruction, which
is commonly caused by stones, tumors, or
infection. Choledocholithiasis is one of the most
common disorder in pancreaticobiliary tract,
and ERCP procedures, using ballooned double-
lumen catheter, wired basket, and mechanical
lithotripsy, found helpful especially in non-
operated patients.
Other cause of obstruction is tumor, with
papyllary cholangiocarcinoma being the most
common, follow by pancreatic head tumors,
whilst the incidence is increasing due to better
sensitivity of developing diagnostic tools.
ERCP is undoubtedly advantageous
in assisting physicians to diagnose and
manage therapeutic measures, especially in
pancreaticobilliar tract disorders. Hopefully this
procedure could be continuously developed into
further extent.1,2
METHODS
Medicine in collaboration with Gastrointestinal
Division of the Department of Radiology,
University of Indonesia. The Indication, result
and complications found within 30 days after
the procedure was noted, the pertinent data
were collected from medical records. In general
indication of the ERCP were obstructive jaundice
or gallstone pancreatitis. The ERCP was done as
a guideline. At the time of ERCP, if found the
billiary stone, we will attempt to perform the
extraction of the stones. But if there were large or
impacted stones that may be be difficult remove,
we just only put biliary stenting. Endoscopic
stent placement was performed if patients with
malignant billiary obstruction.
RESULTS
During the period between January 2008 and
December 2010, 129 ERCP procedures were
done on patients presenting with jaundice. Data
showed 63 procedures indicated by stone (52%)
and 52 cases by tumor/mass (43%) and infection
7 cases (5%). Subjects of this study consist of 63
males (52%) and 59 females (48%), included in
are 7 patients having ERCP 2 times.
Table 1. Demographic data of patients
Variables N (%)
Gender distribution
-- Male 63 (52)
-- Female 59 (48)
Age distribution

ERCP procedures were done during period -- < 30 yrs 8 (7)

of January 2008 until December 2010 in -- 30-39yrs 20 (16)

Radiology Department, Cipto Mangunkusumo -- 40-49yrs 30 (25)

General National Hospital, by using Phillips® -- 50-59yrs 37 (30)
ERCP equipment. All the procedures were done -- > 60 yrs 27 (22)

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Indications of ERCP - Clinical diagnosis

Hepatoma

Duodenal tumor

Cholangiocarcinoma

Pancreatic head tumor

Pancreatitis
Clinical diagnosis

Klatskin’ tumor

Papillary tumor

Gallstones

Figure 1. Subject diversity according to clinical diagnosis (n=122)

ERCP Diagnosis Table 5. ERCP complications

Stent migration 2 cases (1 in papillary tumor and 1 in

Table 2. Results of ERCP procedures (n= 129) pancreatic head tumor)
Results N % Cracked basket 1 case due to large gallstone. Pieces
of the crushed basket were removed
Normal ERCP results 10 8 during the next ERCP procedure
Abnormal ERCP results 96 74 and stent was deployed to handle
the biliary obstruction. The large
Difficult cannulation (unable to go
23 18 gallstone was subsquently removed
through CBD)
Hemorrhage/ Not found
Total 129 100
perforation

Table 3. Final outcome in patients with positive stone

findings (n= 53)

Outcome of stone extraction N %

Successful stone extraction (no remnants) 31 58
Stone remnants persisted 12 23
Stone retention 10 19
Total 53 100
A B
Figure 2. Male, 40 years old with pancreatic head tumor. (A)
Table 4. Stent placement result characteristics (n= 36) Muliple calcifications in pancreas. (B) Stent in Wirsungi duct
Outcome of stent placement N %
Proper placement in CBD 30 83
Proper placement in pancreatic duct 4 11
Extraneous CBD/Migration 2 5
Total 36 100

Other stent placement characteristics:

• Second stent placement: 2 cases
• Stent extraction: 4 cases (3 cases replaced) A B
• Double stent placement: 1 case of
Figure 3. Male, 55 years old with papillary tumor. (A) Plain
cholangiocarcinoma photo: stent. (B) Cholangiography through gallbladder:
• Wall stent placement: 1 case migration of stent from CBD.

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Two duodenal diverticulosis cases were
coincidentally encountered in ERCP procedures
done during the period. Radioopaque stones
found in 2 cases (3%) out of 63 stone-indicated
procedures and 61 cases characterized with
radioluscent stones (97%). Most of the stones
are radioluscent, although 20% of stones contain
calcium carbonate hence appeared radioopaque.3
Figure 4. Female, 59 years old, post-cholecystectomy. The
patient still suffered from jaundice after stent insertion. In
second ERCP, migration of stent was observed, and then a
new stent was inserted into the CBD.
DISCUSSION
According to the results of the National
Health and Nutrition Examination Survey
(NHANES III), over 20 million people in the
United State suffered from gallstone infection
(based on USG results or review of gallstone
surgery).4
The exact incidence of choledocholithiasis
cases is still surely unknown, but there is
assumption on 5-20% range of patient who
treated by cholesistektomi commonly furthered
having choledocholithiasis.5,6
This research have found that 63 patient
with indicated by stone (49%) had treated
with following ERCP procedures. The ERCP
procedures has already perform in 53 cases, in 31
(49%) cases the stone had extracted completely
A B
Figure 5. Female, 33 years old, stone in CBD. (A) Stone extraction in CBD, basket was broken and stone could not be extracted.
(B) Broken basket in CBD. (C) Extraction with new stent.
(no remnant), in 12 (19%) cases the stone
mostly extracted but some remnants cannot be
removed because of quantity and position of
stone which are mostly located in left and right
side of intra hepatic, only those which located in
CBD can be removed completely. 43 (81%) the
stones can removal, only 10 (19%) failed during
examination. Baron TH and Harewoods GC7
reported 94.3% overall succesful stone removal.
Therefore, we tried procedure stent placement
in those cases, included 2 more cases with stone
failure removal. Total cases that treated by
stent placement were 14 cases all. Endobiliary
stents are used for palliative purposes to relieve
symptoms of biliary obstruction. The patency
duration of plastic stents is 2 to 4 months.
Metallic stents is longer (4 to 6 months) than
plastic stents, but the survival for both devices
are not different when stents occlusion are
replaced with new stents.8
Another cause that mostly found in obstructive
icterus case is neoplasma. Over 80% of malignant
ductus biliary lead to carcinoma. The other
tumor commonly found are papyllary tumor
and small cell carcinoma, adenosa squamosa.
Melanoma maligna cases are rarely found,
but rhabdomyosarcoma was been detected in
pediatric patients. Data of prevalence pappyla
vateri tumor in Indonesia still not found. Based
on one research in French announced that pappyla
vateri tumor was rarely found. They only had
111 cases in 20 years during 1976–1995 period,
which were the incidence on male patients were
higher than female patients (3.8 versus 2.7 per
one million people).9
The incidence of cholangicarcinoma in
United State are around 2000–3000 cases
every year which is equivalent to 1–2 cases per
100.000 people.10 Of the total 129 neoplasm’s
cases on this research revealed that 52 tumor
C
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Arman A. Abdullah
cases (43%) were diagnosed infecting billiary
duct with mostly papilla valeri tumor found on
28 cases (54%), cholangio carsinoma (including
Klatskin tumor 11 cases) on 16 cases (31%).
Other neoplasm that were also found with fewer
number comprised pancreatic head tumor 4 cases
(3.2%), duodenal tumor 2 cases (1.6%), and 1
hepatoma’s case (0.8%).
Another cause that lead patient to have ERCP
treatment is post cholesistectomy syndrome. The
treatment of post cholesistectomy syndrome
needs ERCP procedure for observing and
handling obstructive ductus billiari which is
following on cholesistectomy procedure. In
this research, 5 cases (4%) were having ERCP
procedure.
Stent replacement on ERCP is for aiming
billiary drainage which is interrupted by
stone, neoplasm, or stenosis that is caused by
complicated infection or post cholecystectomy. In
this research, stent placement is implemented on
14 (39%) cases of stone, 6 (17%) cases of papilla
tumor, 11 (31%) cases of cholangio carcinoma,
1 (3%) case of head of pancreatic tumor, and 4
(11%) cases of gallbladder infection. Salim S
et al11 reported 53% patients succed in plastic
stent placement in obstructive jaundice 6 in
malignancy and 13 cases non malignancy.
(Figure 2)
About in range 8–10% case procedure, the
migration of stent might be occur during stent
placement on billiary duct, and mostly the stent
will naturally excrete from gastrointestinal
system. In several case rarely occur, stent
get stuck or prick intestine membrane that
causing perforation,. Migration can occur into
the proximal duct or into the gut. Risk factors
associated with proximal stent migration are
malignant strictures, large stent diameter, and
short stent length.10,11 On that case, endoscopy
procedure is necessary on handling stent
migration. However, if the procedure cannot
be execute or stent location undetectable, then
patient must be treat under observation to find
acute abdomen symptom until stent can be
completely evacuate from patient’s body. When
patient’s body show an acute abdomen symptom,
then mostly surgery procedure is needed.
According to this study, the migration occurred
in 2 cases (5%); 1 case is papillary tumor and 1
case is pancreatic head tumor from 36 cases that
perform stent placement had stent migration.14
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Acta Med Indones-Indones J Intern Med
(Figure 3, Figure 4)
Aside from its benefits, ERCP procedure
also hcarries potential risks of complication
side effect which is can reach until 10% from
total procedure in hospital with professional
paramedic and frequently using this procedure.14
Complication side effect that might be occurring
is bleeding/perforation. In this research, bleeding
and perforation was not found.
In this research, 2 cases of contrast
extravasations out from ductus billiary, one case
are caused by illness (hepatoma) and the other
was caused by having previous cholesistectomy
procedure. It was shows that ERCP was effective
for evaluating rupture or leak on ductus billiary
and solved the leakage with stent.
The crush basket incident during evacuating
stone from ductus choledocus is rarely happens.
Kelly at al15 and Ryozawa at al16 report an unusual
complication of ERCP with basket fracture and
retention followed by recovery of the retained
basket at second ERCP. In this report, 1 (1%)
incident occurs during extracting a large and
hard stone which is causing the basket crush.
Then, another basket was required to evacuate the
remaining pieces of the stone. Stent placement
was inserted to handle biliary obstruction. The
stone cannot be removed because it cannot pass
through the biliary duct and cannot be extracted
by a lithotripter. Later success was obtained at
the second attempt. (Figure 5)
CONCLUSION
The ERCP imaging procedure is very
helpful in assisting clinicians to diagnose and
manage therapeutic measures, especially in
pancreaticobiliary tract disorders which need
stone extraction and stent placement.
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