Ampullary Adenoma Research Articles

Common Bile Duct Elongation and Obstruction Secondary to Duodenal Intussusception and Ampullary Adenoma in a Patient with Pancreas Divisum

Small bowel intussusception is an uncommon condition with cases of duodenoduodenal intussusception. (DDI) being exceptionally rare. DDI is very unusual due to the fixed position of the duodenum within the retroperitoneum. In this case, the presence of an ampullary mass caused DDI with sub mucosal elongation of the common bile duct and obstructive jaundice in a patient with pancreas divisum.

Endoscopic Papillectomy for Major and Minor Papillary Adenoma in Familial Adenomatous Polyposis.

ABSTRACTAmpullary adenomas can occur sporadically or in the patients with adenomatous polyposis syndrome, including familial adenomatous polyposis (FAP) and MUTYH-associated polyposis. The potential for malignant transformation is high in the setting of FAP. Although endoscopic resection of major papillary adenoma has been well described, minor papilla adenomas are exceptionally rare. This is the second documented case of an endoscopic papillectomy in a patient with FAP with simultaneous ampullary adenoma of the major and minor papilla.

Preoperative biopsy in periampullary growth can throw surprises!!

Introduction: Periampullary carcinoma are heterogenous group of cancers that comprises of Pancreatic ductal adenocarcinoma, Ampullary adenocarcinoma, Distal Cholangiocarcinoma and Duodenal adenocarcinoma in order of frequency. The surgical management of these tumors are frequently similar due to their shared location. Reported incidence of Benign diseases after pancreatico duodenectomy is as high as 13% . Biopsy is not required in operable cases of periampullary growth. We studied our center biopsy reports in periampullary and Incidence of benign disease of pancreaticoduodenectomy patients. Method: We collected retrospective data for January 2016 to Febrary 2019 of patients diagnosed with Periampullary cancer from our hospital registry. We have included biopsy report of patients who have underwent surgery and palliative chemotherapy. We studied significance of biopsy in diagnosing the disease and incidence of benign diseases in pancreaticoduodenectomy specimen. Result: A total of 185 patients treated for periampullary carcinoma of which biopsy done in 124 patients. Overall Sensitivity in biopsy of periampullary growth is 72% . Interestingly two biopsies reported Lymphangitis carcinomatosa and one reported lymphoma. PET CT of lymphangitis carcinomatosa patient showed lung and liver metastasis which was not seen in contrast CT. A total of 64 patients underwent Pancreatico duodenectomy of which benign diseases were reported in 6 patients- 2 autoimmune pancreatitis, 2 chronic pancreatitis, one ampullary adenoma and one tuberculosis. Conclusion: Pancreaticoduodenectomy though the mortality is less than 2% Morbidity still remains high (30-50%). Though the sensitivity of Biopsy is low its specificity is high and with modern techniques in biopsy, microscopy examination and Immunohistochemistry the sensitivity is likely to improve. Hence would like to consider biopsy of periampullary growth whenever feasible as biopsy can still throw surprises avoiding non productive surgery like pancreaticoduodenectomy.

K-RAS Mutant Gene Found in Pancreatic Juice Activated Chromatin From Peri-ampullary Adenocarcinomas.

External pancreatic duct stents inserted after resection of pancreatic head tumors provide unique access to pancreatic juice analysis of genetic and metabolic components that may be associated with peri-ampullary tumor progression. For this pilot study, portal venous blood and pancreatic juice samples were collected from 17 patients who underwent pancreaticoduodenectomy for peri-ampullary tumors. Portal vein circulating tumor cells (CTC) were isolated by high-speed fluorescence-activated cell sorting (FACS) and analyzed by quantitative reverse transcription polymerase chain reaction (RT-PCR) for K-RAS exon 12 mutant gene expression (K-RASmut). DNA, chromatin, and histone acetylated active chromatin were isolated from pancreatic juice samples by chromatin immunoprecipitation (ChIP) and the presence of K-RASmut and other cancer-related gene sequences detected by quantitative polymerase chain reaction (PCR) and ChIP-Seq. Mutated K-RAS gene was detectable in activated chromatin in pancreatic juice secreted after surgical resection of pancreatic, ampullary and bile duct carcinomas and directly correlated with the number of CTC found in the portal venous blood (P = .0453). ChIP and ChIP-Seq detected acetylated chromatin in peri-ampullary cancer patient juice containing candidate chromatin loci, including RET proto-oncogene, not found in similar analysis of pancreatic juice from non-malignant ampullary adenoma. The presence of active tumor cell chromatin in pancreatic juice after surgical removal of the primary tumor suggests that viable cancer cells either remain or re-emerge from the remnant pancreatic duct, providing a potential source for tumor recurrence and cancer relapse. Therefore, epigenetic analysis for active chromatin in pancreatic juice and portal venous blood CTC may be useful for prognostic risk stratification and potential identification of molecular targets in peri-ampullary cancers.

Clinical Impact of Piecemeal Resection Concerning the Lateral Spread of Ampullary Adenomas

Objective Endoscopic papillectomy (EP) has been recognized to be a safe and reliable treatment modality for ampullary adenomas. The purpose of this study was to determine the safety and efficacy of endoscopic piecemeal resection for laterally spreading ampullary adenomas and to compare these findings with a control population of smaller conventional ampullary tumors treated in the same time period. Methods Between May 1999 and September 2015, 136 patients underwent EP at Tokyo Medical University hospital. A total of 125 patients underwent en bloc resection, and 11 patients underwent piecemeal resection. Results The final pathological diagnoses were 103 adenomas, 14 carcinomas in adenomas, 4 carcinomas, and 4 hyperplasia in the en bloc resection group, versus 7 adenomas, 3 carcinomas in adenoma, and 1 carcinomas in the piecemeal resection group. A single treatment session was possible in 104 (83.2％) of the 125 patients in the en bloc resection group and in 8 (72.7%) of the 11 in the piecemeal resection group. The total resection rate including additional treatments was 98.4% in the en bloc resection group and 100% in the piecemeal resection group.Conclusion Piecemeal resection for laterally spreading ampullary adenomas was sufficiently performed compared with en bloc resection.

Isolated Tubulovillous Adenoma of the Bile Duct

Adenomas of the bile duct typically occur as extensions of ampullary neoplasms. We describe a rare case of an isolated tubulovillous adenoma of the bile duct presenting with painless jaundice and a bile duct stricture on imaging. A 69 year-old Caucasian male with myelodysplastic syndrome (MDS) presented with 3 months of “teacolored” urine and worsening pruritis. Physical examination was most pertinent for scleral icterus, and absence of abdominal tenderness. Laboratory studies were were as follows: alkaline phosphatase 384 IU/L, aspartate transaminase (AST) 60 IU/L, alanine aminotransferase (ALT) 80 IU/L, total bilirubin 12.6 mg/dL, and conjugated bilirubin 10.2 mg/dL. CA 19-9, carcinoembryonic antigen (CEA), and alpha-fetoprotein (AFP) levels were 53 U/ml, 1.2 ng/ml, and 1.5 ng/mL respectively. Magnetic resonance cholangiopancreatography (MRCP) detected a 10-mm length stricture superior to the intra-pancreatic portion of the bile duct, with proximal dilatation of the bile ducts up to a diameter of 18 mm (Figure 1). The patient underwent endoscopic retrograde cholangiography (ERC) with cholangioscopy. Frond-like tissue was visualized immediately distal to the cystic duct (figure 2). The lesion was biopsied under direct cholangioscopic visualization using a mini-forceps. Biopsies demonstrated glandular columnar epithelium in a mixed tubular and villous pattern, with enlarged hyperchromatic nuclei and loss of nuclear polarity, consistent with tubulovillous adenoma (figure 3). No invasive cancer was present in the specimen. A plastic stent was placed, and the patient was referred to surgical oncology. Surgery has been deferred due to underlying MDS. At approximately 6 months after initial presentation, he has no recurrent jaundice, abdominal pain or unintentional weight loss.1299_A.tif Figure 1: MRCP demonstrates a stricture in the common bile duct with upstream dilatationUnlike colon, rectal and ampullary adenomas, isolated tubulovillous adenomas of the bile duct are exceedingly rare. Histologically, they are similar to tubulovillous adenomas in other parts of the gastrointestinal (GI) tract and have the potential to progress to invasive cancer. In fact, foci of adenocarcinoma have been reported in the surgical specimen of patients whose bile duct biopsies demonstrated only adenomatous tissue. Therefore, surgical resection is recommended for patients who are reasonable operative candidates. For patients who are not operative candidates or decline surgery, endoscopic stenting can provide effective palliation for symptomatic jaundice.1299_B.tif Figure 2: Cholangioscopy of the bile duct identified frond-like tissue immediately distal to the cystic duct1299_C.tif Figure 3: Targeted biopsy consistent with tubulovillous adenoma (glandular columnar epithelium in a mixed tubular and villous pattern, with enlarged hyperchromatic nuclei and loss of nuclear polarity)

Hiding in Plain Sight: A Large Ampullary Adenoma Only Seen on Side-View Evaluation

Familial adenomatous polyposis (FAP) is an autosomal dominant genetic disorder characterized by the formation of innumerable adenomatous polyps. Patients with FAP have a high risk of malignancy due to progression of these adenomas to adenocarcinoma. In addition to the high risk for developing colorectal cancer in their lifetime, they are at increased risk for developing adenomatous lesions in extracolonic sites. The ampulla of Vater is one such location, and thus satisfactory visualization of the ampulla is important. However, the location and orientation of the ampulla makes visualization difficult using a standard gastroscope. Here we discuss a case of a patient with FAP found to have a seemingly normal ampulla on initial evaluation using a forward-viewing gastroscope, but on subsequent evaluation using a side-viewing duodenoscope, a 2x2cm ampullary adenoma with low grade dyplasia was visualized and resected. A 53-year-old Caucasian female with history of FAP status-post total proctocolectomy in the mid-1990s presented for surveillance esophagogastroduodenoscopy (EGD) and colonoscopy. She reported having undergone regular surveillance colonoscopies to evaluate for polyps, but her most last endoscopic evaluation was in 2001. During her EGD in 2018, she was first noted to have a seemingly normal duodenum on standard view (Figure 1). It was felt prudent to follow up with a side-viewing duodenoscope for ampullary evaluation. Upon insertion of the duodenoscope, a large 2x2cm ampullary polypoid mass was clearly seen (Figure 2). Biopsies demonstrated tubulovillous adenoma with low-grade dysplasia. Follow up endoscopic ultrasonography showed no evidence of invasion into the bile duct, pancreatic duct, or surrounding mucosa, and ampullectomy was performed. Pathology confirmed tubulovillous adenoma with low grade dysplasia. The patient had no complications and has continued with surveillance endoscopic follow-up (Figure 3). Case Highlights This case highlights the importance of using a side-viewing duodenoscope for complete examination of the duodenum, especially in patients with FAP or other conditions that predispose patients to ampullary/peri-ampullary disease. The prudent gastroenterologist must not only be properly trained to pass a side-viewing duodenoscope, but also have a heightened awareness of the limitations of the standard EGD examination. Even a rather large ampullary lesion may be missed in forward view that can be easily seen on side view.1872_A Figure 1. Normal appearing duodenum on standard forward view1872_B Figure 2. 2x2cm ampullary polypoid mass seen with side-view duodenoscope1872_C Figure 3. Ampulla on follow-up evaluation after ampullectomy

Correction: Outcomes after endoscopic resection of large laterally spreading lesions of the papilla and conventional ampullary adenomas are equivalent

Background Endoscopic resection of ampullary adenomas is a safe and effective alternative to surgical resection. A subgroup of patients have large laterally spreading lesions of the papilla Vateri (LSL-P), which are frequently managed surgically. Data on endoscopic resection of LSL-P are limited and long-term outcomes are unknown. The aim of this study was to compare the outcomes of endoscopic resection of LSL-P with those of standard ampullary adenomas. Methods A retrospective analysis of a prospectively collected and maintained database was conducted. LSL-P was defined as extension of the lesion ≥ 10 mm from the edge of the ampullary mound. Piecemeal endoscopic mucosal resection of the laterally spreading component was followed by resection of the ampulla. Patient, lesion, and procedural data, as well as results of endoscopic follow-up, were collected. Results 125 lesions were resected. Complete endoscopic resection was achieved in 97.6 % at the index procedure (median lesion size 20 mm, interquartile range [IQR] 13 – 30 mm). Compared with ampullary adenomas, LSL-Ps were significantly larger (median 35 mm vs. 15 mm), contained a higher rate of advanced pathology (38.6 % vs. 18.5 %), and had higher rates of intraprocedural bleeding (50 % vs. 24.7 %) and delayed bleeding (25.0 % vs. 12.3 %). Both groups had similar rates of histologically proven recurrence at first surveillance (16.4 % vs. 17.9 %). Median follow-up for the entire cohort was 18.5 months. For patients with at least two surveillance endoscopies (n = 68; median follow-up 29 months, IQR 18 – 48 months), 95.6 % were clear of disease and considered cured. Conclusions LSL-P can be resected endoscopically with comparable outcomes to standard ampullectomy, albeit with a higher risk of bleeding. Endoscopic treatment should be considered as an alternative to surgical resection, even for large LSL-P.

Common bile duct obstruction and elongation across the midline caused by duodenal intussusception secondary to an ampullary adenoma in a patient with pancreas divisum

Common bile duct obstruction and elongation across the midline caused by duodenal intussusception secondary to an ampullary adenoma in a patient with pancreas divisum

Endoscopic resection of advanced ampullary adenomas: a single-center 14-year retrospective cohort study

BackgroundEndoscopic ampullectomy has been recognized as a safe and reliable means to resect selective tumors of the ampulla of Vater and is associated with lower morbidity and mortality rates compared to surgical resection. Success rates range from 42 to 92%, with recurrences reported in up to 33%. Studies on endoscopic resection of advanced lesions such as those with intraductal extension of adenoma (IEA) and lateral spreading adenomas (LSA) are limited. We aimed to evaluate the technical success, complications, and recurrence of endoscopic resection of ampullary adenomas, including advanced lesions.MethodsAll patients referred to the Erasmus Medical Center for endoscopic resection of an ampullary lesion were retrospectively identified between 2002 and 2016. Endoscopic success was defined as complete excision of the adenoma, irrespective of the number of attempts, in the absence of recurrence.ResultsWe included 87 patients with a median age of 65 years. Of these, 56 patients (64%) had an adenoma confined to the ampulla (ACA), 20 patients (23%) had an LSA, and 11 patients (13%) were treated for an IEA. The median lesion sizes were 24.6 mm, 41.4 mm, and 16.3 mm, respectively (P < 0.001). Complications occurred in 22 patients (25.3%), of which hemorrhage was most prevalent (12.6%), followed by perforation (8.1%). Complications were equally divided (P = 0.874). The median follow-up duration was 21.1 months (12–45.9) for ACA, 14.7 months (4.2–34.5) for LSA, and 5.8 months (3.7–22.0) for IEA (P = 0.051). Endoscopic resection was curative in 87.5% of patients with an ACA, 85% in patients with an LSA, and in only one patient with an IEA (P < 0.001). Recurrence occurred in 10 patients (11.5%) (P = 0.733).ConclusionEndoscopic ampullectomy is safe and highly successful in selected patients with an adenoma with or without lateral spreading. Outcomes of endoscopic treatment adenomas with an intraductal extension are less favorable and in these cases surgery should be considered.

Sa1275 ENDOSCOPIC RESECTION OF ADVANCED AMPULLARY ADENOMAS: A SINGLE-CENTER 14 YEAR RETROSPECTIVE COHORT STUDY

Adenomas of the ampulla of Vater are rare. Endoscopic ampullectomy has been recognized as a safe and reliable treatment of selective tumors of the ampulla of Vater and is associated with lower morbidity and mortality rates than surgical resection. However, the success rates for endoscopic ampullectomy range from 42-92%, with recurrence described in up to 33%. Despite the increasing number of studies concerning endoscopic resection of ampullary tumors, data evaluating endoscopic resection of the more advanced ampullary adenomas are limited. We aimed to evaluate the technical success, complications and recurrence of endoscopic resection for treating patients with ampullary adenomas with intraductal extension (IEA), or with a lateral spreading growth pattern (LSA). Between January 2002 and November 2016 all patients referred to the Erasmus Medical Center Rotterdam, for endoscopic resection of an ampullary lesion were retrospectively identified. Cases were selected using ENDOBASE and our local PALGA database. We included patients with a histological diagnosis of adenoma. Endoscopic success was defined as complete excision of the adenoma, irrespective of the number of attempts, and in the absence of recurrence. All patients underwent endoscopic follow-up. We included 84 patients, 56 patients (67%) had an adenoma confined to the ampulla (ACA), 17 patients (20%) had an LSA and 11 patients (13%) were treated for adenomas that demonstrated growth pattern with intraductal extension. Fifty-four percent of patients were men and the median age was 67.6 years. The mean lesion size was 24.6mm (range 5-80) for patients with ACA, 34.8mm (range 23-50) for LSA and 16.3mm (range 10-20) for patients with an IEA (P=0.005) Complications occurred in 22 patients (26.2%), of which hemorrhage was most prevalent (11.9%), followed by perforation (8.3%). Complications were equally divided (P=0.528). The mean follow-up duration was 21.1 months (IQR 12-45.9) for ACA, 14.3 months (IQR 3.3-34.1) for LSA and 5.8 months (IQR 3.7-22.0) for IEA (P=0.043). Endoscopic resection was curative in 87.5% of patients with an ACA, 82.3% in patients with an LSA and in only 9.1% of patients with an IEA (P <0.001). Recurrence occurred in 9 patients (10.7%), 5 of them had a localized adenoma, 3 patients with an LSA and 1 patient with an IEA (P=0.875). Endoscopic ampullectomy is a safe and successful treatment in patients with an adenoma with or without a lateral spreading growth pattern. In case of an intraductal extended adenoma endoscopic success rates are significantly lower.

Intraductal Radiofrequency Ablation for Reducing Ampullary Adenoma Recurrence

A frustrating aspect of treating patients with ampullary adenomas is the high rate of recurrence even after apparently complete endoscopic removal. In

Risk factors for advanced duodenal and ampullary adenomatosis in familial adenomatous polyposis: a prospective, single-center study.

Background and study aims To determine the clinical features associated with advanced duodenal and ampullary adenomas in familial adenomatous polyposis. Secondarily, we describe the prevalence and clinical significance of jejunal polyposis. Patients and methods This is a single center, prospective study of 62 patients with familial adenomatous polyposis. Duodenal polyposis was classified according to Spigelman and ampullary adenomas were identified. Patients with Spigelman III and IV duodenal polyposis underwent balloon assisted enteroscopy. Predefined groups according to Spigelman and presence or not of ampullary adenomas were related to the clinical variables: gender, age, family history of familial adenomatous polyposis, type of colorectal surgery, and type of colorectal polyposis. Results Advanced duodenal polyposis was present in 13 patients (21 %; 9 male) at a mean age of 37.61 ± 13.9 years. There was a statistically significant association between family history of the disease and groups according to Spigelman ( P = 0.03). Seven unrelated patients (6 male) presented ampullary adenomas at a mean age of 36.14 ± 14.2 years. The association between ampullary adenomas and extraintestinal manifestations was statistically significant in multivariate analysis ( P = 0.009). Five endoscopic types of non-ampullary adenoma were identified, showing that lesions larger than 10 mm or with a central depression presented foci of high grade dysplasia. Among 28 patients in 12 different families, a similar Spigelman score was identified; 10/12 patients (83.3 %) who underwent enteroscopy presented small tubular adenomas with low grade dysplasia in the proximal jejunum. Conclusions Advanced duodenal polyposis phenotype may be predictable from disease severity in a first-degree relative. Ampullary adenomas were independently associated with the presence of extraintestinal manifestations.

Successful use of radiofrequency ablation for the management of arecurrent ampullary adenoma with intraductal extension.

Successful use of radiofrequency ablation for the management of arecurrent ampullary adenoma with intraductal extension.

New Indications for Endoscopic Radiofrequency Ablation

Radiofrequency ablation (RFA) is a well-established treatment for several benign, premalignant, and malignant disorders. Although the role of RFA has been clearly defined, new indications for luminal and extraluminal applications of endoscopic RFA-directed therapies have emerged. RFA has recently produced promising results in patients with a variety of gastrointestinal and hepatopancreatobiliary pathologies. For example, endoscopic RFA has been used to treat patients with gastric antral vascular ectasia, chronic radiation proctitis, malignant biliary strictures, and ampullary adenomas with intraductal extension. Furthermore, endoscopic ultrasound-guided RFA appears to be an effective, minimally invasive treatment for ablation of solid and cystic lesions-particularly in the pancreas. We review the newer indications for RFA and discuss potential limitations of endoscopic RFA.

Non-Operative Management of Type 2 ERCP-Related Retroperitoneal Duodenal Perforations: A 9-Year Experience From a Single Center.

BackgroundNo consensus exists on treatment of endoscopic retrograde cholangiopancreatography (ERCP) -related, retroperitoneal duodenal perforations. The aim of this study is to determine the incidence of post-ERCP retroperitoneal periampullary (type 2) duodenal perforations and the clinical outcome of non-surgical management.MethodsPatients who underwent ERCP in our institution during the period from January 1, 2009 to December 31, 2017 were included. Any cases of retroperitoneal periampullary duodenal (type 2) perforation were identified. Relevant data (patient characteristics, indications, radiographic findings, time to diagnosis and surgery, surgical procedures, hospital stay and outcome) were retrospectively collected and reviewed. Results were compared to those from the existing literature.ResultsThere were 24 patients with retroperitoneal type 2 duodenal perforation following 4,196 ERCPs were identified (24/4196, 0.57%) over the 9-year period. ERCP indications were: choledocholithiasis, obstructive jaundice and ampullectomy (ampullary adenoma). Diagnosis (aided by CT scan) was established within the first 12 h in the majority of patients (21/24, 87.5%) and intraprocedural in 3/24, (12.5%). Twelve patients (50%) with deteriorating clinical course were managed with CT-guided percutaneous drainage. Surgical intervention was required in two (8.3%). Overall mortality was 4.2%, 1/24 (one patient died after surgery).ConclusionsRetroperitoneal duodenal perforation is a rare and severe ERCP complication. However, conservative management is feasible in the majority of cases.

An Unusual Case of a Sporadic Ampullary Adenoma presenting as Right Upper Quadrant Abdominal Pain in a Young Female

An Unusual Case of a Sporadic Ampullary Adenoma presenting as Right Upper Quadrant Abdominal Pain in a Young Female

Tranexamic Acid-Induced Acute Renal Cortical Necrosis in Post-Endoscopic Papillectomy Bleeding.

Acute renal failure can be the result of acute renal cortical necrosis (RCN), which commonly occurs from complications occurring during pregnancy. RCN is rarely caused by medications, although tranexamic acid, which is used in patients with acute bleeding for its antifibrinolytic effects, reportedly causes acute RCN in rare cases. An 82-year-old woman experienced gastrointestinal bleeding after endoscopic papillectomy of an ampullary adenoma. The bleeding was controlled with tranexamic acid administration; however, 4 days later, her urine volume decreased and she developed pulmonary edema and dyspnea. Serum creatinine levels increased from 0.8 to 3.9 mg/dL and dialysis was performed. Abdominal pelvic computed tomography with contrast enhancement revealed bilateral RCN with no renal cortex enhancement. Renal dysfunction and oliguria persisted and hemodialysis was continued. Clinicians must be aware that acute RCN can occur after tranexamic acid administration to control bleeding.

Continuing Advancements in Diagnosis and Management of Ampullary Adenoma

Continuing Advancements in Diagnosis and Management of Ampullary Adenoma

Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is a specialized endoscopic procedure to view the biliary and pancreatic ducts fluoroscopically. First introduced in the 1970s as a diagnostic tool, ERCP has since evolved primarily into a therapeutic modality and is today regarded as the premier tool for performing therapeutic interventions involving the biliary and pancreatic ductal systems. Relatively complex, ERCP requires advanced training. Although generally considered safe, it does carry a risk of significant complications, including pancreatitis; thus, the most important factor to mitigate complications is to ensure the presence of an appropriate indication for the procedure. This review addresses the indications (e.g., disorders of the major duodenal papilla, biliary diseases, and pancreatic diseases), contraindications, protocol, and complications of ERCP, as well as an overview of the tools available for ERCP procedures. Figures show ampullary adenomas, choledocholithiasis, Mirizzi syndrome, benign common bile duct stricture, primary sclerosing cholangitis, malignant biliary stricture, bile leak, type I and III choledochal cysts, chronic pancreatitis, pancreatic ductal disruption, classic fish-mouth appearance of the papilla in a patient with main duct intraductal papillary mucinous neoplasm, pancreas divisum, side-viewing duodenoscope used for ERCP, and selected tools of ERCP. Tables list the Rome III criteria, risk-stratifying patients for choledocholithiasis, diagnostic criteria for acute cholangitis, choledochal cyst classification, and the Cambridge classification system for chronic pancreatitis. This review contains 15 highly rendered figures, 5 tables, and 77 references.