ERCP after Roux-en-Y gastrojejunostomy rarely succeeds: Could MRCP be the answer?

Background: ERCP has an expected success rate of greater than 90% but is technically difficult in patients with post-surgical anatomy. It is especially challenging after Roux-en-Y gastrojejunostomy, as the papilla has to be reached through the Roux limb. We describe our tertiary care center experience of ERCP in patients with Roux-en-Y anatomy and present a case in which magnetic resonance cholangiopancreatography (MRCP) demonstrated biliary pathology after failed ERCP. Results: 17 patients (10 women, 7 men), median age 54 years (range 38-87), with prior Roux-en-Y gastrojejunostomy underwent ERCP at our center between 3/90 and 10/96. Indications for ERCP were pancreatitis (3), cholestasis with known or suspected biliary pathology (8) and right subcostal pain with abnormal liver function tests (6). ERCP was a complete success in only 2/17 patients, and was partially successful (only one duct opacified) in another 2 patients. ERCP failed to visualize the desired duct(s) in 13/17 cases; reasons for failure included inability to identify and/or access the Roux limb (5), failure to reach the papilla despite accessing the limb (6), and failure of cannulation despite identification of the papilla (2). Case report: We used MRCP to demonstrate biliary pathology after failed ERCP in a 47 year old man with prior Roux-en-Y gastrojejunostomy and cholecystojejunostomy who presented with cholangitis. Ultrasound examination showed no pathology. At ERCP, the duodenal papilla was identified but could not be cannulated. However, MRCP clearly demonstrated small stones above a distal common bile duct stricture. The patient underwent further surgery to revise the biliary anastomosis. Conclusions: ERCP in the setting of Roux-en-Y gastrojejunostomy is technically challenging, even in experienced hands. MRCP offers a noninvasive way to screen these patients for biliary and pancreatic pathology. Abnormal findings may require interventional radiology or surgery as ERCP is likely to fail.

Duke Scholars

Author Malcolm Stanley Branch Medicine, Gastroenterology

Author Paul Simon Jowell Medicine, Gastroenterology