What is Endoscopic Retrograde Cholangiopancreatography (ERCP)?

ERCP is used to diagnose and treat conditions of the bile ducts, such as gallstones, inflammatory strictures (scars), leaks (from trauma and surgery), and cancer. With safer and relatively non-invasive investigations such as magnetic resonance cholangio-pancreatography (MRCP) and endoscopic ultrasound, ERCP is now performed mostly with a therapeutic intention.

ERCP combines the use of x-rays and an endoscope, which is a long, flexible, lighted tube. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject dye into the bile ducts and pancreatic duct so they can be seen on x- ray.

Why do I need ERCP?

To find out the cause of blockage of the bile duct:

1.Disease of the bile ducts

  • Gallstones
  • Bile duct tumors
  • Suspected injury to bile ducts, either traumatic or iatrogenic

2.Disease of the pancreas

  • Pancreatic tumors
  • Chronic pancreatitis

3.Treatment of the disease

  • Endoscopic sphincterotomy (enlargement of the opening of the ampulla)
  • Removal of bile duct stones
  • Insertion of plastic or metal stent(s)
  • Dilation of bile duct narrowing

How is ERCP performed?

You will be given medication to numb the throat and a sedative to relax during the procedure. Then a flexible camera (endoscope) is inserted through the mouth, passed the stomach into duodenum until it reaches the ampulla of Vater. A plastic catheter or cannula is inserted through the ampulla, and dye is injected into the bile ducts, and/or, pancreatic duct. X-ray is used to look for stones, blockages, or other lesions.

When needed, the opening of the ampulla can be enlarged with an electrified wire (sphincterotome) and access into the bile duct obtained so that stones may be removed or other therapy performed.

If the exam shows a stone or narrowing of the ducts, the instruments will be inserted through the scope to remove or relieve the blockage. Also, tissue samples (biopsy) could be taken for further testing.

Stones from the bile ducts are removed with a basket or balloon. Other procedures during ERCP include insertion of a plastic stent to assist in the drainage of bile. The pancreatic duct can also be accessed and stents inserted.

What precautions should I take before the procedure?

Stomach and duodenum must be empty for the procedure to be accurate and safe. You should not eat or drink after midnight, before the procedure, or for 6 to 8 hours beforehand, depending on the time of the procedure. Your doctor need to know whether you have any allergies, especially to iodine, which is in the dye. Inform your doctor prior to the examination, if you are taking any blood thinners, warfarin, or aspirin.

What complications might arise after the procedure?

Possible complications of ERCP include pancreatitis (inflammation of the pancreas), which can occur in up to 5% of all procedures.

Gut perforation is a risk of any endoscopic procedure, and is an additional risk if a sphincterotomy is performed. Sphincterotomy is also associated with a risk of bleeding.

Sedation may result in low blood pressure, nausea and vomiting. There is also a risk associated with the contrast dye in patients who are allergic to compounds containing iodine.

ERCP usually takes about 30 to 60 minutes. You may experience slight discomfort during the procedure. This is effectively treated with appropriate medication. After the procedure, the patient will return to the ward and be closely monitored.

Possible contraindications for ERCP (reasons to not proceed with the surgery)

1.Absolute contraindication

  • A patient that is unable or unwilling to cooperate.

2.Relative contraindications

  • Recent heart attack.
  • History of contrast allergy.
  • Frail and unfit for surgery.
  • Severe heart and lung disease.

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