Endoscopic retrograde cholangiopancreatography

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Key Terms: Endoscope.

Definition

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique in which a hollow tube called an endoscope is passed through the mouth and stomach to the duodenum (the first part of the small intestine). This procedure was developed to examine abnormalities of the bile ducts, pancreas, and gallbladder. It was developed during the late 1960s and is used today to diagnose and treat blockages of the bile and pancreatic ducts.

The term has three parts to its definition:

• "Endoscopic" refers to the use of an endoscope.
• "Retrograde" refers to the injection of dye up into the bile ducts in a direction opposing, or against, the normal flow of bile down the ducts.
• Cholangiopancreatography means visualization of the bile ducts (cholangio) and pancreas (pancreato).

Purpose

Until the 1970s, methods to visualize the bile ducts produced images that were of relatively poor quality and often misleading; in addition, the pancreatic duct could not be examined at all. Patients with symptoms related to the bile ducts or pancreatic ducts frequently needed surgery to diagnose and treat their conditions.

Using ERCP, physicians can obtain high-quality x rays of these structures and identify areas of narrowing (strictures), cancers, and gallstones. This procedure can help determine whether bile or pancreatic ducts are blocked; it also identifies where they are blocked along with the cause of the blockage. ERCP may then be used to relieve the blockage. For patients requiring surgery or additional procedures for treatment, ERCP outlines the anatomical changes for the surgeon.

Precautions

The most important precaution is that the examination should be performed by an experienced physician. The procedure is much more technically difficult than many other gastrointestinal endoscopic studies. Patients should seek physicians with experience performing ERCP. Patients should inform the physician about any allergies (including allergies to contrast dyes, iodine, or shellfish), medication use, and medical problems. Occasionally, patients may need to be admitted to the hospital after the procedure.

Description

After sedation, a specially adapted endoscope is passed through the mouth, through the stomach, then into the duodenum. The opening to ducts that empty from the liver and pancreas is identified, and a plastic tube or catheter is placed into the orifice (opening). Contrast dye is then injected into the ducts, and with the assistance of a radiologist, pictures are taken.

Preparation

The upper intestinal tract must be empty for the procedure, so patients should NOT eat or drink for at least 6 to 12 hours before the exam. Patients should ask the physician about taking their medications before the procedure.

Aftercare

Someone should be available to take the person home after the procedure and stay with them for a while; patients will not be able to drive themselves because they undergo sedation during this test. Pain or any other unusual symptoms should be reported to the physician.

Risks

ERCP-related complications can be broken down into those related to medications used during the procedure, the diagnostic part of the procedure, and those related to endoscopic therapy. The overall complication rate is 5% to 10%; most of those occur when diagnostic ERCP is combined with a therapeutic procedure. During the exam, the endoscopist can cut or stretch structures (such as the muscle leading to the bile duct) to treat the cause of the patient's symptoms. Although the use of sedatives carries a risk of decreasing cardiac and respiratory function, it is very difficult to perform these procedures without these drugs.

The major complications related to diagnostic ERCP are pancreatitis (inflammation of the pancreas) and cholangitis (inflammation of the bile ducts). Bacteremia (the passage of bacteria into the blood stream) and perforation (hole in the intestinal tract) are additional risks.

Normal Results

Because certain standards have been set for the normal diameter or width of the pancreatic duct and bile ducts, measurements using x rays are taken to determine if the ducts are too large (dilated) or too narrow (strictured). The ducts and gallbladder should be free of stones or tumors.

Questions to Ask the Doctor

• How soon will you know the results?
• Did you see any abnormalities?
• When can I resume any medications that were stopped?
• When can I resume normal activities?
• What future care will I need?

Abnormal Results

When areas in the pancreatic or bile ducts (including those in the liver) are too wide or too narrow compared with the standard, the test is considered abnormal. Once these findings are demonstrated using ERCP, symptoms are usually present; they generally do not change without treatment. Stones, identified as opaque or solid structures within the ducts, are also considered abnormal. Masses or tumors may also be seen, but sometimes the diagnosis is made not by direct visualization of the tumor, but by indirect signs, such as a single narrowing of one of the ducts. Overall, ERCP has an excellent record in diagnosing these abnormalities.

Resources

Periodicals

"Guidelines: The role of ERCP in diseases of the biliary tract and pancreas." Gastrointestinal Endoscopy 50, no. 6 (1999): 915-920.

Other

Endoscopic Retrograde Cholangiopancreatography. [cited June 21, 2001]. .

Measuring Procedural Skills. [cited June 21, 2001]. .

Treatment of Acute Biliary Pancreatitis. [cited June 21, 2001]. .

—David S. Kaminstein, M.D.

View more Health videos

The use of an endoscope to inspect the pancreatic duct and common bile duct. It may also involve biopsy or the introduction of contrast material for radiographic examination.

Endoscopic retrograde cholangiopancreatography
Intervention
Duodenoscopic image of two pigment stones extracted from common bile duct after sphincterotomy.
ICD-9-CM	51.10
MeSH	D002760
OPS-301 code:	1-642

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on X-rays.

ERCP is used primarily to diagnose and treat conditions of the bile ducts, including gallstones, inflammatory strictures (scars), leaks (from trauma and surgery), and cancer. ERCP can be performed for diagnostic and therapeutic reasons, although the development of safer and relatively non-invasive investigations such as magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound has meant that ERCP is now rarely performed without therapeutic intent.

Contents 1 Diagnostic 2 Therapeutic 3 Contraindications 4 Procedure 5 Risks 6 See also 7 References 8 External links

Diagnostic

Fluoroscopic image of common bile duct stone seen at the time of ERCP. The stone is impacted in the distal common bile duct. A nasobiliary tube has been inserted.

Fluoroscopic image showing dilatation of the pancreatic duct during ERCP investigation. Endoscope is visible.

• Obstructive jaundice - This may be due to several causes
• Chronic pancreatitis - a now controversial indication due to widespread availability of safer diagnostic modalities including endoscopic ultrasound, high-resolution CT, and MRI/MRCP
• Gallstones with dilated bile ducts on ultrasonography
• Bile duct tumors
• Suspected injury to bile ducts either as a result of trauma or iatrogenic
• Sphincter of Oddi dysfunction
• Pancreatic tumors no longer represent a valid diagnostic indication for ERCP unless they cause bile duct obstruction and jaundice. Endoscopic ultrasound represents a safer and more accurate diagnostic alternative

Therapeutic

• Any of the above when the following may become necessary
  • Endoscopic sphincterotomy (both of the biliary and the pancreatic sphincters)
  • Removal of stones
  • Insertion of stent(s)
  • Dilation of strictures (e.g. primary sclerosing cholangitis, anastomotic strictures after liver transplantation)

Contraindications

• Recent myocardial infarction.
• Inadequate surgical back-up
• History of contrast dye anaphylaxis
• Poor health condition for surgery.
• Severe cardiopulmonary disease.

Procedure

The patient is sedated or anaesthetized. Then a flexible camera (endoscope) is inserted through the mouth, down the esophagus, into the stomach, through the pylorus into the duodenum where the ampulla of Vater (the opening of the common bile duct and pancreatic duct) exists. The sphincter of Oddi is a muscular valve that controls the opening of the ampulla. The region can be directly visualized with the endoscopic camera while various procedures are performed. A plastic catheter or cannula is inserted through the ampulla, and radiocontrast is injected into the bile ducts, and/or, pancreatic duct. Fluoroscopy is used to look for blockages, or other lesions such as stones.

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

Other procedures associated with ERCP include the trawling of the common bile duct with a basket or balloon to remove gallstones and the insertion of a plastic stent to assist the drainage of bile. Also, the pancreatic duct can be cannulated and stents be inserted. The pancreatic duct requires visualisation in cases of pancreatitis.

In specific cases, a second camera can be inserted through the channel of the first endoscope. This is termed duodenoscope-assisted cholangiopancreatoscopy (DACP) or mother-daughter ERCP. The daughter scope can be used to administer direct electrohydraulic lithotripsy to break up stones, or to help in diagnosis by directly visualizing the duct (as opposed to obtaining X-ray images).^[1]

The gallbladder should be surgically removed (cholecystectomy) following successful removal of gallstones from the bile ducts.^[2]

Risks

The major risk of an ERCP is the development of pancreatitis, which can occur in up to 5% of all procedures. This may be self limited and mild, but may require hospitalization, and rarely, may be life-threatening. Patients at additional risk for pancreatitis are younger patients, patients with previous post-ERCP pancreatitis, females, procedures that involve cannulation or injection of the pancreatic duct, and patients with sphincter of Oddi dysfunction.^[3]

Gut perforation is a risk of any endoscopic procedure, and is an additional risk if a sphincterotomy is performed. As the second part of the duodenum is anatomically in a retroperitoneal location (that is, behind the peritoneal structures of the abdomen), perforations due to sphincterotomies are also retroperitoneal. Sphincterotomy is also associated with a risk of bleeding.^[3]

Oversedation can result in dangerously low blood pressure, respiratory depression, nausea, and vomiting.

There is also a risk associated with the contrast dye in patients who are allergic to compounds containing iodine.

See also

• Percutaneous transhepatic cholangiography

References

1. ^ Farrell JJ, Bounds BC, Al-Shalabi S, Jacobson BC, Brugge WR, Schapiro RH, Kelsey PB (2005). "Single-operator duodenoscope-assisted cholangioscopy is an effective alternative in the management of choledocholithiasis not removed by conventional methods, including mechanical lithotripsy". Endoscopy 37 (6): 542–7. doi:10.1055/s-2005-861306. PMID 15933927. 
2. ^ McAlister VC, Davenport E, Renouf E (2007). McAlister, Vivian. ed. "Cholecystectomy deferral in patients with endoscopic sphincterotomy". Cochrane Database Syst Rev (4): CD006233. doi:10.1002/14651858.CD006233.pub2. PMID 17943900. http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD006233/frame.html. 
3. ^ ^{a b} Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, Pilotto A, Forlano R (2007). "Incidence rates of post-ERCP complications: a systematic survey of prospective studies". Am. J. Gastroenterol. 102 (8): 1781–8. doi:10.1111/j.1572-0241.2007.01279.x. PMID 17509029. 

External links

• MedlinePlus Encyclopedia ERCP
• National Digestive Diseases Information Clearinghouse

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