ERCP - Applications, Procedure, Contraindications, and Complications

Introduction:

Endoscopic retrograde cholangiopancreatography is a diagnostic procedure that is a combination of upper gastrointestinal endoscopy and x-rays to treat problems in the liver, pancreas, gallbladder, bile ducts, and pancreatic ducts. The bile ducts carry bile from the liver to the gallbladder and duodenum. The pancreatic ducts are tubes that carry pancreatic juice from the pancreas to the duodenum.

What Can Be Diagnosed With ERCP?

ERCP is used to find the cause of unexplained abdominal pain and yellowing of the skin and eyes (jaundice).

Other conditions found with ERCP include:

• Pancreatitis.

• Liver, pancreas, and bile ducts tumors.

• Blockage or stone in the bile ducts.

• Bile or pancreatic ducts leaking fluids.

• Blockage or narrowing of the pancreatic ducts.

• Infection in the bile ducts.

How to Prepare for the ERCP procedure?

• Do not eat or drink liquids eight hours before the procedure.

• Inform the doctor about the medications and supplements you are taking.

• Inform the doctor about your previous allergies or reactions to medications or contrast dye and iodine.

• Inform if you are pregnant.

• Inform the doctor about the medical history of bleeding disorders or the current medications such as blood thinners like Aspirin, Clopidogrel, and Warfarin. These medicines should be stopped before the procedure.

• Inform about the heart conditions, and if you have heart valve disease, antibiotics are given before the procedure.

• A sedative is given before the procedure so the patient is in a sleep-like state and does not feel any pain

What Happens During the Procedure?

The patient needs to remove clothing, jewelry, or other objects that interfere with the procedure. The patient is given a hospital gown and lies on an examination table. The doctor will monitor the vital signs during the procedure. An intravenous line is put in the hand, and an oxygen tube is inserted into the nose. An anesthetic spray is sprayed into the back of the throat to prevent gagging when the endoscope is passed into the throat. A mouthguard is put into the mouth to protect the teeth, and saliva is suctioned using a saliva ejector.

The doctor inserts the endoscope down the esophagus into the stomach and through the duodenum until it reaches the bile ducts. Air and contrast dye is injected into the ducts through a small tube that is put inside the endoscope. This may give a feeling of fullness in the abdomen. Many x-rays are taken with changing positions. Once the x-rays of the biliary ducts are completed, the small tube in the endoscope is redirected to the pancreatic duct. Contrast dye is injected into the pancreatic duct, and x-rays are taken. The doctor also takes a tissue sample for examination. The doctor also passes tiny tools through the endoscope to perform some procedures.

Those include:

• Remove small tumors in the ducts.

• Sphincterotomy: This is a procedure that involves cutting the muscle between the common bile and pancreatic duct to enlarge the opening of the ducts. This is done to remove stones in the ducts.

• Insert stents which are tiny plastic tubes that a doctor places in narrowed ducts to hold them open. After gallbladder surgery, a doctor may also insert temporary stents to stop bile leaks.

Once the x-rays and other procedures are over, the endoscope is slowly withdrawn. The procedure mostly takes about one to two hours.

What Happens After ERCP?

The patient is shifted to the recovery room. The patient should not eat or drink anything until the gag reflex is returned. The patient will have a sore throat and pain during swallowing for a few days, which is normal. The doctor discusses the results of the procedure with the patient, and if a biopsy is taken, the result will take a week.

What Is Spyglass ERCP?

ERCP with spyglass is an innovative system that directly visualizes all bile-duct quadrants. The ERCP with a spyglass system enables the doctors to provide a definitive diagnosis and perform the therapeutic intervention in one procedure. ERCP with spyglass is a miniature 6,000-pixel fiber-optic probe attached to a camera head. The probe is inserted through an access and delivery catheter. The catheter is single-use and can be moved in all directions. In addition, the ERCP with spyglass system provides four-way steer-ability and dedicated irrigation channels and this system has a 1.2 mm working channel which allows the use of diagnostic and therapeutic tools.

When Is ERCP Contraindicated?

• Existing bowel perforation.

• Unstable cardiopulmonary, neurologic, or cardiovascular status.

• Structural abnormalities of the esophagus, stomach, and small intestine.

• Previous pancreatoduodenectomy.

• Acute pancreatitis.

• Hypersensitivity to iodine contrast medium.

What Are the Complications Of ERCP?

Some possible complications include:

• Inflammation of the pancreas and gallbladder.

• Infection.

• Bleeding.

• A tear in the esophageal lining or stomach.

• Collection of bile outside the biliary system.

What Are the Other Diagnostic Methods Alternative to ERCP?

Several ERCP alternatives provide the same diagnostic results as the ERCP procedure. However, they cannot provide treatment. Therefore, the doctor should decide whether ERCP or an alternative is suitable for the patient depending upon the symptoms and disease condition.

Some methods include:

• Ultrasound: They are an alternative to the ERCP procedure that uses sound waves. An ultrasound can detect blockages or abnormalities in the biliary system, similar to ERCP.

• CT Cholangiography: It involves the injection of contrast medium or dye into the body, and a scan is performed.

• Endoscopic Ultrasound: This is an alternative to the ERCP procedure in which ultrasound is combined with endoscopy.

• Magnetic Resonance Cholangiopancreatography (MRCP): MRCP is non-invasive and is done externally with a machine that generates a magnetic field around the patient, taking diagnostic images. Dye is not used in the MRCP procedure.

Conclusion:

ERCP is more commonly used since it is less invasive than surgery and has a high success rate. It is usually an outpatient procedure and the patient is discharged on the same day mostly. In addition, it can be used for diagnostic and therapeutic purposes. ERCP is a straightforward procedure but it requires more skill to perform the procedure.