Endoscopic Retrograde Cholangio-Pancreatography: Why And When?

Endoscopic Retrograde Cholangio-pancreatography, or ERCP, is a diagnostic test that makes use of X-rays and an endoscope to inspect the bile and pancreatic ducts. ERCP is also used to remove gallstones, or for taking samples for biopsy.    

What Is ERCP?

These structures include:

• Duodenum – first part of the small intestine
• Bile duct
• Gallbladder
• Pancreatic duct
• Papilla of Vater– a nipple-like structure that opens into the bile and pancreatic ducts

ERCP uses an endoscope (thin, flexible tube). It has a camera and fiber-optic channels at one end, and is connected to an output video feed at the other end. The tube is inserted through the mouth of the patient, and passes into the esophagus, on to the stomach and into the upper part of the digestive tract (duodenum).

In this procedure, the term ‘cholangio-pancreatography’ describes the X-rays that are taken of the bile and pancreatic duct. In order to view the ducts more clearly, a dye is sometimes injected into the ducts so that they show up more clearly in the pictures. In ERCP, a ‘retrograde’ injection of the dye is given, which means that it is injected through the papilla back up into the ducts. This retrograde injection is given through a plastic tube at the side of the endoscope.  

When Is ERCP done? Indications

ERCP is a modern and useful procedure that is used worldwide. It is used for both the diagnosis, and the treatment, of various conditions relating to the digestive tract. Cholangitis (infected bile duct) is the disorder where ERCP is the test of choice. Besides that, there are numerous conditions where ERCP is indicated. Listed below are some of the common indications of ERCP.

• Gallstones – in the gallbladder or bile ducts.
• Acute and chronic pancreatitis – short-term or long-term inflammation of the pancreas, respectively.
• Recurring abdominal pain.
• Jaundice
• Diseases of the bile ducts.
• Open a narrowed bile or pancreatic duct.
• Manometry – measuring the pressure inside the bile ducts.
• Sclerosis - scarring of the ducts.
• Pseudocysts – accumulation of fluids and tissue debris.
• Biopsy – obtaining a tissue sample from the ducts.

See Also: Biliary Atresia: Definition, Causes, Symptoms

Preparations Before ERCP

Endoscopic Retrograde Cholangio-pancreatography in an invasive procedure. It is important to make the required preparations before commencing the procedure. The aim of these preparations is to prevent any complications during the procedure. Certain instructions given before the procedure are:

• Do not eat anything for at least 6-8 hours before the procedure. Drinking small amounts of water after short intervals may be allowed for at least 2 hours before an ERCP. Smoking and chewing gum is also prohibited.
• Certain medications that you may be taking will be temporarily discontinued before the procedure. These include anti-coagulants or any medicines that may interact adversely with the anesthetic.
• Allergies to any medications or anesthesia that may be given during the procedure should be told to the doctor before starting the ERCP.
• The doctor should be aware of any health problems the patient may have, such as heart and lung diseases and diabetes.

ERCP Procedure And Complications

Endoscopic retrograde cholangio-pancreatography can take about 30 minutes to an hour, depending on need of the procedure. It involves the following steps:

1. The back of the throat is numbed using a local anesthetic spray. The patient may also be given a lozenge that will have the same numbing affect after sucking on it.
2. A general anesthetic is then administered intravenously in the back of the arm or neck.
3. The patient will be asked to lie on his side and will be asked to swallow the first segment of the endoscope. Modern endoscopes are extremely thin and flexible, and can be swallowed easily without much difficulty.  
4. The doctor then gently pushes the endoscope down the esophagus, into the Somach and then into the duodenum.
5. Air is pumped down the endoscope to make visibility more clear. The doctor observes the respective parts of the digestive tract through an eye-piece, or through an external video-feed. 
6. A side-channel in the endoscope is used to insert various surgical instruments, as well as dye, into the abdominal cavity.

This is done in order to:

• take X-ray pictures of the ducts to spot a stricture (narrowing), gallstones, tumors, etc.
• take a small piece of tissue (biopsy) from the duodenal or stomach lining, or from the pancreatic or bile ducts near the papilla. This sample is then viewed under a microscope for the presence of abnormal cells.
• widen the opening of the papilla so that any gallstones may fall into the duodenum. These may be collected in a basket or left to be passed with feces.
• insert a stent to widen a constricted or blocked duct. A stent can be a plastic tube or a small wire-mesh. The presence of a stent facilitates bile to flow into the duodenum normally. 

After the procedure, the endoscope is pulled out gently.

Recovery After The Procedure

The procedure is relatively painless but may be a little uncomfortable. Recovery depends upon the cause of the ERCP. If performed simply to obtain X-rays of the bile and pancreatic ducts, the patient may go home after a few hours’ rest. If the procedure involved removing gallstones or inserting a stent, the patient may have to stay at the hospital overnight for observation.

Driving, drinking alcohol, operating machinery or doing any strenuous activity should be avoided for at least 24 hours, to ensure that the sedative has completely worn off. The patient may feel nauseous and bloated during this time. Unless otherwise instructed, normal diet and medications can be resumed after an ERCP.

See Also: Fecal Incontinence: Causes, Diagnosis, Treatment

Possible Complications Following ERCP

Other than having a sore throat for a few days or feeling groggy for a few hours. However, if the patient is already in poor health, the chances of developing certain uncommon complications increase. Immediate consultation with a doctor is required if any of the following develop with 48 hours of an ERCP:

• Increased risk of chest infections.
• Allergic reaction to the anesthetic.
• Damage to the bile or pancreatic ducts – this may cause bleeding, infections or perforations in very rare cases.  
• Unusual pain in the abdomen, especially if it increases in intensity over time.
• Fever
• Difficulty in breathing and swallowing.
• Vomiting blood.
• Pancreatitis- inflammation of the pancreas.