Endoscopic retrograde cholangiopancreatography aka ERCP
The liver is the largest gland of our body and produces ‘bile’ which aids in digestion. This bile is stored in the gall bladder. There is a network of small ducts, known as the ‘bile ducts’, which carry the bile from the liver to the gall bladder and from there to the small intestine. Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure which helps the physician to see the presence of any stone, growth or stricture in the bile ducts with the help of a flexible tube called the endoscope.
Use of ERCP
ERCP is basically used to identify gallstones, narrowing of bile ducts due to any disease, any leak from the bile ducts as a result of any injury or operation and the presence of any tumor in them. The procedure is also used for rectifying the problem wherever possible. ERCP is useful in the following patients:
- Those who have any stricture of the bile ducts as seen on USG
- Those who have any gallstones or abnormal growths as seen on USG
- Those with abnormal liver function tests
- Those with repeated infection of the pancreas
- Those suffering from repeated attacks of jaundice
- Those who have to undergo a transplantation of the liver
The ERCP procedure described and precautions to be taken after ERCP
The ERCP procedure
The Endoscopic Retrograde Cholangiopancreatography is a procedure wherein the entire biliary tree is injected with a contrast dye and then x-ray pictures are taken at fixed intervals of time to see the movement of the dye. As the endoscope is already inside, so in case any stone or stricture is found, it can be corrected during the course of the procedure itself.
The contrast dye used during the procedure contains iodine. So the patient should appraise the doctor about any prior allergy to iodine. The test is performed on an empty stomach. Therefore the patient is abstained from eating or drinking anything for at least six hours before the procedure. After taking the written consent of the patient, sedation is given to allay any anxiety that the patient has and to make her relax. An intravenous line is started to hydrate the patient adequately and to administer any medicine that may be required during the procedure. The back of the throat is anesthetized so as to prevent the gag reflex. A mouth guard is put in place to prevent accidental injury to the teeth and tongue. Then the endoscope is gently introduced into the mouth and pushed inside along with the swallowing movement of the patient. It passes through the esophagus, stomach and duodenum until it reaches the point where the bile duct and the pancreatic duct open into the duodenum. A catheter is then introduced into the duodenal opening under endoscopic vision and the contrast dye is injected into the biliary tree. Serial x-rays are taken and a diagnosis is made based on these x-rays. The entire procedure of ERCP lasts from about half an hour to two hours.
The effect of the sedatives gets over in an hour or two and the patient can go home after that. But it is better for the patient to be driven home by somebody accompanying her. In case some therapeutic procedure is performed during the course of ERCP, then the patient is admitted to the hospital for a day.
Precautions to be taken after ERCP
The patient is advised to take light meal along with lots of liquids after the procedure. There may be some soreness of throat due to the passage of endoscope which should heal spontaneously in a day or two. Patient should consult the doctor immediately in case of high fever accompanied with shivering, severe pain in abdomen or presence of blood in the vomitus.
Pros and cons of the ERCP procedure
There are several pros and cons of the ERCP procedure. The pros of the procedure include the diagnosis of various conditions during the procedure and their treatment. The various conditions that can be diagnosed during ERCP include growths and strictures of the bile duct and the pancreatic duct, gall stones and pancreatic stones, inflammation of the gall bladder and the bile duct, primary biliary cirrhosis and the pseudo pancreatic cysts. The treatments that can be done during ERCP include:
- In case the x-rays suggest some growth, then the mucosal cells of the duct can be scraped for biopsy. Pinch biopsy forceps can be used to squeeze a part of the mass.
- Bile or pancreatic juice sample can be collected directly and sent for examination.
- Sphincterotomy of bile duct valve or pancreatic duct valve can be performed in case of their narrowing or spasm.
- Gall stones and pancreatic stones can be removed directly.
- A balloon catheter can be used to widen the ducts in case x-rays reveal their scarring or narrowing.
- The physician may choose to place a tube in the bile duct which comes out through the nose for continuous drainage of bile. This is called as nasobiliary drainage.
But there can be some side effects of ERCP as well. 3-5% of the patients undergoing ERCP develop pancreatitis. Sometimes it may result in the formation of pancreatic abscess or a pseudo cyst of the pancreas. Perforation in the duodenum or the pancreas may occur accidentally during sphincterotomy and may require surgery to be sealed. It may also lead to bleeding which may sometimes warrant the need of blood transfusion. Rarely, the endoscope itself may cause damage to the esophageal, gastric or duodenal mucosa. The ERCP procedure can result in the infection of bile ducts and pancreatitis. The patient may require hospitalization, antibiotics or surgery to be relieved of these complications.
Apart from the direct consequences of ERCP procedure, patient may have allergic reaction to the contrast dye or have side effects of anesthesia like nausea, breathlessness, dryness of mouth, redness of the skin, blurring of vision, slow pulse rate and fall in blood pressure. There may be infection at the site of intra-venous line. In the long run, patient may develop pancreatic abscess or the stones may form again.