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ERCP (Endoscopic Retrograde Cholangiopancreatography)

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What is ERCP or endoscopic retrograde cholangiopancreatography?

Endoscopy is the technique by which the doctors visualize the internal parts of the body by means of a camera that is fitted in an instrument called an endoscope.

ERCP stands for endoscopic retrograde cholangiopancreatography which is an examination that uses endoscope, radio-opaque dye/contrast, and X-rays to visualize the bile duct and pancreatic duct which carry bile and pancreatic juices to the small intestine.
The different parts of the technique involve the use of various instruments and methods which are as follows:

Endoscope: is used to visualize the inside of the gastrointestinal tract to reach and locate the opening of the bile duct/pancreatic duct in the early part of the small intestine (duodenum).

Radio-opaque dye/contrast: is injected into the bile and pancreatic ducts through its opening to outline the ducts and visualize the abnormality.

X-ray machine and films: the X-rays are projected on the body to capture the image of the contrast outlined bile and pancreatic duct. This is then taken on films or viewed on-screen by doctors.

ERCP

Why ERCP is done? What are the conditions which may need ERCP? 

ERCP is done to visualize, diagnose, and if possible treat any abnormality of the bile or pancreatic duct.

It is done when doctors suspect narrowing or blockage of the bile duct or when they want to know or possibly treat the cause of narrowing or blockage.

• The commonest reason is galls stones causing obstruction of common bile duct

• Infection

• Acute pancreatitis

• Chronic pancreatitis

• Trauma or surgical complications in your bile or pancreatic ducts

• Pancreatic pseudocysts

• Tumors or cancers of the bile ducts

• Tumors or cancers of the pancreas

If a problem is found like gall stones in the common bile duct, the doctor can often perform a procedure to remove it and relieve the obstruction. He may try to open blocked or narrowed ducts. He may put a stent to keep it open.

In cases, where the doctor might suspect a tumor he would take a sample of the tissue for seeing it under a microscope (histopathology).

Thus, ERCP helps in establishing the cause of the problem and in many cases treating the condition. As a result, the ERCP has replaced surgery in most patients with common bile duct and pancreatic disease.

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How to prepare yourself for the ERCP procedure? 

Generally, before undergoing ERCP a person tends to have undergone certain blood tests and noninvasive imaging tests such as ultrasound, CT scan, or MRI to assess the general condition and local issues related to liver or bile duct. The doctor may ask for a few more tests to assess the coagulation status (to assess the ability of the blood to clot on its own), condition of the lungs, and heart.

Your doctor will give you precise instructions about how to prepare which would include the following:

Medical and Drug history: A detailed history of all medical conditions and allergies (eg: contrast allergy used in ERCP) should be properly discussed. The person should inform the doctor about all the medicines, vitamins, and supplements being taken by him including herbal medicines. The medicines that should be given specific attention are as follows:

• Aspirin and aspirin contains medicines

• Blood thinners (like warfarin, heparin, etc.)

• Arthritis medicines

Diabetes medicines (insulin and tablets)

• BP medicines

• NSAIDs painkillers- ibuprofen and naproxen

The doctor would inform and explain how and when to stop or change medicine to prepare for ERCP. He may ask to temporarily stop medicines that affect blood clotting or interact with sedatives given during ERCP.

Diabetes: If a person is diabetic, changes will be made to the morning doses of medicines (tablets or insulin) considering being an empty stomach before your ERCP.

Pregnancy: If you are pregnant, postponing the ERCP until after childbirth should be considered. If the procedure is essential or needed, then ERCP could be considered after making changes in the procedure to protect the fetus from X-rays. Research has found that ERCP is generally safe during pregnancy.

Fasting: the person is asked to not eat, drink, smoke, or eat gum from 8 hours before the ECRP preferably overnight. This is done to keep the stomach empty to allow its proper visualization and to decrease the chances of vomiting during the procedure.

Post ERCP drive assistance: A person is not allowed to drive for 24 hours due to the persistent effect of the sedatives or anesthesia which hampers reflexes and ability to judge required while driving (similar to the effects of alcohol). Thus a person should be accompanied by someone to drive him home.

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How the ERCP procedure is done?

ERCP is done at a hospital or an outpatient center by a doctor having specialized training in ERCP, usually a gastroenterologist.

Sedation: An intravenous (IV) needle will be put in the arm to provide sedatives and other medicines. Generally, sedatives are given with other medicine to relax body parts and prevent pain. This is called conscious sedation where a person remains awake. In some complicated cases, anesthesia is given to induce sleep during the procedure.

The person would also be given a liquid anesthetic to gargle or anesthetic spray will be put on the back of his throat to numb his throat and prevent gaging when an endoscope is passed during the procedure.

For safety reasons, the person would be asked to remove eyeglasses or contact lenses, and dentures.

During the procedure, the person would be monitored for the vital signs to assess tolerance and keep a check on complications occurring during the procedure.

Procedure:

• The person will lie on a special table during the examination generally on their left side or stomach. A plastic mouth guard is placed between the teeth to prevent damage to the teeth and endoscope.

• Many people worry about the discomfort an endoscope can cause when passed down the throat but with the help of the sedatives and medicines most people tolerate the procedure well. Many people fall asleep during the test while others are very relaxed and not aware of the examination.

• The doctor will insert the endoscope into the mouth asking the patient to swallow the tube to assist easy passage. After the scope is inserted through the mouth, the air is gently pushed to open up the esophagus, stomach, and duodenum to allow easy passage and proper visualization of these structures.

• A small camera mounted on the endoscope sends a video to a monitor to guide and locate the structures.

• After locating the opening of the bile and pancreatic ducts on the structure called papilla is seen within the duodenum, the doctor passes a tube called a catheter through the endoscope into the ducts.

• A special dye that can be seen with the help of X-rays is injected into the ducts to make them visible on X-ray images seen on the monitor.

Depending what is seen during ERCP the doctor might do the following things:

Blocked or narrowed ducts– The doctor opens the narrowed duct. He may put a stent (wire mesh or plastic tube) to open up the narrowing.

Bile leak: Stent may be put to stop bile leaking which can be seen after gall bladder surgery.

Stones: may break up or remove stones. He may widen the opening or papillae to assist the removal of the stone.

Tumor or suspected tumor: perform a biopsy or try to remove the tumor in the ducts.

The procedure usually takes between 1 to 2 hours.

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What to expect after ERCP?

After ERCP, the person is kept under observation until the sedatives wear off. The effect of medicines usually causes people to feel tired, have deranged reflexes, or have difficulty concentrating, so it is usually advised not to return to work or drive the same day.
The most common discomfort after the procedure is to feel bloated due to air introduced during the examination. This usually resolves quickly and spontaneously. Some people may experience a mild sore throat. Most people don’t have any significant issues.
The doctor can usually tell the results of the ERCP just after the procedure. If a biopsy is taken, the tissue will be sent to a lab and the biopsy report will take several days to be generated.

What complications can occur with ERCP?

ERCP is safe and tolerated well by the patients especially when done by experienced doctors. Serious complications are uncommon. If complications occur, they can be usually managed. Following are the complications that can occur after ERCP:

Pancreatitis: is the most common complication, occurring in approx. 3 to 5 percent of patients undergoing ERCP. It causes severe abdominal pain and nausea. Usually, ERCP results in mild pancreatitis, which resolves in a few days of hospital stay. Severe pancreatitis is rare after ERCP.

Bleeding: can occur during the ERCP procedure. Usually, bleeding is minimal and stops on its own. Sometimes, it may need to be controlled by some techniques used in the ERCP procedure. Thus, it is important for the patients to stop taking medicines (discussed earlier) that hampers clotting of blood eg: blood thinners, warfarin, etc.

Perforation: the ERCP scope and instruments can cause puncture or hole in the small intestine. This results in a serious condition which generally requires surgery. It can also cause tears in the bile duct or pancreatic duct.

Infection: infrequently ERCP can also cause infection of the bile ducts or bile system called cholangitis. It more commonly affects patients having preexisting medical conditions. This is treated by giving antibiotics and draining excessive fluid.

Aspiration: ERCP procedure may induce vomiting of the food or fluids from the stomach which may be inhaled into the lungs known as aspiration. It can be avoided by keeping the stomach empty by not taking any food or drink several hours before the procedure.

Adverse reaction to sedative: an abnormal reaction to the sedative may occur in some patients, which may cause respiratory or cardiac problems.

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Who is more prone to have complications or what are conditions that make a person more prone to have post ERCP complications?

The tendency to develop complications depends

Indication- what is the reason to do ERCP in the person?

Patient condition- if there are any major medical problems?

Finding- what problem or pathology is found during the ERCP?

Treatment required- what treatment or technique was required to manage the condition?

For example, a patient undergoing ERCP to treat a condition, as for stone removal, have a higher risk of developing a complication than patients undergoing ERCP for diagnosing a problem.

It is important to know and discuss complications with the doctor and to understand the likelihood to develop one.

What are warning signs to get medical help or consult a doctor post ERCP?

If a person or his relatives observe any of the following issues they should immediately get medical attention:

• Severe abdominal pain or pain that gets worse.

• Distended and tight abdomen.

• Vomiting especially bloody or coffee-like in color.

• Bloody or tar colored/black stools.

• Fever or chills

• Difficulty in swallowing or a throat pain that gets worse.

• Chest pain

• Breathing problem.

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