ERCP (Diagnostic) in India

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About the ERCP (Diagnostic)

ERCP procedure or Endoscopic Retrograde Cholangio-Pancreatography is an assessment as well as a procedure meant for rectifying problems in bile and pancreatic ducts. This is considered to be a very critical and life saving procedure involving an endoscope. Examination of critical areas needs to be done and rectification has to be done immediately with planned procedural steps.

Who needs an ERCP?

An ERCP procedure is recommended in order to diagnose the status of bile ducts and the pancreas and if there are problems discovered during diagnosis then they are treated as well. The procedure is appropriate in order to do evaluation of symptoms that are suggestive of certain diseases prevalent in these organs. It is also used as a method of reconfirmation of abnormal results generated from ultrasound, CT scan or imaging tests and blood tests. If CT scan reveals abnormal mass or stones in these organs then ERCP is recommended.

The procedure can even be performed before and after a gall bladder surgery to help in the conducted operation’s performance in overall. If there are stones or tumours of both cancerous and non cancerous nature then they can be removed with the help of ERCP procedure from bile ducts and pancreas. If there have been any complications noted during gall bladder surgery then those can also be diagnosed with the help of this. Patients having any pancreatic disease or suspected disorder for them the ERCP method can suggest the requirement of surgery and the type of surgery that may be best for the treatment. In some cases pancreatic stones can be addressed and removed with the help of ERCP procedure.

Causes of ERCP

Causes of the problems are mainly because of narrowing or blockage of the bile ducts and pancreatic duct. Gall stones are formed and they get stuck to the common bile duct thus requiring surgical interventions. Gall stones are usually formed of cholesterol in maximum cases while for 20% cases it is a result of calcium and pigments like bilirubin giving rise to stones. Other causes can be imbalance of diet and irregular lifestyle giving rise to infection. Alcohol drinking and fatty food consumption results in acute and chronic pancreatitis.

Symptoms of ERCP

The way to know that you may be a patient requiring ERCP is:

  • Abdominal cramps
  • Fever and Nausea
  • Vomiting tendency with occasional bleeding
  • Irritation felt in the stomach
  • General fatigue experienced

 

What is ERCP?

The procedure of ERCP enables the doctor or the surgeon to precisely examine the bile ducts and the pancreatic duct. In this procedure the endoscope which is a lighted tube and can be bent as well has a thickness of the index finger almost and it is inserted via the mouth of the patient and then it is made to access the stomach and the small intestine’s first part that is the duodenum. A small plastic tube named cannula is passed via the endoscope into the opening which is very small in size in the duodenum. The opening is called the ampulla. A contrasting substance or a dye is then injected and then X rays are carried out to start the study and find the status of the liver, pancreas and the ducts.

How is ERCP (Diagnostic) performed?

ERCP surgery

The surgery technique makes use of a combination of luminal endoscopy compiled with fluoroscopic technique of imaging for the purpose of diagnosing and performs treatment of conditions that are associated with pancreatobiliary system. A side viewing instrument named the duodenoscope is utilized in the endoscopic portion that is made to travel through the esophagus and reach the stomach to access the duodenum’s second portion which is the part of small intestine.

In ERCP Sphincterotomy both fluoroscope and endoscope are employed and deep cannulation is done of the bile duct which is then followed by the sphincter of Oddi’s severance with electrocautery (heating).

Coming back to conventional ERCP, next the duodenal pailla is identified with the scope in the position discussed above and further inspection is carried out to find any abnormalities. The duodenal papilla is like a structural protrusion of the ampulla of Vater or the hepatopancreatic ampulla into the duodenal lumen. The ventral pancreatic duct and the common bile duct have a convergence point and that is this ampulla. So this ampulla behaves like a channel for draining pancreatic secretions and bile into the duodenum.

If contrast is injected into the pancreatic duct or if the pancreatic duct gets cannulated for quite a number of times then a temporary pancreatic duct stent placement or rectally administered NSAIDS (diclofenac or indomethacin) has to be considered. This has to be considered aiming to reduce the post-ERCP pancreatitis (PEP) risks. For PEP prophylaxis these two prevention modalities have shown some promise.  Somatostatin, gabexate, heparin, nitroglycerin, allopurinol, steroids, octreotide and many more pharmacological agents have been studied but the results found were pretty disheartening.

In the second portion or segment of the duodenum the minor duodenal papilla is also located and it behaves like an access point for the dorsal pancreatic duct. Dorsal pancreatic duct’s evaluation with ERCP is seldom performed and the ERCP indications are further discussed below:

With the side viewing endoscope the papilla is closely examined and then selective cannulation of ventral pancreatic duct or common bile duct is performed. Once the cannulation of the selected duct is performed then either pancreatogram of the pancreatic duct or cholngiogram of common bile duct is obtained fluoroscopically with the injection of a material that is radiopaque contrasting in nature is done into the duct. These days ERCP is considered by surgeons like a therapeutic surgery where abnormalities that are observed via a fluoroscope can be particularly addressed by the methods of specialized accessories that can be passed via the endoscope’s working channel.

This procedure is a very advanced process and as a result of this serious complications tend to occur at a higher frequency than many other endoscopic processes. As per that special training and specialized devices and equipments are employed and for appropriate indications only this procedure is employed.

Indications that have been recorded for biliary diseases are given below:

Assessment of biliary obstruction and its treatment secondary to choledocholithiasis- if ascending cholangitis, worsening pancreatitis or worsening jaundice which are persistent are present then Precholecystectomy ERCP may be indicated.

  • With intraoperative cholnagiography or common bile duct exploration without the extraction of stone, treatment of choledocholithiasis is identified during cholcystectomy.
  • Bile duct stricture assessment and subsequent treatment- bening and malignat strictures and and congenital abnormalities of the bile duct.
  • Postoperative complications
  • Postoperative biliary leaks’ treatment and assessment
  • Sphincter of Oddi dysfunction of selected patients, their assessment with treatment with little benefit in modified Milwaukee classification type III patients
  • For recurrent and acute pancreatitis for which the underlying cause is unknown in patients; their treatment followed after assessment
  • Symptomatic strictures associated with chronic pancreatitis; assessment and treatment
  • Symptomatic pancreatic duct stones; their treatment after assessment
  • Symptomatic duct stones’ assessment and treatment

Pancreatic malignancies can be diagnosed and the indications are:

  • Biopsy and brushing of the bile duct
  • Pancreatoscopy
  • Intraductal ultrasonography

There are also indications for ampullary diseases like

  • Assessment of ampullary malignancy
  • Ampullary adenomas’ assessment and treatment

If a patient has the possibilities of developing post ERCP pancreatitis, then the process of diagnosis grows apparent within some hours after the procedure. The patient shall experience severe pain in abdomen back pain and nauseated feelings may be accompanied with vomiting sensation) and some amount of fever is also common. But then the observation period does not stretch beyond an hour after the ERCP procedure and is not enough time for checking for post ERCP Pancreatitis. For evolving post ERCP pancreatitis a two hour serum or urinary amylase level (>1000IU/L) is highly predictive if the patient can be kept under observation for a longer duration of time.

Another kind of procedure closely related to ERCP is the employment of miniature endoscopes that can be inserted via the operating channel of the duodenoscope. These can be directly inserted into the pancreatic or the bile duct. The interior side of the duct can be visualized and accordingly biopsies can be taken. There remain other possibilities for therapeutic interventions.

If in the common bile duct the bile duct stones are seen then the opening of the papilla will be made wider with the help of electrocautery or heating and then the stones are removed. For removal of stones sometimes a basket may be employed. If the narrowing of the bile duct is seen in the X-ray images then a small wire mesh or plastic tube which is a stent can be inserted to facilitate the bypassing of the blockage and allow the bile to move to the duodenum. Very mild pain after ERCP stent placement is felt.

ERCP Complications

ERCP complication chances are vastly reduced when performed by expert surgeons but still there persists some amount of complications like:

  • Pancreatitis or inflammation of the pancreas is the commonly occurring complication found in 3 to 5% of the patients undergoing the surgery. Usually it is mild causing nausea and pain in the abdomen region which can be treated during the stay in hospital. It is very rare that pancreatitis grows severe during ERCP.
  • A cut into the ampulla becomes necessary by the endoscopist and as soon as that happen some amount of bleeding can occur at the site of the cut ampulla. However it is minimal and stops in sometime all by itself or it can be controlled during the surgery.
  • A tear or hole in the intestine can happen accidentally due to the insertion of the scope or any other instrument. This happens rarely but when it occurs it is a serious condition requiring immediate surgical intervention.
  • Infection or cholangitis is also very rare in the bile ducts but if it occurs among patients with preexisting conditions then treatment has to be started where antibiotics need to be administered and drainage of excess fluids need to be carried out.


If by accident food or fluid is inhaled in the lungs then that can be a complication but it rarely occurs in patients who do not drink and eat several hours prior before the ERCP test.

Recovery from ERCP (Diagnostic)

Aftercare and recovery

 As the sedative medications start wearing off the patient will be observed for further complications. The medicines administered causes drowsiness and there are difficulties observed in concentration so a patient will be advised to stay away from work.

The discomfort as most patients have expressed is a feeling of bloating which is a result of the introduction of air in the system during the time of examination but this problems can be quickly fixed.  Some patients experience a throat sore which is very mild usually.

Most patient are in a condition to drink clear liquid after the test and in some scenario blood tests have to be conducted right after the ERCP procedure. If biopsy samples have been taken then they are required to be sent to the lab for further analysis right after the procedure.

Some amount of fatigue is very common during the recovery period and for abnormal temperatures observed one should immediately inform the clinical team to check for the conditions.

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Frequently Asked Questions

What is the health care infrastructure of India / Why should opt for India as a destination for your medical treatment?
India is a large country with a rapidly expanding system of healthcare. Like many other countries, there are public and private hospitals in India. This also includes healthcare at three levels.
  • The primary level of healthcare includes Sub Centres and Primary Health Centres.
  • At the secondary level are District Hospitals and smaller Sub-District hospitals. These are the first referral units, mostly from the primary healthcare centres.
  • Finally, the top level of health care provided is the tertiary level, which consists of Medical Colleges and Specialized Hospitals.
Since India boasts of housing a large number of people, the requirement for good healthcare and treatment in India is always there. And this also means prompt delivery of the service. Most of the treatment in India has to be offered at reasonable costs to enable people of all classes to access it. Hence, you can be assured that this country will be a great destination for your medical treatment whichever hospital in India you wish to choose.
What are the conditions of the hospitals in India? Are they JCI certified? What is the quality of the support staff in the hospitals?
The Joint Commission International (JCI) is a global leader in health care accreditation. JCI accreditation is considered a gold standard in worldwide health care. It provides the most skilled and experienced healthcare professionals in the medical industry, as evaluators of the rigorous international standards in healthcare quality and patient safety.
Here are some JCI certified hospitals in India:
  • Fortis Escorts Health Institutes, Delhi
  • Columbia Asia Referral Hospital, Bangalore
  • Fortis Hospital, Bangalore
  • Apollo Hospital, Chennai
  • Sri Ramachandra Medical Center, Chennai
  • Ahalia Foundation Eye Hospital, Kerala
  • Rajagiri Hospital, Kochi
  • Asian Heart Institute, Mumbai
  • Fortis Hospital, Mumbai
  • Kokilaben Dhirubhai Ambani Hospital, Mumbai
  • SevenHills Hospitals, Mumbai
  • Apex Heart Institute (A Unit Of TCVS Pvt)
  • Apollo Gleneagles Hospitals, Kolkata.
  • Fortis Hospitals Ltd, Mulund, Mumbai
  • Narayana Multispeciality Hospital Jaipur (A Unit of Narayana Hrudayalaya Ltd.)
Hospitals in India are ever-changing to accommodate more people with up to date technology. Hospitals in India also attract patients from other countries because of their diverse range of services. Apart from allopathy and conventional treatment procedures, the government of India, along with the hospitals in India also promote alternative medical treatment options like Ayurveda, homeopathy, and yoga. All in all, you will find great options for any kind of treatment in India.
Are the doctors/surgeons in India of the best quality?
Doctors and surgeons in India have to get through examinations and continue to uphold the standard of education that is provided to them. Since doctors get exposure to various patients during their course, they are able to diagnose and treat a wide range of diseases and illnesses. Therefore, one can rely on the doctors of India for their medical services.
What is the process for obtaining a medical visa in India?
The e-Medical Visa for India is an online travel authorization for foreign nationals who wish to seek medical treatment in the country. A medical Indian visa allows the holder to enter the country 3 times.

The e-Medical visa is a short term visa granted for medical treatment reasons. This type of visa is only granted to the patient and not to their family members.

Foreign nationals can acquire an India e-Medical visa by filling in an online application form. This simple process can be done from the comfort of the traveler’s home or office, avoiding a trip to an embassy or consulate.

Applicants must submit their basic personal information, including their full name, nationality, and date of birth. They must also provide a contact email address and phone number as well as their passport details. Finally, some security questions must be answered.

The form is quick and easy to fill out. The approved India medical visa is then delivered to the applicant’s email address within a few business days.
What support services does MediGence provide in India?
MediGence enables you to plan and manage your medical decisions better. These are some of our services offered:
  • Expert Opinion
    We help you seek an Expert Opinion on your diagnosis and treatment from an experienced team of doctors at MediGence and specialists from a reputable hospital.
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  • Visa Assistance
    We provide and help prepare documentation for visa approval and coordinate with the embassy to expedite the visa process.
  • Accommodation Arrangements
    We propose to you a choice of accommodation based on your preference such as long stay, short stay, or luxury properties.
Which are the best cities in India for medical treatment?
India is a beautiful country spread across the vast expanse of the Asian subcontinent. Most of the metro cities have hospitals, in India, with varying levels of infrastructure. Depending on your need and medical service, you can visit your choice of city.
The capital of India is Delhi and has many renowned hospitals like the All India Institute of Medical Sciences, Max Super speciality Hospital Fortis Hospitals, etc.
Other cities offering effective medical care include Bangalore, Chennai, Mumbai, and Hyderabad. These cities come under some of the major metro cities of India.

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