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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.
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 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.
The way to know that you may be a patient requiring ERCP is:
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.
Before the ERCP test as discussed above the patient is not advised to drink or eat several hours prior to the procedure. This ensures there are minimal complications and also an empty stomach will allow the endoscopist to view the entire area with chances of vomiting limited as much as possible.
The patient is further advised to adjust the dosage of their medication and stop taking medications which are specific as may be instructed by the surgeon or doctor before the procedure. As usual most drugs can be continued but some have to be discontinued like aspirin which causes thinning of the blood increasing chances of bleeding during the procedure.
Dietary supplements taken should be discussed in detail with the medical team. Suppose if a patient is diabetic then adjustment in their morning doses of insulin or tablets will be proposed by the surgery team.
If a patient is pregnant then the operation can be postponed after the childbirth if it is possible but if the procedure has to be conducted very urgently then it can be done even during pregnancy quite safely.
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.
Pancreatic malignancies can be diagnosed and the indications are:
There are also indications for ampullary diseases like
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 complication chances are vastly reduced when performed by expert surgeons but still there persists some amount of complications like:
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.
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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