ERCP stands for Endoscopic Retrograde Cholangiopancreatography. It is a procedure to examine the bile ducts and the pancreatic duct. These ducts are drainage channels which drain bile and pancreatic juice from the liver and the pancreas respectively. Special techniques are required to enter the ducts. Once the ducts are entered, various diagnostic and therapeutic interventions may be performed.
It is done by a gastroenterologist with additional specific training in advanced endoscopy. It is done under sedation and usually, an anesthetist is present during the procedure.
The endoscopist passes a special side viewing endoscope through the mouth into the duodenum to visualize the major ampulla, which is the entrance to the bile or pancreatic duct. Instruments are then passed through the endoscope into the opening, and guided into the duct using X-rays. Once the ducts are entered, various treatments can be performed. These include:
- Cholangiogram or Pancreatogram: Dye is injected into the ducts to visualize the anatomy and contents of the ducts under X-rays.
- Sphincterotomy: The muscle surrounding the opening is cut to enlarge the opening. This facilitates various treatments.
- Stone removal: The most common treatment in ERCP is the removal of stones from the common bile duct. This is done using baskets or balloons. Large stones may need to be crushed or fragmented using specialized equipment before they can be removed.
- Stent placement: Stents are hollow tubes that are placed across areas in the duct that are narrowed or blocked so that the drainage channel is restored. There are 2 types of stents: plastic stents that are smaller and that can be easily be deployed and removed, and metal stents that are larger and can last longer.
- Balloon dilation: Special balloon may be used to expand the opening of the duct or an area that is narrowed or blocked. This allows the area to be widened to facilitate treatment and drainage.
- Tissue sampling: Abnormal areas in the ducts may be sampled using brushing or biopsy forceps under X-ray guidance. This can help to diagnose cancer.
- Cholangioscopy: A special ultra-thin endoscope may be passed into the bile duct to visualize the inside directly, to enable precise tissue sampling or to apply a laser to very large stones.
ERCP can help to avoid surgery of the bile duct and pancreatic duct. ERCP is used for the following conditions:
- Removal of stones from the bile duct and pancreatic duct. This can relieve infection, jaundice, and pain, and prevent future attacks.
- Insertion of stents to bypass narrowed and blocked areas. These are typically caused by tumors, stones, and scarring. This can relieve infection, jaundice and pain.
- Obtaining tissues samples from the bile duct, which can make a diagnosis of cancer.
Preparing for ERCP
You should fast for at least 6 hours prior to your ERCP. Longer fasting may be needed if your doctor suspects that your stomach is not emptying properly. You may drink clear fluid up to 2 hours before the procedure but milk is not allowed during the fasting.
In general, most medication should be continued before the gastroscopy with the exception of diabetes medication and blood thinners. Diabetic medication should be omitted during the fasting. You should check with your doctor if your blood thinner needs to be discontinued prior to the procedure.
As you will be given medication to make you sleepy, you must not drive, work or make any important decision after the procedure. Medical Certificate will be issued if needed and you should rest at home for the rest of the day.
Before the ERCP
A nurse will conduct final checks, and bring you into the procedure room. An intravenous line will be inserted. An anesthetist would conduct final assessments.
During the ERCP
A throat spray will be administered to lessen the discomfort of the procedure.
You will be lying on your belly.
Sedation will then be administered by the anesthetist. After you have fallen asleep, the procedure will begin. You will likely not remember any of the procedure. You will be breathing on your own and monitored closely during the procedure.
You will wake up gradually after the procedure is done. All the medication used for sedation have a duration of action of a few minutes.
After the ERCP
You will be cared for in a recovery area or room. The nurses will give you food and drink when they assessed that you are ready. You would be admitted for observation for one day after the procedure. Sometimes, you may have a mild sore throat, bloating and cramping. This normally goes away after 24 hours.
ERCP is an advanced endoscopic technique. Very few specialists and endoscopists undergo additional training after specialization to do this properly. Typically, it takes about an additional 2 years of dedicated ERCP training after completing specialist and general endoscopy training in order to perform ERCP competently. There are various levels of difficulty in ERCP. Most ERCP specialists are able to perform routine cases such as stone removal and stent insertion. However, only top ERCP experts are able to perform difficult cases successfully. It is important to ensure that the doctor performing the ERCP has the correct level of expertise to match the difficulty of the case.
ERCP is safe when performed by properly trained doctors. Complications and failures increase significantly when ERCP is performed by Inadequately trained doctors or those with insufficient cases to maintain their skill. Hence, it is important to ensure that the doctor performing the ERCP has the appropriate expertise for the case. Simple questions such as the following are useful:
- Which public institution where you formally certified to do ERCP independently?
- How many cases have you performed?
- What is your success rate and complication rate?
- What is your rate for needing to repeat ERCP?
- What will you do if the ducts cannot be entered the normal way?
- How will you detect complications and how have you managed these before?
- How many difficult ERCP cases have you done, and what are some examples?
- Advanced Endoscopy