ERCP

What is ERCP?

Endoscopic Retrograde Cholangio Pancreatography (ERCP) is a method for getting into the bile duct and pancreas though the mouth. When invented over 40 years ago, ERCP was a breakthrough that allowed doctors to find local diseases. Today, most local diseases can be detected safely by non-invasive imaging tests such as Computed Tomography (CT), Magnetic Retrograde Cholangio Pancreatography (MRCP) scans and an endoscopic method of imaging called Endoscopic Ultrasound (EUS). ERCP is used mainly to treat diseases that have been detected by these means.

 

ERCP uses an endoscope, which is a long flexible narrow tube with a camera at the end. After the patient is sedated, the specialist passes the endoscope through the mouth and esophagus, to view the lining of the stomach and first part of the small intestine (the duodenum). The goal is to access the papilla of Vater, a small nipple in the duodenum. This papilla is the drainage hole for the bile and pancreatic duct, which bring digestive juices from the liver, gallbladder and pancreas. The doctor injects contrast dyes through the papilla into the ducts and takes X-rays to show lesions such as stones, strictures or blockages. Some of these can be treated right away with other instruments passed through the endoscope.

Treatments

The most common ERCP treatments are:

• Sphincterotomy — This involves making a small cut in the papilla of Vater to enlarge the opening of the bile duct and/or pancreatic duct. This is done to improve the drainage or to remove stones in the ducts. Removed stones are usually dropped in the intestine, and pass through quickly.

• Stenting — A stent is a small plastic tube that is placed and left in a blocked or narrowed duct to improve drainage. The narrowing may need to be stretched (dilated) before the stent is placed. Some stents are designed to pass out into the intestine after a few weeks when they have done their work. Other stents have to be removed or changed after 3-4 months. There are also permanent stents made out of metal.

Complications

There are some drawbacks to ERCP which must be explained and understood before patients agree to undergo the procedure. Working on the pancreas and bile duct can cause complications, even in the best hands. ERCP is not perfect. Occasionally, important lesions may not be seen, and treatment attempts may be unsuccessful.

The most common ERCP complication is pancreatitis (swelling and inflammation of the pancreas). This occurs in about one patient in twenty, and results in the need to stay in hospital for pain medications and IV fluids. This usually lasts for a few days, but can be much more serious. Surprisingly, it is more likely to occur when the pancreas is healthy, where it can affect up to one patient in five.

Other rare complications (less than 1 per 100) include, but are not limited to:

• Heart and lung problems
• Bleeding (after sphincterotomy)
• Infection in the bile duct (cholangitis)
• Perforation (a tear in the intestine)

These may require prolonged stays in hospital and surgical treatment. ERCP can cause fatal complications.

Questions to Ask Your Doctor

• Would MRCP or EUS be helpful in clarifying whether ERCP is needed?
• What exactly are you expecting to find and to do?
• What are the chances of success, and of complications, in my particular case?
• What is your experience of this technique?
• Is there someone with more experience that you can recommend?

Because of the significant risks, it is important that these procedures are performed only by specialists well trained in their use, and doing them on a regular basis with an expert team, including expert surgical back-up when needed.