Endoscopic retrograde cholangiopancreatography (ERCP) is a technique in which a hollow tube called an endoscope is passed through the mouth and stomach to the duodenum (the first part of the small intestine). This procedure was developed to examine abnormalities of the bile ducts, pancreas, and gallbladder. It was developed during the late 1960s and is used today to diagnose and treat blockages of the bile and pancreatic ducts.
The term has three parts to its definition:
"Endoscopic" refers to the use of an endoscope.
"Retrograde" refers to the injection of dye up into the bile ducts in a direction opposing, or against, the normal flow of bile down the ducts.
Cholangiopancreatography means visualization of the bile ducts (cholangio) and pancreas (pancreato).
Purpose
Until the 1970s, methods to visualize the bile ducts produced images that were of relatively poor quality and
often misleading; in addition, the pancreatic duct could not be examined at all. Patients with symptoms related to the bile ducts or pancreatic ducts frequently needed surgery to diagnose and treat their conditions.
Using ERCP, physicians can obtain high-quality x rays of these structures and identify areas of narrowing (strictures), cancers, and gallstones. This procedure can help determine whether bile or pancreatic ducts are blocked; it also identifies where they are blocked along with the cause of the blockage. ERCP may then be used to relieve the blockage. For patients requiring surgery or additional procedures for treatment, ERCP outlines the anatomical changes for the surgeon.
Precautions
The most important precaution is that the examination should be performed by an experienced physician. The procedure is much more technically difficult than many other gastrointestinal endoscopic studies. Patients should seek physicians with experience performing ERCP. Patients should inform the physician about any allergies (including allergies to contrast dyes, iodine, or shellfish), medication use, and medical problems. Occasionally, patients may need to be admitted to the hospital after the procedure.
Description
After sedation, a specially adapted endoscope is passed through the mouth, through the stomach, then into the duodenum. The opening to ducts that empty from the liver and pancreas is identified, and a plastic tube or catheter is placed into the orifice (opening). Contrast dye is then injected into the ducts, and with the assistance of a radiologist, pictures are taken.
Preparation
The upper intestinal tract must be empty for the procedure, so patients should NOT eat or drink for at least 6 to 12 hours before the exam. Patients should ask the physician about taking their medications before the procedure.
Aftercare
Someone should be available to take the person home after the procedure and stay with them for a while; patients will not be able to drive themselves because they undergo sedation during this test. Pain or any other unusual symptoms should be reported to the physician.
Risks
ERCP-related complications can be broken down into those related to medications used during the procedure the diagnostic part of the procedure, and those related to endoscopic therapy. The overall complication rate is 5% to 10%; most of those occur when diagnostic ERCP is combined with a therapeutic procedure. During the exam, the endoscopist can cut or stretch structures (such as the muscle leading to the bile duct) to treat the cause of the patient's symptoms. Although the use of sedatives carries a risk of decreasing cardiac and respiratory function, it is very difficult to perform these procedures without these drugs.
The major complications related to diagnostic ERCP are pancreatitis (inflammation of the pancreas) and cholangitis (inflammation of the bile ducts). Bacteremia (the passage of bacteria into the blood stream) and perfo-ration (hole in the intestinal tract) are additional risks.
Normal results
Because certain standards have been set for the normal diameter or width of the pancreatic duct and bile ducts, measurements using x rays are taken to determine if the ducts are too large (dilated) or too narrow (strictured). The ducts and gallbladder should be free of stones or tumors.
Abnormal results
When areas in the pancreatic or bile ducts (including those in the liver) are too wide or too narrow compared with the standard, the test is considered abnormal. Once these findings are demonstrated using ERCP, symptoms are usually present; they generally do not change without
treatment. Stones, identified as opaque or solid structures within the ducts, are also considered abnormal. Masses or tumors may also be seen, but sometimes the diagnosis is made not by direct visualization of the tumor, but by indirect signs, such as a single narrowing of one of the ducts. Overall, ERCP has an excellent record in diagnosing these abnormalities.
Resources
BOOKS
Ostroff, James W., and Jeanne M. LaBerge. "Endoscopic and Radiologic Treatment of Biliary Disease." In Sleisenger & Fordtran's Gastrointestinal and Liver Disease. Edited by Mark Feldman, et al. Philadelphia: W.B. Saunders Company, 1997.
PERIODICALS
Aliperti, Giuseppe. "Complications Related to Diagnostic and Therapeutic Endoscopic Retrograde Cholangiopancreatography" Gastrointestinal Endoscopy Clinics of North America (April 1996): 379-407.
Baillie, John. "Treatment of Acute Biliary Pancreatitis." New England Journal of Medicine 336, no. 4 (1997): 286.
"Guidelines—The role of ERCP in diseases of the biliary tract and pancreas." Gastrointestinal Endoscopy 50, no. 6 (1999): 915-920.
—An endoscope used in the field of gastroenterology is a hollow, thin, flexible tube that uses a lens or miniature camera to view various areas of the gastrointestinal tract. When the procedure is performed to examine the bile ducts or pancreas, the organs are not viewed directly, but rather indirectly through the injection of contrast. The performance of an exam using an endoscope is referred to as endoscopy. Diagnosis through biopsies or other means and therapeutic procedures can also be done using these instruments.
Visualization
—The process of making an internal organ visible. A radiopaque substance is introduced into the body, then an x-ray picture of the desired area is taken.
QUESTIONS TO ASK THE DOCTOR
How soon will you know the results?
Did you see any abnormalities?
When can I resume any medications that were stopped?
