Endoscopic retrograde cholangiopancreatography

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Duodenoscopic image of two pigment stones extracted from common bile ductafter sphincterotomy.

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use

of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic
ductal systems. Through the endoscope, the physician can see the inside of the stomach and duodenum, and
inject dyes into the ducts in the biliary tree and pancreas so they can be seen on x-rays.

ERCP is used primarily to diagnose and treat conditions of the bile ducts, including gallstones, inflammatory
strictures (scars), leaks (from trauma and surgery), and cancer. ERCP can be performed for diagnostic and
therapeutic reasons, although the development of safer and relatively non-invasive investigations such
as magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound has meant that ERCP
is now rarely performed without therapeutic intent.

Contents
[hide]

• 1 Diagnostic

• 2 Therapeutic

• 3 Contraindicat

ions
 • 4 Procedure

• 5 Risks

• 6 See also

• 7 References

[edit]Diagnostic

Fluoroscopic image of common bile ductstone seen at the time of ERCP. The stone is impacted in the distal common bile
duct. A nasobiliary tube has been inserted.

Fluoroscopic image showing dilatation of the pancreatic duct during ERCP investigation. Endoscope is visible.

 Obstructive jaundice - This may be due to several causes

  Chronic pancreatitis - a now controversial indication due to widespread
availability of safer diagnostic modalities including endoscopic ultrasound,
high-resolution CT, and MRI/MRCP

 Gallstones with dilated bile ducts on ultrasonography

 Bile duct tumors

 Suspected injury to bile ducts either as a result of trauma or iatrogenic

 Sphincter of Oddi dysfunction

 Pancreatic tumors no longer represent a valid diagnostic indication for ERCP

unless they cause bile duct obstruction and jaundice. Endoscopic ultrasound
represents a safer and more accurate diagnostic alternative
[edit]Therapeutic

 Any of the above when the following may become necessary

 Endoscopic sphincterotomy (both of the biliary and the pancreatic

sphincters)

 Removal of stones

 Insertion of stent(s)

 Dilation of strictures (e.g. primary sclerosing cholangitis, anastomotic

strictures after liver transplantation)
[edit]Contraindications

 Recent attack of acute pancreatitis, within the past several weeks.

 Recent myocardial infarction.

 Inadequate surgical back-up

 History of contrast dye anaphylaxis

 Poor health condition for surgery.

 Severe cardiopulmonary disease.

[edit]Procedure

The patient is sedated or anaesthetized. Then a flexible camera (endoscope) is inserted through the mouth,
down the esophagus, into the stomach, through the pylorus into the duodenum where the ampulla of Vater (the
opening of the common bile duct and pancreatic duct) exists. The sphincter of Oddi is a muscular valve that
controls the opening of the ampulla. The region can be directly visualized with the endoscopic camera while
various procedures are performed. A plastic catheter or cannula is inserted through the ampulla, and
radiocontrast is injected into the bile ducts, and/or, pancreatic duct. Fluoroscopy is used to look for blockages,
or other lesions such as stones.

When needed, the opening of the ampulla can be enlarged with an electrified wire (sphincterotome) and access
into the bile duct obtained so that gallstones may be removed or other therapy performed.

Other procedures associated with ERCP include the trawling of the common bile duct with a basket or balloon
to remove gallstones and the insertion of a plastic stent to assist the drainage of bile. Also, the pancreatic duct
can be cannulated and stents be inserted. The pancreatic duct requires visualisation in cases of pancreatitis.

In specific cases, a second camera can be inserted through the channel of the first endoscope. This is termed
duodenoscope-assisted cholangiopancreatoscopy (DACP) or mother-daughter ERCP. The daughter scope can
be used to administer direct electrohydraulic lithotripsy to break up stones, or to help in diagnosis by directly
visualizing the duct (as opposed to obtaining X-ray images).[1]

[edit]Risks

The major risk of an ERCP is the development of pancreatitis, which can occur in up to 5% of all procedures.
This may be self limited and mild, but may require hospitalization, and rarely, may be life-threatening. Patients
at additional risk for pancreatitis are younger patients, patients with previous post-ERCP pancreatitis, females,
procedures that involve cannulation or injection of the pancreatic duct, and patients with sphincter of
Oddi dysfunction.[2]

Gut perforation is a risk of any endoscopic procedure, and is an additional risk if a sphincterotomy is performed.
As the second part of the duodenum is anatomically in a retroperitoneal location (that is, behind the peritoneal
structures of the abdomen), perforations due to sphincterotomies are also retroperitoneal. Sphincterotomy is
also associated with a risk of bleeding.[2]

Oversedation can result in dangerously low blood pressure, respiratory depression, nausea, and vomiting.

There is also a risk associated with the contrast dye in patients who are allergic to compounds containing
iodine.

[edit]See also
 Percutaneous transhepatic cholangiography
[edit]References

1. ^ Farrell JJ, Bounds BC, Al-Shalabi S, Jacobson BC, Brugge WR, Schapiro
RH, Kelsey PB (2005). "Single-operator duodenoscope-assisted

cholangioscopy is an effective alternative in the management of

 choledocholithiasis not removed by conventional methods, including

mechanical lithotripsy". Endoscopy 37 (6): 542–7. doi:10.1055/s-2005-

861306. PMID 15933927.

2. ^ a b Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F,

Pilotto A, Forlano R (2007). "Incidence rates of post-ERCP complications: a

systematic survey of prospective studies".Am. J. Gastroenterol. 102 (8):

1781–8. doi:10.1111/j.1572-0241.2007.01279.x. PMID 17509029.

[hide]
v•d•e
Digestive system surgical and other procedures (ICD-9-CM V3 42-54)

SGs/EsophagusSialography · Esophagectomy · Impedance-pH monitoring · Esophageal pH monitoring · E

Gastrostomy (Percutaneous endoscopic gastrostomy) · Gastrectomy (Billroth I, Billroth II,

Stomach
band, Sleeve gastrectomy, Vertical banded gastroplasty surgery) · Gastroenterostomy · Hill
Upper GI tract

ImagingEndoscopy: Esophagogastroduodenoscopy
Upper gastrointestinal series · Barium swallow

Small bowelBariatric surgery (Duodenal switch, Jejunoileal bypass) · Jejunostomy · Ileostomy · Partial ilea

Digestive tract
Large bowelColectomy · Colostomy · Appendicectomy · Hartmann's operation

RectumLower anterior resection · Abdominoperineal resection

Lower GI tract Anal canalAnal sphincterotomy · Lateral internal sphincterotomy · Transanal hemorrhoidal dearterializati

ImagingEndoscopy: Colonoscopy (Virtual) · Proctoscopy · Sigmoidoscopy · Enteroscopy · Capsule end

Transrectal ultrasonography · Enteroclysis · Small bowel follow-through · Abdominal ultrason

Stool testsFecal pH test · Stool guaiac test · Fecal fat test

LiverHepatectomy · Liver transplantation · Artificial extracorporeal liver support (Liver dialysis, Bioartificial

Accessory Gallbladder, bile ductCholangiography (ERCP, PTC, MRCP) · Cholecystectomy · Cholecystography · Cholescintigraphy · He

PancreasPancreatectomy · Pancreaticoduodenectomy · Pancreas transplantation · Puestow procedure · Frey's proce

PeritoneumParacentesis · Intraperitoneal injection

Abdominopelvic
HerniaHerniorrhaphy · Macewen's operation

Other Laparotomy · Rapid urease test/Urea breath test

CPRs Ranson criteria · MELD

 M: DIG anat(t, g, p)/phys/devp/cell/enzy noco/cong/tumr, sysi/epon

Categories: Gastroenterology | Endoscopy

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