Endoscopic Retrograde Cholangio-Pancreatography (ERCP)
ERCP is a procedure where a special flexible tube (duodenoscope) is inserted from the mouth to the duodenum to examine the bile duct through its opening in the duodenum. This opening is called the papilla. After locating the papilla, the doctor will pass a small plastic tube through the papilla to reach the bile duct or the pancreatic duct. Small amount of radio-opaque contrast will then be injected into the ducts and X-ray images taken to look at the ducts.
Depending on the findings during ERCP, your doctor may decide to make a small incision at the papilla for further treatment.
The bile duct transports bile produced by the liver to the duodenum (small intestine). It is joined by the pancreatic duct at its lower end. The pancreatic duct transports digestive juices produced by the pancreas into the small intestine. The pancreatic duct and the bile duct form a short common channel which opens into the duodenum. This opening is called the papilla. The papilla has a ring of muscles around it which allows the flow of fluid in one direction, preventing the reverse flow of fluid back into the bile duct or the pancreatic duct. It this happens, it can cause infection (cholangitis) or inflammation (pancreatitis). This ring of muscles is called the sphincter (of Oddi).
Your doctor may recommend an ERCP to evaluate or treat the following symptoms/conditions:
- Bile duct stones
- Obstructive jaundice due to bile duct stenosis (narrowing)
- Acute or chronic pancreatitis
- Suspected ampullary tumour
- Suspected bile duct or pancreatic duct cancer
- Bile duct or pancreatic duct leak
How is an ERCP performed?
Your doctor will first take an informed consent during which he will describe the procedure, the benefits as well as the risks involved, as well as alternative methods.
You will be asked not to eat or drink anything for up to six hours before the procedure. Your stomach needs to be empty because:
- Presence of food will block the view.
- Decrease the chance of food or fluid being vomited into the lungs while under sedation (aspiration).
- You may be asked to skip your morning diabetes medicine by your doctor as you may be kept fasted 4 to 6 hours after the procedure.
- You may be asked to stop taking medications such as Aspirin, Ticlid or Plavix one week before the procedure.
- Patients on anticoagulants like Warfarin may need to switch to injections before the procedure.
- However, please continue to take any regularly-prescribed medications unless instructed otherwise.
- You will be told where and what time to report to the Endoscopy Centre.
- At the Endoscopy Centre, the nurse will serve you a sweet tasting syrup to rid your stomach lining of small bubbles and hence improve the visualization.
- The nurse will then spray a medication to the back of your throat to numb it.
- An intravenous cannula will be placed into your hand so as to allow us to administer the sedatives.
- Your parameters (blood pressure, heart rate and blood oxygen level) will be monitored before, during and after the procedure.
- Oxygen may be given by way of a plastic tube.
- Finally a plastic mouth guard will be placed between the teeth to prevent damage to your teeth and the scope.
- You will be asked to lie on your front.
- Once you are fully sedated, your doctor will gently pass the scope into your mouth.
- As the scope is advanced, air will be introduced so as to allow the doctor to see better. You may therefore experience bloating and the urge to belch. Otherwise you should feel little or no pain.
- The procedure will take 45 minutes to 1 hour.
|This is an animation of an ERCP produced by the makers of Spyglass.
The scope is passed into the duodenum so as to see the bile duct opening (the papilla). A catheter is then passed into it under Xray guidance.
|This is a footage of an actual ERCP performed in a patient with a common bile duct stone|
- After the procedure, you will be observed in a recovery area for a period before being transferred to an inpatient ward.
- You will be kept fasted.
- The most common discomfort is a feeling of bloating. This usually resolves quickly within 24 hours.
- Some patients may complain of mild sore throat.
Although ERCP is a safe procedure, complications can occur infrequently. Some of the complications can be serious. The complications tend to be more common when the doctor needs to perform a sphincterotomy.
These complications can happen during or within the first few hours after the ERCP.
- Inflammation of the pancreas (pancreatitis)
- Infective complications such as cholangitis
- Perforation of the intestine, which may require surgery
- Risks of sedation, including obstructed airway, deep sedation, etc.
- Heart attack and stroke for older patients
The risk of death from an ERCP procedure is about 1%.
These complications can happen weeks or months after ERCP
- Stricture (narrowing) of the papilla caused by scarring
- Repeated bouts of cholangitis
bile duct infection due to intestine fluid flowing up the bile duct as a result of a sphincterotomy
For imaging of the bile duct, one alternative is an X-ray study called Magnetic Resonance Cholangio-Pancreatogram (MRCP).
For removal of confirmed bile duct stones, one alternative is to perform a Laparoscopic Common Bile Duct Exploration to remove the bile duct stones.
Most patients will be admitted for an overnight observation after ERCP and will be discharged the next day if he is well. Some patients can be discharged on the same day of ERCP after adequate monitoring.
You will be given an appointment for further follow-up to discuss your ERCP findings and subsequent management.
You may be asked by your doctor to skip your regular antiplatelet agents such as Aspirin, Ticlid or Plavix for another few more days.