Endoscopic Retrograde Cholangiopancreatography (ERCP)

What is ERCP?

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive endoscopic procedure that combines a flexible endoscope and X-ray imaging to diagnose and treat conditions affecting the bile ducts and pancreatic ducts. 

The endoscope is a long, flexible tube with a light and camera attached to the end. It is passed through the mouth and into the digestive system to the point where the bile ducts and pancreatic ducts meet. Contrast dye is injected into these ducts, and X-ray images are taken to visualise any abnormalities.

Who is Suitable for ERCP?

ERCP is usually recommended for patients with suspected or confirmed diseases affecting the bile and pancreatic ducts. Some of the conditions that may require ERCP include the following:

• Gallstones
• Biliary strictures (narrowing of the bile ducts)
• Biliary leaks
• Pancreatitis (inflammation of the pancreas)
• Pancreatic cancer
• Bile duct cancer

Your gastroenterologist will determine your suitability for ERCP based on your medical history, symptoms, and diagnostic test results.

What are the Benefits of ERCP?

ERCP offers several benefits for patients requiring diagnosis or treatment of conditions affecting the bile and pancreatic ducts. Some of the benefits of ERCP include the following:

• Minimally invasive procedure: ERCP is minimally invasive, meaning it typically involves less pain, shorter recovery time, and lower risk than traditional surgery. No external incisions or scars are necessary. 
• Accurate diagnosis: ERCP allows for accurate diagnosis of conditions affecting the bile ducts, liver, gallbladder, and pancreas. This enables your gastroenterologist to develop an effective treatment plan.
• Therapeutic benefits: ERCP can also be used to treat conditions affecting the bile ducts and pancreatic ducts. For example, your gastroenterologist may use ERCP to remove gallstones or place stents in the bile ducts to relieve blockages.
• High success rate: ERCP has a high success rate in diagnosing and treating conditions affecting the bile ducts and pancreatic ducts. By enabling both diagnosis and treatment in one procedure, ERCP can improve patient outcomes and faster relieve symptoms.

What are the Types of ERCP?

There are several types of ERCP procedures, each of which is used to diagnose and treat different conditions. Some of the common types of ERCP include:

• Diagnostic ERCP: This type of ERCP is used to diagnose conditions affecting the bile ducts and pancreatic ducts. Contrast dye is injected into the ducts, and X-ray images are taken to visualise any abnormalities.
• Therapeutic ERCP: This type of ERCP treats conditions affecting the bile and pancreatic ducts. Your gastroenterologist may use ERCP to remove gallstones, drain bile ducts, place stents to open blocked ducts or obtain tissue samples for biopsy.
• Spyglass Cholangioscopy: This is a specialised type of ERCP that uses a tiny camera mounted on the end of a catheter to visualise the inside of the bile ducts in more detail. This procedure helps diagnose and treat complex biliary strictures, tumours, and large bile duct stones.
• Endoscopic Ultrasound-guided ERCP (EUS-ERCP): This is a combination procedure involving endoscopy and ultrasound imaging. EUS-ERCP is used to diagnose and treat conditions affecting the pancreas and bile ducts, such as pancreatic tumours or biliary strictures.

Alternative Options to Endoscopic Retrograde Cholangiopancreatography

In some cases, alternative options to ERCP may be considered. These include:

• Magnetic Resonance Cholangiopancreatography (MRCP): This imaging test uses magnetic resonance imaging (MRI) to create detailed images of the bile and pancreatic ducts. MRCP is non-invasive and does not require contrast dye or X-rays. However, it may not be as accurate as ERCP in detecting minor abnormalities and does not treat the underlying disease.
• Endoscopic Ultrasound (EUS): This procedure uses an endoscope equipped with an ultrasound probe to create images of the bile and pancreatic ducts. EUS is often used to detect small stones, pancreatic tumours or cysts. It can also guide fine-needle aspiration (FNA) biopsies of the pancreas or lymph nodes.
• Percutaneous Transhepatic Cholangiography (PTC): This procedure involves inserting a needle through the skin and into the liver to inject contrast dye into the bile ducts. X-rays are then taken to create images of the ducts, followed by the insertion of stents to unblock obstructions. PTC is often used when ERCP is not possible or has failed.

Preparation Before an ERCP Procedure

Your gastroenterologist will provide instructions on how to prepare before the procedure. You may need to fast for several hours before the procedure and stop taking certain medications. You will be asked to sign a consent form and may be given sedatives to help you relax during the procedure.

What Happens During ERCP Procedure?

ECRP may be performed as a day-only or overnight procedure. You are placed on an X-ray table.

• While asleep, the ERCP scope is inserted into your mouth, down into the stomach and then into the upper part of the small intestine (duodenum).
• Once the endoscope reaches the papilla - where the pancreas and bile ducts meet - a thin wire is inserted through a tube (catheter).
• Dye is then injected into the ducts. X-ray images are taken to diagnose any problem related to the ducts.
• When a problem is detected during the examination, such as a gallstone or narrowing of the ducts, the doctor can treat your condition immediately.
• The gastroenterologist can insert instruments into the scope where necessary to remove or relieve the obstruction. Tissue samples (biopsy) can also be taken for further testing.
• This may include a Sphincterotomy (cutting of the small muscle at the entrance of the duct with a wire) to assist with the drainage of bile from the duct.

Sometimes, a small tube called a stent that can be plastic or metal may need to be left in the duct to help the bile flow into the bowel.

After ERCP Procedure

After the procedure, patients must stay at the hospital for at least 2 hours until the sedative wears off. 

If any kind of treatment is done during ERCP, such as removing a gallstone, you may need to stay in the hospital overnight.

Your gastroenterologist will make sure you do not have signs of complications before you leave.

Recovery after ERCP

It is essential to allow time for recovery after ERCP. While ERCP is generally considered a safe and minimally invasive procedure, there are some steps you can take to help ensure a smooth recovery and minimise any potential complications.

Here are some tips for a smooth ERCP recovery:

• Follow post-procedure instructions: Your gastroenterologist will provide instructions on what to do after the procedure. This may include instructions on what to eat, how much to rest, and when to resume your normal activities. Follow these instructions carefully to help minimise the risk of complications.
• Rest and avoid strenuous activity: After ERCP, you may feel tired from the sedatives used during the procedure. Take it easy for the remainder of the day and avoid strenuous activity or heavy lifting for at least 24 hours.
• Stay hydrated: Drinking fluids after ERCP can help flush out any contrast dye or other substances used during the procedure. Avoid alcohol and caffeinated beverages, which can dehydrate you.
• Watch for signs of complications: While complications after ERCP are rare, it is essential to watch for signs of potential complications. These may include severe abdominal pain, fever, or signs of infection, such as redness or swelling at the injection site. Contact your gastroenterologist immediately if you experience any of these symptoms.
• Follow-up appointments: After ERCP, you will likely need to schedule a follow-up appointment with your gastroenterologist. This will allow them to monitor your progress and ensure that you are healing correctly. Attending this appointment and reporting any concerns or issues you may be experiencing is essential.

Most patients can resume normal activities within a day or two after ERCP. However, it is essential to follow your gastroenterologist's instructions carefully and contact them if you have any concerns or questions about your recovery.

Complications and Risks with ERCP

While ERCP is generally considered a safe procedure, it has risks. Some potential risks and complications of ERCP include:

• Infection
• Pancreatitis (inflammation of the pancreas)
• Bleeding
• Perforation (tearing or puncturing of the bowel)
• Cardiovascular complications, such as heart attack or arrhythmia

The risk of complications is higher in patients with certain pre-existing conditions, such as liver disease or previous abdominal surgery. Your gastroenterologist will discuss the risks and benefits of ERCP with you before the procedure and take steps to minimise the risk of complications.