Endoscopic Retrograde Cholangiopancreatography
Endoscopic Retrograde Cholangiopancreatography
Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives
Definition
Endoscopic retrograde cholangiopancreatography (ERCP) is an imaging technique used to diagnose diseases of the pancreas, liver, gallbladder, and bile ducts. It combines endoscopy and x-ray imaging.
Purpose
ERCP is used in the management of diseases that affect the gastrointestinal tract, specifically the pancreas, liver, gall bladder, and bile ducts. The pancreas is an organ that secretes pancreatic juice into the upper part of the intestine. Pancreatic juice is composed of specialized proteins that help to digest fats, proteins, and carbohydrates. Bile is a substance that helps to digest fats; it is produced by the liver, secreted through the bile ducts, and stored in the gallbladder. Bile is released into the small intestine after a person has eaten a meal containing fat.
A doctor may recommend ERCP if a patient is experiencing abdominal pain of unknown origin, weight loss, or jaundice. These may be symptoms of biliary disease. For instance, gallstones that form in the gallbladder or bile ducts may become stuck there, causing cramping or dull pain in the upper right area of the abdomen, fever, and/or jaundice. Other causes of biliary obstruction include tumors, injury from gallbladder surgery, or inflammation. The bile ducts may also become narrowed (called a biliary stricture) as a result of cancer, blunt trauma to the abdomen, pancreatitis (inflammation of the pancreas), or primary biliary cirrhosis (PBC). PBC may be caused by a condition called primary sclerosing cholangitis, an inflammation of the bile ducts that may cause pain, jaundice, itching, or other symptoms. These symptoms may also be experienced by a patient with cholangitis, or with infection of the bile ducts caused by bacteria or parasites.
ERCP can also be used to diagnose a number of pancreatic disorders. Pancreatitis is an inflammation of the pancreas, caused by chronic alcohol abuse, injury, obstruction of the pancreatic ducts (e.g., by gallstones), or other factors. The condition may be either acute (having a severe but short course) or chronic (persistent). Symptoms of pancreatitis include abdominal pain, weight loss, nausea, and vomiting. ERCP may be used to diagnose cancer of the pancreas; pancreatic pseudocysts (collections of pancreatic fluid); or strictures of the pancreatic ducts. Certain congenital disorders may also be identified by ERCP, such as pancreas divisum, a condition in which parts of the pancreas fail to fuse together during fetal development.
Demographics
Diseases of the pancreas and biliary tract affect millions of Americans each year. According to the National Health and Nutrition Survey, gallbladder disease affects approximately 6.3 million men and 14.2 million women in the United States between the
KEY TERMS
Bile— A bitter yellowish-brown fluid secreted by the liver that contains bile salts, bile pigments, cholesterol, and other substances. It helps the body to digest and absorb fats.
Congenital— Present at birth.
Endoscope— An instrument with a light source attached that allows the doctor to examine the inside of the digestive tract or other hollow organ.
Gastrointestinal tract— A group of organs and related structures that includes the esophagus, stomach, liver, gallbladder, pancreas, small intestine, large intestine, rectum, and anus.
Jaundice— A condition characterized by deposits of bile pigments in the skin, mucous membranes, and the whites of the eyes. It is also known as icterus.
Magnetic resonance imaging— A technique that uses a strong magnetic field and pulses of radio waves to produce cross-sectional images of the body.
Stent— A thin rod-like or tube-like device made of wire mesh, inserted into a blood vessel or duct to keep it open.
Stricture— An abnormal narrowing of a duct or canal.
ages of 24 and 74. Approximately one million new cases of gallstones are diagnosed each year. The incidence of gallstones is higher among women; adults over the age of 40; and people who are overweight. Primary sclerosing cholangitis occurs at a rate of two to seven cases per 100,000 persons. The rate of gallbladder cancer is approximately 2.5 out of 100,000 persons. In addition, approximately 87,000 cases of pancreatitis and 30,000 cases of pancreatic cancer are diagnosed each year in the United States.
Description
ERCP is performed with the patient given either a sedative or general anesthesia. The physician then sprays the back of the patient’s throat with a local anesthetic. The endoscope (a thin, hollow tube attached to a viewing screen) is then inserted into the mouth. It is threaded down the esophagus, through the stomach, and into the duodenum (upper part of the small intestine) until it reaches the spot where the bile and pancreatic ducts empty into the duodenum. At this point a small tube called a cannula is inserted through the endoscope and used to inject a contrast dye into the ducts. The term “retrograde” in the name of the procedure refers to the backward direction of the dye as it is injected through the ducts. A series of x rays are then taken as the dye moves through the ducts.
If the x rays show that a problem exists, ERCP may be used as a therapeutic tool. Special instruments can be inserted into the endoscope to remove gallstones, take samples of tissue for further examination (e.g., in the case of suspected cancer), or place a special tube called a stent into a duct to relieve an obstruction.
Diagnosis/Preparation
ERCP is generally not performed unless other less invasive diagnostic tests have first been used to determine the cause of a patient’s symptoms. Such tests include:
- complete medical history and physical examination
- blood tests (certain diseases can be diagnosed by abnormal levels of blood components)
- ultrasound imaging (a procedure that uses high-frequency sound waves to visualize structures in the human body)
- computed tomography (CT) scan (an imaging device that uses x rays to produce two-dimensional cross-sections on a viewing screen)
Before undergoing ERCP, the patient will be instructed to refrain from eating or drinking for at least six hours to ensure that the stomach and upper part of the intestine are empty. Arrangements should be made for someone to take the patient home after the procedure, as he or she will not be able to drive. The physician should also be given a complete list of all prescription, over-the-counter, and alternative medications or preparations that the patient is taking. The patient should also notify the doctor if he or she is allergic to iodine because the contrast dye contains it.
Aftercare
After the procedure, the patient will remain at the hospital or outpatient facility until the effects of the sedative wear off and no signs of any complications have appeared. A longer stay may be warranted if the patient experiences complications or if other procedures were performed.
Risks
Complications that have been reported with ERCP include pancreatitis; cholangitis (inflammation of the bile ducts); cholecystitis (inflammation of the gallbladder); injury to the duodenum; pain; bleeding;
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
ERCP is usually performed in the x-ray department of a hospital or outpatient facility by a gastroenterologist, a medical doctor who has completed specialized training in the diagnosis and treatment of diseases of the digestive system. An anesthesiologist administers the anesthetic, and a radiologist may be consulted in interpreting the images obtained by the dye injection.
infection; and formation of blood clots. Factors that increase the risk of complications include liver damage, bleeding disorders, a history of post-ERCP complications, and a less experienced endoscopist.
Normal results
Following ERCP, the patient’s biliary and pancreatic ducts should be free of stones and show no strictures, obstructions, or evidence of infection or inflammation.
Morbidity and mortality rates
The overall complication rate associated with ERCP is approximately 11%. Pancreatitis may occur in up to 7% of patients. Cholangitis and cholecystitis occur in less than 1% of patients. Infection, injury, bleeding, and blot clot formation also occur in less than 1%. The mortality rate for ERCP is approximately 0.1%.
Alternatives
Although less invasive techniques exist (such as computed tomography and ultrasonography) to help to diagnose gastrointestinal diseases, these imaging studies are often not precise enough to allow for definite diagnosis of certain conditions. Percutaneous transhepatic cholangiography (PTCA) is an alternative to ERCP that involves the insertion of a long, flexible needle through the skin to the bile ducts; contrast dye is then injected into the ducts so that they may be visualized by x ray. PTCA may be recommended if ERCP fails or cannot be performed. Magnetic resonance cholangiopancreatography (MRCP) is an imaging technology that allows for noninvasive examination of the biliary and pancreatic ducts. Its disadvantage, however, is that unlike ERCP, it cannot be used for therapeutic procedures as well as imaging.
QUESTIONS TO ASK THE DOCTOR
- Why is ERCP recommended in my case?
- What diagnostic tests will be performed prior to ERCP?
- How long will the procedure take?
- When will I find out the results?
- Will you treat the problem if one is found during the procedure?
Resources
BOOKS
Feldman, Mark, et al. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 7th ed. Philadelphia: Elsevier Science, 2002.
PERIODICALS
Ahmed, Aijaz, and Emmet B. Keeffe. “Gallstones and Biliary Tract Disease.” WebMD Scientific American Medicine February 28, 2003 [cited April 7, 2003]. http://www.medscape.com/viewarticle/449563_1.
Aronson, Naomi, Carole Flamm, Rhonda L. Bohn, et al. “Evidence-Based Assessment: Patient, Procedure, or Operator Factors Associated with ERCP Complications.” Gastrointestinal Endoscopy 56, no. 6 (December 2002)(6 Suppl): S294-S302.
Freeman, Martin L. “Adverse Outcomes of ERCP.” Gastrointestinal Endoscopy 56, no. 6 (December 2002) (6 Suppl): S273-S282.
Vandervoort, Jo, et al. “Risk Factors for Complications After Performance of ERCP.” Gastrointestinal Endoscopy 56, no. 5 (November 2002): 652–656.
Yakshe, Paul. “Biliary Disease.” eMedicine, March 29, 2002 [cited April 7, 2003]. http://www.emedicine.com/MED/topic225.htm.
Yakshe, Paul. “Pancreatitis, Chronic.” eMedicine, January 8, 2003 [cited April 7, 2003]. http://www.emedicine.com/med/topic1721.htm.
ORGANIZATIONS
American College of Gastroenterology. 4900 B South 31st St., Arlington, VA 22206. (703) 820-7400. http://www.acg.gi.org.
American Gastroenterological Association. 7910 Wood-mont Ave., 7th Floor, Bethesda, MD 20814. (301) 654-2055. http://www.gastro.org.
American Society for Gastrointestinal Endoscopy. 1520 Kensington Rd., Suite 202, Oak Brook, IL 60523. (630)573-0600. http://www.asge.org.
OTHER
National Digestive Diseases Information Clearinghouse. Endoscopic Retrograde Cholangiopancreatography.
Bethesda, MD: NDDIC, 2002. [cited April 7, 2003]. http://www.niddk.nih.gov/health/digest/pubs/diagtest/ercp.htm.
Stephanie Dionne Sherk
Endoscopic sclerotherapy seeSclerotherapy for esophageal varices
Endoscopic Retrograde Cholangiopancreatography
Endoscopic retrograde cholangiopancreatography
Definition
Endoscopic retrograde cholangiopancreatography (ERCP) is an imaging technique used to diagnose diseases of the pancreas, liver, gallbladder, and bile ducts. It combines endoscopy and x-ray imaging.
Purpose
ERCP is used in the management of diseases that affect the gastrointestinal tract, specifically the pancreas, liver, gall bladder, and bile ducts. The pancreas is an organ that secretes pancreatic juice into the upper part of the intestine. Pancreatic juice is composed of specialized proteins that help to digest fats, proteins, and carbohydrates. Bile is a substance that helps to digest fats; it is produced by the liver, secreted through the bile ducts, and stored in the gallbladder. Bile is released into the small intestine after a person has eaten a meal containing fat.
A doctor may recommend ERCP if a patient is experiencing abdominal pain of unknown origin, weight loss, or jaundice. These may be symptoms of biliary disease. For instance, gallstones that form in the gallbladder or bile ducts may become stuck there, causing cramping or dull pain in the upper right area of the abdomen, fever, and/or jaundice. Other causes of biliary obstruction include tumors, injury from gallbladder surgery, or inflammation. The bile ducts may also become narrowed (called a biliary stricture) as a result of cancer, blunt trauma to the abdomen, pancreatitis (inflammation of the pancreas), or primary biliary cirrhosis (PBC). PBC may be caused by a condition called primary sclerosing cholangitis, an inflammation of the bile ducts that may cause pain, jaundice, itching, or other symptoms. These symptoms may also be experienced by a patient with cholangitis, or with infection of the bile ducts caused by bacteria or parasites.
ERCP can also be used to diagnose a number of pancreatic disorders. Pancreatitis is an inflammation of the pancreas, caused by chronic alcohol abuse, injury, obstruction of the pancreatic ducts (e.g., by gallstones), or other factors. The condition may be either acute (having a severe but short course) or chronic (persistent). Symptoms of pancreatitis
creatitis include abdominal pain, weight loss, nausea, and vomiting. ERCP may be used to diagnose cancer of the pancreas; pancreatic pseudocysts (collections of pancreatic fluid); or strictures of the pancreatic ducts. Certain congenital disorders may also be identified by ERCP, such as pancreas divisum, a condition in which parts of the pancreas fail to fuse together during fetal development.
Demographics
Diseases of the pancreas and biliary tract affect millions of Americans each year. According to the National Health and Nutrition Survey, gallbladder disease affects approximately 6.3 million men and 14.2 million women in the United States between the ages of 24 and 74. Approximately one million new cases of gallstones are diagnosed each year. The incidence of gallstones is higher among women; adults over the age of 40; and people who are overweight. Primary sclerosing cholangitis occurs at a rate of two to seven cases per 100,000 persons. The rate of gallbladder cancer is approximately 2.5 out of 100,000 persons. In addition, approximately 87,000 cases of pancreatitis and 30,000 cases of pancreatic cancer are diagnosed each year in the United States.
Description
ERCP is performed with the patient given either a sedative or general anesthesia. The physician then sprays the back of the patient's throat with a local anesthetic. The endoscope (a thin, hollow tube attached to a viewing screen) is then inserted into the mouth. It is threaded down the esophagus, through the stomach, and into the duodenum (upper part of the small intestine) until it reaches the spot where the bile and pancreatic ducts empty into the duodenum. At this point a small tube called a cannula is inserted through the endoscope and used to inject a contrast dye into the ducts. The term "retrograde" in the name of the procedure refers to the backward direction of the dye as it is injected through the ducts. A series of x rays are then taken as the dye moves through the ducts.
If the x rays show that a problem exists, ERCP may be used as a therapeutic tool. Special instruments can be inserted into the endoscope to remove gallstones, take samples of tissue for further examination (e.g., in the case of suspected cancer), or place a special tube called a stent into a duct to relieve an obstruction.
Diagnosis/Preparation
ERCP is generally not performed unless other less invasive diagnostic tests have first been used to determine the cause of a patient's symptoms. Such tests include:
- complete medical history and physical examination
- blood tests (certain diseases can be diagnosed by abnormal levels of blood components)
- ultrasound imaging (a procedure that uses high-frequency sound waves to visualize structures in the human body)
- computed tomography (CT) scan (an imaging device that uses x rays to produce two-dimensional cross-sections on a viewing screen)
Before undergoing ERCP, the patient will be instructed to refrain from eating or drinking for at least six hours to ensure that the stomach and upper part of the intestine are empty. Arrangements should be made for someone to take the patient home after the procedure, as he or she will not be able to drive. The physician should also be given a complete list of all prescription, over-thecounter, and alternative medications or preparations that the patient is taking. The patient should also notify the doctor if he or she is allergic to iodine because the contrast dye contains it.
Aftercare
After the procedure, the patient will remain at the hospital or outpatient facility until the effects of the sedative wear off and no signs of any complications have appeared. A longer stay may be warranted if the patient experiences complications or if other procedures were performed.
Risks
Complications that have been reported with ERCP include pancreatitis, cholangitis (inflammation of the bile ducts), cholecystitis (inflammation of the gallbladder), injury to the duodenum, pain, bleeding, infection, and formation of blood clots. Factors that increase the risk of complications include liver damage, bleeding disorders, a history of post-ERCP complications, and a less experienced endoscopist.
Normal results
Following ERCP, the patient's biliary and pancreatic ducts should be free of stones and show no strictures, obstructions, or evidence of infection or inflammation.
Morbidity and mortality rates
The overall complication rate associated with ERCP is approximately 11%. Pancreatitis may occur in up to 7% of patients. Cholangitis and cholecystitis occur in less than 1% of patients. Infection, injury, bleeding, and blot clot formation also occur in less than 1%. The mortality rate for ERCP is approximately 0.1%.
Alternatives
Although less invasive techniques exist (such as computed tomography and ultrasonography) to help to diagnose gastrointestinal diseases, these imaging studies are often not precise enough to allow for definite diagnosis of certain conditions. Percutaneous transhepatic cholangiography (PTCA) is an alternative to ERCP that involves the insertion of a long, flexible needle through the skin to the bile ducts; contrast dye is then injected into the ducts so that they may be visualized by x ray. PTCA may be recommended if ERCP fails or cannot be performed. Magnetic resonance cholangiopancreatography (MRCP) is an imaging technology that allows for noninvasive examination of the biliary and pancreatic ducts. Its disadvantage, however, is that unlike ERCP, it cannot be used for therapeutic procedures as well as imaging.
Resources
books
Feldman, Mark, et al. Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed. Philadelphia: Elsevier Science, 2002.
periodicals
Ahmed, Aijaz, and Emmet B. Keeffe. "Gallstones and Biliary Tract Disease." WebMD Scientific American Medicine February 28, 2003 [cited April 7, 2003]. <www.medscape.com/viewarticle/449563_1>.
Aronson, Naomi, Carole Flamm, Rhonda L. Bohn, et al. "Evidence-Based Assessment: Patient, Procedure, or Operator Factors Associated with ERCP Complications." Gastrointestinal Endoscopy 56, no. 6 (December 2002)(6 Suppl): S294-S302.
Freeman, Martin L. "Adverse Outcomes of ERCP." Gastrointestinal Endoscopy 56, no. 6 (December 2002) (6 Suppl): S273-S282.
Vandervoort, Jo, et al. "Risk Factors for Complications After Performance of ERCP." Gastrointestinal Endoscopy 56, no. 5 (November 2002): 652-656.
Yakshe, Paul. "Biliary Disease." eMedicine, March 29, 2002 [cited April 7, 2003]. <www.emedicine.com/MED/topic 225.htm>.
Yakshe, Paul. "Pancreatitis, Chronic." eMedicine, January 8, 2003 [cited April 7, 2003]. <www.emedicine.com/med/topic1721.htm>.
organizations
American College of Gastroenterology. 4900 B South 31st St., Arlington, VA 22206. (703) 820-7400. <www.acg.gi.org>.
American Gastroenterological Association. 7910 Woodmont Ave., 7th Floor, Bethesda, MD 20814. (301) 654-2055. <www.gastro.org>.
American Society for Gastrointestinal Endoscopy. 1520 Kensington Rd., Suite 202, Oak Brook, IL 60523. (630) 573-0600. <www.asge.org>.
other
National Digestive Diseases Information Clearinghouse. Endoscopic Retrograde Cholangiopancreatography. Bethesda, MD: NDDIC, 2002. [cited April 7, 2003]. <www.niddk.nih.gov/health/digest/pubs/diagtest/ercp.htm>.
Stephanie Dionne Sherk
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
ERCP is usually performed in the x-ray department of a hospital or outpatient facility by a gastroenterologist, a medical doctor who has completed specialized training in the diagnosis and treatment of diseases of the digestive system. An anesthesiologist administers the anesthetic, and a radiologist may be consulted in interpreting the images obtained by the dye injection.
QUESTIONS TO ASK THE DOCTOR
- Why is ERCP recommended in my case?
- What diagnostic tests will be performed prior to ERCP?
- How long will the procedure take?
- When will I find out the results?
- Will you treat the problem if one is found during the procedure?
Endoscopic Retrograde Cholangiopancreatography
Endoscopic Retrograde Cholangiopancreatography
Definition
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 six 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 5-10%; 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.
KEY TERMS
Endoscope, endoscopy— 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.
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 perforation (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
OTHER
Endoscopic Retrograde Cholangiopancreatography. [cited June 21, 2004]. 〈http://www.asge.org〉.
Measuring Procedural Skills. [cited June 21, 2004]. 〈http://www.acponline.org/journals/annals/15dec96/procskil.htm〉.
Treatment of Acute Biliary Pancreatitis. [cited June 21, 2004]. 〈http://content.nejm.org〉.
Endoscopic Retrograde Cholangiopancreatography
Endoscopic retrograde cholangiopancreatography
Definition
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.
OTHER
Endoscopic Retrograde Cholangiopancreatography. 21 June 2001 <http://www.asge.org>.
Measuring Procedural Skills. 21 June 2001 <http://www.acponline.org/journals/annals/15dec96/procskil.htm>.
Treatment of Acute Biliary Pancreatitis. 21 June 2001 <http://content.nejm.org>.
David S. Kaminstein
KEY TERMS
Endoscope, endoscopy
—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?
- When can I resume normal activities?
- What future care will I need?