Endoscopic Sphincterotomy

Definition

Endoscopic sphincterotomy or endoscopic retrograde sphincterotomy (ERS) is a relatively new endoscopic technique developed to examine and treat abnormalities of the bile ducts, pancreas and gallbladder. The procedure was developed as an extension to the diagnostic examination, ERCP (endoscopic retrograde cholangiopancreatography); with the addition of "sphincterotomy," abnormalities found during the study could be treated at the same time without the need for invasive surgery.

The term ERS has three parts to its definition;

• endoscopic refers to the use of an endoscope
• retrograde refers to the insertion of the endoscope up into the ducts in a direction opposite to or against the normal flow of bile down the ducts
• sphincterotomy, which means cutting of the sphincter or muscle that lies at the juncture of the intestine with both the bile and pancreatic ducts.

Purpose

Until the 1970s, patients with symptoms related to disease of the bile ducts or pancreas frequently needed surgery to diagnose the cause and treat any abnormalities. ERCP allowed physicians for the first time to obtain high quality x rays of the common bile and pancreatic ducts, and detect areas of narrowing (strictures), stones, and tumors. ERCP was not initially designed for treatment. ERS was developed shortly after and enabled physicians to treat the abnormalities identified by the injection of dye and x rays.

The revolutionary technique made possible the endoscopic removal of stones and stretching of areas of narrowing (strictures). It has since been expanded to include drainage of bile from blocked ducts and treatment of various abnormalities of the pancreas.

Precautions

The most important precaution related to both ERCP and ERS is to have the procedure performed by an experienced physician. ERS is technically more difficult than many other gastrointestinal endoscopic studies, including ERCP. Patients should inquire as to the physician's experience with the procedure. The physician should also be informed of any allergies, medication use, and medical problems.

Description

ERS is generally performed only after ERCP has been successfully accomplished and detail of the anatomy and abnormalities is known. During ERS, a number of various instruments are inserted through the endoscope in order to "cut" or stretch the sphincter. Once this is done, additional instruments are passed that enable the removal of stones and the stretching of narrowed regions of the ducts. Drains (stents) can also be used to prevent a narrowed area from rapidly returning to its previously narrowed state.

Preparation

The upper intestinal tract must be empty for the procedure, so patients must not eat or drink for at least six to 12 hours before the exam. Patients need to inquire about taking their medications before the procedure. Some patients may require antibiotics before and/or after the procedure. When possible, aspirin or NSAIDS should not be taken within several days before the procedure, because they interfere with blood clotting.

Aftercare

When ERS is performed, physicians will usually want to observe the patient closely for several hours to ensure that there are no signs of complications. Pain or any other unusual symptoms should be reported. Admission to the hospital may be advised.

Risks

ERS complications are related either to the drugs used during the procedure, or the results of dye injection or cutting of tissue. The overall complication rate is 5-10%. 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. Cutting or stretching of these structures can sometimes cause a hole or perforation. The use of sedatives also carries a risk of decreasing cardiac and respiratory function, however, it is very difficult to perform these procedures without these drugs.

Other major complications related to ERCP or ERS are pancreatitis (inflammation of the pancreas) and cholangitis (inflammation of the bile ducts). Bacteremia (the passage of bacteria into the blood stream) and bleeding are also risks.

Normal results

Certain standards have been set for the diameter or width of the pancreatic and bile ducts. Measurements by x ray are used to determine if the ducts are too large (dilated) or too narrow (strictured). Lastly, the ducts and gallbladder should be free of any solid particles, such as stones, and free of areas of narrowing.

Resources

OTHER

"Endoscopic Retrograde Cholangiopancreatography." American Society for Gastrointestinal Endoscopy. 〈http://www.asge.org〉.

"Treatment of Acute Biliary Pancreatitis." New England Journal of Medicine Online. 〈http://content.nejm.org〉.

KEY TERMS

Endoscope, Endoscopy— An endoscope as used in the field of gastroenterology is a thin flexible tube which uses a lens or miniature camera to view various areas of the gastrointestinal tract. When the procedure is performed to examine certain organs such as the bile ducts or pancreas, the organs are not viewed directly, but rather indirectly through the injection of x-ray dye. The performance of an exam using an endoscope is referred by the general term endoscopy. Diagnosis through biopsies or other means and therapeutic procedures can be done with these instruments.

NSAIDS— This abbreviation stands for non-steroidal anti-inflammatory drugs, which are medications such as Ibufprofen that are used to control pain and inflammation. Most may be purchased over the counter. One of their major side effects is that they decrease the effect of the normal blood clotting factors in blood. In patients undergoing surgical or endoscopic procedures, this can lead to an increased risk of bleeding.