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Endoscopic retrograde cholangiopancreatography (ERCP)


Medical editor Lars Aabakken MD
Gastroenterologist
Oslo University Hospital

General

Endoscopic retrograde cholangiopancreatography (ERCP) provides an X-ray image of the bile ducts and pancreatic ductal system by direct injection of contrast into the ductal system.

The technique also provides access to both extended diagnostics and therapeutic procedures for the bile ducts and pancreas.

The procedure can be performed on an outpatient basis and is similar to gastroscopy. If a therapeutic procedure is performed, the patient often stays in the hospital for observation. 

For ERCP, a duodenoscope is used which is a special gastroscope with side viewing optic. This makes it significantly more suitable to manipulate the duodenal papilla, however navigation is more difficult. Various customized instruments can be passed through the instrument canal of the endoscope and further on through the papilla.

Indications

Cancer in the pancreas or liver/bile ducts:

  • Diagnostic technique for ambiguous cases (visualization of ductal system and possible brush sampling or biopsy)
  • Preoperative bile/pancreatic duct decompression 
  • Symptom relieving drainage of bile/pancreatic ductal system  in cases of inoperable cancer
  • Local removal of early stage cancer in duodenal papilla 

A common feature is that all of these indications include therapy. Diagnostic ERCP is applied to a diminishing degree, but may still be used for collecting tissue samples (cytology or biopsy).

Goals

  • Obtain a diagnosis
  • Drain stenotic ductal systems

Equipment

  • Side optic endoscope (duodenoscope) with accessories 

Preparation

Plavix®, Clopidogrel®, Brillique®, Pradaxa®, Xarelto®, Eliquis®, Fragmin® or Marevan® (warfarin) should be stopped  to reduce the risk of bleeding during the procedure, if the patients general practitioner doesn´t decides otherwise.

  • Plavix®, Clopidogrel® and Brilique® may be taken up to seven days before the procedure.
  • Pradaxa®, Xarelto® and Eliquis® may be taken up to 48 hours before the procedure.
  • Marevan® (warfarin) may be taken up to 48 hours before the procedure, and the patient must also have an INR control at least an hour before the examination.
  • The patient may continue to take Albyl-E® (acetylsalicylic acid).
  • Fragmin® injections may be taken until the night before the procedure.
  • If the patient has an artificial heart valve, contact the ward in charge of the excamination.

The stomach must be empty before the procedure.

  • The patient can´t eat or drink anything in the last six hours before the procedure.
  • If the patient is very thirsty he/she may drink 1-2 glasses of water until two hours before the procedure, and then only rinse the mouth without swallowing anything.

If the patient have diabetes and use insulin or other essential medecines that can´t be postponed, the patient can get an appointment early in the day.

The procedure is usually carried out under light sedation with Dormicum®/Pethidin®, however propofol-anesthesia is becoming more common. General anesthesia is only exceptionally use.


Implementation

  • The procedure is performed with the patient on the stomach with the right side slightly raised.
  • The endoscope is inserted carefully through the mouth and stomach to the duodenal papilla.
  • A thin plastic tube is manipulated into the bile duct or pancreatic duct and contrast fluid is injected to visualize the ductal system, and an X-ray picture is taken simultaneously. 
  • If necessary, a brush or biopsy forceps is inserted into the duct for sampling.
  • If necessary stenotic areas can be expanded with a balloon, plastic tubing, or a stent.

Follow-up

The patient can often return home the same day, unless a procedure is performed which increases the risk for complications. This is determined on an individual basis.  

Results from biopsies are usually available after 1 week.

If a stent is inserted, this must usually be removed or changed after 2–3 months by a repeated ERCP procedure.

Complications

Most ERCP procedures are carried out without complications. It is common to have a sore throat and light abdominal pain (including gas pain) after the procedure.

Pancreatitis is the most threatening complication and occurs in 4–15% of cases. There are some known risk factors, most significantly previous ERCP pancreatitis and possibly ampullary dysfunction. However, pancreatitis occurs for unknown cause. Fortunately, most cases are mild with only abdominal pain requiring a few extra days in the hospital. However, necrotizing pancreatitis also occurs with significant mortality.

Other, less frequent complications are cholangitis, bleeding, or perforations after endoscopic papillotomy. If any of these are discovered during the examination, they are usually treated conservatively without the need for surgery or other intervention. Delayed bleeding (within 24 hours) also occurs and will often require a repeat endoscopic procedure for treatment.


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