Overview
Definition:
Endoscopic Retrograde Cholangiopancreatography (ERCP) is a specialized endoscopic procedure used to diagnose and treat conditions of the bile ducts and pancreatic duct
It combines endoscopy with fluoroscopy, allowing visualization and intervention within the biliary and pancreatic systems through the ampulla of Vater.
Epidemiology:
ERCP is performed in approximately 10-15% of patients with biliary tract disease and in a smaller percentage of those with pancreatic duct abnormalities
Its incidence is rising with the increasing prevalence of gallstone disease and pancreatic cancer
Demographics vary based on the underlying condition being investigated or treated.
Clinical Significance:
ERCP is a cornerstone in the management of common bile duct stones, cholangitis, biliary strictures, and pancreatic duct obstructions
It offers both diagnostic capabilities and therapeutic interventions, often avoiding more invasive surgical procedures
Proficiency in understanding its indications and managing patients peri-procedurally is crucial for surgeons and gastroenterologists aiming for successful DNB and NEET SS outcomes.
Indications
Diagnostic Indications:
Suspected choledocholithiasis (common bile duct stones) based on elevated liver enzymes and dilated bile ducts on imaging
Suspected malignant biliary obstruction requiring tissue diagnosis (e.g., brush cytology, biopsy)
Evaluation of pancreatic duct abnormalities (e.g., strictures, tumors, pseudocysts)
Unexplained jaundice with suspected biliary obstruction
Diagnosis of chronic pancreatitis complications.
Therapeutic Indications:
Removal of common bile duct stones (lithotripsy may be needed for large stones)
Sphincterotomy to facilitate stone extraction or relieve benign strictures
Balloon dilation of biliary or pancreatic strictures
Stent placement for malignant or benign biliary or pancreatic duct obstruction
Retrieval of impacted stones
Management of biliary leaks or fistulas
Drainage of pancreatic pseudocysts or abscesses.
Absolute Contraindications:
Perforation of the gastrointestinal tract or bile/pancreatic duct
Acute pancreatitis (relative contraindication, procedure may worsen symptoms)
Severe coagulopathy or uncorrected bleeding diathesis
Known allergy to iodinated contrast media (if used)
Severe, unstable medical conditions precluding safe endoscopy (e.g., severe cardiac or respiratory disease).
Relative Contraindications:
Pregnancy (especially in the first trimester due to radiation exposure)
Recent myocardial infarction or stroke
Active severe infection (other than cholangitis which is often an indication)
Patient refusal or inability to consent
Diverticulosis of the duodenum, increasing risk of perforation.
Peri Procedural Care
Preoperative Preparation:
Detailed patient history including allergies, bleeding disorders, and medications (especially anticoagulants and antiplatelets)
Thorough physical examination
Laboratory investigations: CBC, coagulation profile (PT/INR, aPTT), liver function tests, electrolytes, renal function tests, amylase, lipase
Review of imaging (ultrasound, CT, MRI/MRCP) to confirm anatomy and suspected pathology
Informed consent obtained, discussing risks (pancreatitis, bleeding, perforation, infection) and benefits
Nil by mouth for at least 6-8 hours
Prophylactic antibiotics are often administered in specific high-risk patients (e.g., those with biliary obstruction or undergoing sphincterotomy) based on local protocols and guidelines.
Intraprocedural Management:
Sedation and analgesia administered by an anesthesiologist or experienced endoscopist
Continuous monitoring of vital signs (heart rate, blood pressure, oxygen saturation)
Sterilized equipment and accessories
Careful cannulation of the bile or pancreatic duct
Administration of contrast medium under fluoroscopic guidance
Performance of interventions (stone extraction, sphincterotomy, stenting, etc.)
Careful observation for immediate complications during the procedure
Adequate irrigation to clear debris.
Postoperative Care:
Monitoring of vital signs and abdominal pain
Observation for signs of complications: pancreatitis (epigastric pain, nausea, vomiting, elevated amylase/lipase), bleeding (hematemesis, melena, hypotension), perforation (severe abdominal pain, peritonitis), cholangitis (fever, chills, jaundice)
Gradual resumption of diet once bowel sounds return and patient is alert, starting with clear liquids
Pain management
Hydration
Intravenous fluids may be continued if oral intake is poor
Prophylactic antibiotics continued as per protocol if administered pre-operatively
Discharge planning usually occurs once the patient is stable, pain is controlled, and has tolerated oral intake.
Complications
Pancreatitis:
Post-ERCP pancreatitis (PEP) is the most common significant complication, occurring in 2-10% of cases, with higher rates in therapeutic ERCPs
Symptoms include epigastric pain, nausea, and vomiting
Management is primarily supportive: hydration, analgesia, and bowel rest
Severe cases may require hospitalization and monitoring of amylase/lipase levels.
Bleeding:
Bleeding can occur from the sphincterotomy site or duodenal wall
It is more common after sphincterotomy
Mild bleeding may be self-limiting
Significant bleeding may require endoscopic hemostasis (e.g., epinephrine injection, hemoclips) or, rarely, surgical intervention.
Perforation:
Perforation of the duodenum, esophagus, stomach, or bile/pancreatic duct is a rare but serious complication
Symptoms include severe abdominal pain, peritonitis, fever, and hemodynamic instability
Requires immediate surgical consultation and management, often involving laparotomy and repair.
Cholangitis Sepsis:
Bacterial cholangitis can occur due to instrumentation, especially in the presence of biliary obstruction
Symptoms include fever, chills, jaundice, and abdominal pain (Charcot's triad)
Prompt intravenous antibiotics are crucial
In severe cases, urgent biliary drainage via ERCP or percutaneous route may be necessary.
Other Complications:
Aspiration, sedation-related complications, duodenal or biliary injuries not leading to perforation, missed stones, recurrent stones, stent occlusion or migration, post-sphincterotomy bleeding, and adverse reactions to contrast media.
Key Points
Exam Focus:
Understand the nuances of ERCP indications, differentiating between diagnostic and therapeutic needs
Be prepared to discuss the most common and serious complications, particularly post-ERCP pancreatitis
Recall key steps in peri-procedural care, including antibiotic prophylaxis criteria and post-operative monitoring parameters.
Clinical Pearls:
Always review MRCP/CT carefully to anticipate anatomical variations
Consider prophylactic pancreatic duct stenting in high-risk patients undergoing difficult cannulation or sphincterotomy to reduce PEP
Close communication with the anesthesiologist regarding sedation is vital
Vigilant post-operative follow-up is critical for early detection of complications.
Common Mistakes:
Performing ERCP without clear indications, especially when less invasive diagnostic options are available
Inadequate patient preparation or contraindication assessment
Failure to administer prophylactic antibiotics when indicated
Underestimating the risk of PEP and not taking preventive measures
Delayed recognition and management of complications like pancreatitis or cholangitis.