Overview
Definition:
Endoscopic Retrograde Cholangiopancreatography (ERCP) is a specialized endoscopic procedure used to diagnose and treat conditions of the bile ducts and pancreatic ducts
It combines upper gastrointestinal endoscopy with fluoroscopy to visualize these ducts
The endoscope is passed down to the duodenum, and a small catheter is guided into the ampulla of Vater, through which contrast dye is injected into the biliary and pancreatic ducts for imaging.
Epidemiology:
ERCP is performed in thousands of patients annually worldwide, particularly for gallstone-related biliary obstruction and pancreatic duct pathology
Its incidence is closely tied to the prevalence of these conditions, which are common in middle-aged and elderly populations
Geographic variations exist, influenced by diet, lifestyle, and the availability of advanced endoscopic facilities.
Clinical Significance:
ERCP is a cornerstone in the management of various hepatobiliary and pancreatic disorders
It offers a less invasive approach compared to traditional surgery for many conditions, allowing for both diagnosis and therapeutic intervention in a single session
Proficiency in understanding its indications, performing it safely, and managing post-procedure care is crucial for surgical and gastroenterology residents preparing for DNB and NEET SS examinations.
Indications
Diagnostic Indications:
Suspected choledocholithiasis with abnormal liver function tests or dilated bile ducts
Unexplained biliary obstruction or strictures
Suspected pancreatic duct stones or strictures
Investigation of pancreatic divisum or other congenital anomalies
Evaluation of biliary leaks or fistulas
Diagnosis of tumors of the biliary or pancreatic ducts
Assessment of complications from pancreatic surgery.
Therapeutic Indications:
Removal of common bile duct stones
Sphincterotomy to relieve biliary or pancreatic obstruction
Biliary or pancreatic duct stenting for strictures or leaks
Balloon dilation of biliary or pancreatic strictures
Retrieval of impacted stones from the common bile duct
Management of cholangitis or pancreatitis secondary to obstruction
Decompression of the pancreatic duct in specific cases.
Relative Contraindications:
Severe acute pancreatitis (unless specific indications exist for decompression)
Bleeding diathesis or uncorrected coagulopathy
Recent myocardial infarction or unstable cardiac disease
Pregnancy (risk vs
benefit assessment)
Known allergy to contrast media (alternative imaging or premedication required)
Lack of skilled endoscopist or inadequate facilities
Severe underlying systemic illness precluding safe anesthesia or procedure.
Preoperative Preparation
Patient Assessment:
Thorough medical history and physical examination
Assessment of comorbidities (cardiac, pulmonary, renal)
Review of previous surgical history and endoscopic procedures
Detailed assessment of bleeding risk and coagulation status (PT/INR, aPTT, platelet count)
Identification of any contrast allergies.
Laboratory Investigations:
Complete blood count (CBC)
Liver function tests (LFTs) including AST, ALT, ALP, GGT, Bilirubin (total and direct)
Amylase and lipase levels
Coagulation profile (PT/INR, aPTT)
Serum creatinine and electrolytes.
Imaging Modalities:
Abdominal ultrasound to assess for gallstones, biliary dilatation, and pancreatic head abnormality
CT scan of the abdomen for better visualization of the pancreas, bile ducts, and surrounding structures, especially in cases of suspected malignancy or complex pathology
MRCP (Magnetic Resonance Cholangiopancreatography) is often used as a non-invasive initial diagnostic tool to assess biliary and pancreatic ductal anatomy and identify stones/strictures, potentially obviating the need for diagnostic ERCP.
Patient Counseling And Consent:
Informed consent is mandatory
Explain the procedure, its purpose, potential risks (e.g., pancreatitis, bleeding, perforation, infection), benefits, and alternatives
Discuss the need for bowel preparation and dietary restrictions
Confirm the patient understands the risks and benefits
Address any patient concerns or questions.
Medications And Prophylaxis:
Review and adjust anticoagulant and antiplatelet medications as per protocol
Prophylactic antibiotics may be indicated in patients with specific risk factors for cholangitis (e.g., biliary obstruction, previous biliary surgery, immunocompromise) or as per institutional guidelines
Somatostatin analogues may be considered in high-risk patients for pancreatitis prevention.
Procedure Steps And Techniques
Endoscope And Equipment:
A duodenoscope (side-viewing endoscope) is typically used
Specialized cannulas, guidewires, sphincterotomes, balloons, retrieval baskets, and stents are essential accessories
Contrast media (iodinated) and fluoroscopy are critical for imaging.
Patient Positioning And Sedation:
Patients are typically placed in the left lateral decubitus position
Sedation is usually administered, often involving midazolam and a narcotic analgesic (e.g., fentanyl), with or without propofol for deeper sedation, and the procedure is performed under continuous monitoring of vital signs.
Cannulation Of Biliary Or Pancreatic Duct:
The duodenoscope is advanced to the second part of the duodenum, locating the ampulla of Vater
A catheter is then advanced through the accessory channel of the duodenoscope and carefully guided into either the common bile duct or the pancreatic duct (selective cannulation).
Contrast Injection And Imaging:
Once cannulation is achieved, contrast dye is injected slowly under fluoroscopic guidance to delineate the ductal anatomy
Images are captured to identify filling defects (stones), irregularities (strictures), leaks, or masses
Adequate opacification of the entire ductal system is crucial for diagnostic accuracy.
Therapeutic Interventions:
Based on findings, therapeutic interventions are performed
These include: Sphincterotomy (cutting the sphincter of Oddi) to facilitate stone extraction or stent placement
Balloon dilation of strictures
Mechanical lithotripsy for large stones
Stone extraction using balloons or baskets
Placement of biliary or pancreatic stents (plastic or metal) to bypass obstructions or seal leaks
Brush cytology or biopsies can be obtained for suspicious lesions.
Post Procedure Care
Immediate Monitoring:
Patients are transferred to a recovery area for close monitoring of vital signs (heart rate, blood pressure, oxygen saturation, respiratory rate)
Observe for signs of pain, nausea, vomiting, abdominal distension, and any signs of bleeding or perforation.
Pain Management:
Mild abdominal discomfort is common due to insufflation
Adequate analgesia should be provided
Severe or worsening abdominal pain may indicate a complication like pancreatitis or perforation and requires prompt investigation.
Hydration And Diet:
Intravenous fluids are typically administered until the patient can tolerate oral intake
A clear liquid diet is usually started 4-6 hours post-procedure if there is no nausea or vomiting
Progression to a regular diet is based on patient tolerance
Specific dietary recommendations may be given based on the underlying condition.
Medications And Antibiotics:
Continue antibiotics if prophylactic antibiotics were administered or if there is evidence of infection
Administer antiemetics as needed
Pain medication should be available
Patients on anticoagulants/antiplatelets should have their management resumed according to protocol.
Discharge Criteria:
Patients can typically be discharged on the same day or the next day if they are hemodynamically stable, tolerating oral intake, have minimal pain, and there are no signs of immediate complications
Clear instructions regarding diet, activity, medications, and warning signs of complications should be provided.
Warning Signs For Patients:
Patients should be instructed to seek immediate medical attention if they experience severe abdominal pain, fever, chills, persistent nausea or vomiting, jaundice, black tarry stools, or difficulty breathing.
Complications
Post Ercp Pancreatitis:
The most common complication, occurring in 2-10% of procedures
Risk factors include difficult cannulation, multiple attempts, sphincterotomy, and young age
Symptoms include severe abdominal pain, nausea, vomiting, elevated amylase/lipase
Management is conservative with hydration and pain control.
Bleeding:
Can occur from the site of sphincterotomy or biopsy
Usually minor, but can be significant, especially in patients on anticoagulants
Management may involve endoscopic hemostasis (clipping, cautery) or transfusion.
Perforation:
Rare but serious complication, occurring in <1% of procedures
Can happen at any point along the upper GI tract or biliary/pancreatic tree
Symptoms include severe abdominal pain, rigidity, fever
Requires immediate surgical intervention.
Cholangitis And Sepsis:
Infection of the biliary tree, particularly in cases of complete biliary obstruction
Symptoms include fever, jaundice, right upper quadrant pain (Charcot's triad) and can progress to sepsis (Reynold's pentad)
Requires urgent decompression of the biliary tree and broad-spectrum antibiotics.
Cardiopulmonary Complications:
Related to sedation and the procedure itself, including aspiration, hypoxia, hypotension, or arrhythmias
Close monitoring during and after the procedure is essential.
Other Complications:
Cholecystitis, duodenal injury, retained stones after attempted extraction, adverse reactions to contrast media.
Key Points
Exam Focus:
Understand the diagnostic vs
therapeutic indications
Be aware of absolute and relative contraindications
Differentiate between post-ERCP pancreatitis and other complications
Recall antibiotic prophylaxis guidelines and common post-procedure warning signs.
Clinical Pearls:
Always consider MRCP as a less invasive initial diagnostic step for biliary/pancreatic duct issues
Careful patient selection and informed consent are paramount
Anticipate and manage post-ERCP pancreatitis promptly
it’s the most common complication
Adequate hydration post-procedure is crucial for preventing complications.
Common Mistakes:
Performing ERCP for purely diagnostic reasons when MRCP is sufficient
Inadequate pre-procedure workup, especially regarding coagulation status
Failing to recognize and manage early signs of complications like pancreatitis or perforation
Discharging patients without adequate warning signs instructions.