What is endoscopic retrograde cholangiopancreatography (ERCP)?

Indications and Procedures

Endoscopic retrograde cholangiopancreatography (ERCP) is usually performed if a patient is experiencing jaundice, unexplained pain in the upper abdomen, or unexplained weight loss. It is used to determine the sources of these conditions. ERCP can be used to find tumors, blockages, cysts, tissue irregularities, or gallstones. It may also be used to discover the source of inflammation in the liver, bile ducts (which drain the liver, gallbladder, and pancreas), gallbladder, or pancreas. If imaging or blood tests are confusing or inconclusive, this procedure may be used to clarify those inconsistencies. ERCP may also help to plan surgery for a patient who is already known to be suffering from gallbladder or pancreatic disease or who has a mass or tumor shown in imaging processes.

ERCP is usually performed by a gastroenterologist who has had further training specifically in ERCP procedures. It may be performed in a hospital or a clinic. The patient lies down on a radiology bed and is sedated, usually through an IV, to relax the involuntary muscles. An anesthetic is sprayed in the patient’s throat to counteract any gag reflex, and a guard may be placed over the teeth and gums to protect them during the procedure. The endoscope is inserted into the throat, and the patient is asked to swallow to help the endoscope into the correct position. The endoscope is then guided through the digestive system to the duodenum. Then a small catheter is inserted into the hollow endoscope until it reaches the duct system. Iodine or another type of contrast solution (dye) is put into the catheter so that the duct system can be shown on x-rays. X-rays are then taken and examined while the endoscope remains in place. The patient may be asked to change positions so the doctor can view different structures.

Usually, this procedure is performed in an outpatient setting, and the patient is released to go home (with a designated driver) after the sedative wears off. Occasionally, a patient may stay in the hospital for a longer period, particularly when further procedures, as described below, are performed at the time of the ERCP or when complications develop.

Uses and Complications

Some problems can be identified and solved during the ERCP procedure. Depending what is shown on the x-rays taken during this procedure, the doctor may be able to perform further procedures, such as removing gallstones (which may involve crushing the stones and removing them or simply leaving them in the intestines to pass through the digestive system naturally), taking tissue biopsies, dilating a duct with a balloon, performing a sphincterotomy, or inserting a stent. Other problems, such as possible cancers, will need to be identified through tissue samples and treated later.

Serious complications from ERCP are rare. One possible serious complication is aspiration (inhaling) of saliva, which may lead to pneumonia. Other serious complications may include perforation, inflammation, bleeding, injury, or infection of any of the organs examined or the stomach, esophagus, or intestines. Complications from sedation and contrast dyes, such as allergies, are also possible. More common complications are nausea and stomach pain. One may feel discomfort (such as a sore throat), tenderness, or bloating, depending on whether air is blown into the endoscope during the process to open up the structures that the doctor wishes to view.

Factors that complicate this procedure include obesity, allergies, diabetes, hypertension, or certain drugs, especially anticlotting drugs. Another complicating factor may be that the patient has not fasted for at least six hours prior to this procedure as instructed.

Perspective and Prospects

Endoscopic procedures were first reported in 1968. Improvements to the procedure, then called endoscopic cholangiopancreatography (ECPG), occurred throughout the early 1970s, when Japanese doctors worked with engineers to develop better instruments to use during the procedure. The procedure spread through Europe during the 1970s and soon became known as a valuable diagnostic tool despite its potential for serious complications in its early stages. From the mid-1970s, it was recognized as a cost-saving alternative to surgical procedures with a much quicker recovery time for the patient. With the addition of x-ray technology, it became an often used diagnostic and therapeutic tool.

With improvements in imaging technology, such as high-quality ultrasound, computed tomography (CT) scans, endoscopic ultrasonography, and magnetic resonance imaging (MRI), the use of this procedure for solely diagnostic purposes has diminished somewhat. Its use as a therapeutic tool is still acknowledged, however, and it is still an alternative diagnostic procedure when noninvasive procedures result in inconclusive diagnosis.

Bibliography

Aronson, Naomi. Endoscopic Retrograde Cholangiopancreatography. Washington, D.C.: Department of Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality, 2002.

Cotton, P. B., and J. W. Leung, eds. Advanced Digestive Endoscopy: ERCP. Hoboken, N.J.: Wiley-Blackwell, 2006.

Longstreth, George F. "ERCP." MedlinePlus, August 8, 2011.

Mahnke, Daus. "Endoscopic Retrograde Cholangiopancreatography." Health Library, May 30, 2013.

National Digestive Diseases Information Clearinghouse. "ERCP (Endoscopic Retrograde Cholangiopancreatography)." National Digestive Diseases Information Clearing House, June 29, 2012.

Seigel, J. H., J. Delmont, and A. G. Harris. Endoscopic Retrograde Cholangiopancreatography: Technique, Diagnosis, and Therapy. New York: Raven Press, 1991.

Talley, N. J.Clinical Gastroenterology: A Practical Problem-Based Approach. 3d ed. New York: Churchill-Livingstone/Elsevier, 2011.