ERCP – Endoscopic Retrograde Cholangiopancreatography

What is ERCP?

ERCP or Endoscopic Retrograde Cholangiopancreatography is an invasive endoscopic procedure to inspect and remedy problems occurring in the gall bladder, liver, and pancreas.ERCP is both a diagnostic and therapeutic tool. ERCP is considered relatively safe and can be performed in children, adolescents, adults and the elderly.

ERCP seeks to investigate the initial portion of the small intestine- the duodenum, to spot any obstruction in the bile ducts. Most often, Doctors also carry out therapeutic procedures, during an ERCP, to clear the obstruction in the bile ducts or a biopsy to support further investigation.

Doctors usually perform this procedure under conscious sedation or general anesthesia. The risk of complications is relatively low with ERCP. There is only a 1% infection complication rate for ERCP which includes all bacteria types.

Why Do I Need ERCP?

The reasons for an ERCP procedure are many. ERCP is performed to :

– Validate abnormal results from a CT scan or ultrasound.

– Aiding the diagnosis and treatment of conditions in the gall bladder, pancreas and liver.

-Assist in both pre and post gall bladder surgery as well as in better management of complications.

– Diagnosis and removal of bile duct stones.

– Diagnosis and treatment of both cancerous and non-cancerous tumors.

– Evaluate the need for surgery or the treatment method to be adopted for victims of pancreatic disease.

– Effectively treat Jaundice or yellow discoloration of the skin caused by a blockage in the bile duct.

– Diagnose reason for persistent upper abdominal pain which other tests like an MRCP/MRI, CT could not spot.

How do I Prepare for ERCP?

Preparation for an ERCP begins a few days before the scheduled date of the procedure. For instance,

– It is imperative to inform your medical history along with the medications. Patients taking blood thinners, aspirin, or NSAIDs( non-steroidal anti-inflammatory drugs) or any diabetic medications need to inform their specialists. Blood thinners will have to be stopped a few days before the procedure.

– Those that suffer from any heart abnormalities or lung conditions must keep their specialists informed to enable them to perform necessary tests prior to the procedure.

– Information about allergies is vital as doctors need to understand and estimate any potential risks of the contrast dye injected during an ERCP.

– Since patients receive sedative medications during ERCP, they will need someone to accompany them on the way back home.

How is an ERCP Performed?

ERCP is a specialized procedure, therefore only highly experienced and skilled gastric surgeons should conduct the investigation. The steps of the procedure are as follows:

– Patients are asked to lie down either on their left side, stomach or back on a special table in the ERCP room. A plastic mouthpiece is placed inside the mouth as a protective measure.

– An IV sedation or in some cases general anesthesia is given to patients.

– A duodenoscope, which is a highly flexible tube of considerable length, attached with a camera and light at the end, is used during ERCP. The tube can be easily negotiated in the curves and bends of the stomach and duodenum.

– Doctors insert the duodenoscope into the patient’s mouth, and through the back of the throat into the food pipe or the esophagus, to the stomach and then into the duodenum. Air is passed via the duodenoscope to enable the specialist to view the inside of the stomach and intestine during the examination.

– A plastic catheter (cannula) is directed via the scope to make an entry into the papilla, the place where the bile duct enters the duodenum.

– Specialists inject a contrast dye that comprises of a radio-opaque material, into the ducts. X- Rays of the bile and pancreatic ducts are taken which provides information about the presence and location of stones or other abnormalities in the ducts. This examination also reveals the presence of tumors or any other blockages.

– Specialists can perform therapeutic procedures during an ERCP to remedy the condition. For instance, if x-rays show the presence of stones, it is possible to widen the papilla or even open it up to remove stones from the duct.

– The endoscope also permits the passing of other instruments through it incase biopsies need to be performed. Even metal or plastic stents can be inserted. Tubing can be performed to remove the blockage of pancreatic or bile ducts.

– If needed, Doctors also perform a sphincterotomy, where the sphincter muscle in the papilla is cut to improve drainage from the duct.

– The whole procedure may take anywhere from 30 minutes to an hour. Patients are shifted to the recovery room once the procedure is completed enabling time for the effect of the sedatives to wear off. Generally, taking rest for a day helps resolve abdominal discomfort or sore throat.

– Some patients are admitted for further observation depending on their progress during the recovery period.

What is the price of ERCP in India?

The cost of ERCP in India ranges from ₹15000 and ₹35000 depending on what area needs examination.

When will I get the results?

Usually, it is possible to get the ERCP test results on the same day as the procedure. The results of a biopsy will take several days to be ready.

What do the test results mean?

The results of ERCP provide vital information about the abnormalities in the ducts as well as the presence of blockages or stones. The results will also point to the presence or absence of tumors. Doctors can initiate prompt treatment measures on the basis of the results of ERCP.

Do I Need To Fast for ERCP?

You need fast or be on an empty stomach prior to an ERCP.  This is because an empty stomach provides better visualization as well as reduces the risks of aspiration and vomiting.

What else do I need to know before I go for ERCP?

– You and your family should be aware of a few risks of the procedure, although by and large, the procedure is relatively safe.

– A lot depends on the experience and expertise of the physician performing the procedure.

– Statistics show that complications can arise in one to five percent of the cases. It also depends on the primary medical condition of the patient.

– The success rate of an ERCP procedure is between 70 to 95%. Highly skilled physicians demonstrate a higher success rate.

– Pancreatitis is the most common complication caused by the use of the dye.

– Infection post ERCP cannot be overlooked.

– You cannot drive during this period till you are completely alright.

What are the complications associated with ERCP?

Cholangitis: The bile ducts can get infected leading to this condition. Doctors prescribe antibiotics during the procedure and for a few days during the recovery.

Bleeding: There are chances of bleeding in case the papilla sphincter is cut during the procedure. Usually, bleeding is not excessive and gets all right on its own. Otherwise, doctors employ hemo clips or use epinephrine injection to narrow the blood vessels to control excessive bleeding.

Pancreatitis: Nearly 3% to 7% of patients that go through ERCP complain of abdominal pain that does not get relieved by passing gas. If pain develops within 6 hours of the ERCP procedure, then doctors suspect it to be a case of Post ERCP pancreatitis. Chances of pancreatitis after 12 hours of ERCP are very less. Most of the post-ERCP pancreatitis is relatively mild and settles down. In a few cases, pancreatitis can lead to life-threatening complications.

Perforation: Tear or perforation of ducts, bowel, stomach or even esophagus could occur while performing ERCP. This is, fortunately, a very rare complication that heals on its own, yet in some cases becomes severe needing emergency surgery.

Aspiration: The risk of aspiration is high among those that have not fasted for several hours before the procedure.

Allergy: Major allergic reaction to sedatives or anesthesia.

What should I do if I experience the side-effects of the ERCP procedure?

Post ERCP, following symptoms, calls for immediate medical attention:

– Extreme abdominal bloating
– Chills and fever
– Vomiting blood
– Black, red or maroon stool
– Severe abdominal pain
– Difficulty swallowing

Can ERCP be performed during pregnancy?

It is safe to perform ERCP during pregnancy, but it should be done only to aid specific therapy. In this situation, doctors perform the procedure using the wire-guided cannulation method. ERCP performed during pregnancy is however associated with a higher chance of Post ERCP pancreatitis as compared to normal patients undergoing the procedure.

Can ERCP be performed on newborns?

ERCP in newborns is safe and the success rate is high in expert hands. The complications and risks are similar to those among adults.

Any dos and don’ts with respect to ERCP?