ERCP
Dr David Scott
Gastroenterologist
Tamworth Base Hospital
ERCP
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What is it?
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When is it recommended?
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How is it performed?
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What are the complications?
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What’s new in ERCP?
What is ERCP?
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Endoscopic Retrograde Cholangiopancreatogram
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Essentially it is a
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radiological procedure
performed via an endoscope
to diagnose and treat
conditions of the bile and pancreatic ducts
When is it recommended?
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Gall stones in the bile duct
Malignant bile duct obstruction
Bile duct leak post cholecystectomy
Benign bile duct obstructions
Tissue sampling of bile duct lesion
Sphincter of Oddi Dysfunction (type 1)
Pancreatic duct stones and obstruction
Pancreatic pseudocysts
Others…
Complications Of Gall Stones
Biliary colic
(pain but
normal BR)
Cholecystitis
(pain and fever
but normal BR)
Biliary colic
(pain and
raised BR)
Cholangitis
(pain and fever
and raised BR)
Pancreatitis
(pain +/raised BR)
Malignant Bile Duct Obstruction
Bile
duct
cancer
Pancreatic
cancer
Clinical Presentations for ERCP
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Gall stones:
PAIN AND JAUNDICE
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Malignant obstruction:
PAINLESS JAUNDICE
Special Situations
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Gallstone Pancreatitis
<24 hours if persisting bile duct obstruction and
severe pancreatitis
 Otherwise avoid
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Gall bladder in situ
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Depends on the surgeon
Pre-procedure investigations
Liver tests
 Platelet count and coagulation profile
 Imaging
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Ultrasound
 CT
 CT cholangiogram
 MRCP
 Endoscopic Ultrasound
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Pre-procedure Imaging
Transabdominal Ultrasound
MRCP
Endoscopic Ultrasound
Sens 25-82%
Spec 50-85%
Sens 81-91%
Spec 100%
Sens 84-100%
Spec 87-100%
CT Cholangiogram
Pre-procedure imaging has revolutionised ERCP
How is it performed?
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Similar to a Gastroscopy
NBM for 6 hours prior (no bowel prep)
 IV sedation (not usually intubated)
 Left lateral position (sometimes prone)
 NOT sterile – just clean
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Different to a Gastroscopy
Side viewing endoscope
 Portable image intensifier used
 Diagnostic and therapeutic equipment
 About 30 minutes
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Cannulation of the
Bile Duct
Major Papilla Anatomy
Common channel
Common bile duct
Pancreatic duct
Image property of Marco Bruno, AMC Amsterdam, From: Atlas of human anatomy. Gosling et al. Gower Medical Publishing Ltd. 1985
Sphincterotomy
Sphincterotomy
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Biliary sphincter is like a valve
Needs to be cut to allow most interventions to
relieve biliary obstruction
Highest risk part of standard ERCP
Perforation
 Bleeding
 Pancreatitis
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Stents
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Plastic
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Biliary
7 or 10 FG
 Need to be removed/replaced within 3 months
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Pancreatic
5 FG
 Need to be removed within 2-4 weeks
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Metal
10mm
 Not removable (usually)
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Cardiologists and ERCP
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Aspirin
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OK
Clopidogrel / Warfarin / Enoxaparin
No sphincterotomy
 Stent can solve acute problem and allow definitive
treatment to be deferred
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Implantable defibrillator
No sphincterotomy without local technician
 Need to go to tertiary centre
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Complications of ERCP
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Failure
5 - 10%
Pancreatitis
5% (severe in 0.5%)
Bleeding
1%
Perforation
0.1%
Anaesthetic complications
Predicting Post ERCP Pancreatitis
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Doctor Factors
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Procedure Factors
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Low case volume, trainee
Difficult cannulation, pancreatic injection, precut
Patient Factors
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Young, female, normal BR, previous pancreatitis
Reducing the Risks of ERCP
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Patient selection
Patient selection
Patient selection
Wire guided technique
Pancreatic stents
Don’t persist indefinitely
Teamwork
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Radiographer
Nursing
Assistant * VERY IMPORTANT ROLE *
 2nd Assistant
 Anaesthetics / Recovery
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Medical
Endoscopist
 Anaesthetist
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Anaesthetic Nurse
Anaesthetist
Anaesthetic Stuff
‘Scout’ nurse
‘Scrub’ nurse
Equipment
Video
Assistant’s Table
XRay viewer
Processor
XRay Machine
Diathermy Machine
Radiographer
Endoscopist
ERCP Set up
What’s new in ERCP?
Summary
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More like interventional radiology than
endoscopy
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Patient selection important
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Needs Teamwork and Communication