Endoscopic Retrograde
Cholangiopancreatography ERCP
During ERCP an X-ray is taken of the pancreatic duct and bile ducts. With newer diagnostic
imaging technologies emerging, the diagnostic role of ERCP is diminishing and ERCP is
evolving into a predominantly therapeutic procedure.
Procedure
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The patient is sedated and given potent (opiate) pain relief after on overnight fast. A
local anaesthetic is sprayed to the back of the throat.
Using a modified endoscope, the ampulla of Vater is located and a thin catheter is
passed through an opening in the endoscope and through the ampulla. A dye is then
injected into the pancreatic and bile ducts, enabling images of these ducts to be
obtained.
Uses For many years ERCP was the investigation of choice for investigating pancreatic and
biliary disorders. The availability of CT and MRI scan has now reduced the indications for
investigation by ERCP. The following list of uses is taken from the US National Institute of
Health guidelines1.
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Choledocholithiasis
o Diagnosis of choledocholithiasis: magnetic resonance
cholangiopancreatography2, endoscopic ultrasound and ERCP have comparable
sensitivity and specificity.
o Patients undergoing cholecystectomy do not require ERCP preoperatively if there
is low probability of having choledocholithiasis. Laparoscopic common bile duct
exploration and postoperative ERCP are both safe and reliable in clearing
common bile duct stones.
o ERCP with endoscopic sphincterotomy and stone removal is a valuable
therapeutic modality in choledocholithiasis with jaundice, dilated common bile
duct, acute pancreatitis or cholangitis.
Benign strictures:
o Strictures can initially be managed with intermittent biliary balloon dilatation at the
time of ERCP or simple endoscopic stent placement.
Pancreatic or biliary cancer
o The main benefit of ERCP is palliation of biliary obstruction when surgery is not
elected. In patients who have pancreatic or biliary cancer and who are surgical
candidates, there is no established role for preoperative biliary drainage by
ERCP.
o ERCP the most commonly performed procedure for cholangiocarcinoma and can
provide a tissue diagnosis through brush cytology of the bile duct. Relief from
biliary obstruction can be provided with temporary plastic stenting or permanent
metal stenting3.
o Tissue sampling for patients with pancreatic or biliary cancer not undergoing
surgery may be achieved by ERCP, but this is not always diagnostic.
o ERCP is the best means to diagnose ampullary cancers.
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Pancreatitis
o ERCP has no role in the diagnosis of acute pancreatitis except when biliary
pancreatitis is suspected. In patients with severe biliary pancreatitis, early
intervention with ERCP reduces morbidity and mortality compared with delayed
ERCP.
o ERCP with appropriate therapy is beneficial in selected patients who have either
recurrent pancreatitis or pancreatic pseudocysts. In patients with acute, relapsing
and chronic pancreatitis a variety of endoscopic therapies can be performed.
After pancreatic sphincterotomy, stones can be removed from the pancreatic
duct, strictures can be stented. Peripancreatic fluid collections and pseudocysts
can also be managed by pancreatic duct drainage or direct endoscopic cyst
puncture and stenting techniques.
Sphincter of Oddi dysfunction.
Complications
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The main complications of the ERCP as a diagnostic procedure are pancreatitis,
infection and bleeding4. The insertion of a therapeutic stent increases the risk of
bleeding, pancreatitis, bile duct damage and leakage, and infection.
Less than 1 in 10 patients will have such a complication and severe life-threatening
complications only occur in 1-2% of patients. The risk of a complication when a
sphincterotomy is not performed is less (2-5%) and depends on the number and size of
the stents inserted.
References Used
1. National Institute of Health; Statement on Endoscopic Retrograde
Cholangiopancreatography (ERCP) For Diagnosis and Therapy. Volume 19, Number 1;
January 14-16, 2002.
2. Health Technology Assessment; A systematic review and economic evaluation of
magnetic resonance cholangiopancreatography compared with diagnostic endoscopic
retrograde cholangiopancreatography. 2004; Vol 8: number 10.
3. Brugge WR; Endoscopic techniques to diagnose and manage biliary tumors. J Clin
Oncol 2005 Jul 10;23(20):4561-5.
4. Freeman ML et al; Adverse outcomes of endoscopic retrograde
cholangiopancreatography. Rev Gastroenterol Disord 2002 Fall;2(4):147-68.
Internet and Further Reading
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OMNI: Cholangiopancreatography, Endoscopic Retrograde.
Last issued 02 Nov 2005