ERCP:
Our Initial Attempts
Dr.Jimma Hossain
MBBS; MD
Trained in Advanced Endoscopy, India.
Asstt.Professor- Gastroenterology,
Rangpur Medical College, Rangpur.
Definition of ERCP
• Endoscopic Retrograde
Cholangiopancreatography
• The technique that combines the use of
endoscopy and fluoroscopy to diagnose and
treat certain problems of biliary and
pancreatic ductal systems.
 Since its initial inception four decades ago ERCP has
evolved from a diagnostic to therapeutic procedure.
 Such an evolution required developments in
technology, techniques and training.
Brief History of ERCP
• The first endoscope was developed in 1806
by Philipp Bozzini ‘for the examinations of
canals and cavities of the human body’.
Brief History of ERCP
• H/o four decades, spanning the 1970s to 2000s.
• 1970s-diagnosis and therapy-first reports of
sphincterotomy.
Brief History of ERCP

1980s-refinement and reporting- in accessories,
radiographic imazing.

Reporting of adverse events.

Stent placement.

Acceptance of ERCP by medical community.
Brief History of ERCP

1990s-Training and expanding therapy.
Emphasis on advanced training.
 endoscopic photography, videography.
 Therapy of pancreatic disorders.
 Safer sphincterotomy- computer assisted blended
current.
 SEMS.
 Complementary techniques-EUS,MRCP.

Brief History of ERCP

2000s-Prevention,pulverizng.
 Pancreatitis
 Pancreatic
 Pulvarizing
stents
lagre stones
Diagnostic ERCP

Diagnostic ERCP largely been supplanted by noninvasive imazing –
 Abdominal
 MRI-MRCP
 EUS
CT
Diagnostic ERCP

To define etiology of acute relapsing pancreatitis
 Divisum,



anomalous PB union, annular pancreas, SOD.
To differentiate chronic pancreatitis from intraductal
neoplasm.
To define presence or absence of CBD stones in
jaundice, cholangitis or acute pancreatitis.
Distinguish benign from malignant biliary stricture.
Diagnostic ERCP

To define etiology of acute relapsing
pancreatitis
 Divisum,
anomalous PB union,
annular pancreas, SOD.
To differentiate chronic pancreatitis from
intraductal neoplasm.
To define presence or absence of CBD
stones in jaundice, cholangitis or acute
pancreatitis.
Distinguish benign from malignant biliary
stricture.
Therapeutic ERCP

Endoscopic sphincterotomy was first described by
Classen and Kawai independently in Germany and Japan
respectively.

That was beginning of therapeutic ERCP.
Therapeutic ERCP

Biliary endotherapy

Obstructing calculi in biliary tree

Obstructing worms

Obstructing strictures

Ductal disruption

Senting for malignant obstruction.
Therapeutic ERCP

Pancreatic endotherapy



Obstructing caculi-50% requires
ESWL
Obstructing strictures
Treatment of ductal disruption
 Pancreato-cutaneous fistula
 Internal fistulas
Pseudocysts
 Pancreatic ascites
 Pl effusion
 Pancreato-biliary fistula.

Required logistics and manpower
 ERCP room-300 square feet
 ERCP table -30 inch in width
 Manpower
 Endoscopist
 Two assistant
 Nurse anaesthetist/
anaesthesiologist
 C-arm operator
Required logistics and manpower
 Core equipments
 Side –viewing duodenoscope with wide channels
 C-arm X-ray
 Accessories
Essential ERCP Accessories
 Electro-surgery generator
 Guidewires
 Cannulas
 Sphincterotomes
 Stone retrieval balloons and baskets
 Lithotriptors
 Dilating balloons and catheters
 Snares and FB forceps
 Stents with delivery systems etc.
Sedation and analgesia for ERCP
 ERCP requires moderate to deep sedation
 Can be administered by nurse anaesthetist or
anaesthesiologst.
 Should have ability to recue from any level of sedation.
Complications of ERCP
 Overall short-term complication rate-5-10%
 Death from ERCP is rare,<0.5%
 Most often related to cardio-pulmonary complications.
Complications of ERCP
 Pancreatitis
 Haemorrhage
 Perforation
 Cholangitis
 Stent related
 Cardio-pulmonary
ERCP –Our first case
 Mrs. Archana Rani Roy, 60 yrs of age, a house




wife, non-diabetic, normotensive lady
Presented with h/o recurrent episodes of upper
abdominal pain, fever and jaundice for 2 months
H/o Lap chole 6 months back
Physical examination showed mild firm
hepatomegaly
Imazing showed biliary dilatation and a stone in
lower CBD
We planned for therapeutic ERCP.
ERCP –Our first case
 We tried ERCP with a therpeutic intend. But
diagnostic ERCP could be possible only.
 Selective CBD cannulation was done.
 Cholangiogram showed dilated intra & extra hepatic
biliary tree and a large stone in lower part of CBD.
Therapeutic procedures
 Endoscopic esophageal variceal band ligation
 Haemorrhoidal band ligation
 Endoscopic polypectomy
 Achalasia balloon dilatation.
 Liver abscess drainage.
Case- Haemorrhoids
Mr AMM Alam ,50
yrs,Banker,normotensive ,non-diabetic.
 Presented to us with h/o intermittent
painless fresh p/r bleeding since 2010

Anoscopy showed 3 columns of 2nd
degree internal haemorrhoids.
 We planned for banding treatment for
haemorrhoids.

Aspiration of liver abscess

Amoebic liver abscess
◦ >90% respond dramatically to metronidazole
◦ Decreases pain and fever within 72 hrs.

Indications for aspiration
◦ To rule out pyogenic,particularly with multiple
lesions.
◦ Failure to respond clinically in 3 to 5 days
◦ Threat of imminent rupture
◦ Rupture of lt lobe-abscess into pericardium