ERCP (endoscopic retrograde cholangiopancreatography)

Question 1

Define ERCP.

Answer 1

Endoscopic retrograde cholangiopancreatography (ERCP)

A technique that uses a combination of luminal endoscopy and fluoroscopic imaging to diagnose and treat conditions associated with the pancreatobiliary system.

Question 2

Summarise the steps involved in the ERCP procedure.

Answer 2

A side-viewing duodenoscope is passed through the oesophagus and stomach and into the second portion of the duodenum and the ampulla of Vater is found on the duodenal papilla.

After the papilla has been examined with the side-viewing endoscope, selective cannulation of either the CBD or the ventral pancreatic duct is performed. Once the chosen duct is cannulated, either a cholangiogram (CBD) or a pancreatogram (pancreatic duct) is obtained fluoroscopically after injection of radiopaque contrast material into the duct.

Question 3

What are the indications for ERCP?

Answer 3

ERCP has a higher rate of severe complications that most other endoscopic procedures so is mostly used for therapeutic rather than diagnostic reasons.

• Choledocholithiasis e.g. CBD
• Acute/chronic pancreatitis due to obstruction
• Diagnosis of pancreatic/biliary malignancy
• Dilatation of benign strictures
• Manometry to measure sphincter of Oddi dysfunction

Question 4

What are the contraindications for ERCP?

Answer 4

• Patient refusal
• Unstable cardio/neurologic/pulmonary status
• Existing bowel perforation
• Oesophageal stricture
• Gastric or bowel volvulus/obstruction
• Altered anatomy e.g. Roux-en-Y jejunostomy

Question 5

What are the possible complications of ERCP?

Answer 5

• Pancreatitis - ~ 20% incidence. Majority are mild. Avoid major cannulation trauma and stent insertion. Evidence shows that post ERCP diclofenac/indometacin reduces incidence
  
  • Treat by bowel rest, analgesia, IV fluids.
• Infection
• Bleeding - 1-2% with sphincterotomy and stone extraction
• Perforation of duodenum with development of acute abdomen
• Failure of gallstone removal
• Bile duct injury - usually managed with stent insertion

Question 6

Which of these are complications of ERCP?

• Perforation
• Aspiration pneumonia
• Haemorrhage
• Acute hepatitis
• Acute pancreatitis
• Acute cholecystitis
• Ascending cholangitis

Answer 6

Not acute hepatitis or acute cholecystitis; all of the rest.

ERCP is not a technique without complications which may relate to sedation or sphincterotomy in particular.

Question 7

Is MRCP a good alternative to ERCP?

Answer 7

Comparable for diagnostic purposes but does not offer any therapeutic options and so some patients will go on to have ERCP anyway