ERCP – Procedure Uses and Indications:
ERCP is a modern diagnostic cum therapeutic procedure that has completely revolutionized the treatment of diseases of Hepato- Biliary & Pancreatic tract (Ducts).
What is ERCP
- ERCP (Endoscopic Retrograde Cholangio-Pancreatography) provides valuable information that cannot be obtained by other diagnostic examinations of the abdomen such as abdominal ultrasound, CT scan, or MRI.
- Therapeutic measures can be performed at the time of ERCP to remove stones in the bile ducts, pancreatic duct or to relieve obstruction of the bile ducts.
- ERCP can be used to directly visualize the ampulla or ductal opening in the duodenum and take a biopsy of suspected tumors at that site
- Endoscopic access to biliary –pancreatic duct system has
Structure:
The common bile duct carries bile juice from the liver and gall bladder. The pancreatic duct carries pancreatic juice. Both these join together to form the Common Bile duct CBD and open into the duodenum of the small intestine through a common opening.
These are small ducts and therefore any obstruction by gall stones etc leads to blockage in bile flow and development of jaundice, pancreatitis etc according to the level and severity of the blockage.
The usual causes of blockage are:
- CBD stones
- Pancreatic duct calculi
- Tumors
- External compression-like lymph nodes, pancreatic tumors
Pre-op investigations include USG Abdomen, MRCP and liver function tests to detect jaundice.
MRCP is done using MRI and injection of contrast in some cases to confirm the diagnosis or to rule out certain strictures or tumors. MRCP is a diagnostic tool only and intervention is not possible
Indications:
CBD stones- Sometimes the gall bladder stones may slip and enter the bile duct and therefore lead to obstruction of bile flow. the patient develops pain abdomen and jaundice
Pancreatitis secondary to obstructed CBD- This blockage of CBD may also block the pancreatic duct
Cholangitis- Blockage of CBD leads to infection and development of this condition
Tumors- The ampulla may be blocked by pancreatic tumors leading to Jaundice
Strictures- Of CBD
The procedure involves passing a long side-viewing endoscope through the mouth and reaches the duodenum where the entry point or ampulla is located. The fiber optic scope enables us to see the image on a monitor and guide the endoscope to cannulate the CBD and proceed with further steps.
This also necessitates the use of fluoroscopic guidance using a C-Arm Xray machine
Calculi found in the duct are then removed using special types of equipment that can be passed through the scope itself
A dye is injected to see the presence of any structures which are then treated with balloon dilatation
Image showing fluoroscopic view
Tumors found in that region biopsy can be taken and Metal stenting was done
Complications: rarely pancreatitis, Infection
Postoperative care:
The patient gets complete relief and gets discharged after one day.
The presence of Gall bladder stones needs gall bladder surgery which will be decided after evaluating the patient condition and severity. A stent is usually placed after the procedure and it shall be removed after 6 weeks.
RECENT ADVANCES
SPY-GLASS ENDOSCOPY:
Dedicated Spyglass endoscopes are typically smaller diameter (3.5 mm) advanced to the bile duct through the working channel of a therapeutic duodenoscope. The spyglass endoscope offers the ability to visualize and provide therapy for large intraductal stones by using electrohydraulic lithotripsy (EHL) or laser lithotripsy. EHL uses a bipolar lithotripsy probe, which can discharge energy with the aid of a generator. Laser lithotripsy uses a laser beam which is transmitted by a flexible quartz fiber advanced through the working channel of the endoscope and can break even resistant hard stones
Spyglass endoscopy for indeterminate bile duct strictures- In the setting of indeterminate biliary strictures, this modality allows for direct visualization, of the internal area of CBD, branch ducts for endoscopic findings suggestive of malignancy including tumor surface, intraductal nodules or masses, and papillary or villous mucosal projections.
ERCP has greatly simplified patient care diagnosis and treatment in the hepato-biliary field. This procedure gives excellent results and patient gets immediate relief for above mentioned biliary-pancreatic conditions. The advent of ERCP has revolutionized patient care and become the standard of treatment.