ERCP - Procedure Uses and Indications
ERCP is a modern diagnostic cum therepautic procedure that has completely revolutionized 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 duodenum and take biopsy of suspected tumours at that site.
- Endoscopic access to biliary – pancreatic duct system has.
The common bile duct carries bile juice from liver and gall bladder. The pancreatic duct carries pancreatic juice. Both these join together to form the Common Bile duct CBD and open into duodenum of 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 level and severity of blockage.
The usual Causes of Blockage are
- CBD stones
- Pancreatic duct calculi
- External compression like lymph nodes , pancreatic tumours.
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 tumours. MRCP is diagnostic tool only and intervention is not possible.
CBD stones- Sometimes the gall bladder stones may slip and enter the bile duct and therefore lead to obstruction of bile flow. patient develops pain abdomen and jaundice.
Pancreatitis secondary to obstructed CBD – This blockage of CBD may also block pancreatic duct Cholangitis – Blockage of CBD leads to infection and development of this condition.
Tumours – The ampulla may be blocked by pancreatic tumours leading to Jaundice Strictures- Of CBD.
The procedure involves passing a long side viewing endoscope through mouth and reaches the duodenum where the entry point or ampulla is located. The fibre optic scope enables us to see the image on a monitor and guide the endoscope to cannulate the CBD and proceed further steps.
This also necessitates the use of fluoroscopic guidance using C-Arm Xray machine.
Calculi found in the duct are then removed using special equipments that can be passed through the scope itself.
Dye is injected to see the presence of any strictures which are then treated with balloon dilatation.
Tumors found in that region biopsy can be taken and Metal stenting done Complications:
- Rarely Pancreatitis
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.
Spy Glass Endoscopy:
Dedicated Spy glass 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.
Spy glass endoscopy for indeterminate bile duct strictures- In the setting of indeterminate biliary strictures, this modality allows for direct visualization, of 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 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.