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Endoscopic retrograde cholangiopancreatography
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<h2 id="medical-uses">Medical uses</h2> <h3>Diagnostic</h3> <p>The following represent indications for ERCP, particularly if or when less invasive options are not adequate or definitive: </p> <ul><li><a href="/facts/Obstructive_jaundice/TCyoLMJU">Obstructive jaundice</a> – This may be due to several causes <ul><li>Gallstones with dilated bile ducts on <a href="/facts/Ultrasonography/31Pa5IH9">ultrasonography</a></li> <li>Indeterminate biliary strictures and suspected <a href="/facts/Bile_duct_tumor/N5twpETV">bile duct tumors</a><a class="footnote-ref" id="fnref:3" href="#fn:3"><sup>3</sup></a></li> <li>Suspected injury to bile ducts either as a result of trauma or of <a href="/facts/Iatrogenic/GfgeWAXs">iatrogenic</a> origin</li> <li><a href="/facts/Sphincter_of_Oddi/GhjmhR6v">Sphincter of Oddi dysfunction</a></li></ul></li> <li>Chronic <a href="/facts/Pancreatitis/gmbNTcCG">pancreatitis</a> is currently a controversial indication due to widespread availability of safer diagnostic modalities including <a href="/facts/Endoscopic_ultrasound/4kJgYu8a">endoscopic ultrasound</a>, <a href="/facts/CT_scan/NusPJ2S8">CT</a>, and <a href="/facts/MRI/Vh9yG9qq">MRI</a>/<a href="/facts/Magnetic_resonance_cholangiopancreatography/kFzSD3jh">MRCP</a></li> <li><a href="/facts/Pancreatic_cancer/6h9GIInW">Pancreatic tumors</a> no longer represent a valid diagnostic indication for ERCP unless they cause bile duct obstruction and jaundice. Endoscopic ultrasound represents a safer and more accurate diagnostic alternative</li></ul> <h3>Therapeutic</h3> <p>ERCP may be indicated in the above diagnostic scenarios when any of the following are needed: </p> <ul><li><a href="/facts/Biliary_endoscopic_sphincterotomy/nH2jIbn1">Endoscopic sphincterotomy</a> of the <a href="/facts/Sphincter_of_Oddi/GhjmhR6v">sphincter of Oddi</a></li> <li>Extraction of gallstones or other <a href="/facts/Biliary_sludge/t8sMcsvv">biliary debris</a><a class="footnote-ref" id="fnref:4" href="#fn:4"><sup>4</sup></a></li> <li>Insertion of a <a href="/facts/Self-expandable_metallic_stent/8sA4v5zu">stent</a> through the <a href="/facts/Major_duodenal_papilla/1CNVEb1T">major duodenal papilla</a> and <a href="/facts/Ampulla_of_Vater/YBduX0We">ampulla of Vater</a> into the <a href="/facts/Common_bile_duct/9TsYu0sc">common bile duct</a> and/or the <a href="/facts/Pancreatic_duct/tLKRDmSE">pancreatic duct</a></li> <li>Dilation of <a href="/facts/Stenosis/X0x2tAk7">strictures</a> (e.g. <a href="/facts/Primary_sclerosing_cholangitis/bI0YIfhV">primary sclerosing cholangitis</a>, <a href="/facts/Anastomosis/fScK17o8">anastomotic</a> strictures after liver transplantation)<a class="footnote-ref" id="fnref:5" href="#fn:5"><sup>5</sup></a></li> <li>Extraction of <a href="/facts/Liver_fluke/PFtKoVM1">liver flukes</a> from the biliary system (e.g., <a href="/facts/Opisthorchiasis/0vQokeLV">opisthorchiasis</a>, <a href="/facts/Clonorchiasis/s86RzFkT">clonorchiasis</a>, <a href="/facts/Fasciolosis/dtoqocWS">fasciolosis</a>)</li></ul> <h2 id="contraindications">Contraindications</h2> <ul><li><a href="/facts/Acute_pancreatitis/d15Wh2q2">Acute pancreatitis</a> (unless persistently elevated or rising bilirubin suggests ongoing obstruction)<a class="footnote-ref" id="fnref:6" href="#fn:6"><sup>6</sup></a></li> <li>(Irreversible) coagulation disorder if sphincterotomy planned</li> <li>Recent <a href="/facts/Myocardial_infarction/xoGw0qcG">myocardial infarction</a> or pulmonary embolism</li> <li>Severe <a href="/facts/Cardiopulmonary/WXwudzzc">cardiopulmonary</a> disease or other serious morbidity</li></ul> <p>Hypersensitivity to iodinated contrast medium or a history of iodinated contrast dye <a href="/facts/Anaphylaxis/F9IDQxeL">anaphylaxis</a> is not a contraindication of ERCP, though it should be discussed with your health provider, and you should tell them you are allergic to iodine, as an alternative contrast iodine-free material ("dye") is then injected gently into the ducts (pancreatic or biliary) and x-rays are taken.<a class="footnote-ref" id="fnref:7" href="#fn:7"><sup>7</sup></a> </p> <h2 id="procedure">Procedure</h2> <p>The patient is sedated or anaesthetized. Then a flexible camera (<a href="/facts/Endoscope/oIXca2vs">endoscope</a>) is inserted through the mouth, down the esophagus, into the stomach, through the <a href="/facts/Pylorus/920mWuBz">pylorus</a> into the <a href="/facts/Duodenum/IAIgHBmq">duodenum</a> where the <a href="/facts/Ampulla_of_Vater/YBduX0We">ampulla of Vater</a> (the union of the common bile duct and pancreatic duct) exists. The <a href="/facts/Sphincter_of_Oddi/GhjmhR6v">sphincter of Oddi</a> is a muscular valve that controls the opening to the ampulla. The region can be directly visualized with the endoscopic camera while various procedures are performed. A plastic catheter or <i>cannula</i> is inserted through the ampulla, and radiocontrast is injected into the bile ducts and/or pancreatic duct. <a href="/facts/Fluoroscopy/ySerh62e">Fluoroscopy</a> is used to look for blockages, or other lesions such as stones.<a class="footnote-ref" id="fnref:8" href="#fn:8"><sup>8</sup></a><a class="footnote-ref" id="fnref:9" href="#fn:9"><sup>9</sup></a> </p><p>When needed, the sphincters of the ampulla and bile ducts can be enlarged by a cut (sphincterotomy) with an electrified wire called a sphincterotome for access into either so that gallstones may be removed or other therapy performed.<a class="footnote-ref" id="fnref:10" href="#fn:10"><sup>10</sup></a> </p><p>Other procedures associated with ERCP include the trawling of the common bile duct with a basket or balloon to remove gallstones and the insertion of a plastic <a href="/facts/Stent/h8Ss3zlE">stent</a> to assist the drainage of bile.<a class="footnote-ref" id="fnref:11" href="#fn:11"><sup>11</sup></a> Also, the pancreatic duct can be cannulated and stents be inserted. </p><p>The pancreatic duct requires visualisation in cases of pancreatitis. Ultrasound is frequently the first investigation performed on admission; although it has little value in the diagnosis of pancreatitis or its complications. contrast-enhanced computed tomography (MD-CECT) is the most used imaging technique. However, magnetic resonance imaging (MRI) offers diagnostic capabilities similar to those of CT, with additional intrinsic advantages including lack of ionizing radiation and exquisite soft tissue characterization.<a class="footnote-ref" id="fnref:12" href="#fn:12"><sup>12</sup></a> </p><p>In specific cases, other specialized or ancillary endoscopes may be used for ERCP. These include mother-baby and SpyGlass cholangioscopes (to help in diagnosis by directly visualizing the duct as opposed to only obtaining X-ray images<a class="footnote-ref" id="fnref:13" href="#fn:13"><sup>13</sup></a><a class="footnote-ref" id="fnref:14" href="#fn:14"><sup>14</sup></a><a class="footnote-ref" id="fnref:15" href="#fn:15"><sup>15</sup></a>) as well as balloon enteroscopes (e.g. in patients that have previously undergone <a href="/facts/Digestive_system_surgery/Go7rj6Xn">digestive system surgery</a> with post-<a href="/facts/Pancreaticoduodenectomy/KqnXSoVH">Whipple</a> or <a href="/facts/Roux-en-Y_anastomosis/LGgXcaKd">Roux-en-Y</a> surgical anatomy).<a class="footnote-ref" id="fnref:16" href="#fn:16"><sup>16</sup></a> </p> <h2 id="risks">Risks</h2> <p>One of the most frequent and feared complications after endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP). In previous studies, the incidence of PEP has been estimated at 3.5 to 5%.<a class="footnote-ref" id="fnref:17" href="#fn:17"><sup>17</sup></a><a class="footnote-ref" id="fnref:18" href="#fn:18"><sup>18</sup></a> According to Cotton et al., PEP is defined as a "clinical pancreatitis with amylase at least three times the upper limit of normal at more than 24 hours after the procedure requiring hospital admission or prolongation of planned admission". Grading of severity of PEP is mainly based on the length of hospital stay.<a class="footnote-ref" id="fnref:19" href="#fn:19"><sup>19</sup></a> </p><p>Risk factors for developing PEP include technical matters related to the ERCP procedure and patient-specific ones. The technical factors include manipulation of and injection of contrast into the pancreatic duct, cannulation attempts lasting more than five minutes, and biliary balloon sphincter dilation; among patient-related factors are female gender, younger age, and Sphincter of Oddi dysfunction. A systematic review of clinical trials concluded that a previous history of PEP or pancreatitis significantly increases the risk for PEP to 17.8% and to 5.5% respectively.<a class="footnote-ref" id="fnref:20" href="#fn:20"><sup>20</sup></a><a class="footnote-ref" id="fnref:21" href="#fn:21"><sup>21</sup></a> </p><p><a href="/facts/Gastrointestinal_perforation/TjuCNtyk">Intestinal perforation</a> is a risk of any gastroenterologic endoscopic procedure, and is an additional risk if a <a href="/facts/Sphincterotomy/4QkWetxL">sphincterotomy</a> is performed. As the second part of the duodenum is anatomically in a <a href="/facts/Retroperitoneal_space/UCoKE1WL">retroperitoneal</a> location (that is, behind the peritoneal structures of the abdomen), perforations due to sphincterotomies are retroperitoneal. Sphincterotomy is also associated with a risk of bleeding.<a class="footnote-ref" id="fnref:22" href="#fn:22"><sup>22</sup></a> ERCP may provoke hemobilia from trauma to friable hilar tumors or a guide-wire penetrating the bile duct wall, creating a <a href="/facts/Biliary_fistula/fjlx7P12">biliary fistula</a>. Delayed bleeding is a rare but potentially serious complication of sphincterotomy, particularly as many patients are discharged home within hours of ERCP. </p><p>There is also a risk associated with the <a href="/facts/Iodinated_contrast/WCkoRRyE">contrast dye</a> in patients who are allergic to compounds containing <a href="/facts/Organoiodine_compound/P6LDC4IP">iodine</a>, which can be very severe, even if the anaphylactoid reactions occur while patients are in a hospital.<a class="footnote-ref" id="fnref:23" href="#fn:23"><sup>23</sup></a><a class="footnote-ref" id="fnref:24" href="#fn:24"><sup>24</sup></a> </p><p>Oversedation can result in dangerously low blood pressure, respiratory depression, nausea, and vomiting. </p><p>Other complications (less than 1%) may include heart and lung problems, infection in the bile duct called <a href="/facts/Cholangitis/37cKJUB4">cholangitis</a>, that can be life-threatening, and is regarded as a medical emergency. Using antibiotics before the procedure shows some benefits to prevent cholangitis and septicaemia.<a class="footnote-ref" id="fnref:25" href="#fn:25"><sup>25</sup></a> In rare cases, ERCP can cause fatal complications.<a class="footnote-ref" id="fnref:26" href="#fn:26"><sup>26</sup></a> </p><p>Cases of hospital-acquired (i.e., nosocomial) infections with <a href="/facts/Carbapenem_resistant_enterobacteriaceae/5NJULG5Y">carbapenem resistant enterobacteriaceae</a> linked to incompletely disinfected duodenoscopes have occurred in the U.S. since at least 2009 per the <a href="/facts/Food_and_Drug_Administration/rCEnh9WB">Food and Drug Administration</a>.<a class="footnote-ref" id="fnref:27" href="#fn:27"><sup>27</sup></a> Outbreaks were reported from <a href="/facts/Virginia_Mason_Hospital/KPhwLBjf">Virginia Mason Hospital</a> in Seattle in 2013, <a href="/facts/UCLA_Health_System/goqzYsVH">UCLA Health System</a> Los Angeles in 2015, Chicago and Pittsburgh.<a class="footnote-ref" id="fnref:28" href="#fn:28"><sup>28</sup></a> The FDA issued a safety communication "Design of ERCP Duodenoscopes May Impede Effective Cleaning" in February 2015,<a class="footnote-ref" id="fnref:29" href="#fn:29"><sup>29</sup></a> which was updated in December 2015,<a class="footnote-ref" id="fnref:30" href="#fn:30"><sup>30</sup></a> and more recently in 2022 which recommended disposable components.<a class="footnote-ref" id="fnref:31" href="#fn:31"><sup>31</sup></a> </p><p>Prevalence of vitamin K and vitamin D deficiency,<a class="footnote-ref" id="fnref:32" href="#fn:32"><sup>32</sup></a> as bile is to assist in the breakdown and absorption of fat in the intestinal tract; a relative deficiency of bile can lead to fat malabsorption and deficiencies of fat-soluble vitamins. </p> <h2 id="see-also">See also</h2> <ul><li><a href="/facts/Percutaneous_transhepatic_cholangiography/uIwHDLju">Percutaneous transhepatic cholangiography</a></li> <li><a href="/facts/Reynolds%2527_pentad/KXkTxJzq">Reynolds' pentad</a></li> <li><a href="/facts/Charcot%2527s_cholangitis_triad/AYqmBYq3">Charcot's cholangitis triad</a></li> <li><a href="/facts/Primary_sclerosing_cholangitis/bI0YIfhV">Primary sclerosing cholangitis</a></li></ul> <h2 id="external-links">External links</h2> <ul><li><i><a href="/facts/MedlinePlus/bl3BjdjK">MedlinePlus Encyclopedia</a></i>: <a href="https://medlineplus.gov/ency/article/007479.htm">ERCP</a></li> <li><a href="https://web.archive.org/web/20110424095147/http://digestive.niddk.nih.gov/ddiseases/pubs/ercp/">National Digestive Diseases Information Clearinghouse</a></li> <li><a href="https://www.endoscopy-campus.com/en/ercp-en/">Endoscopy Campus, Archives and Videos</a></li></ul> <h2 id="references">References</h2> <ol> <li id="fn:1"><p>Adler, Douglas G.; Baron, Todd H.; Davila, Raquel E.; Egan, James; Hirota, William K.; Leighton, Jonathan A.; Qureshi, Waqar; Rajan, Elizabeth; Zuckerman, Marc J.; Fanelli, Robert; Wheeler-Harbaugh, Jo; Faigel, Douglas O.; Standards of Practice Committee of American Society for Gastrointestinal, Endoscopy. 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