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Endoscopic retrograde cholangiopancreatography
Use of endoscopy and fluoroscopy to treat and diagnose digestive issues

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced procedure combining endoscopy and fluoroscopy to diagnose and treat issues in the biliary and pancreatic ductal systems. Performed by specialized gastroenterologists, ERCP allows visualization of the stomach and duodenum via an endoscope, with injection of contrast medium to highlight ducts on radiographs. It is primarily used to detect and treat conditions such as gallstones, strictures, leaks, and cancer in these ducts. While ERCP serves both diagnostic and therapeutic roles, safer, less invasive alternatives like magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound have reduced its diagnostic-only use.

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Medical uses

Diagnostic

The following represent indications for ERCP, particularly if or when less invasive options are not adequate or definitive:

Therapeutic

ERCP may be indicated in the above diagnostic scenarios when any of the following are needed:

Contraindications

Hypersensitivity to iodinated contrast medium or a history of iodinated contrast dye anaphylaxis 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.7

Procedure

The patient is sedated or anaesthetized. Then a flexible camera (endoscope) is inserted through the mouth, down the esophagus, into the stomach, through the pylorus into the duodenum where the ampulla of Vater (the union of the common bile duct and pancreatic duct) exists. The sphincter of Oddi 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 cannula is inserted through the ampulla, and radiocontrast is injected into the bile ducts and/or pancreatic duct. Fluoroscopy is used to look for blockages, or other lesions such as stones.89

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.10

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 stent to assist the drainage of bile.11 Also, the pancreatic duct can be cannulated and stents be inserted.

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.12

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 images131415) as well as balloon enteroscopes (e.g. in patients that have previously undergone digestive system surgery with post-Whipple or Roux-en-Y surgical anatomy).16

Risks

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%.1718 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.19

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.2021

Intestinal perforation is a risk of any gastroenterologic endoscopic procedure, and is an additional risk if a sphincterotomy is performed. As the second part of the duodenum is anatomically in a retroperitoneal 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.22 ERCP may provoke hemobilia from trauma to friable hilar tumors or a guide-wire penetrating the bile duct wall, creating a biliary fistula. Delayed bleeding is a rare but potentially serious complication of sphincterotomy, particularly as many patients are discharged home within hours of ERCP.

There is also a risk associated with the contrast dye in patients who are allergic to compounds containing iodine, which can be very severe, even if the anaphylactoid reactions occur while patients are in a hospital.2324

Oversedation can result in dangerously low blood pressure, respiratory depression, nausea, and vomiting.

Other complications (less than 1%) may include heart and lung problems, infection in the bile duct called cholangitis, 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.25 In rare cases, ERCP can cause fatal complications.26

Cases of hospital-acquired (i.e., nosocomial) infections with carbapenem resistant enterobacteriaceae linked to incompletely disinfected duodenoscopes have occurred in the U.S. since at least 2009 per the Food and Drug Administration.27 Outbreaks were reported from Virginia Mason Hospital in Seattle in 2013, UCLA Health System Los Angeles in 2015, Chicago and Pittsburgh.28 The FDA issued a safety communication "Design of ERCP Duodenoscopes May Impede Effective Cleaning" in February 2015,29 which was updated in December 2015,30 and more recently in 2022 which recommended disposable components.31

Prevalence of vitamin K and vitamin D deficiency,32 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.

See also

References

  1. 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. (July 2005). "ASGE guideline: The role of ERCP in diseases of the biliary tract and the pancreas". Gastrointestinal Endoscopy. 62 (1): 1–8. doi:10.1016/j.gie.2005.04.015. PMID 15990812. /wiki/Doi_(identifier) ↩

  2. Tharian, B.; George, N. E.; Tham, T. C. (2015). "What is the current role of endoscopy in primary sclerosing cholangitis?". World Journal of Gastrointestinal Endoscopy. 7 (10): 920–927. doi:10.4253/wjge.v7.i10.920. PMC 4530326. PMID 26265986. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530326 ↩

  3. Tabibian, James H (2015). "Advanced endoscopic imaging of indeterminate biliary strictures". World Journal of Gastrointestinal Endoscopy. 7 (18): 1268–1278. doi:10.4253/wjge.v7.i18.1268. PMC 4673389. PMID 26675379. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4673389 ↩

  4. Coucke, E. M.; Akbar, H.; Kahloon, A.; Lopez, P. P. (2022). "Biliary Obstruction". StatPearls. StatPearls. PMID 30969520. https://www.ncbi.nlm.nih.gov/books/NBK539698/ ↩

  5. Tabibian, James H.; Asham, Emad H.; Han, Steven; Saab, Sammy; Tong, Myron J.; Goldstein, Leonard; Busuttil, Ronald W.; Durazo, Francisco A. (March 2010). "Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video)". Gastrointestinal Endoscopy. 71 (3): 505–512. doi:10.1016/j.gie.2009.10.023. PMID 20189508. /wiki/Doi_(identifier) ↩

  6. Scheurer, U (1 October 2000). "Acute Pancreatitis - ERCP / Endoscopic Papillotomy (EPT) Yes Or No?". Swiss Surgery. 6 (5): 246–248. doi:10.1024/1023-9332.6.5.246. PMID 11077490. /wiki/Doi_(identifier) ↩

  7. "ERCP (Endoscopic Retrograde Cholangiopancreatography) | MNGI". https://www.mngi.com/patient-services/ercp-endoscopic-retrograde-cholangiopancreatography ↩

  8. "Endoscopic Retrograde Cholangiopancreatography (ERCP) | NIDDK". https://www.niddk.nih.gov/health-information/diagnostic-tests/endoscopic-retrograde-cholangiopancreatography ↩

  9. "Endoscopie bending rubber". https://smarttechmed.com/endoscope-bending-rubber/ ↩

  10. Deng, D. H.; Zuo, H. M.; Wang, J. F.; Gu, Z. E.; Chen, H.; Luo, Y.; Chen, M.; Huang, W. N.; Wang, L.; Lu, W. (2007). "New precut sphincterotomy for endoscopic retrograde cholangiopancreatography in difficult biliary duct cannulation". World Journal of Gastroenterology. 13 (32): 4385–4390. doi:10.3748/wjg.v13.i32.4385. PMC 4250869. PMID 17708616. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4250869 ↩

  11. Kelly, N. M.; Caddy, G. R. (2008). "Successful Endoscopic Management of Fractured Dormia Basket During Endoscopic Retrograde Cholangiopancreatography for Choledocholithiasis". The Ulster Medical Journal. 77 (1): 56–58. PMC 2397011. PMID 18271088. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2397011 ↩

  12. Busireddy, K. K.; Alobaidy, M.; Ramalho, M.; Kalubowila, J.; Baodong, L.; Santagostino, I.; Semelka, R. C. (2014). "Pancreatitis-imaging approach". World Journal of Gastrointestinal Pathophysiology. 5 (3): 252–270. doi:10.4291/wjgp.v5.i3.252. PMC 4133524. PMID 25133027. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4133524 ↩

  13. Cholangioscopy~technique at eMedicine https://emedicine.medscape.com/article/1891395-technique ↩

  14. Komanduri, Sri; Thosani, Nirav; Abu Dayyeh, Barham K.; Aslanian, Harry R.; Enestvedt, Brintha K.; Manfredi, Michael; Maple, John T.; Navaneethan, Udayakumar; Pannala, Rahul; Parsi, Mansour A.; Smith, Zachary L.; Sullivan, Shelby A.; Banerjee, Subhas; Banerjee, S. (2016). "Cholangiopancreatoscopy". Gastrointestinal Endoscopy. 84 (2): 209–221. doi:10.1016/j.gie.2016.03.013. PMID 27236413. https://doi.org/10.1016%2Fj.gie.2016.03.013 ↩

  15. Farrell JJ, Bounds BC, Al-Shalabi S, Jacobson BC, Brugge WR, Schapiro RH, Kelsey PB (2005). "Single-operator duodenoscope-assisted cholangioscopy is an effective alternative in the management of choledocholithiasis not removed by conventional methods, including mechanical lithotripsy". Endoscopy. 37 (6): 542–7. doi:10.1055/s-2005-861306. PMID 15933927. S2CID 260128740. /wiki/Doi_(identifier) ↩

  16. Azeem, Nabeel; Tabibian, James H.; Baron, Todd H.; Orhurhu, Vwaire; Rosen, Charles B.; Petersen, Bret T.; Gostout, Christopher J.; Topazian, Mark D.; Levy, Michael J. (April 2013). "Use of a single-balloon enteroscope compared with variable-stiffness colonoscopes for endoscopic retrograde cholangiography in liver transplant patients with Roux-en-Y biliary anastomosis". Gastrointestinal Endoscopy. 77 (4): 568–577. doi:10.1016/j.gie.2012.11.031. PMID 23369652. /wiki/Doi_(identifier) ↩

  17. Dumonceau, Jean-Marc; Andriulli, Angelo; Elmunzer, B.; Mariani, Alberto; Meister, Tobias; Deviere, Jacques; Marek, Tomasz; Baron, Todd; Hassan, Cesare; Testoni, Pier; Kapral, Christine (22 August 2014). "Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Updated June 2014". Endoscopy. 46 (9): 799–815. CiteSeerX 10.1.1.886.8874. doi:10.1055/s-0034-1377875. PMID 25148137. S2CID 9899581. /wiki/CiteSeerX_(identifier) ↩

  18. GallRiks. Annual report 2016. http://www.ucr.uu.se/gallriks/fou/arsrapporter [accessed 31 May 2018]. http://www.ucr.uu.se/gallriks/fou/arsrapporter ↩

  19. Cotton, P.B.; Lehman, G.; Vennes, J.; Geenen, J.E.; Russell, R.C.G.; Meyers, W.C.; Liguory, C.; Nickl, N. (May 1991). "Endoscopic sphincterotomy complications and their management: an attempt at consensus". Gastrointestinal Endoscopy. 37 (3): 383–393. doi:10.1016/S0016-5107(91)70740-2. PMID 2070995. /wiki/Doi_(identifier) ↩

  20. Chen, Jian-Jun; Wang, Xi-Mo; Liu, Xing-Qiang; Li, Wen; Dong, Mo; Suo, Zong-Wu; Ding, Po; Li, Yue (15 May 2014). "Risk factors for post-ERCP pancreatitis: a systematic review of clinical trials with a large sample size in the past 10 years". European Journal of Medical Research. 19 (1): 26. CiteSeerX 10.1.1.981.3789. doi:10.1186/2047-783X-19-26. PMC 4035895. PMID 24886445. Gale A541256167. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4035895 ↩

  21. Park, Namyoung; Lee, Sang Hyub; You, Min Su; Kim, Joo Seong; Huh, Gunn; Chun, Jung Won; Cho, In Rae; Paik, Woo Hyun; Ryu, Ji Kon; Kim, Yong-Tae (2021). "Optimal timing of endoscopic retrograde cholangiopancreatography for acute cholangitis associated with distal malignant biliary obstruction". BMC Gastroenterology. 21 (1): 175. doi:10.1186/s12876-021-01755-z. PMC 8052855. PMID 33865307. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052855 ↩

  22. Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, Pilotto A, Forlano R (2007). "Incidence rates of post-ERCP complications: a systematic survey of prospective studies". Am. J. Gastroenterol. 102 (8): 1781–8. doi:10.1111/j.1572-0241.2007.01279.x. PMID 17509029. S2CID 38954883. /wiki/Doi_(identifier) ↩

  23. Dewachter, Pascale; Mouton-Faivre, Claudie (1 November 2015). "Allergie aux médicaments et aliments iodés : la séquence allergénique n'est pas l'iode" [Allergy to iodinated drugs and to foods rich in iodine: Iodine is not the allergenic determinant]. La Presse Médicale (in French). 44 (11): 1136–1145. doi:10.1016/j.lpm.2014.12.008. PMID 26387623. /wiki/Doi_(identifier) ↩

  24. Bottinor, W.; Polkampally, P.; Jovin, I. (2013). "Adverse Reactions to Iodinated Contrast Media". The International Journal of Angiology. 22 (3): 149–154. doi:10.1055/s-0033-1348885. PMC 3770975. PMID 24436602. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3770975 ↩

  25. Brand, Martin; Bizos, Damon; O'Farrell, Peter JR (6 October 2010). "Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography". Cochrane Database of Systematic Reviews (10): CD007345. doi:10.1002/14651858.CD007345.pub2. PMID 20927758. /wiki/Doi_(identifier) ↩

  26. Cotton, Peter B. (2013-05-31). "ERCP (Endoscopic Retrograde Cholangio-Pancreatography)". Medical University of South Carolina (MUSC) Digestive Disease Center. Archived from the original on 2018-03-21. Retrieved 2013-06-09. https://web.archive.org/web/20180321192751/http://ddc.musc.edu/public/testsprocedures/procedures/ercp.cfm ↩

  27. Sharon Begley; Toni Clarke (20 February 2015). "FDA knew devices spread fatal 'superbug' but does not order fix". Reuters. Retrieved 20 February 2015. https://www.reuters.com/article/us-usa-ucla-devices-idUSKBN0LO02Q20150220 ↩

  28. "Deadly superbug infected patients at Seattle hospital". CBS. CBS Interactive Inc. January 22, 2015. Retrieved 21 February 2015. http://www.cbsnews.com/news/deadly-superbug-infected-patients-at-seattle-hospital/ ↩

  29. "Design of Endoscopic Retrograde Cholangiopancreatography (ERCP) Duodenoscopes May Impede Effective Cleaning: FDA Safety Communication". Medical Devices. US FDA. 19 February 2015. Archived from the original on February 20, 2015. Retrieved 19 February 2015. https://web.archive.org/web/20150220024405/http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm434871.htm ↩

  30. Medwatch ED-530XT Duodenoscopes by FUJIFILM Medical Systems, U.S.A.: Safety Communication - FUJIFILM Medical Systems Validates Revised Reprocessing Instructions Safety alerts for Human Medical Products. U.S. FDA, 23 December 2015, retrieved 5 January 2016 https://web.archive.org/web/20151225092242/http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm478949.htm ↩

  31. "The FDA is Recommending Transition to Duodenoscopes with Innovative Designs to Enhance Safety: FDA Safety Communication". FDA. 5 April 2022. Archived from the original on September 4, 2019. https://web.archive.org/web/20190904163815/https://www.fda.gov/medical-devices/safety-communications/fda-recommending-transition-duodenoscopes-innovative-designs-enhance-safety-fda-safety-communication ↩

  32. Fisher, Leon; Byrnes, Elizabeth; Fisher, Alexander A. (1 September 2009). "Prevalence of vitamin K and vitamin D deficiency in patients with hepatobiliary and pancreatic disorders". Nutrition Research. 29 (9): 676–683. doi:10.1016/j.nutres.2009.09.001. hdl:1885/32031. PMID 19854384. /wiki/Doi_(identifier) ↩