ERCP (Endoscopic Retrograde Cholangiopancreatography) : A diagnostic and interventional

 

ERCP (Endoscopic Retrograde Cholangiopancreatography)

ERCP indications include
: obstructive jaundice, biliary or pancreatic ductal system disease treatment or tissue sampling, suspicion for pancreatic cancer, pancreatitis of unknown cause, manometry for sphincter of Oddi, nasobiliary drainage, biliary stenting for strictures and leakage, drainage of pancreatic pseudocysts, and balloon dilation of the duodenal papilla and ductal strictures. Sphincterotomy is indicated in cases of the sphincter of Oddi dysfunction or stenosis, difficulty with biliary stenting or accessing the pancreatic duct, biliary strictures, bile duct stones, bile sump syndrome following choledochoduodenostomy, choledochocele, and in poor surgical candidates with ampullary carcinoma. 

• Preparations of patient before ERCP

1. UGI Empty ; NPO 8 hours before ERCP ( fasting overnight)
2. CBC , clotting screening 
3. Respiratory and CVS assessment 
4. Prophylactic antibiotics with biliary obstruction
5. Smoking, chewing gum prohibited
6. Removable of any dentures , jewellery or contact lenses 
7. Before ERCP , CT scans , MRI, USG , previous cholangiography or pancreatography reviewed
8. Deep sedation for stable endoscope position for proper cannulation, therapeutic intervention, and avoidance of complications

After the procedure

1. Monitored in the endoscopy area for 1-2 hrs until sedation worn off
2. Eating or drinking if throat not numb 
3. Gall stone removal , stent placement ( overnight hospital stay)

Complications

1. Highly specialised procedure
2. Safe when performed by experienced physicians
3. Success rate around 70% to 95% , depends upon physician
4. Complications in one to five
5. Bowel perforation or hemorrhage
6. Risk:

• Infection , pancreatitis (2-9%), allergic reaction to sedative , excessive bleeding , puncture of GI (.1 % to .6), tissue damage due to radiation exposure , death in rare cases.

CI

1. Unstable cardiopulmonary , neurologic or CVS status or an existing bowel perforation
2. Structural abnormalities of esophagus , stomach or small bowel.
3. Altered surgical anatomy
4. ERCP with sphincterotomy or ampullectomy is CI in coagulopathic patients.
5. Acute Pancreatitis
6. Previous pancreaoduodenectomy
7. Recent MI
8. Contrast dye anaphylaxis

Contrast media 

• Low osmolar low viscousity non ionic Iopromid
• High osmolar low viscosity Ioglicinate
• Transhepatic percutaneous cholangiography