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ERCP

Understanding ERCP

ERCP stands for ‘endoscopic retrograde cholangiopancreatography’. ERCP is a very useful procedure, as it can be used both to diagnose and to treat various conditions, such as gallstones, acute pancreatitis (inflammation of the pancreas that develops quickly over a few days) and chronic pancreatitis (inflammation of the pancreas that is more persistent).

An endoscope is a thin, flexible, telescope. It is passed through the mouth, into the gullet (oesophagus) and down towards the stomach and the first part of the gut after the stomach (the duodenum). The doctor is able to look inside as endoscope contains fibre-optic channels which allow light to shine down.

Cholangiopancreatography means X-ray pictures of the bile duct and pancreatic duct. These ducts do not show up very well on ordinary X-ray pictures. However, if a dye that blocks X-rays is injected into these ducts then X-ray pictures will show up these ducts clearly. Some dye is injected through the papilla back up into the bile and pancreatic ducts (a ‘retrograde’ injection). A plastic tube in a side channel of the endoscope is used for doing this . Thereafter X-ray pictures are shot.

The bile ducts and nearby structures

The liver makes the bile. The liver is in the upper right part of the tummy (abdomen). Bile passes from liver cells into tiny tubes called bile ducts. These join together (like the branches of a tree) to form the common bile duct. Bile constantly drips down the common bile duct and through an opening called the papilla into the first part of the gut after the stomach (the duodenum).

The gallbladder lies under the liver on the right side of the upper abdomen. It is like a pouch which comes off the common bile duct. It is a ‘reservoir’ which stores bile between meals. The gallbladder squeezes (contracts) when one eats. This empties the stored bile back into the common bile duct. The bile passes along the remainder of the common bile duct into the duodenum. Bile helps to digest food, particularly fatty foods. The pancreas is a large gland that makes chemicals (enzymes). These flow down the pancreatic ducts, into the main pancreatic duct, and through the papilla into the duodenum. The pancreatic enzymes are vital in order to digest food. Some hormones such as insulin are also made by pancreas.

Procedure of ERCP

The back of one’s throat may be numbed by spraying on some local anaesthetic. Usually a sedative is given by an injection into a vein in the back of one’s hand or arm. The sedative makes the person drowsy and relaxed but it does not ‘put one to sleep’.

One lies on one’s side on a couch. The doctor then asks to swallow the first section of the endoscope. Modern endoscopes are quite thin (thinner than an index finger) and quite easy to swallow. The doctor then gently pushes it down one’s oesophagus into one’s stomach and duodenum.

The doctor on a TV monitor which is connected to the endoscope. Air is passed down a channel in the endoscope into the stomach and duodenum to make the lining easier to see.

The endoscope also has a ‘side channel’ down which various tubes or instruments can pass. These can be manipulated by the doctor who can do various things. For example:

1. Inject a dye into the bile and pancreatic ducts. X-ray images shot immediately after the injection of dye show up the detail of the ducts. This may show narrowing (stricture), stuck gallstones, tumours pressing on the ducts, etc.

2.Take a small sample (biopsy) from the lining of the duodenum, stomach, or pancreatic or bile duct near to the papilla. The biopsy sample can be looked at under the microscope to check for abnormal tissue and cells.

3. If the X-rays show a gallstone stuck in the duct, the doctor can widen the opening of the papilla to let the stone out into the duodenum. A stone can be grabbed by a ‘basket’ or left to be passed out with the stools (faeces).

4. If the X-rays show a narrowing or blockage in the bile duct, the doctor can put a stent inside to open it wide. A stent is a small wire-mesh or plastic tube. This then allows bile to drain into the duodenum in the normal way. One will not be aware of a stent, which can remain permanently in place.

The endoscope is gently pulled out when the procedure is finished. An ERCP can take anything from 30 minutes to over an hour, depending on what is done.

Preparing for ERCP

The sort of instructions can include:

Nothing should be eaten from several hours before the procedure.

Advice about medication which may need to be stopped before the procedure, will be given.

Post ERCP care

If the procedure was done just to obtain X-ray pictures then most people are ready to go home after resting for a few hours. One should not drive, operate machinery or drink alcohol for 24 hours after having the sedative. If one goes home on the same day as the procedure one will need somebody to accompany the person home and to stay with him for 24 hours until the effects of the sedative have fully worn off.

Most people are able to resume normal activities after 24 hours. Because of the effect of the sedative, most people remember very little about the procedure. A short hospital stay may be required a procedure such as removing a gallstone or inserting a small wire-mesh or plastic tube (a stent) was done.

Complexities or side effects of ERCP

Most ERCPs are done without any problems. Some people have a mild sore throat for a day or so afterwards. One may feel tired or sleepy for several hours, caused by the sedative. Uncommon complications include the following:

There is a slightly increased risk of developing a chest infection following an ERCP.

Occasionally, the endoscope causes some damage to the gut, bile duct or pancreatic duct. This may cause bleeding, infection and, rarely, perforation.

Tummy (abdominal) pain – in particular, if it becomes gradually worse and is different or more intense to any ‘usual’ indigestion pains or heartburn that you may have.

Raised temperature (fever).

Throwing up blood

Difficulty in breathing

Inflammation of the pancreas (pancreatitis) sometimes occurs after ERCP. This can be serious in some cases.

If one is already in poor general health, the risk of complications is higher. The benefit from this procedure needs to be weighed up against the small risk of complications.

In case someone is expecting pregnancy, one’s doctor should be informed about it. It may still be possible to perform ERCP if one is pregnant, providing certain precautions are taken.

CONCLUSION:

A procedure that uses an endoscope and X-rays to look at the bile duct and the pancreatic duct is called ERCP. This procedure can also be used to remove gallstones or take small samples of tissue for analysis or a biopsy. With improved diagnostic facilities ERCP is now mostly used for treatment of Jaundice. It is life saving when perfordmed at required time.