Introduction to Endoscopic Retrograde
Cholangiopancreatography (ERCP)


BILE AND PANCREATIC DUCT
 
Ducts are drainage routes into the duodenum. The ducts that drain the liver and gallbladder are called biliary ducts whereby pancreatic duct is duct that drains the pancreas.

The bile and pancreatic ducts join together just before they drain into the duodenum, about three (3) inches from the stomach. The drainage opening is called the major papilla. The papilla is surrounded by a circular muscle, called the sphincter of Oddi.
 
HepatobiliaryPancreatic.jpg

WHAT IS ERCP?
 
Endoscopic Retrograde Cholangiopancreatography, or ERCP, is a specialized technique used to study of the ducts that drain the liver and pancreas. ERCP is for 2 main objectives:- 
  • Diagnostic ERCP is when X-ray contrast dye is injected into the bile duct, the pancreatic duct, or both. This contrast dye is squirted through a small tube called catheter that fits through the ERCP endoscope. Then, X-rays are taken during the ERCP to get images of these ducts. 
  • Therapeutic ERCP is when an ERCP is done for treatment due to the narrowing or blockage of bile or pancreatic duct such as:-
    • Choledocholithiasis
    • Biliary pancreatitis
    • Cholangiocarcinoma or pancreatic cancer palliative treatment    
WHAT CAN BE DONE THROUGH AN ERCP SCOPE?
 
Sphincterotomy
 
Sphincterotomy is cutting the muscle that surrounds the opening of the ducts, or the papilla. The cut is to enlarge the opening and looks through the ERCP scope at the papilla. A small wire on a specialized catheter uses electric current to cut the tissue. A sphincterotomy does not cause discomfort. The actual cut is quite small, usually less than ½ inches. This small cut, or sphincterotomy, allows various treatments in the ducts.
 
 
Sphincterotomy.jpg

Stone Removal
 
The most common treatment through an ERCP scope is removal of bile duct stones. After a sphincterotomy is performed to enlarge the opening of the bile duct, stones can be pulled from the duct into the bowel. A variety of balloons and baskets attached to specialized catheters can be passed through the ERCP scope into the ducts allowing stone removal.
 
StoneRemoval.jpg

Stent Placement
 
Stents are placed into the bile or pancreatic ducts to bypass strictures, or narrowed parts of the duct. These narrowed areas of the bile or pancreatic duct are due to scar tissue or tumors that cause blockage of normal duct drainage. There are two types of stents that are commonly used.
  • Plastic stents use for benign diseases; it can be pushed through the ERCP scope into a blocked duct to allow the normal drainage.
  • Metallic stents flexible and springs open to a larger diameter than plastic stents. Mostly use for cancer patient.
StentPlacement.jpg
Tissue Sampling
 
One procedure that is commonly performed through the ERCP scope is to take samples of tissue from the papilla or from the bile or pancreatic ducts. Tissue samples can help decide if a stricture, or narrowing, is due to a cancer. 
 
BEFORE, DURING, AND AFTER A THERAPEUTIC ERCP
 
You should not eat for at least 6 hours before the procedure.
 
You will have an intravenous needle placed in your arm so you can receive medicine during the procedure. You will be given sedatives that will make you comfortable during the ERCP. Some patients require antibiotics before the procedure.
 
The procedure is performed on an X-ray table. After the ERCP is complete you will go to recovery are until the sedation effects reside. 
 
WHAT ARE POSSIBLE COMPLICATIONS OF THERAPEUTIC ERCP?
 
The risks of ERCP include complications as follow:-
·         Pancreatitis
·         Bleeding
·         Infection
·         Perforation
 
The overall ERCP complication rate is 6 – 10% depending on your age, other medical problems, type of therapy is performed, and the indication for the procedure. 

BIBLIOGRAPHY OF DOCTOR
TeeTJ1-(3).jpg

Dr.Tee Teong Jin
MD,FACP,FACG,AM
Consultant Physician ,
Gastroenterologist and
Hepatologist

• Taiwan certified Internal Medicine specialist, Gastroenterologist and Hepatologist
• Fellow of American College of Physician
• Fellow of American College of Gastroenterology
• International member of American Society of Gastrointestinal Endoscopy
• Member of Academy Medicine Malaysia
• Member of Malaysian Society of Gastroenterology and Hepatology
• Fellowship in Advanced Endoscopy (Nanjing Medical University Hospital )
 


 
Dr.Tee pursued further advanced Endoscopy training at Nanjing Medical University Hospital affliated Drum Tower Hospital. He had observed 309 ERCP Cases and performed more than 230 therapeutic ERCP during his training in China. His expertise in therapeutic ERCP included Biliary drainage, stone removal and stenting.