Endoscopic retrograde cholangiography and pancreaticography (ERCP) is an endoscopic examination in which bile ducts and pancreatic ducts are visualized via an access through the mouth. This means that no tissue incisions are necessary, as the endoscope can be advanced directly to the bile ducts via existing access routes.
During an ERCP, the doctor examines the bile and pancreas @ Pepermpron /AdobeStock
ERCP plays a central role in diseases that affect the bile ducts and pancreatic ducts. With the exception of rare cases, purely diagnostic ERCP examinations are no longer common. Only the detection of primary sclerosing cholangitis, which cannot be diagnosed in any other way, occasionally justifies its diagnostic use.
For therapeutic use, a papillotomy, the opening of the sphincter at the common opening of the pancreatic and bile ducts into the duodenum(papilla, papila vateri, papilla duodeni major), is usually required.
The typical main symptom that often leads to an ERCP is a yellowing of the sclera and skin(jaundice, icterus) as a sign of a bile drainage disorder. Furthermore, the urine becomes darker in color, the stool lighter in color and increased itching becomes noticeable.
As a rule, sonography ( ultrasound) is used to confirm the blockage of the bile ducts and laboratory tests are used to rule out liver tissue damage and increased decay of red blood cells. Typical obstructions are gallstones or tumors.
A blockage of the pancreas, e.g. as part of chronic pancreatitis, can lead to severe pain.
ERCP and papillotomy cannot be performed if the examination is more dangerous for the patient concerned than the bile or pancreatic disease to be treated. This would be the case, for example, in the event of an acute heart attack or severe blood clotting disorders.
ERCP is performed under anesthesia. The actual examination usually takes between 30 and 60 minutes.
An endoscope with side-view optics is pushed in front of the papilla and the ducts are selectively probed with a thin wire, depending on the problem. After ensuring by X-ray fluoroscopy that the wire is in the desired duct, contrast medium is injected into the duct. As a rule, it is then clear at the latest whether a stone or a narrowing is the cause of the symptoms.
Using a papillotome, a plastic catheter with a short cutting wire, a controlled incision of a few millimeters, the papillotomy, can then be made by applying a high-frequency current via the heat effect.
After papillotomy, there is sufficient space to work with baskets or balloon catheters to extract stones or to insert stents made of plastic or expanding metal mesh to bridge narrowings.
The stomach must be empty for the ERCP examination, so the patient must have an empty stomach on the day of the examination. Current blood values, which rule out unrestricted blood clotting and other risks, must have been determined. For the examination, medication is administered that severely restricts consciousness (sedation). As a rule, the patient is not aware of the examination.
After ERCP and papillotomy, inpatient monitoring is advisable so that an immediate response can be made to any complications that may occur. In the event of pain, for example, a painkiller can be administered promptly.
The patient must not eat anything at first because food in the stomach stimulates the activity of the pancreas, which may be irritated by the examination, and increases the risk of acute pancreatitis. Drinking water or unsweetened tea is not considered problematic.
If there are no complaints on the following day and no alarm signs in the blood values, a cautious diet can be started.
If the patient can be discharged on the day of the examination, the patient's limited ability to drive after sedation must be taken into account. The patient must not drive for 24 hours.
If stones have been successfully removed, no follow-up care is required; if a tumor was the cause, further measures may need to be taken with regard to the underlying disease.
The main side effect of ERCP is acute pancreatitis, which occurs after approx. 5% of examinations. The risk is higher if the doctor lacks experience, in the case of particularly difficult anatomical conditions or very specific diseases.
Furthermore, the risk for female patients is generally somewhat higher than for male patients.
ERCP, papillotomy, extraction of gallstones and the insertion of stents are successful in experienced hands in well over 90 % of cases.
If stones have been removed from the bile duct, removal of the gallbladder(cholecystectomy) is usually also necessary for definitive healing so that no further stones migrate from the gallbladder into the duct, even if these can pass more easily into the small intestine on their own after papillotomy.
If a stricture caused by a malignant tumor has been treated, radical surgery is unavoidable for a cure. Unfortunately, due to the advanced stage of the tumor or the patient's age and concomitant diseases, surgery is often no longer possible and drainage of the bile serves as a palliative measure to ensure quality of life.
If the drainage of the pancreatic duct in the context of painful chronic pancreatitis is restored by ERCP, papillotomes, stone extracts or stents, around 2/3 of patients can expect their pain to end or be largely eliminated.
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