2. Introduction
• ERCP is a combined endoscopic and fluoroscopic procedure
in which an upper endoscope is lead into 2nd part of
duodenum, making it possible for passage of other tools via
major duodenal papilla into biliary and pancreatic ducts.
• Contrast material is injected into these ducts, allowing it
as diagnostic and therapeutic tool when needed.
4. Indications
Diagnostic
• Cholestatic jaundice
• Acute Cholangitis
• Choledocholithiasis
• Sphincter of Oddi manometry
• Suspected sclerosing cholangitis
• Recurrent acute pancreatitis
• Chronic pancreatitis
• Evaluation of pancreatic pseudocyst
• Pancreatic fistula, pancreatic ascites
• Brush cytology or biopsy for confirmation of diagnosis
5. Therapeutic
• Biliary drainage for cholangitis, pruritus,
post-operative bile leak
• Extraction of stones, round worms or hydatid
daughter cysts from bile duct
• Bile duct and pancreatic duct stricture dilatation
• Pancreatic duct and CBD stone extraction
• Pancreatic duct stenting in chronic pancreatitis,
pancreatic ascites and fistula
• Sphincterotomy in case of sphincter of oddi
dysfunction or stenosis
• Balloon dilation of the duodenal papilla and
ductal strictures
6. Contraindications
• Unstable cardiopulmonary, neurology or cardiovascular
status and existing bowel perforation.
• Structural abnormalities of esophagus, stomach
and duodenum.
• Altered surgical anatomy.
• ERCP with sphincterotomy or ampullectomy is
contraindicated in cogulopathic patients.
7. Contrast Media
• Non ionic tri-iodinated low osmolar contrast agent
1. Iopamidol
2. Iohexol
3. Iopramide
8. Sedation
• Inj Diazepam [0.3mg/kg body weight]
• Inj Pethidine 75mg IM before 1 hour
• local anaesthetic agent like Xylocaine spray can be given.
11. Patient preparation
• NPO from midnight or atleast 6 hours prior to procedure.
• Information about any medications [anticoagulants,
analgesics], major illness, pregnancy, allergy or
previous other surgeries.
• Recent bood investigations, radiological reports to look for
gall stones, pancreatic calcifications or any other diagnosis.
• May need IV antibiotics prior to ercp.
12. • local anesthetic sprayed onto the tongue/throat
before the procedure.
• known allergic to iodine contrast, pre treated with
either 40mg prednisone 12 hours and 2 hours before
or 40mg daily for 3 days before procedure.
• smooth muscle relaxant-Buscopan 20mg IM before
10 mins or atropine 0.6mg IM before 1 hour or
0.5-1ml glucagon Iv is given to reduce duodenal spasm
and relax the sphincter of oddi for passage of
endoscope and insertion of cannula.
13. PROCEDURE
• With the patient in the prone or semiprone position,
the duodenoscope is passed through a mouth guard.
• Duodenoscope is then advanced through stomach
pylorus into the duodenal bulb.
• The scope should be advanced to the second part of
duodenum to visualise the major duodenal papilla,
a protuberance at the junction of the horizontal and
vertical duodenal folds.
• The recommended wire guided technique is done through
a guide wire that passes under fluoroscopy into common bile
duct or pancreatic duct before contrast injection.
14. • On the other hand, the standard contrast-assisted method involves
contrast material injection after introducing the cannulation device
tip into the major duodenal papillary orifice to assure proper
positioning.
• Difficult cannulation may be due to periampullary diverticulum,
impacted biliary stone, bile duct stenosis, or tumor of the bile duct
or pancreatic head.
• Infrequently, cannulation of the minor papilla with sphincterotomy
may be done in cases of idiopathic recurrent acute pancreatitis
or patients with pancreas divisum.
15.
16.
17. Therapeutic ERCP
• Brushing and biopsy
• Balloon dilation
• Stenting
• Sphincter of Oddi manometry
• Sphincterotomy
• Nasobiliary drainage
18. Brushing and biopsy
• Most of the strictures in the
hepatobiliary ducts are caused
by tumor compression the duct
walls.
• Sample tissue is taken from
stricture during ERCP procedure
to confirm pathological diagnosis
19. • Under fluoroscopic control,
guide wire is introduced past
through the stricture, then
advance brush catheter upto the
stricture.
• The brush is moved up and
down several times to scrap and
extract diseasesd tissues from
stricture.
• The brush is removed from
endoscope, cut off the wire
placed in a formalin solution to
be sent for pathological study.
20. Forceps Biopsy
• Small biopsy forcep is advanced
over guide wire to stricture.
• Forceps are obtained touching
the stricture walls, closed tightly
to clamp tissues and pull back
maintaing closed condition from
endoscope.
• tissue sample is placed in
formalin solution and sent to
pathological study.
32. After care
• NPO for 4 hours until anaesthetic effect return to normal.
• Avoid alcohol for atleast 24 hours
• Monitoring vitals hourly for 4-6 hours then
4 hourly for next 24 hours.
• Monitoring in the recovery room for 30-45 mins,
until the effects of sedation remain.
34. Complications of ERCP
• Post ERCP pancreatitis-
1.New or worsened abdominal pain.
2.New or prolongation of hosptalisation for atleast 2 days.
3.Serum amylase levels obtained 2-6 hours post-ERCP are
considered normal if less than 1.5 times the upper limit
of normal.
4.Serum lipase levels obtained at same time are considered
normal if less than 4 times the upper limit of normal.
35. Risk Factors for post-ERCP pancreatitis-
1.Balloon dilation of biliary sphincter
2.H/O post ERCP pancreatitis
3.Pancreatic duct injection
4.Pancreatic sphincterotomy
5.Precut sphincterotomy
6.Suspected sphincter of Oddi dysfunction
7.Increase cannulation attempts duration [more than 10 mins]
8.Young age
36. Methods of reducing post-ERCP pancreatitis
• Alternatives to ERCP like MRCP and EUS have similar
sensitivity for detection of pancreatobiliary disorders
without risk of pancreatitis.
• Pharmacological prophylaxis- significant reduction
of PEP with indomethacin or diclofenac given rectally
just before ERCP.
37. Modifications in techniques to avoid PEP
• Pancreatic duct stents- Temporary pancreatic duct stents
show the benefits of lowering the risk and severity of PEP
in high risk individuals.
• Wire guided cannulation-The use of wire guided cannulation
beofre contrast injection has been shown resulting in greater
success of biliary cannulation and lower risk of PEP by avoiding
injection of contrast into pancreas
38. Hemorrhage
• Most ERCP-associated bleeding is intraluminal, intraductal
bleeding and can also occur
• It is a complication related to sphincterotomy rather than
diagnostic ERCP.
• It can be immediate or delayed, with recognition occuring upto 2
weeks after procedure.
• Risk of post -ERCP hemorrhage was associated with hemodialysis,
visible bleeding during the procedure, higher bilirubin and use of
pure-cut current for sphincterotomy
• Treatmen of bleeding includes injection therapy with epinephrine,
with or without thermal therapy and endoscopic clips
39. Perforation
• Guidewire induced perforation
• Periampullary perforation during sphincterotomy
• Luminal perforation at a site remote from papilla
RISK FACTORS-
• Sphincterotomy
• Billroth 2 anatomy
• Intramural injection of contrast
• Prolonged duration of procedure
• Biliary stricture dilation
• Sphincter of Oddi dysfunction
40. Infections
Cholangitis-
• Seen in combined percutaneous-endoscopic procedures
• stent placement in malignant strictures
• incomplete or failed biliary drainage
• primary sclerosing cholangitis
Cholecystitis-
• Seen in gall bladder stones and filling of gall bladder with contrast.
• Placement of self expandable metal stents particularly if stent is
covered and cystic duct is obstructed.
41. Cardiopulmonary complications-
• Cardiac arrhythmia
• Hypoxemia
• Aspiration
Other complications-
• Pneumothorax
• Hepatic abscess formation
• Antibiotic related diarrhea
• Perforation of colonic diverticula
• Duodenal hematoma
42. References
• Harrison’s Principles of Internal Medicine 21st edition.
• API Textbook of Medicine 12th edition.
• Sleisenger and Fordtran’s Gastrointestinal and
liver disease 11th edition.
