Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic method in gastroenterology that combines endoscopy and radiology. It involves radiographic imaging of the biliary system and pancreatic duct (pancreatic duct) during an endoscopic examination.
Indications (areas of application)
- Biliary tract imaging
- Imaging of the pancreatic duct to rule out inflammation, tumors, or pseudocysts
- Cholelithiasis (gallstones) – gallstone detection.
- Cholestasis (biliary obstruction) due to tumors, inflammation or unclear conditions.
The procedure
ERCP is performed using an endoscope that is inserted through the mouth into the stomach and on into the small intestine (duodenum). There, the papilla of Vater, the common excretory duct of the liver, gallbladder, and pancreas, is sought, and a catheter is inserted into it via which X-ray contrast medium is injected. The contrast medium is thus introduced retrogradely, i.e. against the normal direction of flow of the bile, into the bile ducts. Fluoroscopy with X-rays makes it possible to assess stenoses (narrowing) of the ducts, for example due to gallstones, biliary calculi or tumors. Similarly, the pancreatic duct (pancreatic duct) is also visualized. The examination is usually performed on an outpatient basis with the patient lying down in analgosedation (painless twilight sleep). As with most other endoscopic methods, diagnostic and therapeutic procedures can be performed simultaneously. In case of stenosis (narrowing) of the papilla (common orifice of the main bile duct and the ductus pancreaticus) or for stone removal, a papillotomy (papilla splitting) may be necessary. In addition, ERCP may be used for inoperable tumors in the biliary tract to restore the passage of bile by inserting a stent (implant placed in hollow organs to keep them open).
After the examination
- According to guidelines, therapy with indomethacin (100 mg rectally) has been given after ERCP since 2014 to prevent pancreatitis (inflammation of the pancreas; post-ERCP pancreatitis (PEP)). This is expected to reduce the risk of PEP in high-risk patients from 16.9% to 9.2% by.
- General indomethacin prophylaxis in all ERCP patients may be inadvisable: a study with placebo group showed that single administration of 100 mg indomethacin rectally did not reduce the risk; in fact, there was an increased incidence of PEP in patients with pancreatic duct stenting plus indomethacin administration (18.8%) versus pancreatic duct stenting plus placebo (10.7%, p =0.48). The authors advise against general indomethacin prophylaxis in all ERCP patients; they continue to see an indication in high-risk groups.
- A meta-analysis showed that diclofenac or indomethacin significantly reduced the risk of post-ERCP pancreatitis (PEP) to 0.6 (95% confidence interval, 0.46-0.78; p = 0.0001) [ 5, 6].
Potential complications
- Injury or perforation (puncture) of the wall of the esophagus (food pipe), stomach, or duodenum (duodenum) is very rare
- Mild pancreatitis (inflammation of the pancreas), which is usually harmless.
- Hypersensitivity or allergies (e.g., anesthetics/anesthetics, medications, etc.) may temporarily cause the following symptoms: Swelling, rash, itching, sneezing, watery eyes, dizziness or vomiting.
- After the examination may experience difficulty swallowing, sore throat, mild hoarseness. These complaints usually disappear after a few hours by themselves.
- Tooth damage caused by the endoscope or the bite ring are rare.
- Infections, after which severe life-threatening complications concerning heart, circulation, respiration, etc. occur, are very rare. Similarly, permanent damage (eg, paralysis) and life-threatening complications (eg, sepsis / blood poisoning) after infections are very rare.
- In the case of papilla splitting, there is a slight increase in risk of injury and more severe postoperative bleeding. Likewise, cholangitis (bile duct inflammation) or pancreatitis may occur.
- Transmission of germs wg.construction difficulty of cleaning
