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Duodenoscopic image of two pigment stones extracted from common bile duct after sphincterotomy

Fluoroscopic image of common bile duct stone seen at the time of ERCP. The stone is impacted in the distal common bile duct.

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. It is an x-ray examination of the bile ducts which is aided by a video endoscope. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on x rays.

ERCP is performed for diagnostic or therapeutic reasons. It is the Gold standard for recurrent pancreatitis.

• Obstructive jaundice - This may be due to several causes
• Chronic pancreatitis - a now controversial indication due to widespread availability of safer diagnostic modalities including endoscopic ultrasound, high-resolution CT, and MRI/MRCP
• Gallstones with dilated bile ducts on ultrasonography
• Bile duct tumors
• Suspected injury to bile ducts either as a result of trauma or iatrogenic
• Sphincter of Oddi dysfunction
• Pancreatic tumors no longer represent a valid diagnostic indication for ERCP unless they cause bile duct obstruction and jaundice. Endoscopic ultrasound represents a safer and more accurate diagnostic alternative

• Any of the above when the following may become necessary
  • Endoscopic sphincterotomy (both of the biliary and the pancreatic sphincters)
  • Removal of stones
  • Insertion of stent(s)
  • Dilation of strictures (e.g. primary sclerosing cholangitis, anastomotic strictures after liver transplantation)

1. Absolute contraindication:
   • The uncooperative patient.
2. Contraindication
   • Recent attack of acute pancreatitis, within the past several weeks.
   • Recent myocardial infarction.
   • Inadequate surgical back-up
   • History of contrast dye anaphylaxis
3. Relative contraindications:
   • Poor health condition for surgery.
   • Severe cardiopulmonary disease.
   • Ascites.

The patient is often sedated or anaesthetized. Then a flexible camera (endoscope) is inserted through the mouth, down the esophagus, into the stomach, through the pylorus into the duodenum where the ampulla of Vater (the opening of the common bile duct and pancreatic duct) exists. The sphincter of Oddi is a muscular valve that controls the opening of the ampulla. The region can be directly visualized with the endoscopic camera while various procedures are performed. A plastic catheter or cannula is inserted through the ampulla, and radiocontrast is injected into the bile ducts, and/or, pancreatic duct. Fluoroscopy is used to look for blockages, or leakage of bile into the peritoneum (the abdominal cavity).

A wire and balloon may be passed into the bile duct, then inflated in order to expand the opening of the bile duct to allow passage of gallstones. When needed, the opening of the ampulla can be enlarged with an electrified wire (sphincterotome) and access into the bile duct obtained so that gallstones may be removed or other therapy performed.

Other procedures associated with ERCP include the trawling of the common bile duct with a basket or balloon to remove gallstones and the insertion of a plastic stent to assist the drainage of bile. Also, the pancreatic duct can be cannulated and stents be inserted. The pancreatic duct requires visualisation in cases of pancreatitis.

Gut perforation is a risk of any endoscopic procedure as well as the ERCP holding a 5% risk of developing acute pancreatitis.

Dyes: Dyes used to allow the physician to image the organs can cause allergic reactions. Iodine is a component of one of these dyes, and if you are allergic to shellfish, you will be at risk with the dye. Also, the dyes can be harmful to the kidneys. If your kidneys have poor function, the dye could cause renal failure ( called Contrast Nephropathy)[^[1]]. If you are at such risk, then ask the physician, ask about how to promote flushing the dye from your system and how to recover from kidney damage. If you are on dialysis, you should be dialyzed after the procedure to flush out the dyes.

Sedation: Experienced anesthesia providers will provide you sedation only in an "as needed" amount to keep you comfortable. Oversedation can result in dangerously low blood pressure and nausea and vomiting. Nausea and vomiting are especially dangerous, as these prevent you from drinking to flush the dyes out of your kidneys.

• Percutaneous transhepatic cholangiography

• What is ERCP?. AGA Patient Center. American Gastroenterological Association. Retrieved on 2007-06-29.
• [1] - ERCP at eDoctor.co.in