ERCP

Dr David Scott Gastroenterologist Tamworth Base Hospital

ERCP

What is it? When is it recommended?

How is it performed?
What are the complications? Whats new in ERCP?

What is ERCP?

Endoscopic Retrograde Cholangiopancreatogram Essentially it is a

radiological procedure performed via an endoscope to diagnose and treat conditions of the bile and pancreatic ducts

When is it recommended?

Gall stones in the bile duct Malignant bile duct obstruction Bile duct leak post cholecystectomy
Benign bile duct obstructions Tissue sampling of bile duct lesion Sphincter of Oddi Dysfunction (type 1) Pancreatic duct stones and obstruction Pancreatic pseudocysts Others

Complications Of Gall Stones

Biliary colic (pain but normal BR) Cholecystitis (pain and fever but normal BR) Biliary colic (pain and raised BR) Cholangitis (pain and fever and raised BR)

Pancreatitis (pain +/raised BR)

Malignant Bile Duct Obstruction

Bile duct cancer

Pancreatic cancer

Clinical Presentations for ERCP

Gall stones:

Malignant obstruction:

PAIN AND JAUNDICE

PAINLESS JAUNDICE

Special Situations

Gallstone Pancreatitis
<24 hours if persisting bile duct obstruction and severe pancreatitis Otherwise avoid

Gall bladder in situ

Depends on the surgeon

Pre-procedure investigations
Liver tests Platelet count and coagulation profile Imaging

Ultrasound CT CT cholangiogram MRCP Endoscopic Ultrasound

Pre-procedure Imaging
Transabdominal Ultrasound MRCP Endoscopic Ultrasound

Sens 25-82% Spec 50-85%

Sens 81-91% Spec 100%

Sens 84-100% Spec 87-100%

CT Cholangiogram Pre-procedure imaging has revolutionised ERCP

How is it performed?

Similar to a Gastroscopy
NBM for 6 hours prior (no bowel prep) IV sedation (not usually intubated) Left lateral position (sometimes prone) NOT sterile just clean

Different to a Gastroscopy
Side viewing endoscope Portable image intensifier used Diagnostic and therapeutic equipment About 30 minutes

Cannulation of the Bile Duct

Major Papilla Anatomy

Common channel Common bile duct Pancreatic duct

Image property of Marco Bruno, AMC Amsterdam, From: Atlas of human anatomy. Gosling et al. Gower Medical Publishing Ltd. 1985

Sphincterotomy

Sphincterotomy

Biliary sphincter is like a valve Needs to be cut to allow most interventions to relieve biliary obstruction Highest risk part of standard ERCP
Perforation Bleeding Pancreatitis

Stents

Plastic

Biliary
7 or 10 FG Need to be removed/replaced within 3 months

Pancreatic
5 FG Need to be removed within 2-4 weeks

Metal
10mm Not removable (usually)

Cardiologists and ERCP

Aspirin

OK

Clopidogrel / Warfarin / Enoxaparin

No sphincterotomy Stent can solve acute problem and allow definitive treatment to be deferred

Implantable defibrillator
No sphincterotomy without local technician Need to go to tertiary centre

Complications of ERCP

Failure 5 - 10% Pancreatitis 5% (severe in 0.5%) Bleeding 1% Perforation 0.1% Anaesthetic complications

Predicting Post ERCP Pancreatitis

Doctor Factors

Low case volume, trainee

Difficult cannulation, pancreatic injection, precut Young, female, normal BR, previous pancreatitis

Procedure Factors

Patient Factors

Reducing the Risks of ERCP

Patient selection Patient selection Patient selection Wire guided technique Pancreatic stents Dont persist indefinitely

Teamwork

Radiographer Nursing
Assistant * VERY IMPORTANT ROLE * 2nd Assistant Anaesthetics / Recovery

Medical
Endoscopist Anaesthetist

Anaesthetic Nurse
Anaesthetist Anaesthetic Stuff Video Scrub nurse Scout nurse

Equipment
Assistants Table

XRay viewer XRay Machine Processor

Diathermy Machine Radiographer Endoscopist

ERCP Set up

Whats new in ERCP?

Summary

More like interventional radiology than endoscopy Patient selection important Needs Teamwork and Communication