What you need to know about:

ERCP (Endoscopic Retrograde Cholangio Pancreatography)

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Overview of

ERCP (Endoscopic Retrograde Cholangio Pancreatography)

in Thailand

Endoscopic retrograde cholangiopancreatography, or ERCP, is an endoscopic test that is used to examine and treat problems of the bile ducts, pancreatic ducts, and gallbladder. Bile ducts are the tubes that drain bile from the liver and pancreatic ducts drain pancreatic juice from the pancreas. Both ducts empty into the duodenum, which is the first part of the small intestine.The procedure is used to assist the examination, diagnosis and treatment of bile duct and pancreatic duct abnormalities which may include; obstruction at bile duct, pancreatic duct from gallstones and polyps. ERCP combines the usage of X-ray together with an endoscope. The endoscope is inserted into the mouth and guided through the stomach into the small intestine and into the opening of the bile duct. A contrast media is injected into the duct for X-ray to examine abnormalities in the bile and pancreatic ducts. If gallstones are found in the bile duct, the opening may be enlarged to remove the stone by an elective wire. The cut at the opening will heal within a week.

Goals of

ERCP (Endoscopic Retrograde Cholangio Pancreatography)

ERCP may be done for many reasons. The most common reason is to find and remove gallstones stuck in the bile duct. Other common reasons are to look for causes of acute pancreatitis (inflammation or irritation of the pancreas), to unblock the ducts when they are not able to drain because of tumor in the bile ducts or pancreas, and to treat leaking of the bile or pancreas ducts. These problems are usually first found through imaging tests which are considered safer initial tests that do not have as many risks as ERCP. Examples of initial imaging tests are ultrasound of the belly, a special kind of MRI study called MRCP, or by an ultrasound scope test called an Endoscopic Ultrasound. These can tell your doctor whether you need to have an ERCP to follow-up on abnormalities found on these non-invasive imaging tests.

Price of

ERCP (Endoscopic Retrograde Cholangio Pancreatography)

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Pros and cons of

ERCP (Endoscopic Retrograde Cholangio Pancreatography)

Pros

-ERCP is highly effective in diagnosing various conditions during the procedure. This includes; growths and strictures of the bile duct and the pancreatic duct, gall stones and pancreatic stones, inflammation of the gall bladder and the bile duct, primary biliary cirrhosis and the pseudo pancreatic cysts.  

-ERCP is also ideal for treating conditions related to the biliary tract .The treatments that can be done during ERCP include: biopsy samples, bile or pancreatic juice sampling, removal of gall or pancreatic stones, placing a tube for bile drainage as well as performing a sphincterotomy of bile duct valve or pancreatic duct valve  

Cons

-Possible chance of developing pancreatitis, pancreatic abscess  

-Perforation in the duodenum or the pancreas may occur accidentally during sphincterotomy and may require surgery to be sealed. It may also lead to bleeding which may sometimes warrant the need of blood transfusion.  

-Rarely, the endoscope itself may cause damage to the esophageal, gastric or duodenal mucosa.  

-The ERCP procedure can result in the infection of bile ducts and pancreatitis. The patient may require hospitalization, antibiotics or surgery to be relieved of these complications.  

-Patient may have allergic reaction to the contrast dye or have side effects of anesthesia like nausea, breathlessness, dryness of mouth, redness of the skin, blurring of vision, slow pulse rate and fall in blood pressure. There may be infection at the site of intra-venous line. In the long run, patient may develop pancreatic abscess or the stones may form again.

How it works:

ERCP (Endoscopic Retrograde Cholangio Pancreatography)

ERCP is performed by gastroenterologists or surgeons who are specially trained to do them. An endoscope is a long, flexible tube with a camera and a light at the tip. The test is done while you are asleep and this can be done by your doctor with the help of a doctor who specializes in putting patients to sleep and waking them up again, called an Anesthesiologist. Often medications through your veins are used to help you fall asleep, but sometimes general anesthesia is necessary. The endoscope or tube is passed through the mouth, esophagus, and stomach into the duodenum where the bile duct enters; this is known as the papilla. A small tube is passed through the scope to come out of its tip. This is used to enter the papilla and the ducts, place wires to help with treatments, and to squirt x-ray dye to see what is going on inside the ducts. This lets your doctor decide on how best to treat blockages, stones, or tumors. Your doctor can then use their equipment to help treat and improve these problems. For example, if stones are seen, the bile duct opening can be widened, and stones can be taken out of the duct. The papilla has a muscle that surrounds the bile duct opening and this can be cut using electricity through a small wire on the end of the tube. This is called a sphincterotomy, which can let the duct drain better and allow the doctor to do treatments to help problems in the ducts.

Preparation before

ERCP (Endoscopic Retrograde Cholangio Pancreatography)

Pre - treatment

You will be required to not eat prior to your procedure, usually at least 6-8 hours before your scheduled procedure. The stomach should be empty so your doctor can see where they are going. This also helps prevent you from throwing up and sucking it down the wrong pipe into your lungs (aspiration).  You should discuss all your medicines with your doctor, as some may need to be changed or temporarily stopped for the test. This step is really important if you are taking medications to thin out your blood. These include medicines like warfarin (Coumadin), heparin, enoxaparin (Lovenox); and/or new blood thinning medications like dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa). You should also talk about medications that keep your blood platelets from causing a clot, like clopidogrel (Plavix), ticagrelor (Brilinta), and prasugrel (Effient). You should also ask what you should do with your insulin, or other medicines for diabetes. Nonsteroidal anti-inflammatory drugs (NSAIDs) are common medications used to treat arthritis, pain, or inflammation; and include ibuprofen, naproxen, and diclofenac, to name a few. These medications do not need to be stopped and you can also continue aspirin if you are taking it. You should let your doctor know of any medication allergies, including those to iodine or intravenous (IV) contrast dye.

Recovery after

ERCP (Endoscopic Retrograde Cholangio Pancreatography)

Post - treatment

After the procedure, the you will be transferred to the recovery area and observed until most of the effects from the medication have worn off. This usually takes one to two hours.You may feel bloated or slightly nauseated from the medication or the procedure. Very rarely a patient experiences vomiting and may belch or pass some gas through the rectum. Upon discharge, the patient should be driven home by his/her companion and is advised to stay home for the rest of the day. The patient can resume usual activity the next day. Even though the physician may explain to the patient or companion regarding the findings after the procedure, it is still necessary to call the physician the next day to ensure that the patient understands the results of the examination.

Risks & side effects

While ERCP is generally safe and most people do well, there are risks of having one. Your physician should discuss the potential risks with you prior to your procedure. Bleeding may happen and is more common if the bile duct opening is widened by cutting. The bleeding is usually small and stops on its own. Sometimes patients can vomit blood or blood can pass through their stool as a sign of bleeding. (not sure if this would scare the reader but explaining symptoms may be helpful) If it happens during the ERCP, it can be treated during the procedure. This can be done with small metal clips, injection of epinephrine medicine (which constricts blood vessels), or by burning the bleeding area with electricity. Infection of the bile ducts (cholangitis) can occur, especially if the bile ducts are not draining well. Fevers and abdominal pain may be a sign of infection. Antibiotics during the procedure and for a few days following ERCP are needed for some patients. Pancreatitis (inflammation or irritation of the pancreas) occurs in 3% to 7% of all patients who have an ERCP. This will cause really bad stomach pain in the top of your belly going through to your back. This pain that does not get better by belching or passing gas. While most ERCP related pancreatitis is mild, it can rarely be very bad or even life threatening. You may have to stay in the hospital for to treat this. Perforation (a tear or hole) of the esophagus, stomach, small bowel, or ducts may happen. Worsening abdominal pain may be a sign of this. If this is small, it may heal on its own with closely watching you in the hospital. If it is big, then it may need endoscopy or surgery to fix it, which may cause more problems. Aspiration (stomach contents going into your lungs) may occur when food from the stomach refluxes into the back of the throat and is sucked down into the lungs. This can cause trouble breathing or a lung infection called pneumonia. This risk is small if patients do not eat for several hours prior to the procedure. Bad Reaction to the sleeping medicines or anesthesia. This could include rash, nausea, vomiting, or more severe reactions to medications. A review of prior allergies or side effects will be done prior to giving you any new medications.

FAQs:

ERCP (Endoscopic Retrograde Cholangio Pancreatography)

Why might I need an ERCP?

You may need ERCP to find the cause of unexplained abdominal pain or yellowing of the skin and eyes (jaundice). It may be used to obtain more information if you have pancreatitis or cancer of the liver, pancreas, or bile ducts.  ERCPs can be used to detect:  

-Blockages or stones in the bile ducts

-Fluid leakage from the bile or pancreatic ducts

-Blockages or narrowing of the pancreatic ducts

-Tumors

-Infection in the bile ducts

-Your healthcare provider may have other reasons to recommend an ERCP.

How is ERCP different from MRCP (magnetic resonance cholangiopancreatography)?

MRCP is a procedure that uses magnetic resonance imaging of both intrahepatic and extrahepatic bile ducts and pancreatic duct. MRCP is also commonly used and has proven useful for imaging modalities of the biliary tree.  An MRCP involves the use of magnetic resonance imaging (MRI) for internal diagnostics on a patient. The procedure is non-invasive, unlike ERCP procedure, and involves a simple process of scanning the patient using magnetic and radio frequencies from an MRI. MRCP is used to examine parts of a patient’s abdominal section such as the gall bladder, pancreas, liver, and bile ducts.  MRCP has advantages and disadvantages over ERCP procedure. However, both procedures can be effective and useful in many different medical circumstances. Some of the main advantages of MRCP are that it is non-invasive and does not require the use of contrast material. This is good for elderly patients. MRCP is also advantageous for patients that are sensitive during medical procedures and patients that cannot have contrast material. The disadvantage to MRCP is that sometimes the image quality is not adequate for diagnosis.

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