endoscopic retrograde cholangiopancreatography

The following represent indications for ERCP, particularly if or when less invasive options are not adequate or definitive:

Image:ERCP stone.jpg stone seen at the time of ERCP. The stone is impacted in the distal common bile duct. A nasobiliary tube has been inserted.]]

Image:ERCP dilatation.png

• Obstructive jaundice – This may be due to several causes
• Gallstones with dilated bile ducts on ultrasonography
• Indeterminate biliary strictures and suspected bile duct tumors{{cite journal |last1=Tabibian |first1=James H |title=Advanced endoscopic imaging of indeterminate biliary strictures |journal=World Journal of Gastrointestinal Endoscopy |date=2015 |volume=7 |issue=18 |pages=1268–1278 |doi=10.4253/wjge.v7.i18.1268 |pmid=26675379 |pmc=4673389 |doi-access=free }}
• Suspected injury to bile ducts either as a result of trauma or of iatrogenic origin
• Sphincter of Oddi dysfunction
• Chronic pancreatitis is currently a controversial indication due to widespread availability of safer diagnostic modalities including endoscopic ultrasound, CT, and MRI/MRCP
• Pancreatic tumors no longer represent a valid diagnostic indication for ERCP unless they cause bile duct obstruction and jaundice.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

ERCP may be indicated in the above diagnostic scenarios when any of the following are needed:

• Endoscopic sphincterotomy of the sphincter of Oddi
• Extraction of gallstones or other biliary debris{{cite book | chapter-url=https://www.ncbi.nlm.nih.gov/books/NBK539698/ | title=StatPearls | chapter=Biliary Obstruction | year=2022 | publisher=StatPearls | pmid=30969520 | last1=Coucke | first1=E. M. | last2=Akbar | first2=H. | last3=Kahloon | first3=A. | last4=Lopez | first4=P. P. }}
• Insertion of a stent through the major duodenal papilla and ampulla of Vater into the common bile duct and/or the pancreatic duct
• Dilation of strictures (e.g. primary sclerosing cholangitis, anastomotic strictures after liver transplantation){{cite journal |last1=Tabibian |first1=James H. |last2=Asham |first2=Emad H. |last3=Han |first3=Steven |last4=Saab |first4=Sammy |last5=Tong |first5=Myron J. |last6=Goldstein |first6=Leonard |last7=Busuttil |first7=Ronald W. |last8=Durazo |first8=Francisco A. |title=Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video) |journal=Gastrointestinal Endoscopy |date=March 2010 |volume=71 |issue=3 |pages=505–512 |doi=10.1016/j.gie.2009.10.023 |pmid=20189508 }}
• Extraction of liver flukes from the biliary system (e.g., opisthorchiasis, clonorchiasis, fasciolosis)

• Acute pancreatitis (unless persistently elevated or rising bilirubin suggests ongoing obstruction){{cite journal |last1=Scheurer |first1=U |title=Acute Pancreatitis - ERCP / Endoscopic Papillotomy (EPT) Yes Or No? |journal=Swiss Surgery |date=1 October 2000 |volume=6 |issue=5 |pages=246–248 |doi=10.1024/1023-9332.6.5.246 |pmid=11077490 }}
• (Irreversible) coagulation disorder if sphincterotomy planned
• Recent myocardial infarction or pulmonary embolism
• Severe cardiopulmonary disease or other serious morbidity

Hypersensitivity to iodinated contrast medium or a history of iodinated contrast dye anaphylaxis is not a contraindication of ERCP, though it should be discussed with your health provider, and you should tell them you are allergic to iodine, as an alternative contrast iodine-free material ("dye") is then injected gently into the ducts (pancreatic or biliary) and x-rays are taken.{{cite web | url=https://www.mngi.com/patient-services/ercp-endoscopic-retrograde-cholangiopancreatography | title=ERCP (Endoscopic Retrograde Cholangiopancreatography) | MNGI }}

File:Detailed diagram of an endoscopic retrograde cholangio pancreatography (ERCP) CRUK 001.svg

The patient is 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 union of the common bile duct and pancreatic duct) exists. The sphincter of Oddi is a muscular valve that controls the opening to 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 other lesions such as stones.{{cite web | url=https://www.niddk.nih.gov/health-information/diagnostic-tests/endoscopic-retrograde-cholangiopancreatography | title=Endoscopic Retrograde Cholangiopancreatography (ERCP) | NIDDK }}{{cite web | url=https://smarttechmed.com/endoscope-bending-rubber/| title=Endoscopie bending rubber}}

When needed, the sphincters of the ampulla and bile ducts can be enlarged by a cut (sphincterotomy) with an electrified wire called a sphincterotome for access into either so that gallstones may be removed or other therapy performed.{{cite journal | pmc=4250869 | year=2007 | last1=Deng | first1=D. H. | last2=Zuo | first2=H. M. | last3=Wang | first3=J. F. | last4=Gu | first4=Z. E. | last5=Chen | first5=H. | last6=Luo | first6=Y. | last7=Chen | first7=M. | last8=Huang | first8=W. N. | last9=Wang | first9=L. | last10=Lu | first10=W. | title=New precut sphincterotomy for endoscopic retrograde cholangiopancreatography in difficult biliary duct cannulation | journal=World Journal of Gastroenterology | volume=13 | issue=32 | pages=4385–4390 | doi=10.3748/wjg.v13.i32.4385 | pmid=17708616 | doi-access=free }}

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.{{cite journal | pmc=2397011 | year=2008 | last1=Kelly | first1=N. M. | last2=Caddy | first2=G. R. | title=Successful Endoscopic Management of Fractured Dormia Basket During Endoscopic Retrograde Cholangiopancreatography for Choledocholithiasis | journal=The Ulster Medical Journal | volume=77 | issue=1 | pages=56–58 | pmid=18271088 }} Also, the pancreatic duct can be cannulated and stents be inserted.

The pancreatic duct requires visualisation in cases of pancreatitis. Ultrasound is frequently the first investigation performed on admission; although it has little value in the diagnosis of pancreatitis or its complications. contrast-enhanced computed tomography (MD-CECT) is the most used imaging technique. However, magnetic resonance imaging (MRI) offers diagnostic capabilities similar to those of CT, with additional intrinsic advantages including lack of ionizing radiation and exquisite soft tissue characterization.{{cite journal | pmc=4133524 | year=2014 | last1=Busireddy | first1=K. K. | last2=Alobaidy | first2=M. | last3=Ramalho | first3=M. | last4=Kalubowila | first4=J. | last5=Baodong | first5=L. | last6=Santagostino | first6=I. | last7=Semelka | first7=R. C. | title=Pancreatitis-imaging approach | journal=World Journal of Gastrointestinal Pathophysiology | volume=5 | issue=3 | pages=252–270 | doi=10.4291/wjgp.v5.i3.252 | pmid=25133027 | doi-access=free }}

In specific cases, other specialized or ancillary endoscopes may be used for ERCP. These include mother-baby and SpyGlass cholangioscopes (to help in diagnosis by directly visualizing the duct as opposed to only obtaining X-ray images{{EMedicine|article|1891395|Cholangioscopy|technique}}{{cite journal |doi=10.1016/j.gie.2016.03.013 |title=Cholangiopancreatoscopy |year=2016 |last1=Komanduri |first1=Sri |last2=Thosani |first2=Nirav |last3=Abu Dayyeh |first3=Barham K. |last4=Aslanian |first4=Harry R. |last5=Enestvedt |first5=Brintha K. |last6=Manfredi |first6=Michael |last7=Maple |first7=John T. |last8=Navaneethan |first8=Udayakumar |last9=Pannala |first9=Rahul |last10=Parsi |first10=Mansour A. |last11=Smith |first11=Zachary L. |last12=Sullivan |first12=Shelby A. |last13=Banerjee |first13=Subhas |last14=Banerjee |first14=S. |journal=Gastrointestinal Endoscopy |volume=84 |issue=2 |pages=209–221 |pmid=27236413 |doi-access=free }}{{cite journal |vauthors=Farrell JJ, Bounds BC, Al-Shalabi S, Jacobson BC, Brugge WR, Schapiro RH, Kelsey PB |title=Single-operator duodenoscope-assisted cholangioscopy is an effective alternative in the management of choledocholithiasis not removed by conventional methods, including mechanical lithotripsy |journal=Endoscopy |volume=37 |issue=6 |pages=542–7 |year=2005 |pmid=15933927 |doi=10.1055/s-2005-861306|s2cid=260128740 }}) as well as balloon enteroscopes (e.g. in patients that have previously undergone digestive system surgery with post-Whipple or Roux-en-Y surgical anatomy).{{cite journal |last1=Azeem |first1=Nabeel |last2=Tabibian |first2=James H. |last3=Baron |first3=Todd H. |last4=Orhurhu |first4=Vwaire |last5=Rosen |first5=Charles B. |last6=Petersen |first6=Bret T. |last7=Gostout |first7=Christopher J. |last8=Topazian |first8=Mark D. |last9=Levy |first9=Michael J. |title=Use of a single-balloon enteroscope compared with variable-stiffness colonoscopes for endoscopic retrograde cholangiography in liver transplant patients with Roux-en-Y biliary anastomosis |journal=Gastrointestinal Endoscopy |date=April 2013 |volume=77 |issue=4 |pages=568–577 |doi=10.1016/j.gie.2012.11.031 |pmid=23369652 }}

One of the most frequent and feared complications after endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP). In previous studies, the incidence of PEP has been estimated at 3.5 to 5%.{{cite journal |last1=Dumonceau |first1=Jean-Marc |last2=Andriulli |first2=Angelo |last3=Elmunzer |first3=B. |last4=Mariani |first4=Alberto |last5=Meister |first5=Tobias |last6=Deviere |first6=Jacques |last7=Marek |first7=Tomasz |last8=Baron |first8=Todd |last9=Hassan |first9=Cesare |last10=Testoni |first10=Pier |last11=Kapral |first11=Christine |title=Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Updated June 2014 |journal=Endoscopy |date=22 August 2014 |volume=46 |issue=9 |pages=799–815 |doi=10.1055/s-0034-1377875 |pmid=25148137 |citeseerx=10.1.1.886.8874 |s2cid=9899581 }}GallRiks. Annual report 2016. http://www.ucr.uu.se/gallriks/fou/arsrapporter [accessed 31 May 2018]. According to Cotton et al., PEP is defined as a "clinical pancreatitis with amylase at least three times the upper limit of normal at more than 24 hours after the procedure requiring hospital admission or prolongation of planned admission". Grading of severity of PEP is mainly based on the length of hospital stay.{{cite journal |last1=Cotton |first1=P.B. |last2=Lehman |first2=G. |last3=Vennes |first3=J. |last4=Geenen |first4=J.E. |last5=Russell |first5=R.C.G. |last6=Meyers |first6=W.C. |last7=Liguory |first7=C. |last8=Nickl |first8=N. |title=Endoscopic sphincterotomy complications and their management: an attempt at consensus |journal=Gastrointestinal Endoscopy |date=May 1991 |volume=37 |issue=3 |pages=383–393 |doi=10.1016/S0016-5107(91)70740-2 |pmid=2070995 }}

Risk factors for developing PEP include technical matters related to the ERCP procedure and patient-specific ones. The technical factors include manipulation of and injection of contrast into the pancreatic duct, cannulation attempts lasting more than five minutes, and biliary balloon sphincter dilation; among patient-related factors are female gender, younger age, and Sphincter of Oddi dysfunction.{{citation needed|date=June 2022}} A systematic review of clinical trials concluded that a previous history of PEP or pancreatitis significantly increases the risk for PEP to 17.8% and to 5.5% respectively.{{cite journal |last1=Chen |first1=Jian-Jun |last2=Wang |first2=Xi-Mo |last3=Liu |first3=Xing-Qiang |last4=Li |first4=Wen |last5=Dong |first5=Mo |last6=Suo |first6=Zong-Wu |last7=Ding |first7=Po |last8=Li |first8=Yue |title=Risk factors for post-ERCP pancreatitis: a systematic review of clinical trials with a large sample size in the past 10 years |journal=European Journal of Medical Research |date=15 May 2014 |volume=19 |issue=1 |page=26 |id={{Gale|A541256167}} |doi=10.1186/2047-783X-19-26 |pmid=24886445 |pmc=4035895 |citeseerx=10.1.1.981.3789 |doi-access=free }}{{cite journal | doi=10.1186/s12876-021-01755-z | title=Optimal timing of endoscopic retrograde cholangiopancreatography for acute cholangitis associated with distal malignant biliary obstruction | year=2021 | last1=Park | first1=Namyoung | last2=Lee | first2=Sang Hyub | last3=You | first3=Min Su | last4=Kim | first4=Joo Seong | last5=Huh | first5=Gunn | last6=Chun | first6=Jung Won | last7=Cho | first7=In Rae | last8=Paik | first8=Woo Hyun | last9=Ryu | first9=Ji Kon | last10=Kim | first10=Yong-Tae | journal=BMC Gastroenterology | volume=21 | issue=1 | page=175 | pmid=33865307 | pmc=8052855 | doi-access=free }}

Intestinal perforation is a risk of any gastroenterologic endoscopic procedure, and is an additional risk if a sphincterotomy is performed. As the second part of the duodenum is anatomically in a retroperitoneal location (that is, behind the peritoneal structures of the abdomen), perforations due to sphincterotomies are retroperitoneal. Sphincterotomy is also associated with a risk of bleeding.{{cite journal|vauthors=Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, Pilotto A, Forlano R|year=2007|title=Incidence rates of post-ERCP complications: a systematic survey of prospective studies|journal=Am. J. Gastroenterol.|volume=102|issue=8|pages=1781–8|doi=10.1111/j.1572-0241.2007.01279.x |pmid=17509029|s2cid=38954883 }} ERCP may provoke hemobilia from trauma to friable hilar tumors or a guide-wire penetrating the bile duct wall, creating a biliary fistula. Delayed bleeding is a rare but potentially serious complication of sphincterotomy, particularly as many patients are discharged home within hours of ERCP.

There is also a risk associated with the contrast dye in patients who are allergic to compounds containing iodine, which can be very severe, even if the anaphylactoid reactions occur while patients are in a hospital.{{cite journal |last1=Dewachter |first1=Pascale |last2=Mouton-Faivre |first2=Claudie |title=Allergie aux médicaments et aliments iodés : la séquence allergénique n'est pas l'iode |trans-title=Allergy to iodinated drugs and to foods rich in iodine: Iodine is not the allergenic determinant |language=fr |journal=La Presse Médicale |date=1 November 2015 |volume=44 |issue=11 |pages=1136–1145 |doi=10.1016/j.lpm.2014.12.008 |pmid=26387623 }}{{cite journal | pmc=3770975 | year=2013 | last1=Bottinor | first1=W. | last2=Polkampally | first2=P. | last3=Jovin | first3=I. | title=Adverse Reactions to Iodinated Contrast Media | journal=The International Journal of Angiology | volume=22 | issue=3 | pages=149–154 | doi=10.1055/s-0033-1348885 | pmid=24436602 }}

Oversedation can result in dangerously low blood pressure, respiratory depression, nausea, and vomiting.{{fact|date=August 2024}}

Other complications (less than 1%) may include heart and lung problems, infection in the bile duct called cholangitis, that can be life-threatening, and is regarded as a medical emergency. Using antibiotics before the procedure shows some benefits to prevent cholangitis and septicaemia.{{cite journal |last1=Brand |first1=Martin |last2=Bizos |first2=Damon |last3=O'Farrell |first3=Peter JR |title=Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography |journal=Cochrane Database of Systematic Reviews |date=6 October 2010 |issue=10 |pages=CD007345 |doi=10.1002/14651858.CD007345.pub2 |pmid=20927758 }} In rare cases, ERCP can cause fatal complications.{{cite web |last=Cotton |first=Peter B. |url=http://www.ddc.musc.edu/public/testsProcedures/procedures/ERCP.cfm |title=ERCP (Endoscopic Retrograde Cholangio-Pancreatography) |publisher=Medical University of South Carolina (MUSC) Digestive Disease Center |date=2013-05-31 |access-date=2013-06-09 |archive-url=https://web.archive.org/web/20180321192751/http://ddc.musc.edu/public/testsprocedures/procedures/ercp.cfm |archive-date=2018-03-21 |url-status=dead }}

Cases of hospital-acquired (i.e., nosocomial) infections with carbapenem resistant enterobacteriaceae linked to incompletely disinfected duodenoscopes have occurred in the U.S. since at least 2009 per the Food and Drug Administration.{{cite news|author1=Sharon Begley|author2=Toni Clarke|title=FDA knew devices spread fatal 'superbug' but does not order fix|url=https://www.reuters.com/article/us-usa-ucla-devices-idUSKBN0LO02Q20150220|access-date=20 February 2015|work=Reuters|date=20 February 2015}} Outbreaks were reported from Virginia Mason Hospital in Seattle in 2013, UCLA Health System Los Angeles in 2015, Chicago and Pittsburgh.{{cite news|title=Deadly superbug infected patients at Seattle hospital|url=http://www.cbsnews.com/news/deadly-superbug-infected-patients-at-seattle-hospital/|access-date=21 February 2015|work=CBS|publisher=CBS Interactive Inc.|date=January 22, 2015}} The FDA issued a safety communication "Design of ERCP Duodenoscopes May Impede Effective Cleaning" in February 2015,{{Cite news|url = https://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm434871.htm|archive-url = https://web.archive.org/web/20150220024405/http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm434871.htm|url-status = dead|archive-date = February 20, 2015|title = Design of Endoscopic Retrograde Cholangiopancreatography (ERCP) Duodenoscopes May Impede Effective Cleaning: FDA Safety Communication|work=Medical Devices|publisher=US FDA|date = 19 February 2015|access-date = 19 February 2015}} which was updated in December 2015,Medwatch [https://web.archive.org/web/20151225092242/http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm478949.htm ED-530XT Duodenoscopes by FUJIFILM Medical Systems, U.S.A.: Safety Communication - FUJIFILM Medical Systems Validates Revised Reprocessing Instructions] Safety alerts for Human Medical Products. U.S. FDA, 23 December 2015, retrieved 5 January 2016 and more recently in 2022 which recommended disposable components.{{cite journal | url=https://www.fda.gov/medical-devices/safety-communications/fda-recommending-transition-duodenoscopes-innovative-designs-enhance-safety-fda-safety-communication | archive-url=https://web.archive.org/web/20190904163815/https://www.fda.gov/medical-devices/safety-communications/fda-recommending-transition-duodenoscopes-innovative-designs-enhance-safety-fda-safety-communication | url-status=dead | archive-date=September 4, 2019 | title=The FDA is Recommending Transition to Duodenoscopes with Innovative Designs to Enhance Safety: FDA Safety Communication | journal=FDA | date=5 April 2022 }}

Prevalence of vitamin K and vitamin D deficiency,{{cite journal |last1=Fisher |first1=Leon |last2=Byrnes |first2=Elizabeth |last3=Fisher |first3=Alexander A. |title=Prevalence of vitamin K and vitamin D deficiency in patients with hepatobiliary and pancreatic disorders |journal=Nutrition Research |date=1 September 2009 |volume=29 |issue=9 |pages=676–683 |doi=10.1016/j.nutres.2009.09.001 |pmid=19854384 |hdl=1885/32031 |hdl-access=free }} as bile is to assist in the breakdown and absorption of fat in the intestinal tract; a relative deficiency of bile can lead to fat malabsorption and deficiencies of fat-soluble vitamins.

• Percutaneous transhepatic cholangiography
• Reynolds' pentad
• Charcot's cholangitis triad
• Primary sclerosing cholangitis

{{reflist}}

• {{MedlinePlusEncyclopedia|007479|ERCP}}
• [https://web.archive.org/web/20110424095147/http://digestive.niddk.nih.gov/ddiseases/pubs/ercp/ National Digestive Diseases Information Clearinghouse]
• [https://www.endoscopy-campus.com/en/ercp-en/ Endoscopy Campus, Archives and Videos]

{{Operations and other procedures on the digestive system}}

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Category:Endoscopy

Category:Digestive system procedures