Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of

endoscopy An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...

and

fluoroscopy Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a physician to see the internal structure and functio ...

to diagnose and treat certain problems of the

biliary A bile duct is any of a number of long tube-like structures that carry bile, and is present in most vertebrates. Bile is required for the digestion of food and is secreted by the liver into passages that carry bile toward the hepatic duct. It ...

pancreatic duct The pancreatic duct, or duct of Wirsung (also, the major pancreatic duct due to the existence of an accessory pancreatic duct), is a duct joining the pancreas to the common bile duct. This supplies it with pancreatic juice from the exocrine pancre ...

al systems. It is primarily performed by highly skilled and specialty trained gastroenterologists. Through the endoscope, the physician can see the inside of the

stomach The stomach is a muscular, hollow organ in the gastrointestinal tract of humans and many other animals, including several invertebrates. The stomach has a dilated structure and functions as a vital organ in the digestive system. The stomach i ...

and

duodenum The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear, and the terms anterior intestine or proximal intestine m ...

, and inject a

contrast medium A contrast agent (or contrast medium) is a substance used to increase the contrast of structures or fluids within the body in medical imaging. Contrast agents absorb or alter external electromagnetism or ultrasound, which is different from radiop ...

into the ducts in the biliary tree and

pancreas The pancreas is an organ of the digestive system and endocrine system of vertebrates. In humans, it is located in the abdomen behind the stomach and functions as a gland. The pancreas is a mixed or heterocrine gland, i.e. it has both an end ...

so they can be seen on

radiographs Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...

. ERCP is used primarily to diagnose and treat conditions of the bile ducts and main pancreatic duct, including

gallstone A gallstone is a calculus (medicine), stone formed within the gallbladder from precipitated bile components. The term cholelithiasis may refer to the presence of gallstones or to any disease caused by gallstones, and choledocholithiasis refers to ...

s, inflammatory strictures (scars), leaks (from trauma and surgery), and cancer. ERCP can be performed for diagnostic and therapeutic reasons, although the development of safer and relatively non-invasive investigations such as

magnetic resonance cholangiopancreatography Magnetic resonance cholangiopancreatography (MRCP) is a medical imaging technique. It uses magnetic resonance imaging to visualize the biliary and pancreatic ducts non-invasively. This procedure can be used to determine whether gallstones are ...

(MRCP) and

endoscopic ultrasound Endoscopic ultrasound (EUS) or echo-endoscopy is a medical procedure in which endoscopy (insertion of a probe into a hollow organ) is combined with ultrasound to obtain images of the internal organs in the chest, abdomen and colon. It can be used ...

has meant that ERCP is now rarely performed without therapeutic intent.

Medical uses

Diagnostic

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

Obstructive jaundice Jaundice, also known as icterus, is a yellowish or greenish pigmentation of the skin and sclera due to high bilirubin levels. Jaundice in adults is typically a sign indicating the presence of underlying diseases involving abnormal heme me ...

– This may be due to several causes ** Gallstones with dilated bile ducts on

ultrasonography Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies fr ...

** Indeterminate biliary strictures and suspected

bile duct tumor Bile (from Latin ''bilis''), or gall, is a dark-green-to-yellowish-brown fluid produced by the liver of most vertebrates that aids the digestion of lipids in the small intestine. In humans, bile is produced continuously by the liver (liver bile) ...

s ** Suspected injury to bile ducts either as a result of trauma or of

iatrogenic Iatrogenesis is the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence. "Iatrogenic", ''Merriam-Webster.com'', Merriam-Webster, Inc., accessed 2 ...

origin ** Sphincter of Oddi dysfunction * Chronic

pancreatitis Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormones. There are two main types: acute pancreatitis, and chronic pancr ...

is currently a controversial indication due to widespread availability of safer diagnostic modalities including

, CT, and

MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves ...

/ 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

Therapeutic

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

sphincter of Oddi The sphincter of Oddi (also hepatopancreatic sphincter or Glisson's sphincter), abbreviated as SO, is a muscular valve that in some animals, including humans, controls the flow of digestive juices (bile and pancreatic juice) out of the pancreas t ...

* Extraction of gallstones or other biliary debris * Insertion of a

stent In medicine, a stent is a metal or plastic tube inserted into the lumen of an anatomic vessel or duct to keep the passageway open, and stenting is the placement of a stent. A wide variety of stents are used for different purposes, from expandab ...

through the

major duodenal papilla Major (commandant in certain jurisdictions) is a military rank of commissioned officer status, with corresponding ranks existing in many military forces throughout the world. When used unhyphenated and in conjunction with no other indicators ...

and ampulla of Vater into the

common bile duct The common bile duct, sometimes abbreviated as CBD, is a duct in the gastrointestinal tract of organisms that have a gallbladder. It is formed by the confluence of the common hepatic duct and cystic duct and terminates by uniting with pancreati ...

and/or the

* Dilation of

strictures A stenosis (from Ancient Greek στενός, "narrow") is an abnormal narrowing in a blood vessel or other tubular organ or structure such as foramina and canals. It is also sometimes called a stricture (as in urethral stricture). ''Stricture' ...

(e.g.

primary sclerosing cholangitis Primary sclerosing cholangitis (PSC) is a long-term progressive disease of the liver and gallbladder characterized by inflammation and scarring of the bile ducts, which normally allow bile to drain from the gallbladder. Affected individuals may ha ...

anastomotic An anastomosis (, plural anastomoses) is a connection or opening between two things (especially cavities or passages) that are normally diverging or branching, such as between blood vessels, leaf veins, or streams. Such a connection may be normal ...

strictures after liver transplantation) * extraction of

liver fluke Liver fluke is a collective name of a polyphyletic group of parasitic trematodes under the phylum Platyhelminthes. They are principally parasites of the liver of various mammals, including humans. Capable of moving along the blood circulation, t ...

s from the biliary system (e.g.,

opisthorchiasis Opisthorchiasis is a parasitic disease caused by certain species of genus '' Opisthorchis'' (specifically, '' Opisthorchis viverrini'' and '' Opisthorchis felineus''). Chronic infection may lead to cholangiocarcinoma, a cancer of the bile ducts. ...

clonorchiasis Clonorchiasis is an infectious disease caused by the Chinese liver fluke (''Clonorchis sinensis'') and two related species. Clonorchiasis is a known risk factor for the development of cholangiocarcinoma, a neoplasm of the biliary system. Sympt ...

fasciolosis Fasciolosis is a parasitic worm infection caused by the common liver fluke '' Fasciola hepatica'' as well as by '' Fasciola gigantica''. The disease is a plant-borne trematode zoonosis, and is classified as a neglected tropical disease (NTD). ...

)

Contraindications

Acute pancreatitis Acute pancreatitis (AP) is a sudden inflammation of the pancreas. Causes in order of frequency include: 1) a gallstone impacted in the common bile duct beyond the point where the pancreatic duct joins it; 2) heavy alcohol use; 3) systemic disease; ...

(unless persistently elevated or rising bilirubin suggests ongoing obstruction) * (Irreversible) coagulation disorder if sphincterotomy planned * Recent

myocardial infarction A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may ...

or pulmonary embolism * Severe

cardiopulmonary The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...

disease or other serious morbidity Hypersensitivity to iodinated contrast medium or a history of iodinated contrast dye

anaphylaxis Anaphylaxis is a serious, potentially fatal allergic reaction and medical emergency that is rapid in onset and requires immediate medical attention regardless of use of emergency medication on site. It typically causes more than one of the follow ...

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.

Procedure

The patient is sedated or anaesthetized. Then a flexible camera (

endoscope An endoscope is an inspection instrument composed of image sensor, optical lens, light source and mechanical device, which is used to look deep into the body by way of openings such as the mouth or anus. A typical endoscope applies several modern t ...

) is inserted through the mouth, down the esophagus, into the stomach, through the

pylorus The pylorus ( or ), or pyloric part, connects the stomach to the duodenum. The pylorus is considered as having two parts, the ''pyloric antrum'' (opening to the body of the stomach) and the ''pyloric canal'' (opening to the duodenum). The ''pylori ...

into the

where the ampulla of Vater (the union of the common bile duct and pancreatic duct) exists. The

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 A cannula (; Latin meaning 'little reed'; plural or ) is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples. In simple terms, a cannula can surround the inner or outer surfaces ...

'' is inserted through the ampulla, and radiocontrast is injected into the bile ducts and/or pancreatic duct.

Fluoroscopy Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a physician to see the internal structure and functio ...

is used to look for blockages, or other lesions such as stones. 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. 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

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. 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. 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) as well as balloon enteroscopes (e.g. in patients that have previously undergone

digestive system surgery Digestive system surgery, or gastrointestinal surgery, can be divided into upper GI surgery and lower GI surgery. Subtypes Upper gastrointestinal Upper gastrointestinal surgery, often referred to as upper GI surgery, refers to a practise of surg ...

with post- Whipple or

Roux-en-Y In general surgery, a Roux-en-Y anastomosis, or Roux-en-Y, is an end-to-side surgical anastomosis of bowel used to reconstruct the gastrointestinal tract. Typically, it is between stomach and small bowel that is distal (or further down the gast ...

surgical anatomy).

Risks

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%. 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. 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. 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.

Intestinal perforation Gastrointestinal perforation, also known as ruptured bowel, is a hole in the wall of part of the gastrointestinal tract. The gastrointestinal tract includes the esophagus, stomach, small intestine, and large intestine. Symptoms include severe ab ...

is a risk of any gastroenterologic endoscopic procedure, and is an additional risk if a

sphincterotomy Anal sphincterotomy is a surgical procedure that involves treating mucosal fissures from the anal canal/sphincter. The word is formed from sphincter + otomy (to cut, to separate). Procedure # The surgery can be performed under any kind of anesthes ...

is performed. As the second part of the duodenum is anatomically in a

retroperitoneal The retroperitoneal space (retroperitoneum) is the anatomical space (sometimes a potential space) behind (''retro'') the peritoneum. It has no specific delineating anatomical structures. Organs are retroperitoneal if they have peritoneum on their ...

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. ERCP may provoke hemobilia from trauma to friable hilar tumors or a guide-wire penetrating the bile duct wall, creating a

biliary fistula A biliary fistula is a type of fistula in which bile flows along an abnormal connection from the bile ducts into nearby hollow structure. Types of biliary fistula include: * bilioenteric fistula: abnormal connection to small bowel, usually duodenu ...

. 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 Radiocontrast agents are substances used to enhance the visibility of internal structures in X-ray-based imaging techniques such as computed tomography (contrast CT), projectional radiography, and fluoroscopy. Radiocontrast agents are typically io ...

in patients who are allergic to compounds containing

iodine Iodine is a chemical element with the symbol I and atomic number 53. The heaviest of the stable halogens, it exists as a semi-lustrous, non-metallic solid at standard conditions that melts to form a deep violet liquid at , and boils to a vi ...

, which can be very severe, even if the anaphylactoid reactions occur while you are in a hospital. Oversedation can result in dangerously low blood pressure, respiratory depression, nausea, and vomiting. 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. In rare cases, ERCP can cause fatal complications. Cases of hospital-acquired (i.e., nosocomial) infections with

carbapenem resistant enterobacteriaceae Carbapenem-resistant Enterobacteriaceae (CRE) or carbapenemase-producing Enterobacteriaceae (CPE) are Gram-negative bacteria that are resistant to the carbapenem class of antibiotics, considered the drugs of last resort for such infections. They ...

linked to incompletely disinfected duodenoscopes have occurred in the U.S. since at least 2009 per the

Food and Drug Administration The United States Food and Drug Administration (FDA or US FDA) is a List of United States federal agencies, federal agency of the United States Department of Health and Human Services, Department of Health and Human Services. The FDA is respon ...

. Outbreaks were reported from

Virginia Mason Hospital Virginia Mason Hospital is a 336-bed teaching hospital in Seattle, Washington, part of the Virginia Mason Medical Center. The hospital is accredited by the Joint Commission and the Commission on Accreditation of Rehabilitation Facilities (CARF). F ...

in Seattle in 2013,

UCLA Health System UCLA Health is a health system which comprises a number of hospitals, the David Geffen School of Medicine at UCLA and an extensive primary care network in the Los Angeles region. As a regional health provider, it benefits from the academic affili ...

Los Angeles in 2015, Chicago and Pittsburgh. The FDA issued a safety communication "Design of ERCP Duodenoscopes May Impede Effective Cleaning" in February 2015, which was updated in December 2015, and more recently in 2022 which recommended disposable components. Prevalence of vitamin K and vitamin D deficiency, 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.

References

External links

*
National Digestive Diseases Information ClearinghouseEndoscopy Campus, Archives and Videos
{{Operations and other procedures on the digestive system Endoscopy Digestive system procedures