Reference: September 2024 | Issue 9 | Vol 10 | Page 29
Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive advanced therapeutic endoscopic procedure that is used to diagnose and treat conditions that affect the bile ducts, liver, gallbladder, and pancreas by using an endoscope. Most commonly, this includes bile duct stones or bile duct blockages (strictures), which may or may not require stenting, as well as diagnosing and treating bile duct cancers and pancreatic cancers. It is also useful in the management of surgical complications from gallbladder surgery, for example, an injury to bile ducts during gallbladder surgery.
It is performed using an endoscope which passes through the oesophagus and the stomach and reaches the second part of the duodenum. ERCP also uses a fluoroscopy in tandem to examine a patient’s ducts and carry out procedures.
Indications
One of the most common signs and/or symptoms that will result in patients needing an ERCP is the development of jaundice (with or without pain), along with blood tests (liver tests and bilirubin raised), and scans (either ultrasound CT and/or MRI) that show a bile duct stone or a stricture (benign or malignant) within the bile ducts, or a mass from the pancreatic head pressing on the bile ducts and resulting in jaundice.
Historically, cases such as this were treated with either open surgery or a laparoscopic procedure. In some scenarios, it would have resulted in death if the patient was not fit for surgery, especially in the case of elderly patients. But ERCP has no age limit and can be performed at any age. It can be lifesaving in the case of sepsis in the bile ducts and liver due to such blockages.
ERCP is most commonly performed while patients are under light sedation. The exceptions are patients who cannot tolerate the procedure under sedation, in which case, general anaesthesia is given instead. The procedure is carried out in the main operating theatre or an endoscopy suite.
Risks and recovery
The recovery time following an ERCP is just two hours, providing there are no complications. For most patients, this is a day case procedure. Patients who already have an advanced diagnosis, ie, cancer or infection in the bile ducts from bile duct stone(s), may be kept in hospital and the procedure is done while they are an inpatient.
As with every medical procedure or medication, ERCP comes with some risks and complications. However, the risk of complication is less than 5 per cent in the vast majority of cases and can range from 5 to 20 per cent on a case by case basis, depending on other co-morbidities.
Some of the most common risks associated with this procedure include:
Post-ERCP pancreatitis:
There is a one in 20 risk of swelling that causes abdominal pain. In such a case, patients will be kept on-site for one to two days for further treatment. In rare cases, pancreatitis can require surgery or admission to the ICU.
Internal bleeding (sphincterotomy bleed):
The risk for this complication is slight (one in 30) and can occur 24-48 hours after the procedure (delayed bleeding). Generally, any bleeding is minor and settles itself, but further treatment might be necessary.
Perforation:
The risk of perforation during ERCP is one in 50-100. If this occurs, patients may have to stay in hospital for a number of days and are treated with antibiotics, painkillers, and intravenous fluids. In rare cases surgery may be needed.
Medication-related side-effects:
The sedative medications used can sometimes lower patients’ blood pressure, heart rate, or oxygenation levels. Rarely, patients may also experience an allergic reaction to the numbing spray used prior to this procedure. If any of these side-effects occur, the patient is treated in the hospital.
Infection:
Infection occurs in up to one in 30 cases. This is usually treated with antibiotics.
Missed diagnosis:
There is a chance that small stones or strictures may be missed during this procedure, however this is very rare.
Procedure failure:
If this happens (one in 20 risk), alternative treatments can be discussed. In some cases, a second attempt at ERCP to clear the duct may be required.
X-ray exposure:
This procedure includes exposure to X-rays. If relevant, patients should be asked to confirm that they are not pregnant prior to the procedure.
On rare occasions patients may require a short hospital stay with medications +/- antibiotics or pain relief if complications occur.
The most common complication is, as mentioned previously, an inflammation of the pancreas after ERCP as the pancreas and its pancreatic duct lie very close to the bile duct. The pancreatic duct opens through the same channel into the small bowel in almost every individual (with some exceptions). Due to the nature of this procedure, internal bleeding can happen, but most of the time the bleeding stops itself. If it requires endoscopic treatment, this can be done during the procedure.
Preparation
Before their ERCP procedure, patients are required to fast for at least six hours to ensure an empty stomach. If carried out as an outpatient procedure, a recent blood test, including a clotting test, may be required.
On the day of the procedure, patients are admitted to the endoscopy unit, where a nurse will check their vital signs before they meet our team. After receiving a numbing spray and sedation, the procedure will involve a camera being guided into the patient’s bile duct to perform the necessary treatment, lasting between 20 minutes to an hour.
Post-procedure, patients are monitored as the sedation wears off. Patients are required to continue fasting for two hours post-procedure and are advised to stick to a liquid diet for 12 hours. Discomfort in the throat is normal.
Conclusion
ERCP offers transformative care for patients with digestive ailments, providing potential cures for several gastrointestinal diseases. It allows patients to receive treatment on the same day, avoiding the need for traditional laparoscopic surgical procedures and extended hospital stays. This minimally invasive approach significantly reduces recovery times and associated risks.
To learn more about the procedure visit www.materprivate.ie.
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