ERCP (Endoscopic Retrograde Cholangiopancreatography)

Overview

ERCP stands for Endoscopic Retrograde Cholangiopancreatography. It is a procedure to examine the bile ducts and the pancreatic duct. These ducts are drainage channels which drain bile and pancreatic juice from the liver and the pancreas respectively. Special techniques are required to enter the ducts. Once the ducts are entered, various diagnostic and therapeutic interventions may be performed.

It is done by a gastroenterologist with additional specific training in advanced endoscopy. It is done under sedation and usually, an anesthetist is present during the procedure.

Procedure

The endoscopist passes a special side viewing endoscope through the mouth into the duodenum to visualize the major ampulla, which is the entrance to the bile or pancreatic duct. Instruments are then passed through the endoscope into the opening, and guided into the duct using X-rays. Once the ducts are entered, various treatments can be performed. These include:

  • Cholangiogram or Pancreatogram: Dye is injected into the ducts to visualize the anatomy and contents of the ducts under X-rays.
  • Sphincterotomy: The muscle surrounding the opening is cut to enlarge the opening. This facilitates various treatments.
  • Stone removal: The most common treatment in ERCP is the removal of stones from the common bile duct. This is done using baskets or balloons. Large stones may need to be crushed or fragmented using specialized equipment before they can be removed.
  • Stent placement: Stents are hollow tubes that are placed across areas in the duct that are narrowed or blocked so that the drainage channel is restored. There are 2 types of stents: plastic stents that are smaller and that can be easily be deployed and removed, and metal stents that are larger and can last longer.
  • Balloon dilation: Special balloon may be used to expand the opening of the duct or an area that is narrowed or blocked. This allows the area to be widened to facilitate treatment and drainage.
  • Tissue sampling: Abnormal areas in the ducts may be sampled using brushing or biopsy forceps under X-ray guidance. This can help to diagnose cancer.
  • Cholangioscopy: A special ultra-thin endoscope may be passed into the bile duct to visualize the inside directly, to enable precise tissue sampling or to apply a laser to very large stones.

Indications

ERCP can help to avoid surgery of the bile duct and pancreatic duct. ERCP is used for the following conditions:

  • Removal of stones from the bile duct and pancreatic duct. This can relieve infection, jaundice, and pain, and prevent future attacks.
  • Insertion of stents to bypass narrowed and blocked areas. These are typically caused by tumors, stones, and scarring. This can relieve infection, jaundice and pain.
  • Obtaining tissues samples from the bile duct, which can make a diagnosis of cancer.

Preparing for ERCP

You should fast for at least 6 hours prior to your ERCP. Longer fasting may be needed if your doctor suspects that your stomach is not emptying properly. You may drink clear fluid up to 2 hours before the procedure but milk is not allowed during the fasting.

In general, most medication should be continued before the gastroscopy with the exception of diabetes medication and blood thinners. Diabetic medication should be omitted during the fasting. You should check with your doctor if your blood thinner needs to be discontinued prior to the procedure.

As you will be given medication to make you sleepy, you must not drive, work or make any important decision after the procedure. Medical Certificate will be issued if needed and you should rest at home for the rest of the day.

Before the ERCP

A nurse will conduct final checks, and bring you into the procedure room. An intravenous line will be inserted. An anesthetist would conduct final assessments.

During the ERCP

A throat spray will be administered to lessen the discomfort of the procedure.

You will be lying on your belly.

Sedation will then be administered by the anesthetist. After you have fallen asleep, the procedure will begin. You will likely not remember any of the procedure. You will be breathing on your own and monitored closely during the procedure.
You will wake up gradually after the procedure is done. All the medication used for sedation have a duration of action of a few minutes.

After the ERCP

You will be cared for in a recovery area or room. The nurses will give you food and drink when they assessed that you are ready. You would be admitted for observation for one day after the procedure. Sometimes, you may have a mild sore throat, bloating and cramping. This normally goes away after 24 hours.

Quality

ERCP is an advanced endoscopic technique, unfortunately, not all gastroenterologists in Singapore are trained for this procedure. There are various levels of difficulty in ERCP. Most ERCP specialists are able to perform routine cases such as stone removal and stent insertion. However, several complicated ERCP procedures requires special experts to get the job done not just successfully but also safely.

It is best to discuss with the doctor to be referred to a skillful ERCP procedurist to reduce the risk of complication and increase the chance of successful procedure.

ERCP代表内镜逆行胰胆管造影术。这是检查胆管和胰管的程序。这些导管是排泄通道,分别从肝脏和胰腺排出胆汁和胰液。进入管道需要特殊技术。进入导管后,可以进行各种诊断和治疗干预。

这是由肠胃科医生在高级内窥镜检查中接受的其他专门培训完成的。它是在镇静下完成的,通常在手术过程中需要麻醉师.

内镜逆行胰胆管造影术过程

内窥镜医师将特殊的侧视内窥镜通过嘴巴进入十二指肠以可视化主要壶腹,该壶腹是胆汁或胰管的入口。然后,仪器通过内窥镜进入开口,并使用X射线导入导管。一旦进入导管,就可以进行各种治疗。这些包括:

-胆管造影术或胰管造影术:将染料注入导管以在X射线下可视化导管的解剖结构和内容。
-括约肌切开术:切开开口周围的肌肉以扩大开口。 
-结石清除:ERCP中最常见的治疗方法是从胆总管中清除结石。这是使用篮子或气球完成的。大型石头可能需要使用专门的设备压碎或破碎,然后才能取出。
-支架放置:支架是空心管,它们放置在变窄或堵塞的管道区域中,以便排泄通道恢复。支架有2种类型:较小的塑料支架,可以轻松部署和卸下,而金属的支架则更大,可以持续更长的时间。
-气球扩张:可以使用特殊的气球进行扩张管道的开口或变窄或堵塞的区域。这样可以扩大面积以方便治疗和引流。
-组织样本采样:可以在X射线引导下使用刷子或活检钳对导管中的异常区域进行采样。这可以帮助诊断癌症。
-胆管镜检查:可以将特殊的超薄内窥镜穿入胆管以直接观察内部,以便进行精确的组织采样或对非常大的结石施加激光。

什么时候需要到ERCP ?

ERCP可以帮助避免对胆管和胰管进行手术。 ERCP用于以下情况:

从胆管和胰管中清除结石。这样可以减轻感染,黄疸和疼痛,并防止将来发作。

插入支架以绕过狭窄和阻塞的区域。这些通常是由肿瘤,结石和疤痕引起的。这样可以减轻感染,黄疸和疼痛。

从胆管获取组织样本,可以诊断出癌症。

为ERCP做准备

您应该在ERCP之前禁食至少6个小时。如果您的医生怀疑您的胃没有排空,则可能需要更长的禁食时间。您可以在手术前2小时喝清水,但禁食期间不允许喝牛奶。

通常,除糖尿病药物和血液稀释剂外,大多数药物应在胃镜检查之前继续使用。禁食期间应避免使用糖尿病药物。在手术之前,您应该咨询医生是否需要停止使用稀释剂。

由于将要服药使您昏昏欲睡,因此手术后您不得开车,工作或做出任何重要决定。如有需要,将颁发《医疗证明》,您应该整天在家里休息。

质量 

ERCP是一种先进的内窥镜技术,不幸的是,并非所有新加坡的肠胃科医生都接受过此程序的培训。 ERCP中存在各种难度级别。大多数ERCP专家都能够执行例行手术,例如清除结石和插入支架。但是,一些复杂的ERCP程序需要特别的专家才能成功和安全地完成手续。 最好与医生讨论转诊到经验丰富的ERCP医生,以减少并发症的风险并增加成功手术的机会。