ERCP is the acronym for endoscopic retrograde cholangiopancreatography. It is a medical technique that employs a combination of fluoroscopy and endoscopy to diagnose and treat disorders affecting the biliary tree or pancreatic ducts.
Conditions such as gall stones, inflammatory scars and cancer are primary indications which call for ERCP. Whilst ERCP may be used for diagnostic purposes there are safer and non-invasive alternative procedures available such as magnetic resonance cholangiopancreatography (MRCP). Hence ERCP is used mainly in cases where treatment is needed.
ERCP was first widely used as a diagnostic tool as early as the 1970s. However, contemporary usage is mainly for therapeutic purposes due to the availability of diagnostic modalities such as ultrasound (US), computed tomography (CT) and MRCP.
ERCP is associated with a high risk of medical complications and as a result it is vital that the potential benefits from usage outweigh the potential complications. The American Society for Gastrointestinal Endoscopy (ASGE) has published guidelines with regards to the use of ERCP for pancreatic and biliary tree diseases.
According to the ASGE, indications for ERCP with pancreatic disease are for the assessment and treatment of:
- Symptomatic pancreatic duct stones
- Symptomatic strictures accompanying chronic pancreatitis
- Recurrent acute pancreatitis of unknown etiology
- Symptomatic pancreatic pseudocysts of pancreatic fluid collections (benign)
The ASGE guidelines also allow for the usage of ERCP to diagnose pancreatic malignancies when pancreatoscopy is required as well as bile duct brushing and biopsy and intraductal US. ERCP may also be used for the assessment and treatment of ampullary adenomas and malignancies.
The ASGE ERCP indications for biliary tract disease are for the assessment and treatment of:
- Biliary obstruction due to stones, especially in cases where jaundice is clinically evident
- Bile duct strictures that are congenital, benign or malignant
The use of ERCP as a routine procedure before a laparoscopic cholecystectomy is not an indication.
ERCP should be completely avoided in patients with underlying cardiovascular, neurological and cardiopulmonary complications who are at risk for further destabilization of their clinical status. It is also absolutely contraindicated in patients who present with bowel perforation due to potentially fatal consequences that could result from performing an ERCP.
Relative contraindications to the procedure include anatomical abnormalities of the upper gastrointestinal tract (i.e. esophagus, stomach and duodenum). Anatomical abnormalities include, but are not limited to strictures, herniation, volvulus and obstruction. Patients with coagulopathies and those who present with acute pancreatitis are also placed into this category. The exception in acute pancreatitis is if it is caused by gallstones and stone removal is necessary with ERCP.
There are a number of risk factors associated with ERCP. These include, but are not limited to, infections, allergic reaction to the sedatives used in the procedure, pancreatitis, hemorrhage, inadvertent puncturing of the GI tract or ducts and in rare circumstances death. It is important that patients who have undergone ERCP look out for symptoms such as difficulties swallowing, vomiting, fever and pain in the abdomen, chest or throat that is worsening. Experiencing these symptoms requires the affected patients to seek urgent medical care.
Reviewed by Afsaneh Khetrapal, BSc (Hons)