Generality
Cholangiopancreatography, or ERCP, is a rather invasive medical procedure, which combines endoscopy and fluoroscopy, in order to identify - and possibly treat - pathologies of the pancreas and bile and pancreatic ducts.
As a rule, the realization of a cholangiopancreatography is up to a gastroenterologist.
Brief review of what the bile ducts and pancreatic ducts are
The bile ducts (or bile ducts ) are the channels responsible for transporting bile - that is, the fluid that allows the digestion of fats - from the liver to the gall bladder and from the gall bladder to the duodenum (intestine tract).
Pancreatic ducts (or pancreatic pathways ), on the other hand, are the channels responsible for receiving the digestive juices produced by the so-called exocrine pancreas ( pancreatic juices ) and pouring them into the duodenum, during the digestion of a meal.
What is cholangiopancreatography?
Cholangiopancreatography, or endoscopic retrograde colangiopancreatography, is the diagnostic test that combines the technique of endoscopy with the technique of fluoroscopy, for the diagnosis and treatment of pathologies affecting the pancreas, biliary and pancreatic tract.
Also known by the acronym ERCP, cholangiopancreatography is therefore a rather invasive diagnostic procedure (endoscopy and fluoroscopy are invasive), which makes it possible to identify and treat a suffering damage to the pancreas and / or one of the ducts within which flow bile and juices pancreatic.
Endoscopy and fluoroscopy: what they are in summary
- Endoscopy is the particular medical procedure that allows the observation of the hollow organs (eg stomach) and the cavities of the human body (eg abdomen) from inside, using a special camera.
The camera used for observation is part of a technological instrument, similar to a straw, which is called an endoscope . Basically, the endoscope is a diagnostic tool; however, in some circumstances, if properly equipped, it can also be used as a surgical instrument (eg, removal of a tumor).
Endoscopy is invasive, because the introduction of the endoscope is a troublesome operation, which requires the patient's sedation.
- Fluoroscopy, on the other hand, is a particular radiological procedure, which uses X-rays and a fluorescent screen ( fluoroscope ) to scan the organs and other internal anatomical structures of the human body from the outside in real time.
Sometimes, for fluoroscopy to be even more detailed, doctors inject or have the patient ingest a contrast agent (eg barium platinocyanide).
Fluoroscopy is invasive, as X-rays are harmful to humans.
What does ERCP mean?
ERCP is the English acronym of Endoscopic Retrograde Cholangio-Pancreatography, which in Italian means Colangio-Pancreatografia Endoscopic Retrograde.
History
The first uses of cholangiopancreatography date back to the 1970s.
Initially, the purpose of the aforementioned procedure was only diagnostic.
Indications
The main reasons that lead a doctor to prescribe a cholangiopancreatography are:
- The simultaneous presence of symptoms such as abdominal pain, unexplained weight loss and jaundice;
- An ultrasound or a CT scan that showed the presence of calculi in the biliary tract or a tumor in the pancreatic region.
Diagnostic use of cholangiopancreatography
The diagnostic cholangiopancreatography allows the identification of medical conditions such as:
- Gallstones (or gallbladder stones ), bile duct stenosis, injuries to the bile ducts of traumatic or iatrogenic origin and the so-called sphincter dysfunction of Oddi . These conditions have in common the fact that they can all trigger the phenomenon of obstructive jaundice or acute pancreatitis .
Obstructive jaundice is the medical condition that, starting from an obstacle to the outflow of bile towards the duodenum, involves the stagnation of the aforementioned bile in the liver and the consequent passage of bilirubin (contained in the bile) into the blood.
Acute pancreatitis, on the other hand, is a rapid and sudden inflammation of the pancreas, which produces violent symptoms that are impossible to notice from the beginning.
- Chronic pancreatitis . It is the inflammation of the pancreas with gradual onset and progressive character, which determines the slow destruction of the gland in question; obviously the dysfunction of the latter depends on the destruction of the pancreas.
- Pancreatic tumors . They are malignant or benign neoplasms that originate from the uncontrolled proliferation of an exocrine cell of the pancreas or an endocrine cell of the pancreas.
Among the various tumors of the pancreas that can affect the human being, the most dangerous - and, unfortunately, even the most common - are the malignant tumors of the exocrine pancreas (pancreatic carcinoma, pancreatic acinar cell carcinoma, pseudopapillary pancreatic cancer). and pancreatoblastoma).
- The pancreas divisum . It is a congenital anomaly of the pancreas, in which the main pancreatic duct is not a unitary structure, but divided into two distinct channels, as during the fetal life of the human being.
Furthermore, cholangiopancreatography with diagnostic purposes is also a valid instrument for the manometric study of the biliary tract and an effective technique for taking a sample of cells from the bile or pancreatic ducts, in order to subject it to accurate laboratory investigations ( biopsy ) .
The use of cholangiopancreatography for bioptic purposes is particularly useful, when there is a suspicion (based on previous radiological examinations) of a neoplasm of the biliary or pancreatic tract.
Therapeutic use of cholangiopancreatography
Therapeutic cholangiopancreatography can be used to:
- The removal of gallstones ;
- The insertion of a stent inside the bile ducts ( biliary stenting ). This procedure allows the elimination of a narrowing in a bile duct, through the insertion in the latter of a plastic tube, metal or other special material;
- The elimination, through surgery, of a stenosis against a bile duct;
- Performing an operation known as endoscopic sphincterotomy . In practical terms, it consists of cutting the particular muscle located between the common bile duct and the main pancreatic duct.
Endoscopic sphincterotomy can be used to prevent some possible complications arising from cholecystectomy ( gallbladder removal) and to treat an obstructive jaundice due to the presence of gallstones.
Preparation
In preparation for a cholangiopancreatography, every future patient must:
- If you suffer from any allergies (medicines, foods, etc.), if you suffer from any chronic illness (eg, asthma, heart disease, etc.), if you take medicines that alter the mechanism of blood coagulation (eg: aspirin, warfarin etc.) or if you have recently performed a diagnostic test in which a barium contrast agent has been used.
On the basis of the patient's report to the doctors, these could provide some important instructions, on which the success of the cholangiopancreatography depends and its execution without complications for the patient (eg: patients taking warfarin are required to temporarily suspend the use of the aforementioned drug, to reduce the risk of serious bleeding).
- A few days before the exam, take a series of tests to evaluate vital signs; this series of tests includes a blood test, a blood pressure check and an electrocardiogram.
- If doctors consider it essential for the success of the procedure, undergo prophylactic antibiotic therapy.
- At least 8 hours before the procedure, start a complete fast, which will end only at the end of the exam.
- Just before the procedure, completely empty the bladder and remove any jewelry, dentures, contact lenses, etc.
- Ask a relative or close friend to keep themselves free on the day of the procedure, so that he can assist them when they return home.
Procedure
From the procedural point of view, cholangiopancreatography can be divided into three consecutive phases, which in chronological order are: the patient's accommodation phase (first phase), the patient's sedation and anesthesia phase (second phase), and, finally, the executive phase (third phase).
Cholangiopancreatography procedures must take place in well-equipped environments, such as hospitals, and their execution is the responsibility of a gastroenterologist, that is a doctor who specializes in the treatment and treatment of diseases and disorders of the digestive system.
First phase: patient accommodation
The first phase of cholangiopancreatography foresees that the patient undresses, to wear a hospital gown prepared for the occasion, and sits on the couch belonging to the instrument for fluoroscopy.
For the purpose of the success of the exam, the position that the patient must take on the couch is on the left side .
Clearly, at this stage the patient can count on the help of a medical staff nurse.
Second phase: sedation and anesthesia of the patient
The second phase of cholangiopancreatography involves the intervention of an anesthesiologist, who has the specific task of sedating and anesthetizing the patient, so that the latter does not experience pain during insertion of the endoscope and subsequent passage along the internal organs.
Sedation takes place intravenously and consists of the administration of mostly analgesic-sedative drugs. Anesthesia, on the other hand, is local and affects the throat; to do this, the anesthesiologist uses a special spray, which sprays into the patient's mouth in the direction of the area to make the person insensitive to pain.
The second phase of cholangiopancreatography ends when sedation and anesthetic drugs have begun to take effect; it is at this time, in fact, that the patient is ready to undergo the third and final procedural phase.
Third phase: endoscopy and fluoroscopy
Recalling that cholangiopancreatography combines endoscopy with fluoroscopy, the third phase of this procedure is one in which the gastroenterologist performs the endoscope housing in the duodenum and performs, thanks to the help of a contrast agent, the collection of images under the fluoroscope.
The endoscope housing is a delicate operation; it starts from the patient's mouth, continues along the esophagus and the stomach, and ends at the level of the duodenum, exactly where this intestinal tract joins the bile and pancreatic ducts (ampulla of Vater).
Fluoroscopy occurs only once the endoscope housing is completed, as it requires the latter; the endoscope, in fact, besides being a camera that reproduces on an external monitor what it picks up, is also the instrument through which it is possible to spray the contrast medium for fluoroscopy.
The main objects of study of fluoroscopy are the bile ducts and pancreatic ducts; often, in order to better observe them, the doctor injects you with a gas that determines their expansion. As in the case of contrast media, injection is also performed by the endoscope located at the duodenal level for the aforementioned gas.
| Table. The highlights of cholangiopancreatography in short. | |
| Procedure phase | What happens? |
| First phase | Patient preparation. Arrangement of the patient on the fluoroscope table. The patient should lie on his left side. |
| Second phase | Intravenous sedation Throat anesthesia by spray. |
| Third phase | Endoscope housing in the duodenum, exactly where bile and pancreatic ducts open. The placement of the endoscope takes place by taking advantage of the passage offered by the digestive tract, mouth, esophagus and stomach. During the operation of placing the endoscope and even when the housing is completed, the doctor observes, on a connected monitor, what the camera of the instrument takes up. Using the endoscope in the duodenum, the doctor also injects the contrast medium necessary for fluoroscopy. |
What is the duration of a cholangiopancreatography?
A cholangiopancreatography can last from 30 to 60 minutes ; duration depends on the purpose of the procedure (a therapeutic cholangiopancreatography tends to last longer than a diagnostic cholangiopancreatography).
Sensations during cholangiopancreatography
The patient may experience a slight discomfort or a kind of burning pain when the anesthesiologist practices intravenous sedation. However, both eventualities are two temporary and short-lived sensations.
The local anesthetic has a bitter taste, which for some might be very unpleasant; however, anesthesia is essential for the later stages of cholangiopancreatography.
Probably the most annoying moments of the medical procedure in question are those in which the gastroenterologist introduces the endoscope into the digestive tract; in fact, during this operation the patient feels unable to breathe. In reality, the endoscope is very thin and its presence in the mouth does not hinder the passage of air in any way; the fact that the patient seems not to breathe is mainly due to the effects of local anesthesia and agitation.
After the procedure
At the end of cholangiopancreatography and for a maximum of 24 hours thereafter, the patient may develop sensations such as drowsiness, heavy eyelids, confusion, dry mouth, blurred vision, speech problems, mild amnesia, abdominal bloating and intestinal problems. Except for abdominal bloating and intestinal problems, which depend on the gas used for the expansion of the bile and pancreatic ducts, all other sensations are the normal consequences of sedatives and local anesthetic.
Regarding the return home, this depends on the purpose of cholangiopancreatography:
- Normally, on the occasion of a diagnostic cholangiopancreatography, the patient can return home the day of the procedure, provided that he proves to be well and has not developed complications.
- On the occasion of a therapeutic cholangiopancreatography, instead, the practice wants the patient to spend at least one night in the hospital, so that the attending physician can monitor the response to the treatment carried out.
Variants of the ERCP
There are variations to the ERCP procedure described above.
Without going into details, these variants are:
- Cholangiopancreatography with final biopsy;
- Percutaneous transhepatic cholangiography;
- Retrograde wirsungraphy;
- MRI or cholangiopancreatography by magnetic resonance.
risks
Not easy to perform even for an experienced doctor, cholangiopancreatography is a procedure that presents several risks ; those who undergo this diagnostic-therapeutic procedure, in fact, can be the victim of serious complications such as:
- Pancreatitis . It represents the most important complication of cholangiopancreatography (both in frequency and in severity).
According to some statistics, it would characterize just over 5% of the procedures; according to others, however, almost 20%.
Although it may vary in terms of severity, post-ERCP pancreatitis always requires hospitalization and specific treatment; of post-ERCP pancreatitis it is possible to die, especially if the inflammation of the pancreas is particularly severe and the treatments are not immediate.
Studies relating to risk factors for post-ERCP pancreatitis have shown that they are predisposed to the complication in question: young people, women and subjects with sphincter dysfunction of Oddi;
- Injury or, worse, perforation of one of the organs along which the endoscope flows (therefore esophagus, stomach, duodenum, biliary tract and pancreatic pathways). Particularly common and, unfortunately, quite serious is the perforation of the duodenum, an example of intestinal perforation;
- Infection at the level of one of the bile ducts ( cholangitis ). It is a fairly rare event (it affects less than 1% of patients);
- Hemorrhagic phenomena . Hemorrhages due to ERCP are rarely severe;
- Allergic reaction to contrast medium or to drugs used for sedation and anesthesia . Certain allergic reactions may be fatal; fortunately, they are a very rare complication;
- Development of a cardiac arrhythmia .
Contraindications
Cholangiopancreatography has several contraindications; in fact, its execution is not suitable for:
- People with hypersensitivity or an allergy to contrast media employed;
- People who have recently suffered from a myocardial infarction or pulmonary embolism;
- Individuals with chronic cardiopulmonary diseases or other serious medical conditions, always of a chronic nature;
- Subjects with acute pancreatitis not due to biliary obstruction;
- Individuals with a coagulation disorder (but only if the cholangiopancreatography involves some surgical incision).
Results
A cholangiopancreatography provides clearer and more detailed images than an endoscopic ultrasound of the same organs and this represents a significant advantage, considering the severity of pancreatic and biliary and pancreatic ducts.
Curiosity
Cholangiopancreatography is very effective in detecting pancreatic tumors; according to statistics, in fact, its execution would make it possible to highlight a pancreatic cancer - the most deadly and widespread pancreatic cancer - in almost 90% of the circumstances.
Disadvantages
The most important disadvantages of cholangiopancreatography are invasiveness and not easy to perform. Regarding invasiveness, however, it is good to remind readers that the ERCP is certainly less invasive than an "open-air" surgery for the treatment of some pancreatic disease.
When are the results of a diagnostic ERCP ready?
In general, the results of a diagnostic cholangiopancreatography are available to patients at the end of the procedure; their immediate discussion with the doctor is therefore quite common.
The only juncture in which patients have to wait a few days to know the outcome of the diagnostic ERCP (and for the discussion of this outcome) is when, during the procedure, there was the collection of a sample of cells for a biopsy; in fact, laboratory analyzes on cells taken during a cholangiopancreatography for bioptic purposes require, for their realization, at least 2-3 days.
