ERCP PROCEDURE

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GB Thapa, BScMIT.........ERCP
2068.01.05

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(Duct of Wirsung)
(Duct of Sartorini)
(Papilla of
Vater)
Ampulla of Vater
(Hepatopancreatic ampulla)
Kerckring's folds
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Know/Understand/Perform:
• Anatomy visualized during endoscopy.
• Endoscope, connection of Endoscopy to radiology.
• Clinical indications, contraindications, pre-medications,
patient preparations, complications & after care.
• Equipment preparation & medicine management.
• ERCP procedure ,role of own & each team members.
• Why & how brushing / biopsy taken, balloon catheter used,
sphincterotomy performed, biliary stones removed & stents
are placed.
• Steps where fluoroscopic guidance/spot filming required.
• Management of serious patient in the Procedure room.
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• Coordinate between doctor, other staffs, patient &
visitors.
• Appointment management.
• ERCP room, equipments & medication preparation.
• Radiation protection.
• Pre & post procedure preparations.
• Fluoroscopy & film series.
• Radiographs preparation.
• Assist in counseling, informed consent, related
information.
• Understand that what the doctor doing, Anticipate
what will be done next & why it is being done & what
will be the my role during every steps of procedure.
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• Endoscope ( to see inside the
body) : long & flexible tube
containing a light source, lens
system for focusing & fiber
optics to conduct light.
• First endoscope by Philippe Bozzine
in 1806 : consisted of a simple
silver tube, at one end was lighted
by a candle, & a mirror reflected
the light.
• Modern endoscope is modified
version developed by Max Nitze
(In 1877). The fiber optics in
modern scopes emits light &
transmits images back to a video
camera & displayed in monitor. 11
2068.01.05

• Endoscopes are designed to
either view anatomy
directly in front of the scope
or they can be angled to
view the sides of the
anatomy. For ERCP the side
viewing scope is used to
visualize the papilla of Vater.
• First ERCP performed by
Ludwig Demling & Meinhard
Classen in 1973.
ENDOSCOPE
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• ERCP is a specialized fusion of
endoscopic & radiological procedure
used for diagnostic & therapeutic
purposes of many diseases of the
pancreas & biliary ducts under
fluoroscopy guidance.
• By inserting a flexible instrument
or thin catheter through the
working channel of the endoscope
into the ducts & injecting a
contrast agent filling the ducts
that can be directly visualized on
TV monitor & spot films taken in
different stages of the procedure. 14
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• Gastroenterologist/Gastrosurgeon/trained physician
may insert instruments through the endoscope in
order to obtain biopsies, brush cytology, remove
CBD stones, dilate a stricture & remove obstruction
of the duct, or place a drainage tube into a duct.
• Useful diagnostic method when the biliary ducts
are not dilated & when no obstruction exists at
the ampulla.
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ERCP is associated with a 5%-10% risk of pancreatitis:
 Risk is increased :
• In those cases where cannulation of the ducts is
difficult.
• If the pancreas is normal.
• When a sphincterotomy is performed.
• A prior history of ERCP-induced pancreatitis .
 Less common risks: bleeding, infection &
perforation etc.
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Clinical & radiographic findings indicating
abnormalities in the biliopancreatic system:
• Jaundice (undiagnosed cause).
• Severe or persistent abdominal pain suggesting
biliary or pancreatic disease.
• Symptoms, clinical examination, laboratory
findings, x-ray or other examinations suggesting
structural abnormalities.
• Stones , cysts or tumor within the duct system
which may missed by other imaging modalities .
• Acute obstructive suppurative cholangitis, biliary
pancreatitis, Recurrent pancreatitis.
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• Strictures (narrowing by scar tissue, cyst or tumor)
of the ducts or ampulla of Vater.
• Tumors of the ampulla, CBD or pancreatic ducts .
• Complications following biliary surgery /Post
-cholecystectomy.
• To evaluate congenital anomalies & anatomical
details for further planning.
• Pancreatic pseudocysts.
To collect bilio-pancreatic samples for laboratory
investigations & biopsies for cytological study.
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Endoscopic management of biliary stones
(Sphincter of Oddi manometry, balloon dilation,
sphincterotomy, stone extraction, placement of
stents or drainage tubes across the obstructed
ducts to open their drainage as required .
Surgicomedical management of biliary trauma.
In case of stent occlusion.
Complicated CBD stones: Jaundice, Ac.
Pancreatitis, Ac. Chalangitis (Charcot’s triad in case of
Acute suppurative cholangitis : Abdominal pain, recurrent
or persistent jaundice & rigors).
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Ascites.
Pyloric stenosis.
Acute infective pancreatitis.
Severe cardiorespiratory diseases.
Oesophageal obstruction/Varices/cancer.
Surgically unfit patient.
History of previous severe sensitivity reaction to
contrast media & other medication.
Acute glaucoma, & prostatitis .
(Anticholinergic drugs contraindicated).
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• Nonionic tri-iodinated contrast agent:
Iopamidol (Neopam, Solutrast ,Iopamiro), Iohexol
(Omnipaque), Iopramide (Ultravist) or Ioversol
(Optiray).
Pancreatic duct: Low osmolar (1.5 mgI/ml )
Bile duct: Low osmolar (2.8 mgI/ml)
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• A side viewing fibre-
optic endoscope.
• Polythene catheters.
• Over-couch /under- couch
x-ray tubes with tilting table.
• Fluoroscopic unit with
spot film devices &
image intensifier
television system.
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• Lead aprons, Thyroid shields, Lead goggles.
• Catheters, Aspirator, Disposable syringes 5ml,10 ml, 50ml;
Buscopan inj. 20 mg, Inj. Glucagon 1 ml, Diazepam inj. 10 mg,
Anaesthetic lozenge/Spray, Contrast media, Gauze swabs,
Emergency drugs, Sample collection vials with formalin,
Stents, brushes, guide wires, Stone baskets etc.
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Balloon catheter cannula Plastic stent
Stent with wire mesh
Extraction balloon
Needle knife forceps
Stone basket
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Guide wires
Papillotomes (Sphincterotomes)
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• NPO from midnight or at least 6 hours before
procedure.
• Information about any medications (warfarin
or other anticoagulants & anaelgesics), major
illnesses, pregnancy, allergy, previous
treatments so
that to provide appropriate instructions prior
to ERCP.
• Recent Blood test report: PT, Bilirubin,
Albumin, LFT, Haemogram profile, etc.
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• Control film (Recent radiograph AP /LAO of
upper abdomen), report of
USG/CT/MRI/cholangiogram if available: to check
opaque gall stones, pancreatic calcifications or
calculi,diagnosis.
• Counseling, Informed consent.
• Remove glasses, contact lenses, dentures,
jewellery & other radio opaque materials if
present.
PATIENT PREPARATION
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• May need antibiotics IV prior to ERCP.
• Amethocaine lozenge 30 min. prior to
examination.
• A local anaesthetic sprayed onto the
tongue/throat immediately before
intubation.
• May require sedation : inj. Diazepam 10 mg
I/V 9or 0.3 mg /kg body weight) ,or Inj.
Pethidine 75mg I/M before 1 hour.
PATIENT PREPARATION
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• Known allergic to iodine contrast: pre-treated
with either 40 mg prednisone 12 hours & 2
hours before or 40 mg daily for 3 days before
the exam.
• Smooth muscle relaxant : Buscopan 20 mg I/M
before 10 min, or Atropine 0.6 mg I/M before 1
hour Or 0.5-1 ml Glucagon I/V is given to
reduce duodenal spasms & relax the sphincter of
Oddi for passage of endoscope & insertion of
cannula.
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• Ordering Gastrosurgeon
or gastroenterologist.
• A Radiologist (optional).
• A Radiographic
Technologist.
• Nurses.
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1. INITIAL PROCEDURE: Insertion of Endoscope & initial
cholangiogram.
2. SPHINCTER OF ODDI MANOMETRY.
3. STRICTURES: Brush cytology or tissue Biopsies.
4. SPHINCTEROTOMY.
5. USE OF BALLOON CATHETER or STONE BASKET to
remove stones.
6. PLACEMANT OF STENT.
SPOT FILMS: Scout film, Initial cholangiogram, Post
procedural film, Drainage film.
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• Monitoring of BP, pulse, breathing, & blood oxygen
levels during the test.
• Open IV canulation.
• Throat sprayed with a topical anesthetic (4%
xylocaine) or Gargling with.
• Patient lies on left lateral or LAO position on the
fluoroscopic table.
• Endoscope is introduced through the mouth, down
the esophagus , stomach, duodenal loop into the
Papilla of Vater under the guidance of fluoroscopy.
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• Air is introduced into the gut to expand the
stomach & bowel for ease passage of the
endoscope.
• The endoscope is flushed by NS or CM since the
remaining air may give confusing shadows as of
biliary calculi. Scout film is taken.
• Aspiration of bile in case of biliary obstruction &
send for lab test (culture & sensitivity test).
• The rule of thumb is to have fluoroscopy in during
injection of CM, manipulation of guide wires,
balloon catheters, stone baskets, brushings,
biopsies, & Stent placement procedures.
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The scout radiograph notice the gas pattern created by the air. 36
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• After the Ampulla of Vater is visually identified
in the second part of duodenum, Patient is
turned prone to assist in selective cannulation of
the biliary duct. It is easier to cannulate the
pancreatic duct because it is straight in the
papilla, & the CBD is slightly angled to the side.
• If necessary, the pancreatic duct is always
examined first without overfilling the duct with
CM. But injection of CM in the Pancreatic duct is
much more harmful.
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• A polythene catheter prefilled with CM, without
any air bubble, is introduced via the endoscope
through the ampulla into the distal end of the
biliary duct (CBD).
• If failed to introduce, then attempt to introduce a
guide wire into the Papillary opening. A catheter is
directed up the duct right over the guide wire &
placed into the CBD, inside the papilla of Vater.
• A small test injection of the CM under fluoroscopic
guidance is made to determine the position of
cannula is in right position.
• And the CM is injected to fill the biliary ducts & gall
bladder.
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• Early Bile ducts filling films to show calculi:
Prone-straight & posterior oblique,
supine-straight, both obliques.
• Intrahepatic ducts: Trendelenburg.
• Lower end of CBD & gall bladder: Semi –
erect .
• Because the injected CM rapidly drained
from normal ducts, radiographs must be
exposed immediately within 5 minutes.
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• Endoscope is removed to prevent obscuring the
duct visualization & further radiographs are taken.
Also an erect view of the gall bladder should be
taken using over couch tube.
• Delayed films of gall bladder & CBD are taken to
evaluate emptying rate.
• Usually four types of spot films are taken for all
ERCP’s: the initial scout, the initial
cholangiogram, the post procedure
cholangiogram, & the drainage film.
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• In addition to fluoroscopy, images can be
recorded from direct viewing via the
endoscope by video - tape or 35 mm
attachments.
• For therapeutic ERCP, special instruments are
passed through the working channel of the
endoscope that are used for cutting & opening
into the bile duct, gallstone removal,
dilatation of a stricture & stent or drain
placement.
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 Failed cannulation of the CBD, Failed stone
extraction.
 10% chance of complication if sphincterotomy is
performed .
2-5% if a sphincterotomy not performed.
 Possibility of complications is higher in
therapeutic ERCP than with diagnostic ERCP.
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1. General (May prone to all cases):
Weakness, dizziness or fainting.
Localized irritation of the vein/ tender lump.
Hyperamylasaemia ( approx. 70%)
Increased severity of pain(abdomen, chest &
back).
Temporary bloating, Nausea or vomiting.
Adverse reaction due to sedative/ Contrast
media.
Aggravation of cardiac or pulmonary diseases,
cardiopulmonary accident & may follow death .
Severe complications: Need to be hospitalized.
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2. DUE TO INSTRUMENTAL MANIPULATION:
Aspiration pneumonia.
Rupture/perforation of the oesophagus, stomach,
duodenum, CBD, PD.
GI bleeding, Blood in stool, black tar-like stools.
(t/t: Injection epinephrine at the site through the catheter
within the endoscope, may need IV infusion also.)
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3. INFECTIONS:
Pancreatitis (6-10%):
• Most common complication, caused by irritation
because of injecting too often or too much
contrast agent in the pancreatic duct.
• Mild to severe: t/t include hospitalization,
observation, rest, IV hydration, & medication.
Cholangitis, Bacteramia, Septicemia.
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• Brushing & biopsy.
• Balloon dilation.
• Stenting.
• Sphincter of Oddi manometry.
• Sphincterotomy : Endoscopic stone
dislodgement, Endoscopic lithotripsy.
• Nasobiliary drainage (Nasobiliary tube) .
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1. BRUSHING & BIOPSY
• Most of the strictures f in the
hepatobiliary ducts are
caused by tumor compression
in the duct walls.
• Sample tissue is taken from
the stricture during ERCP
procedure to confirm
pathological diagnosis.
• Two ways of tissue sample
collection : Brushing & Biopsy.
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BRUSHING BIOPSY
• Under fluoroscopic control, a guide wire is
introduced, past through the stricture, then
advanced a brush catheter up to the stricture.
• The brush is moved up & down several times to
scrap & extract diseased tissues from the stricture
before the brush pulled back into the protective
sheath.
• The brush is removed from the endoscope, cut off
the wire, placed in a formalin solution to be sent
for pathological study.
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ERCP image of Biopsy brushing of the
Stricture caused by tumor near hepatic ducts.
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FORCEPS BIOPSY
• A guide wire is introduced as for brushing biopsy
procedure.
• A small biopsy forceps is advanced over the guide
wire to the stricture.
• Forceps is opened touching the stricture walls, closed
tightly to clamp tissues & pull back maintaining the
closed condition from the endoscope.
• The tissue sample placed in a formalin solution to be
sent to pathology department.
• May be repeated several times until enough tissue has
been taken. Fluoroscopic guidance will be needed
each time to insure that the tissue is being taken from
the stricture.
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A guide wire is positioned above the stricture & a opened biopsy forceps located at the
stricture.
Forceps
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• If a narrowed area: a stricture from scar tissue,
cancer, inflammation or gallstones is encountered
in either the pancreatic duct or the bile duct,
a balloon may be inflated inside the duct
to stretch out this stricture. The stretching
may or may not be permanent.
• The inflated balloon beyond the stone is also used
to pull down the stone. If the balloon is
too small to act as a dam behind the
stone, then a stone basket may be used.
• Placement of wiremesh is one of the methods used
in treating strictures of the duct.
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Fluorospot images demonstrate a wire basket with larger stone. The radiograph on
the right is a magnified version of the picture on the left.
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ERCP: valuable in detecting & treating main
pancreatic duct leaks with transpapillary
stenting (placement of a plastic tube across the
papilla).
A stent (a small plastic or metal tube is pushed
through the endoscope & placed into a
narrowed area in the CBD or pancreatic duct
(or in both ducts) & left in place after the ERCP.
Stenting allows the bile to drain freely into
the intestine & relieve jaundice & pain.
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•Serious infection may occur if a blocked stent is
left in place for a long time.
•Metal Stents are usually left in permanently.
•In general, plastic bile duct stents must be
removed in 3-4 months, while pancreatic duct stents
in 1-2 weeks.
•Some pancreatic stents are designed to fall out on
their own; however, an x-ray 1 week after the
procedure is performed to ensure this.
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• Most common stent: plastic (polyethylene)
temporary use, also used in bile leakage at the post
surgical cholecystectomy site, Swelling around the
papilla of Vater, Pancraetitis.
• Metallic stents: permanent , usually used when the
duct is being restricted by a tumor, malignancy &
low probability of prognosis.
• The initial placement of a metal stent must be
correct, because once the stent is released from the
endoscope it expands in both diameter & length.
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• Placement of a plastic /temporary stent in the CBD
is common practice after a sphincterotomy to
insure that the duct will not close down again & to
increase bile drainage.
• Pancreatic fistula (connections betn. the PD &
other structures) ,also respond to transpapillary
drainage.
• Pancreatic ascites (a large collection of abdominal
fluid attributed to pancreatic duct rupture), can be
effectively treated through similar means.
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• Pseudocysts (walled-off pancreatic or
peripancreatic fluid collections in pancreatitis)
may be drained via the papilla if they connect with
the pancreatic duct.
• If they do not, drainage can be achieved by creating
a cystogastrostomy or cystoduodenostomy using a
needle-knife papillotome. (papillotome: a catheter
with a steel wire that is manipulated to different bowed
angles which allows the GI doctor to cauterize).
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Pancreatic stent
CBD stent
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Pictures taken through the endoscope camera show a stent (left) & bile
draining from the stent (right). Sometimes a stent can be placed to help
drain the biliary ducts & gallbladder without performing a sphincteroctomy.
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A long stent that transverses
the entire length of the CBD.
Stents in CBD & PD
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ERCP image showing the hepatic ducts;
CHD, cystic duct, and CBD. The spiral
appearance of the cystic duct due to the
valve of Heister. The pancreatic ducts &
ampulla of Vater are not demonstrated.
Fluorospot image at the completion of the
ERCP. A stent placed in the CBD (white arrow).
After a stone was removed & the stent placed,
bile flowed freely into the duodenum.
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• Sphincter of Oddi manometry is considered in the
patient with recurrent acute pancreatitis of
otherwise unknown cause.
• Technique to measure pressures in the ducts
sphincter. A special catheter & apparatus is used
for measuring the pressures of the sphincters in the
ducts at the time of ERCP.
• If the pressures are higher than normal, it is
indicated for a sphincterotomy.
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INDICATIONS:
• Diagnosed biliary stones in
high-risk surgical patients
with intact gallbladder.
• Obstructed drainage.
• Biliary pancreatitis.
• Increased pressure recorded by manometry.
• Residual or recurrent CBD stones following
cholecystectomy.
• To facilitate stent placement.
• Papillary stenosis due to a tumor or scarring.
5. SPHINCTEROTOMY
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• A sphincterotome (Papillotome) is a small catheter
with a steel wire which can be bowed in different
angles. A sphincterotomy is performed with the
sphincterotome passed through the endoscope
before stone extraction attempted.
• Sphincterotomy is done making a small cut in
sphincter to enlarge the lumen with an electrically
heated wire (Sphincterotome or papillotome)
connecting to the cauterizer. Placement of the wire
is at the ten o’clock position to start cauterizing.
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Sphincterotomy may follow stone extraction with
the use of Balloon catheter or Stone basket (Dormia
basket).
• A guide wire is placed in the upper portion of the
CBD beyond the stone under fluoroscopy
guidance.
• Once the guide wire is properly placed, a balloon
catheter is pulled upto the guide wire.
• When the balloon has reached the optimal distance
in the duct & that the guide wire is still in the
proper location, the balloon is then inflated, &
slowly pulled down the duct & out the papilla in the66
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• If the duct is more dilated, the balloon may slip
passing through the sides of the stone. So repeated
attempts may be needed to pull down the stone.
• If the balloon is too small to act as a dam behind the
stone & failed to extract, then stone basket may be
used.
• A stone basket is advanced over the guide wire up
to the stone & then open the basket .
• The basket is wiggled up & down the duct to try to
snare the stone under fluoroscopic guidance to
insure that the stone is caught in the basket.
SPHINCTEROTOMY: Stone extraction
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• Once the stone is lodge in the basket, it is slowly pulled
down the duct to the duodenum under the fluoroscopic
guidance in order to insure that the stone is still
lodged in the basket.
• This process may be repeated if there are more stones
left.
• Smaller stones or stones that seem to be crushed by
the stone basket may be removed again by using the
balloon catheter.
• Over 90% of CBD stones may be successfully removed
by using a basket or Balloon & left to pass into the
intestines where they will be eliminated in the stool.
SPHINCTEROTOMY: Stone extraction
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Fluorospot image: large stone in the stone basket
and the extreme dilation caused by the obstruction.
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Endoscopic pictures showing large cholesterol stone (white arrow) is released
from a wire basket into the duodenum after sphincterotomy (blue arrow).
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• In cases of severe obstruction, a long-thin plastic
tube (a nasobiliary tube), is left in the bile duct &
brought out through the nose for a few days.
• NBD allows bile to drain, so more x-rays can be
taken after a few days using contrast agent to check
when the duct is clear.
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• NPO for 4 hour until Anaesthetic effect return to
normal.
• Avoid alcohol at least for 24 hours.
• Vital sign recording ½ hourly for 4-6 hours, then 4
hourly for next 24 hours.
• Monitoring in the recovery room for 30 - 45
minutes, until the effects of sedation remained.
• Arrangements for somebody to drive them home
& to stay with them for the remainder of the day
because of sedation. No driving or work is allowed
until the next day.
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• Broad spectrum antibiotics in cases of biliary or
pancreatic obstruction.
• Monitoring of serum/urine amylase level if
pancreatitis is suspected.
• Close observation: High fever, Chills, rigor, Blood in
stool, Black, tar-like stools, Increased pain in
abdomen/chest/back, Nausea or Vomiting,
Weakness, Dizziness, or fainting.
• Absolute bed rest.
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The initial cholangiogram that helps make
the diagnosis and the treatment plan.
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The post procedure cholangiogram is used to demonstrate the
completion
of the procedure after the removal of stones and/or stent placement. 78
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The drainage film is taken to verify that the ampulla of the Vater
is draining contrast freely and to visualize the section of the CBD
that was obscured by the endoscope.
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Radiograph after removal of CBD stone , & administration of CM showing filling
of the intrahepatic & biliary duct, & unrestricted draining into the duodenum .
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Stones
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Fluorospot image demonstrates the use of the endoscope to collect a tissue
sample for histological analysis. Right Is magnified radiograph of left.
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Fluorospot radiographs showing a wire mesh type bridge within the CBD..
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Fluorospot radiographs showing a stricture of the CBD
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Fluorospot images : stones in the CBD on the left radiograph, and cystic duct on
the right radiograph (arrows).
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• Fluorospot images demonstrate the main pancreatic duct (duct of Wirsung) of
different patients.
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Refreshment !
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ERCP PROCEDURE

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