ERCP is a test which allows the doctor to look directly at the lining of the biliary tract and pancreatic ducts. Diagnostic ERCP is recommended for jaundice, elevated liver enzymes, bile duct obstruction and as a therapeutic test for bile duct stones and strictures. In order to do the test, an endoscope is carefully passed through the mouth into the esophagus, stomach and duodenum. The endoscope is a long flexible tube, about the thickness of your index finger, with a bright light at its tip. The video camera on the endoscope transmits images of the biliary and pancreatic ducts to a monitor allowing the physician to examine the ducts checking for any disease or abnormalities. If necessary, stones or strictures can be treated through the scope during an ERCP. Tissue samples (biopsies) can be taken during an ERCP as well.

Diagnosis

ERCP can help doctors diagnose the reasons for

→ Jaundice and dark urine

→ Elevated liver enzymes and bilirubin

→ Bile duct obstruction on imaging

→ Pancreatitis of unknown origin

→ To evaluate abnormalities in the biliary system in other imaging like ultrasound and CT scan

→ Unexplained abdominal pain

→ Cholangitis and biliary infection

→ Diagnosis and surveillance of pancreatic duct disease

ERCP can also detect stones, strictures, tumours and dilated ducts. The procedure is used to look for early signs of biliary and pancreatic pathology. The doctor can also take samples from abnormal-looking tissues during ERCP. The procedure, called a biopsy, allows the doctor to later look at the tissue with a microscope for signs of disease.

Cholangiography: Direct visualization of the bile ducts is obtained that will help to diagnose obstruction, stones and strictures especially in patients with post-surgical anatomy.

Manometry: is a modality when applied with ERCP can help to assess sphincter of oddi function and differentiate functional obstruction from mechanical obstruction so that therapeutic yield is high.

Treatment

ERCP can help doctors with the following issues

→ Removal of bile duct stones (choledocholithiasis)

→ Removal of large bile duct stones by mechanical lithotripsy or cholangioplasty

→ Dilate narrowed segments (stricture dilation) of the biliary tract and place metallic stents across them (biliary stenting)

→ Treatment for sphincter of oddi dysfunction

→ Control of bleeding from ampullary ulcers or vascular malformation

→ Pancreatic duct stone removal

→ Palliative treatment for obstructing malignancy (metal stenting) or bleeding tumour (laser, electrocoagulation, heater probe, injection)

→ Ampullectomy for ampullary polyps and tumours

Interventions

Sphincterotomy: sphincter of oddi is cut to allow passage of stones

Endoscopic Papillary Balloon Dilation (EPBD): balloon dilation for stricture dilation

CRE (Controlled Radial Expansion) balloon dilatation for stricture dilatation

Mechanical Lithotripsy: large stones are fragmented and removed

Endoscopic Biliary Stent placement: stents are placed for strictures and obstruction

Ampullectomy: ampullary polyps and tumours are removed en-bloc or piecemeal with this procedure, surgery can be avoided.

SEMS (Self Expanding Metal Stent) placement: for obstructing malignancy that is not amenable to surgery, SEMS can be placed for symptomatic relief

Cholangioscopy with SpyGlass: direct visualization of ducts allowing targeted therapy for difficult stones and strictures

Preventive

Colonic cancer surveillance: colorectal cancer is on the rise in Asian countries. Surveillance is recommended in average and high-risk patients to detect this dreaded disease in the early stage which may help in endoscopic treatment avoiding surgery.

Surveillance of patients with IBD (Inflammatory Bowel Disease): Patients with long-standing IBD are prone to develop colorectal cancer which can be screened by colonoscopy combined with chromo-endoscopy or NBI.

Early detection and characterization of premalignant colonic polyp followed by removal: Early detection and removal of premalignant polyps prevents malignant transformation and future cancer development.

Family history screening: Patients with family history of colorectal cancer should undergo colonoscopy screening starting at age 40 or 10 years before earliest family member diagnosis to enable early intervention.