ERCP

ERCP is an endoscopic intervention used for the diagnosis and treatment of obstructive diseases at gall and pancreas canals. The actual term is "Endoscopic Retrograde Colangio-Pancreatography". Doctor visualizes the problems at liver, gall bladder, gall canals and pancreas by sending an endoscopy tube called "duodenoscope" to the duodenum and may perform several applications for diagnosis and treatment at the same session. Procedure is performed by a team specialized at this field consisting of gastroenterology specialist, assistant, nurse and anaesthesia specialist.

In what conditions ERCP is performed?
ERCP is performed in principal for the treatment of obstruction of gall canals and pancreas canals. Those patients usually have manifestations like jaundice, stomach ache and fever. Additionally it may be used for some other disorders of gall bladder, liver and pancreas. Your doctor will decide whether ERCP is indicated for you by evaluating your clinical manifestations, blood analysis and results of tests such as ultranonography or computerized tomography.

Conditions where ERCP is indicated:


Diseases of gall canal


-Stone and mud of gall canal
-Narrowing's due to cancer or benign tumors
-Injuries of gall canal, gall leakage
-Dysfunction of Oddi sphincter
-Obstruction due to parasites
-Liver cysts in connection with gall canal


Pancreas diseases


-Acute or chronic pancreatitis
-Pancreas cancer
-Pancreas cysts (pseudo cysts) and pancreas canal leakage
-Pancreas stones
-Tumors of Ampulla Vateri
-Upper abdominal pains of unexplained origin
-Unexplained weight loss


Equipment


Three primary materials are used for ERCP procedure


Duodenoscope: It is a special, flexible, thin endoscopy device which contains fiberoptic cables that transmits light and thin canals for catheter, air and water inside and a micro-camera at the tip. Doctor sends the doudenoscope through the mouth to the point where gall canal is opening to the intestine and performs interventions.


X-ray Device: A special fluid administered to the gall canals via catheter inside of the duodenoscope, canals become available to be visualized at X-ray device. By the way cause of obstruction such as stone, tumor or other disorders may be visualized. Two TV screen is used in ERCP procedure one of which is for the images taken from duodenoscope and the other is for images taken from X-ray device.


Catheters, other materials: These are biopsy clamps, brushes and several materials sent into the canal via duodenoscope for cutting, enlarging, stone catching, breaking, removing and stent placing.


How is it done?
A device for monitorization of blood oxygen level, heart rate and blood pressure is placed to the finger and arm a spray is spouted to the treat to inhibit gag reflex. Patient lay down to the table on his/her left side or back. Medication administered by anaesthesia doctor until reaching a sleep situation for relaxation and loosening. A plastic protective material is placed to the mouth that the endoscope will pas inside for the purpose of protecting the teeth. After the relaxation and sleep are achieved doctor initiates the procedure.


Doctor gently advances the tube called duodenoscope through the mouthpiece towards oesophagus. After the tip of endoscopy tube passed the stomach and reached to the hole where gall canal is opened (papilla) at the beginning segment of small intestine doctor gives the device appropriate position.


Most important part of ERCP is sending the catheter towards the canal through the milimetric hole placed at the centre of nipple shaped papilla where the gall canal opens to the intestine. When catheter is placed into the gall canal, iodized paint that can be seen under x-ray administered via it and a detailed image of the gall canals is obtained. Doctor defines at which segment of the canal the obstruction exists and what the obstructive disease is by looking at the screen. Afterwards treatment phase takes place.


Doctor plans which treatment to be performed and uses the treatment methods of ERCP in order to unclog the obstruction or to remove the stones. These are procedures such as cutting of the papilla muscle (sphyncterotomy), widening (sphyncteroplasty), and stent placement, breaking and removing the stones, cyst drainage, nasobiliary drainage, nasopancreatic drainage.


Treatment methods performed during ERCP


Sphyncterotomy: It is the cutting of muscle fibbers in shape of circle that encircles the hole where gall canal opens to intestine by using electric current. This hole which is in several millimetres of diameter may be widened to 10-15 mm. Therefore stones placed at gall canal may be extracted or stent may be placed. Sphycterotomy is painless and usually bleeding does not occur. Stone extraction. After the papilla is widened by cutting or with balloon, stones are pulled with devices like basket or balloon, passed through papilla and left to the intestine. Large stones are catched with breaking baskets, they are broke and extracted. Extraction of pancreas stones is technically more complex and needs experience.


Stones that pass to the main gall canal cause the gall flow to stop and thus jaundice, fever, pain and itch.
Stone is caught via a catheter sent via duodenoscope.
By lifting the stones to the intestine the canal is cleared.


Nasobiliary drainage: One tip of a long catheter in a several millimetres of diameter is placed to the gall canal and the other tip is ejected from the nostril and bound to a bag to provide the drainage of gall. This may stay for several days and patient may eat this way. It is effective for the treatment of gall leakage due to surgical injuries.
Enlargement of narrowing's (Dilatation): A narrowed segment of canals may be enlarged by enlargement balloon or a plug. This is similar to the procedure done to heart vessels during angiography.


Stent placement: Thin pipes that are called as stent are placed between intestine and gall or pancreas canal after enlargement of the narrowing. Aim is to ensure the flow of gall or pancreas fluid. Stents may be plastic or metal and selected depending on the type of disease.
ERCP procedure takes a time between 15 minutes and 1 hour. This time depends on the expertise of doctor, anatomy of patient and type of disease. After the end of procedure doctor pulls back the endoscope. Iodized substance (contrast) administered to the canal spontaneously pours to the intestine. Patients sleep during the procedure and do not remember the procedure afterwards.


Preparation for ERCP
You must not eat or drink from 6-8 hours before the procedure. You may swallow important medications such as tension and heart drugs with a little quantity of water. Patients with diabetes must not take their hypoglycaemic drugs and insulin. In case of manifestations of hypoglycaemia you may drink one glass of transparent fruit juice such as sour-cherry juice.


You must inform your doctor in presence of allergy, asthma, pregnancy, suspected pregnancy, heart, and kidney or lung disease. These kind of condition may effect your status during ERCP, thus informing your doctor about is important for taking necessary precautions.


Medication that prevents clotting of blood must be stopped 1 week before ERCP. These medications increase the risk of bleeding during an incision at the opening of canal. Analgesics must be stopped 2 days afore.


Discuss the benefits, risk and adverse effects of the treatment with your doctor. Read carefully the consent form given to you.
Hand over your belongings such as eye-glasses, prosthetic teeth, and lens or hearing device.
Medications that cause sleep will be administered during ERCP. Therefore driving after discharging the hospital is inconvenient. You must come to hospital with a relative who will accompany you.


What is pancreatitis?


It is the inflammatory disease of pancreas. It is classified as instantly initiated (acute) or continuous and relapsing (chronic) pancreatitis. Acute pancreatitis majorly occurs due to the bladder stones that block the opening of pancreas canal in our country. The other reasons of pancreatitis are alcohol consumption, high calcium levels, mumps, excessively high blood lipids, some medications, scorpion or snake stings, surgeries, abdomen traumas, pancreas cancer and some unexplained pancreatitis types.


Pancreatitis attack occurs due to the self-tissue damage of the pancreatic fluid that contains enzymes for the digestion of foods. A severe damage initiated at pancreas may cause the release of substances that will generate a broad inflammatory state in body. This may result with a significant loss of functions of vital organs beyond pancreas.


ERCP procedure itself may usually cause a mild pancreatitis attack.
At acute pancreatitis a pain that is characterized by upper abdominal region initiation, gradually increasing strength in hours and expanding through the back like a belt. Pain increase with lying backside and decrease with sitting. Nausea and vomiting may be present. Hypotension, fluid loss, reduced urine amount and respiration difficulty may develop in severe conditions.


In chronic pancreatitis recurring abdominal pain, diarrheal, weight loss, diabetes and deficiency of some vitamins may be seen. Pancreas cannot produce the fluid necessary for digestion of foods and absorption of nutrients is spoiled. Diabetes may develop due to the decreased release of insulin. The most frequent cause of chronic pancreatitis is continuous consumption of alcohol. Besides causes of acute pancreatitis may also cause chronic pancreatitis. Even occasional, risk of pancreas cancer is increased for those with chronic pancreatitis.


ERCP in the treatment of Pancreatitis


If acute pancreatitis is due to a stone that blocks the lower tip of gall tract, extraction of the stone with an early ERCP may provide a fast recovery. In chronic pancreatitis, pancreas canal is deformed due to the recurring inflammation attacks, partially narrowed or enlarged. Therefore, pancreas fluid difficultly reaches to the intestine. Stones or clogs that block pancreas canal may be cleared by ERCP and pancreas stent may be placed in order to keep canal open.
Pancreas cysts may also treated with ERCP method.


What is jaundice?
Even "Jaundice" is known as the contagious hepatitis by many people, actually it is yellow coloration of skin and white regions of the eyes due to accumulation of a substance called "bilirubin". Jaundice is not a disease but one of the manifestations of many diseases.
Oxygen carrying cells (erythrocytes) are broke up at spleen after they completed their 120 days life and bilirubin found at erythrocytes comes out. Bilirubin transported to the liver via blood and taken and processed by liver cells is then poured to the intestines through gall canals. Bilirubin is the substance that gives the specific colors of faeces and gall. Yellowing is seen at skin and other organs when bilirubin production is increased or excretion is decreased.


Causes of jaundice:


1) Conditions that the demolition of erythrocytes is increased (Some anaemia's, thalassemia etc.)
2) Liver diseases Includes contagious viral hepatitis (hepatitis A, B, C, E, G)
3) Blockage jaundice there is a blockage at the flow of bilirubin from liver cells to intestine. Blockage of gall canal due to stone or tumor is the most common example.

ERCP is only used for the treatment of "blockage jaundice".


ERCP in children
ERCP is usually used for relapsing acute pancreatitis attacks, choledoch stones or congenital choledoch cysts in children. ERCP in children may be performed with success at experienced centres. Amount of radiation is minimized and reproductive organs are protected.


How is gall bladder stone treated?
Gall bladder and gall canal (choledoch) are connected but different organs. Treatment of gall bladder stone is taking out the the bladder with closed (laparoscopic) or open surgery. ERCP is used for the treatment of stones that passed to the canal from bladder or already formed at canal. For some patients that the surgery may not be performed, drainage of gall bladder may be done with ERCP.


Before laparoscopic (closed) gall bladder surgery, performance of ERCP depends on some conditions and is not necessary for all cases.

What is MRCP?


It is the abbreviation of "Magnetic Resonance Cholangio-Pancreatography".
It means imaging of gall canals, gall bladder and pancreas canal by MR device. Image is same as ERCP. MRCP is not an invasive procedure and there are no risks such as anaesthesia, pancreatitis or perforation as of ERCP.
MRCP is only used for diagnosis; it does not have any therapeutic utility. Treatment of disorders diagnosed at ultrasonography, tomography or MRCP are treated with ERCP method.


Cholangitis

Cholangitis is the infection of canals that transports the gall from liver to gall bladder and from gall bladder to the intestine. Cause is usually bacterial growth at canal that is blocked by stone or tumor. Infection may spread to the liver or blood. This may cause a general infection which may cause mortality called sepsis.
Manifestations of cholangitis are pain at upper right quadrant of abdomen, tingling, faeces in colour of glass paste, urine in colour of tea, nausea, vomiting and jaundice.
Cholangitis is a life-threatening condition and requires emergency treatment. Treatment is providing gall drainage by ERCP and administration of wide spectrum antibiotics.


ERCP in Pancreas Cancer
Lower segment of the gall canal at opening to the intestine pass through pancreas. A tumor at the apex of pancreas may block the gall canal and cause blockage thus jaundice and bacterial growth at upper segments (cholangitis).
For patients with pancreas cancer that does not have surgical treatment chance placement of stent with ERCP ensures the flow of gall to the intestine and thus treatment of severe conditions such as cholangitis, sepsis, jaundice and itch.

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