1. Dr David Scott Gastroenterologist Tamworth Base Hospital
ERCP
Dr David Scott
Gastroenterologist
Tamworth Base Hospital

2. ERCP What is it? When is it recommended? How is it performed?
What are the complications?
What’s new in ERCP?

3. What is ERCP? Endoscopic Retrograde Cholangiopancreatogram
Essentially it is a
radiological procedure
performed via an endoscope
to diagnose and treat
conditions of the bile and pancreatic ducts

5. When is it recommended? Gall stones in the bile duct
Malignant bile duct obstruction
Bile duct leak post cholecystectomy
Benign bile duct obstructions
Tissue sampling of bile duct lesion
Sphincter of Oddi Dysfunction (type 1)
Pancreatic duct stones and obstruction
Pancreatic pseudocysts
Others…

6. Complications Of Gall Stones
Biliary colic
(pain but
normal BR)
Cholecystitis
(pain and fever
but normal BR)
Biliary colic
(pain and
raised BR)
Cholangitis
(pain and fever
and raised BR)
Pancreatitis
(pain +/-
raised BR)

7. Malignant Bile Duct Obstruction
cancer
Pancreatic
cancer

8. Clinical Presentations for ERCP
Gall stones:
PAIN AND JAUNDICE
Malignant obstruction:
PAINLESS JAUNDICE

9. Special Situations Gallstone Pancreatitis Gall bladder in situ
<24 hours if persisting bile duct obstruction and severe pancreatitis
Otherwise avoid
Gall bladder in situ
Depends on the surgeon

10. Pre-procedure investigations
Liver tests
Platelet count and coagulation profile
Imaging
Ultrasound CT
CT cholangiogram
MRCP
Endoscopic Ultrasound

11. Pre-procedure Imaging
Transabdominal Ultrasound
MRCP
Endoscopic Ultrasound
Sens 25-82%
Spec 50-85%
Sens 81-91%
Spec 100%
Sens %
Spec %
CT Cholangiogram
Pre-procedure imaging has revolutionised ERCP

12. How is it performed? Similar to a Gastroscopy
NBM for 6 hours prior (no bowel prep)
IV sedation (not usually intubated)
Left lateral position (sometimes prone)
NOT sterile – just clean
Different to a Gastroscopy
Side viewing endoscope
Portable image intensifier used
Diagnostic and therapeutic equipment
About 30 minutes

16. Cannulation of the Bile Duct

17. 17

18. Major Papilla Anatomy Common channel Common bile duct Pancreatic duct
Image property of Marco Bruno, AMC Amsterdam, From: Atlas of human anatomy. Gosling et al. Gower Medical Publishing Ltd. 1985

30. Sphincterotomy

31. Sphincterotomy Biliary sphincter is like a valve
Needs to be cut to allow most interventions to relieve biliary obstruction
Highest risk part of standard ERCP
Perforation
Bleeding
Pancreatitis

35. Stents Plastic Metal Biliary Pancreatic 10mm Not removable (usually)
7 or 10 FG
Need to be removed/replaced within 3 months
Pancreatic
5 FG
Need to be removed within 2-4 weeks
Metal
10mm
Not removable (usually)

36. Cardiologists and ERCP
Aspirin OK
Clopidogrel / Warfarin / Enoxaparin
No sphincterotomy
Stent can solve acute problem and allow definitive treatment to be deferred
Implantable defibrillator
No sphincterotomy without local technician
Need to go to tertiary centre

37. Complications of ERCP Failure 5 - 10% Pancreatitis 5% (severe in 0.5%)
Bleeding 1%
Perforation 0.1%
Anaesthetic complications

38. Predicting Post ERCP Pancreatitis
Doctor Factors
Low case volume, trainee
Procedure Factors
Difficult cannulation, pancreatic injection, precut
Patient Factors
Young, female, normal BR, previous pancreatitis

39. Reducing the Risks of ERCP
Patient selection
Wire guided technique
Pancreatic stents
Don’t persist indefinitely

41. Teamwork Radiographer Nursing Medical
Assistant * VERY IMPORTANT ROLE *
2nd Assistant
Anaesthetics / Recovery
Medical
Endoscopist
Anaesthetist

42. ERCP Set up Anaesthetic Nurse Anaesthetist ‘Scout’ nurse
Anaesthetic Stuff
‘Scrub’ nurse
Equipment
Video
Assistant’s Table
XRay viewer
Processor
XRay Machine
Diathermy Machine
Radiographer
Endoscopist
ERCP Set up

43. What’s new in ERCP?

44. Spyglass® Intraductal Endoscopy44

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49. Summary More like interventional radiology than endoscopy
Patient selection important
Needs Teamwork and Communication