Diseases and disorders of the digestive system can be difficult to diagnose, particularly because many symptoms are shared across a variety of different conditions. Having diarrhea, for instance, could be indicative of anything from a temporary stomach bug to a virus to a chronic digestive disorder. Because of this, gastroenterologists have to rely on many different types of diagnostic tools in order to suss out what is truly ailing us.
Sometimes doctors even have to use multiple diagnostics tools with one patient when the problem is especially elusive. This is notable when the issue seems to be related to an organ like the pancreas which performs numerous functions. Fortunately, doctors have developed a highly useful procedure that is specifically designed to diagnose and treat problems with the pancreatic and biliary ductal systems: ERCP.
What is Endoscopic Retrograde Cholangiopancreatography (ERCP)?
The acronym ERCP stands for endoscopic retrograde cholangiopancreatography; that mouthful of a name indicates that the procedure is used for acquiring direct images of the pancreatic ducts through the use of endoscopy. An important aid in internal medical imaging, an endoscope generally involves a long plastic tube with a tiny camera and tools at one end that can be inserted into the body (a colonoscopy is an example of a common endoscopic procedure).
In ERCP, compared to some other types of endoscopy, the procedure works in conjunction with an x-ray. After the flexible tube is inserted and eventually makes its way to the pancreas, a radiographic contrast dye is injected in the area; this dye allows the subsequent x-ray to very clearly highlight any problems found in the bile ducts.
What Does the Pancreas Do?
To understand why the procedure is even necessary, it’s helpful to know a little bit about the function of the pancreas and bile ducts. The pancreas is interesting because it is part of both the digestive system and the endocrine system. As part of the endocrine system, it mainly regulates blood sugar levels. In the digestive system, however, it contributes “pancreatic juice,” a mix of chemical enzymes that helps break down food.
Digestion is a process that begins as soon as food enters the mouth; we chew and mash it up, and that masticated food makes its way down the esophagus and into the stomach and intestines. Once there, stomach acid, pancreatic fluid, bile from the liver, and liquid in the small intestine starts to break down the food into components that can be used by the body.
It is the secretion of these “juices” from a specific organ to the digestive tract where problems can occur. One of the most common problems that can happen is the development of gallstones in the gallbladder. Normally just a ‘holding tank’ for bile secreted from the liver, the gallbladder can be the site where gallstones form when the composition of the bile is abnormal or out of balance. Sometimes these gallstones are too big and can actually cause a blockage in the common bile duct, the main pathway for several digestive liquids to flow into the stomach.
Why the Procedure is Performed
A blockage caused by gallstones is just one of the reasons a doctor might turn to ERCP as a tool for diagnosis or therapy. The common factor that typically leads to ERCP is a condition that involves a blockage or narrowing of the bile or pancreatic ducts. Here are some examples:
- Chronic pancreatitis (inflammation of the pancreas)
- Acute pancreatitis
- Trauma or complications from a surgery in the pancreatic or bile ducts
- Cancer or tumors in the bile ducts or pancreas
- Pancreatic pseudocysts (pancreatic fluid that has collected in a sac in the abdomen)
Though most endoscopic procedures are relatively safe, there are some complications that can arise due to their minimally invasive nature. For this reason, a gastroenterologist will almost always utilize other imaging tests prior to establishing the need for ERCP; examples include magnetic resonance imaging (MRI), magnetic retrograde cholangiopancreatography (MRCP), and endoscopic ultrasound.
How is ERCP Performed
Depending on the patient’s circumstances, the ERCP procedure can be done on an outpatient basis. Either way, the first step is an intravenously-delivered sedative that will help the patient relax. Additionally, the patient will be given an anesthetic liquid to gargle in order to ease the passage of the flexible tube down the back of your throat as well as to prevent gagging.
Most endoscopes have a tiny camera, lights, and some small tools at the end of the tube. So as the doctor carefully slides the scope down the esophagus and into the stomach, the images will be fed to a video monitor. After the stomach, the scope will push into the duodenum, the first part of the small intestine; this is also the site of the major duodenal papilla, the primary conduit for bile on the other digestive fluids that aid digestion. Once at the major duodenal papilla, the doctor will extend a small catheter into the duct and inject the contrast material. It is at this point that a type of x-ray called fluoroscopy will be used to evaluate the situation.
In some cases, when ERCP is used for diagnosis only (which is becoming more rare), the doctor will retract the scope and discuss treatment options. Depending on the state of the ducts, however, there are some options for the doctor to move immediately into treatment:
- Break apart or remove stones
- Clear a blocked duct
- Open up a narrowed duct (as in a sphincterotomy)
- Perform a biopsy to evaluate a tumor
- Remove a tumor
- Insert a stent (a small tube that holds open a duct)
How Should I Prepare for ERCP?
The preparation for ERCP is fairly straightforward and primarily involves finding a ride home after the procedure; the sedatives the doctor will use cause drowsiness and so driving isn’t recommended. The other part of preparation is largely dependent on your specific medical history. Certain medications that affect blood clotting or the sedatives might be suspended until after the procedure.
Safety and Possible Complications
ERCP is overall a fairly safe procedure, and only 5-10% of patients experience any complications at all. Of those who do have complications, the most common is pancreatitis, an inflammation of the pancreas. Depending on the severity this can usually be treated with over-the-counter pain medication like ibuprofen and naproxen.
Other complications can include an infection of the bile ducts or gallbladder, excessive bleeding, allergic reaction to the sedatives, or a perforation in the ducts where the scope has been active. There have also been some cases where tissue damage can occur because of exposure to x-rays. Generally, though, these complications are rare.
Though it is safe, ERCP is still a minimally invasive procedure and can be intimidating to some. However, with continual improvements in imaging technology, ERCP has come to be used primarily for treatment purposes when a problem with biliary and pancreatic ducts has been detected. You might not be able to “feel” if your pancreas or bile ducts aren’t functioning properly, but it’s important to always be aware of any changes in your digestive system and normal activity.
If you have concerns about your gastrointestinal health and would like to consult with a gastroenterologist, contact GI Associates to make an appointment.