What is ERCP (Endoscopic Retrograde Cholangiopancreatography)?

What is ERCP (Endoscopic Retrograde Cholangiopancreatography)?

ERCP is an invasive procedure that serves as the gold standard for visualizing the biliary tract and treating extrahepatic biliary obstruction, involving the advancement of an endoscope into the duodenum, cannulation of the ampulla, and injection of contrast into the common bile duct (CBD) with fluoroscopic imaging. 1

Procedure Details

• ERCP is typically performed by gastroenterologists or general surgeons in an interventional suite or operating room under general anesthesia 1, 2
• The procedure involves advancing an endoscope into the duodenum, cannulating the ampulla, and injecting contrast into the CBD while obtaining fluoroscopic images 1
• ERCP may be performed with additional interventions such as sphincterotomy, biopsy, or stent deployment in the CBD or pancreatic duct 1

Current Role in Clinical Practice

• ERCP has evolved from a primarily diagnostic tool to an almost exclusively therapeutic procedure due to advances in non-invasive imaging techniques like MRCP 1
• The main indications for ERCP are therapeutic interventions rather than diagnosis 1
• ERCP remains the standard procedure for stent placement in cases of obstructive jaundice, with success rates exceeding 90% for distal CBD strictures 1

Therapeutic Applications

• Management of CBD stones is the primary indication for ERCP, with clearance rates of 80-95% using balloon sweep techniques 1
• Therapeutic interventions include:
  • Sphincterotomy and stone extraction 1, 3
  • Stent placement for biliary obstruction 1
  • Tissue sampling through brush cytology or forceps biopsy 1
  • Treatment of biliary strictures 1

Diagnostic Capabilities

• ERCP can provide direct visualization of the biliary and pancreatic ducts 1
• Tissue diagnosis can be obtained through endoscopically directed brushing or biopsy 1
• For solid pancreatic neoplasms, ERCP-guided FNA has sensitivity ranging from 57.1% (pancreatic body/tail) to 82.4% (pancreatic head) 1
• Transpapillary brush cytology or forceps biopsy during ERCP offers specificity close to 100% 1

Risks and Complications

• ERCP carries significant risks compared to non-invasive imaging techniques 1
• Major complications occur in 4-5.2% of cases, including:
  • Pancreatitis (3-5%)
  • Bleeding (2% when combined with sphincterotomy)
  • Cholangitis (1%)
  • Perforation 1, 4
• Procedure-related mortality is approximately 0.4% 1
• Risk factors for complications include patient selection, endoscopist's skills, and procedural difficulties 4

Limitations

• ERCP is limited in patients with previous gastroenteric anastomoses due to difficulty advancing the endoscope into the biliopancreatic limb 1
• For stones larger than 15mm, ERCP alone may not be successful, requiring advanced endoscopic techniques 1
• In suspected sclerosing cholangitis or biliary stricture, ERCP should be performed with caution due to risk of suppurative cholangitis 1

ERCP vs. Alternative Imaging Modalities

• MRCP has emerged as a safe, non-invasive alternative for diagnostic imaging of the biliary tree 1
• MRCP accuracy for detecting biliary tract obstruction approaches that of ERCP when performed in experienced centers 1
• Endoscopic ultrasound (EUS) is equivalent to MRCP in detecting bile duct stones and lesions causing extrahepatic obstruction 1
• When extrahepatic obstruction is considered but the need for endoscopic intervention is unclear, MRCP or EUS should be performed first to avoid unnecessary ERCP 1

Best Practices for ERCP Use

• ERCP should be reserved for cases where therapeutic intervention is likely needed 1
• General anesthesia for ERCP has been shown to increase procedural success rates compared to conscious sedation (97% vs 91%) 2
• A multidisciplinary approach involving endoscopy, hepatobiliary-pancreatic surgery, and interventional radiology is recommended for complex cases 5