Ercp Endoscopic Retrograde Cholangiopancreatography Biology Essay

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An endoscope is a thin, flexible, telescope. It is passed through the mouth, into the esophagus and down towards the stomach and duodenum. The endoscope contains fiber optic channels which allows light to shine down so the doctor can see inside. The endoscope is used by a highly trained subspecialist, the gastroenterologist, to diagnose and treat various problems of the GI tract. The GI tract includes the stomach, intestine, and other parts of the body that are connected to the intestine, such as the liver, pancreas, and gallbladder.

Cholangio-pancreatography means x-ray pictures of the bile and pancreatic ducts. These ducts do not show up very well on ordinary x-ray pictures. However, if a dye that blocks x-rays is injected into these ducts then x-ray pictures will show up these ducts clearly. Some dye is injected through the papilla back up into the bile and pancreatic ducts (a 'retrograde' injection). Retrograde refers to the direction in which the endoscope is used to inject a liquid enabling X-rays to be taken of the parts of the GI tract called the bile duct system and pancreas. This is done via a plastic tube in a side channel of the endoscope. X-ray pictures are then taken.

The process of taking these X-rays is known as cholangiopancreatography. Cholangio refers to the bile duct system, pancrea to the pancreas.

Anatomy  Demonstrated

The gallbladder lies under the liver on the right side of the upper abdomen. It is like a pouch which comes off the common bile duct. It is a 'reservoir' which stores bile between meals. The gallbladder contracts (squeezes) when you eat. This empties the stored bile back into the common bile duct. The bile passes along the remainder of the common bile duct into the duodenum. Bile helps to digest food, particularly fatty foods.

The pancreas is a large gland that makes enzymes (chemicals). These flow down the pancreatic ducts, into the main pancreatic duct, and through the papilla into the duodenum. The pancreatic enzymes are vital to digest food. (The pancreas also makes some hormones such as insulin.)

Reasons for the Exam

Due to factors related to diet, environment and heredity, the bile ducts, gallbladder and pancreas are the seat of numerous disorders. These can develop into a variety of diseases and/or symptoms. ERCP helps in diagnosing and often in treating the condition.

Indications for imaging

ERCP is used for:

Gallstones, which are trapped in the main bile duct

Blockage of the bile duct

Yellow jaundice, which turns the skin yellow and the urine dark

Undiagnosed upper-abdominal pain

Cancer of the bile ducts or pancreas

Pancreatitis (inflammation of the pancreas)

The main symptoms of pancreatitis are acute, severe pain in the upper abdomen, frequently accompanied by vomiting and fever. The abdomen is tender, and the patient feels and looks ill. The diagnosis is made by measuring the blood pancreas enzymes which are elevated. A sound wave test (ultrasound) or abdominal CT exam often shows an enlarged pancreas. The condition is treated by resting the pancreas while the tissues heal. This is accomplished through bowel rest, hospitalization, intravenous feeding and, pain medications.

When pancreatitis is caused by gallstones, it is necessary to remove the gallbladder. This is usually done after the acute pancreatitis has resolved. At times, an ERCP (Endoscopic Retrograde CholangioPancreatography) test is recommended. This involves passing a flexible tube through the mouth and down to the small intestine. A small catheter is then inserted into the bile duct to see if any stones are present. If so, they are then removed with the scope.


Absolute contraindication:

The uncooperative patient.

Relative contraindications:

Recent attack of acute pancreatitis, within past several weeks.

Recent myocardial infarction.

Inadequate surgical back-up.

History of contrast dye anaphylaxis.

Poor health condition for surgery.

Severe cardiopulmonary disease.


Possible ERCP Treatments

If x-rays illustrate a blockage of the papilla or the duct systems, the physician could possibly treat the problem immediately. Common treatments would include balloon dilation (stretching), sphincterotomy, stenting and positioning of drainage tubes.

 ERCP Equipment

The "endoscope" is a flexible tube with a tiny video camera and light on the end of it. The inner components of the scope consist of a channel through which tiny instruments and accessories are passed and can be poked out the tube's end. These instruments and accessories include a catheter for injecting contrast media ("dye") into the ducts, an inflatable balloon that is used to stretch tight areas of the bile duct or pancreatic duct, a "basket" for removing and manipulating stones, and a sphincterotome to incise tissue and make the bile duct or pancreatic duct opening larger, biopsy forceps and cytology brush to obtain microscopic exam, and stents to bridge blockages. Other openings allow the physician to squirt (or suck out) water or air into your intestine as well as clean the camera lens. The physician is able to control the movement of the tube by gently pushing and pulling on its outside end while also steering the inside end with control knobs that the physician holds in his hand. Images from the endoscope are transmitted onto a video television screen in the procedure room. Simultaneously, an x-ray image of the bile duct and pancreatic duct is obtained. X-ray films are taken to document

Patient Preparation

When preparing a patient for a gastrointestinal x-ray examination, every consideration should be given to informing the patient of the examination's purpose, the technique and duration of the procedure, and any anticipated discomfort or risk. This prepares the patient psychologically for the procedure and is of equal importance for the preparation of the patient's alimentary tract for receiving the contrast material. Optimum evaluations of the esophagus, stomach, small intestine, and colon are done only when these organs are empty and clean. This is the objective of the detailed and at times arduous preparation instructions which are given to patients prior to these examinations. These instructions should be thoroughly familiar to the referring physician and understood by the patient.

Patients should ingest no solids for at least 6-7 hours and no liquids for at least four hours prior to the procedure. If a gastric emptying problem is suspected, a longer period of fasting may be needed. If circumstances do not permit an adequate fast, lavage of the stomach through a large bore tube can adequately remove stomach contents. For some procedures, topical pharyngeal anesthesia alone is sufficient, especially when the endoscopy is performed with a small diameter endoscope. For prolonged examinations, those in children, or in patients with a high degree of anxiety, rapid onset sedatives and/or analgesics are often necessary. Anticholinergics (e.g., atropine) have been given to decrease saliva, gastric secretions and motility, and perhaps reduce the likelihood of vasovagal reactions; however, controlled studies of their value as endoscopic premedication do not support their routine use. For procedures in which paresis of gastroduodenal motility is necessary, parenteral glucagon may be useful

The patient is prepared as for upper gastrointestinal endoscopy. Because of the longer duration and potential discomfort of the procedure an intravenous line is desirable. If cannulation is delayed, or therapeutic maneuvers prove necessary, repeated doses of sedatives or analgesics may be needed. Careful monitoring of vital signs and level of consciousness is essential throughout and immediately after the examination. Glucagon, with or without anticholinergics administered intravenously will reduce duodenal motility. Use of iodinated contrast agents for ERCP appears to be safe in individuals with a history of systemic reactions to intravascular contrast agents.

When an obstructed duct is suspected, most endoscopists administer antibiotics intravenously prior to the ERCP, and continue antibiotics for 24-48 hours if contrast has been instilled into an obstructed system. The benefits of adding antibiotics to contrast solution have not been proven. Depending on the indication for the ERCP, surgical support should be available anticipating possible abdominal surgery.

Contrast Medium

Pancreas - LOCM 240

Bile Duct - LOCM 150, dilute contrast medium ensure that will not be abscured.


The procedure takes place in a special room that has an instant x-ray machine called a fluoroscope. The patient will lie on your left side on an examining table in an x-ray room. Once you enter the procedure room the nurse will place small monitoring devices on your skin so that they can measure your pulse, blood pressure and blood oxygen as necessary during ERCP. Local anesthetic may be sprayed onto the back of your throat to make it numb to try and prevent you from having a gag reflex. You will then be instructed to lie down on the procedure table. The Nurse will help position you onto your left side. Once situated you will be made comfortable and covered up with a sheet and repositioned to a face down position with your head tilted to the right. You will then be prepped for an IV line so they can begin conscious sedation.

The sedative will then be administered to help achieve relaxation, reduce anxiety and assist in helping the patient attain a sleep like state. The medication is titrated to the patient's response and is adjusted accordingly. A plastic guard will then be placed in your mouth to protect your teeth.

When the nurse gives the physician the go ahead, based on your sedated state, the doctor will begin the procedure. The first step is to place the thin flexible tube (endoscope) through the mouth guard. The endoscope will not interfere with your breathing. You will then be instructed to swallow while the doctor gently moves the endoscope down your throat and into the esophagus. The tube is a half-inch in diameter and is long enough to stretch from your mouth through your stomach and into the main bile duct that enters the duodenum (the start of your small intestine).

You will likely have a feeling of pressure against your throat while the tube is in place. You may also experience a full feeling in your stomach. You will not feel the doctor doing the diagnostic maneuvers or any therapeutic treatments. Images from the tip of the endoscope are transmitted onto the television monitors and help to assist during the maneuvers.

When dye is injected into the bile and/or pancreatic duct x-ray films are taken by the physicians command. This will indicate whether there are any blockages or other concerns. This image is also on a television monitor parallel to the endoscope image monitor. At this stage the physician can start determining what treatments, if any, should be administered. Such treatments could include sphincterotomy, stent placement, stone removal, duct dilatation, pseudocyst drainage, or nasobiliary drainage.

The ERCP procedure can take 30 to 90 minutes. At the end of the procedure the doctor will remove the endoscope without any discomfort. The contrast dye will pass out of your body naturally. Most patients sleep through the procedure and have little or no recollection of the procedure.

The stomach leads to the first part of the small intestine, also called the duodenum. The common bile duct carries bile from the liver to the duodenum, and enters the duodenum a few centimeters beyond the stomach.

Gallstones usually form in the gallbladder. Gallstones sometimes pass from the gallbladder into the common bile duct, and block the flow of bile into the duodenum. This can result in serious illness. Additionally, tumors of the pancreas and duodenum can block the bile duct, also preventing the flow of bile into the duodenum.

ERCP is a technique in which an endoscope, with a camera on its end, is passed down the esophagus, through the stomach, and into the duodenum. The entrance of the common bile duct into the duodenum can be viewed through the endoscope. Next, the surgeon can pass a special instrument on the end of the endoscope into the common bile duct as it enters the duodenum. Dye is injected through this instrument into the common bile duct; this allows for the visualization of gallstones by X-ray.

If gallstones are present in the common bile duct, the surgeon cans perform a sphincterotomy. A small incision is made through the endoscope, which enlarges the opening of the common bile duct into the duodenum. The stones can then pass through.

Side-effects or complications from having an ERCP

Most ERCPs are done without any problems. Some people have a mild sore throat for a day or so afterwards. You may feel tired or sleepy for several hours caused by the sedative. Uncommon complications include the following:

There is a slightly increased risk of developing a chest infection following an


Occasionally, the endoscope causes some damage to the gut, bile duct or

pancreatic duct. This may cause bleeding, infection, and rarely, perforation. If

any of the following occur within 48 hours after an ERCP, consult a doctor


Abdominal pain. (In particular, if it becomes gradually worse, and is different or

more intense to any 'usual' indigestion pains or heartburn that you may have.)

Fever (raised temperature).

Difficulty breathing and vomiting blood.

Pancreatitis (inflammation of the pancreas) sometimes occurs after ERCP. This

can be serious in some cases.

Mild sore throat

The risk of complications is higher if you are already in poor general health. The benefit from this procedure needs to be weighed up against the small risk of complications.


An ERCP is performed primarily to identify and/or correct a problem in the bile ducts or pancreas. This means the test enables a diagnosis to be made upon which specific treatment can be given. If a gallstone is found during the exam, it can often be removed, eliminating the need for major surgery. If a blockage in the bile duct causes yellow jaundice or pain, it can be relieved.

Alternative Testing

Alternative tests to ERCP include certain types of x-rays (CAT scan, CT) and sonography (ultrasound) to visualize the pancreas and bile ducts. In addition, dye can be injected into the bile ducts by placing a needle through the skin and into the liver. Small tubing can then be threaded into the bile ducts. Study of the blood also can provide some indirect information about the ducts and pancreas.

Radiation protection

Direct lead rubber waist level protection

 "28 Day Rule"

General Fluoroscopic radiation protection / dose reduction methods

 Exposure Factors














18 x 24CM

Related Diagram And Anatomy Pictures

Digestive System Anatomy

Parotid Gland

Sublingual Gland

Submandibular Gland





Hepatic Flexure

Ascending Colon




Sigmoid Flexure



Sigmoid Colon

Descending Colon


Transverse Colon

Splenic Flexure of Transverse Colon




Figure 2:


Wall Layers

Fundus Of Stomach


Duodenal Bulb


Figures 3:

Duodenal Bulb


Common Bile Duct

Duodenal Papilla

Pancreatic Duct



Figure 6:

Sigmoid Colon


Rectal Valves

Sphincter Muscles

Anal Canal

Figure 5:

Cystic Duct


Common Hepatic Duct

Common Bile Duct

Duodenal Papilla

Pancreatic Duct

Figure 4:

Transverse Colon

Splenic Flexure

Descending Colon

Sigmoid Colon