Endoscopic retrograde cholangiopancreatography (ERCP) is a combined therapeutic and diagnostic procedure based on a combination of endoscopic and radiopaque technologies. With the help of ERCP, the system of the ducts of the liver and pancreas is visualized, the duodenal mucosa and the fater papilla are examined, and some therapeutic manipulations are performed. ERCP makes it possible to detect inflammatory, obstructive, tumor lesions of the bile ducts and pancreas. It is made with the help of special endoscopic equipment with the use of contrast under the control of fluoroscopy.
Endoscopic retrograde cholangiopancreatography is recommended for a fairly extensive range of lesions of the bile duct system and pancreas. It is usually used for those conditions that can be eliminated or significantly facilitated by medical manipulations performed within the framework of ERCP. Such conditions include a variety of chronic inflammatory processes of the ducts, which are often accompanied by their spasm and difficulty in the outflow of bile or pancreatic secretions. The second common cause for ERCP is the presence of small concretions leading to cholestasis and attacks of hepatic colic. This study not only confirms the presence of stones (this can also be done with ultrasound), but also makes it possible to eliminate the problem by removing concretions or performing a papilosphincterotomy.
Chronic pancreatitis is also a common indication for endoscopic retrograde cholangiopancreatography. Often, the cause or consequence of this condition is the stagnation of secretions in the pancreatic duct system, which is easily detected with ERCP. As part of a therapeutic and diagnostic study, a special stent can be installed in the excretory part of the ducts to facilitate the outflow of secretions, which has a positive effect on the dynamics of the disease. Similarly, with the help of ERCP, a palliative procedure can be performed in the presence of a tumor of the fater papilla or duodenum – this will reduce the intensity of cholestasis and jaundice caused by it until a more radical treatment of cancer. Sometimes such manipulation is carried out in the presence of mechanical jaundice of unclear origin, including ambiguous results of ultrasound or other studies.
Due to the relatively high invasiveness of ERCP, this technique has a number of contraindications. Absolute contraindications are diagnosed acute pancreatitis, the presence of cysts or bleeding foci in the pancreas. Conducting ERCP in these conditions is fraught with aggravation of the inflammatory process and aggravation of the clinical picture of pathology. In addition, the absolute contraindications to endoscopic retrograde cholangiopancreatography include malignant tumors of the pancreas and conditions in which it is undesirable to accelerate the outflow of bile – first of all, acute phases of cholecystitis and viral hepatitis. Allergy to contrast iodine-containing substances is also a reason for the cancellation of ERCP. Relative contraindications to this therapeutic and diagnostic procedure are pregnancy, severe concomitant pathologies of the gastrointestinal tract or other organs.
In the vast majority of cases, the manipulation is preceded by ultrasound examinations. With their help, conditions are identified in which it is necessary to carry out a therapeutic and diagnostic procedure (the presence of small concretions, narrowing of the ducts), with ambiguity of ultrasound results, endoscopic retrograde cholangiopancreatography is performed to clarify the diagnosis. ERCP is performed on an empty stomach, sedatives are prescribed to the patient on the eve of the procedure, and maintenance of an optimal drinking regime is recommended. About half an hour before the procedure, premedication is performed – intramuscular administration of drugs to facilitate the study (atropine sulfate, platyphylline, etc.).
Methodology of conducting
A special probe for ERCP is inserted through the oral cavity, esophagus and stomach into the duodenum – the patient turns to the lying position on his left side. Endoscopic retrograde cholangiopancreatography is performed in several stages – first, an audit of the intestinal mucosa and the surface of the large (Fater’s) papilla is performed to assess its condition. At the next stage of ERCP, the papilla is canulated by inserting a probe into its lumen, while the depth of introduction depends on the objectives of the study. If it is necessary to study all the ducts of the hepatobiliary tree and pancreas, a relatively shallow penetration is sufficient, with a selective procedure, the probe is inserted to the area under study. After that, under the control of fluoroscopy, a slow injection of 25-40 ml of contrast solution begins, carefully studying the sequence of filling the ducts in order to detect pathology.
If concretions of acceptable size (up to 10-15 mm in diameter) are detected, they can be removed to restore the patency of the biliary tract. This procedure can be performed both by direct “pulling” of the stone, and with the help of papillosphincterotomy – dissection of the Fater papilla. With its narrowing or other problems of a similar plan, stenting of the bile ducts is possible within the framework of the ERCP – the installation of special plastic tubes in their lumen to facilitate the outflow of bile. In the absence of any structural changes in the hepatobiliary tree or pancreatic ducts, the rate of contrast evacuation is evaluated under the control of fluoroscopy – this allows detecting motor disorders in this system. The results of ERCP when performed as part of preoperative preparation are carefully analyzed by the surgeon and used by him as preparation for surgical intervention.