ERCP - Endoscopic Retrograde Cholangiopancreatography

ERCP – Endoscopic Retrograde Cholangiopancreatography

The biliary tree is that portion of the anatomy which drains the gallbladder, liver and pancreas into the duodenum (most proximal portion of the upper intestine). The liver produces bile which drains into the common hepatic duct. The gallbladder stores bile produced by the liver and which drains into the cystic duct. The cystic and hepatic ducts join to form the common bile duct. The pancreas produces pancreatic enzymes which drain into the pancreatic duct. Most commonly the common bile duct and pancreatic duct join to form the ampulla of Vater. This empties into the duodenum through an opening called the papilla of Vater.

Problems in the biliary tree (for example, the presence of gall stones) may require a radiological examination of the biliary tree, an ERCP. To do so, the endoscopist passes a special endoscope called a cholangioscope into the stomach, out through the pylorus and into the duodenum. He/she then locates the papilla of Vater endoscopically. An ERCP cannula is advanced through the endoscope and into the opening of the papilla. Sometimes a guidewire is used to better position the ERCP catheter, particularly if a specific duct is to be visualized only (for example the common bile duct). Contrast media is then injected into the biliary tree to enable X-ray visualization of the biliary tree.

If the presence of stones is confirmed, it is possible to remove them endoscopically. Because stones are often too large to pass through the papilla, a sphincterotomy may be Performed. To do so, a papillotome (also called a sphincterotome) is positioned (usually over a guidewire) so that its cutting wire is across the papilla of Vater. Current is applied to the papillotome from a generator cutting the sphincter muscle. The choice of papillotome design and dimension is determined by the nature of the patient’s anatomy and by physician preference.

Stones may then pass through the various ducts and out into the duodenum now that the size of the opening of the papilla has been increased. Stones that do not pass on their own are removed using an occlusion balloon. The occlusion balloon is passed over a guidewire so that the balloon portion is above the location of the stones. The position of the balloon is determined under fluoroscopy. Once positioned, the balloon is inflated and the catheter pulled back. The inflated balloon sweeps stones down the duct through the papilla and into the duodenum as the catheter is pulled back. Stones that are difficult to remove using an occlusion balloon can also be removed using a helical wire basket.

Another procedure that can be performed endoscopically is balloon dilatation of the biliary tree. Strictures of the ducts can occur as a result of scarring, inflammation or cancer. These strictures prevent the normal passing of stones and bile. Dilatation is performed to open strictures restoring the normal lumen size on the duct.

If the physician believes that the stricture will recur (most often in cancer patients), he/she may position a stent in the location, of the stricture to keep it permanently open. Stents are of various shapes and materials.

Stents are positioned in the following manner. A guidewire is passed through the ERCP cannula which was used to visualize the biliary tree and the location of the stricture. A guide catheter is advanced over the guidewire so that its tip is well beyond the stricture. The stent is placed over the guide catheter and a pusher catheter behind the stent. The pusher catheter is then used to advance the stent over the guide catheter until it is properly positioned. The guidewire and guide catheter are removed with the pusher catheter ensuring that the stent remains properly positioned. Finally, the pusher catheter is removed.

Amsterdam stents may become blocked over time. These blocked or occluded stents must be removed and replaced. The stent remover is specifically designed for this purpose. The stent remover catheter is advanced through the cholangioscope until it exits the scope channel in the vicinity of the stent. The loop is then place around the end of the stent to be removed. The stent remover handle is then operated closing the loop around the stent. The stent can then be removed.

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ERCP – Endoscopic Retrograde Cholangiopancreatography