Endoscopic Retrograde Cholangio-Pancreatography (ERCP)
A blocked bile duct results in jaundice (yellow eyes) and dark tea-colored urine and may be accompanied by pain, fever, poor appetite and weight loss. An ultrasound or CT scan helps to confirm the diagnosis and determine the cause of obstruction. Where appropriate, ERCP is used to relieve the obstructed bile duct. ERCP stands for Endoscopic Retrograde Cholangio [bile duct] Pancreato [pancreatic duct]-graphy and is an advanced technique used to diagnose and treat diseases of the bile and pancreatic ducts. It is a minimally invasive procedure that involves two technologies: endoscopy and radiology. An endoscope is introduced through the mouth into the duodenum to identify the papilla. Injection of contrast is performed and X-ray pictures are obtained to diagnose the problem, followed by treatment through the scope.
What are some reasons to perform ERCP?
- Jaundice due to a blocked bile duct
Bile duct stones
Tumours of the bile duct, pancreas or papilla - Infection of the bile duct (cholangitis)
- Pancreatic diseases
Acute & chronic pancreatitis
Pancreatic cancer - Injury to the bile ducts during surgery
ERCP is performed with sedation to allow a comfortable experience for the patient. Miniature instruments are used to cut open the papilla. This can be followed by removal of stones or insertion of a tube (called a stent) to relieve jaundice due to a blocked bile duct, or relieve blockage in a pancreatic duct.
Most stones (>90%) can be removed successfully using ERCP. Even large stones can be crushed completely by using a special device called lithotripter. Occasionally “giant” stones are treated by biliary stenting because all efforts have failed to remove them and the patient declines surgery, or is at a high risk for surgery.
Tumors of the pancreas and bile duct cause a stricture that in turn causes blockage of bile flow and results in jaundice, itch and impaired quality of life. For patients who cannot tolerate surgery, or have advanced tumors that cannot be operated upon, ERCP is a good method to relieve the blockage and improve the quality of life. This is achieved by placement of stents. Metal stents have a larger diameter (10 mm) and stay open for a longer time than plastic stents which have a diameter of 3 mm. A change of stent may be required after 4 to 6 months, as a result of stent blockage by tumour or debris. In experienced and trained hands, complications arising from ERCP are uncommon. These include bleeding, infection, pancreatitis and perforation.
In summary, ERCP is an effective minimally invasive procedure used to treat jaundice due to bile duct blockage by stones or inoperable tumor. It has replaced traditional surgery in the treatment of these conditions.
About the author. Dr Yap Chin Kong, is a leading Specialist and Senior Consultant in Gastroenterology, Liver Diseases and Endoscopy. He was awarded a Merit Scholarship to study Medicine at the National University of Singapore and graduated with a Bachelor of Medicine & Bachelor of Surgery degree in 1983. In 1988 he obtained his Masters degree in Medicine (Singapore) and became a Member of the Royal College of Physicians (United Kingdom). He became a Fellow of the Academy of Medicine (Singapore) in 1994 and a Fellow of the Royal College of Physicians (Edinburgh) in 2000. In 1992, he was awarded the Health Manpower Development Program Award by the Ministry of Health to pursue advanced training in therapeutic ERCP (Endoscopic Retrograde Cholangio-Pancreatography) at the Academic Medical Centre in Amsterdam, The Netherlands. After a year of extensive experience he returned in 1993 to develop endoscopy further at the Singapore General Hospital until he left for private practice in 2004. He pioneered the use of endoscopic ltrasonography at SGH for a decade. During this time, he taught many generations of medical students and post-graduate doctors. In 2002, he continued to pursue his interest in early cancers of the stomach and colon and visited the Showa University Hospital in Yokohama, and the National Cancer Centre in Tsukiji, Tokyo. He lectured and taught at workshops locally and internationally, combining the best of Western and Eastern techniques. A Master endoscopist, he developed an innovative cap-fitted gastroscopy technique that is used to help countless patients worldwide. He was President of the Gastroenterological Society of Singapore (1999 to 2003) and was President of the Asia-Pacific Digestive Week in 2003. He is currently in private practice at Mount Elizabeth Medical Centre. His broad specialist experience include advanced endoscopy techniques such as ERCP treatment of bile duct stones and pancreas diseases, endoscopic ultrasound, treatment of esophagus, stomach, colon and liver cancers, viral hepatitis and inflammatory bowel disease. He is Visiting Consultant to the National University Hospital and Kandang Kerbau Womens’ & Childrens’ Hospital where he supervises gastroenterologists-in-training and performs endoscopy for sick children.