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Endoscopic Retrograde Cholangiopancreatography (ERCP)

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Definition:
Endoscopic retrograde cholangiopancreatography (ERCP) enables the physician to diagnose problems in the liver, gallbladder, bile ducts, and pancreas. The liver is a large organ that, among other things, makes a liquid called bile that helps with digestion. The gallbladder is a small, pear-shaped organ that stores bile until it is needed for digestion. The bile ducts are tubes that carry bile from the liver to the gallbladder and small intestine. These ducts are sometimes called the biliary tree. The pancreas is a large gland that produces chemicals that help with digestion and hormones such as insulin.
click & see the pictures
This procedure uses x-rays and an endoscope to see inside your digestive system and diagnose problems such as tumors, gallstones, and inflammation in your liver, gallbladder, bile ducts, or pancreas. Your doctor might use the test to investigate the cause of jaundice, upper abdominal pain, or unexplained weight loss.

Why an ERCP is Performed
ERCP is most commonly performed to diagnose conditions of the pancreas or bile ducts, and is also used to treat those conditions. It is used to evaluate symptoms suggestive of disease in these organs, or to further clarify abnormal results from blood tests or imaging tests such as ultrasound or CT scan. The most common reasons to do ERCP include abdominal pain, weight loss, jaundice, or an ultrasound or CT scan that shows stones or a mass in these organs.

ERCP may be used before or after gallbladder surgery to assist in the performance of that operation. Bile duct stones can be diagnosed and removed with an ERCP. Tumors, both cancerous and noncancerous, can be diagnosed and then treated with indwelling plastic tubes that are used to bypass a blockage of the bile duct. Complications from gallbladder surgery can also sometimes be diagnosed and treated with ERCP.

In patients with suspected or known pancreatic disease, ERCP will help determine the need for surgery or the best type of surgical procedure to be performed. Occasionally, pancreatic stones can be removed by ERCP.

If the exam shows a gallstone or narrowing of the ducts, the physician can insert instruments into the scope to remove or relieve the obstruction. Also, tissue samples (biopsy) can be taken for further testing.

Preparation
For a week before the test, don’t take aspirin or other NSAIDs because they can irritate the stomach lining and increase your chance of bleeding during the procedure. Also tell the doctor if you are taking blood-thinning medicines or any diabetes medications. People with heart valve problems may also have to take antibiotics before the procedure. Avoid eating or drinking anything for eight hours before the test because it needs to be done on an empty stomach.

Tell your doctor if you are allergic to iodine, which is used for the procedure. Arrange for someone to drive you home because the medication given during the test will make you drowsy.

Your stomach and duodenum must be empty for the procedure to be accurate and safe. You will not be able to eat or drink anything after midnight the night before the procedure, or for 6 to 8 hours beforehand, depending on the time of your procedure. Also, the physician will need to know whether you have any allergies, especially to iodine, which is in the dye. You must also arrange for someone to take you home—you will not be allowed to drive because of the sedatives. The physician may give you other special instructions.

What can be expected during ERCP
Your throat will be sprayed with a local anesthetic before the test begins to numb your throat and prevent gagging. You will be given medication intravenously to help you relax during the examination. While you are lying in a comfortable position on an X-ray table, an endoscope will be gently passed through your mouth, down your esophagus, and into your stomach and duodenum. The procedure usually lasts about an hour. The endoscope does not interfere with your breathing. Most patients fall asleep during the procedure or find it only slightly uncomfortable. You may feel temporarily bloated during and after the procedure due to the air used to inflate the duodenum. As X-ray contrast material is injected into the pancreatic or bile ducts, you may feel some minor discomfort.

What happens when the test is performed
The test is performed by a specially trained gastroenterologist either in the doctor’s office or in a hospital. You are usually given a sedative through an IV line. You wear a hospital gown for the procedure and lie on your side against a backrest on an x-ray table. If you wear dentures, remove them. A local anesthetic is sprayed into your throat to prevent you from having a gag reflex (choking feeling) when the endoscope is placed inside. The endoscope is about a third of an inch in diameter and 21/2 feet long with a light on the end. It also has holes at the end that allow your doctor to pump air into your intestine, squirt fluid, and suck out liquid or air.

You are asked to swallow at the moment the tube is placed into your throat. This helps guide the endoscope into your esophagus.You are likely to feel pressure against your throat while the tube is in place and you might experience a “full” feeling in your stomach. The doctor or doctor’s assistant gently advances the tube until it reaches your duodenum, the first part of the small intestine.

Next, the doctor inserts a slender tube, called a cannula, through the endoscope, and places the tip of the cannula into the bile duct or the pancreatic duct. These ducts are natural tubes of tissue that drain liquids out of the liver and pancreas. Once the tip of the cannula is lodged inside one of these ducts, the doctor injects contrast dye (usually iodine) through the cannula. The dye can be seen by x-rays, so it lights up the ducts clearly on an x-ray image, showing any obstruction (such as from gallstones or cancer) or unusual widening of the ducts (indicating an obstruction in the past). It also can light up the gallbladder, which connects to the bile duct, and helps the doctor to visualize the liver and pancreatic tissue around the ducts.

Depending on what the x-rays show, the doctor may undertake different interventions using tools operated through the endoscope. The doctor can remove gallstones or take biopsies of suspicious tissue. He or she can prop open narrowed bile ducts with a stent, a tube-shaped object that can be inserted through the scope. Depending on what is done, the test can take from 30 minutes to two hours.

Risk Factors:Complications are rare. One possibility is aspiration-accidentally inhaling saliva into the lungs – which can cause pneumonia. Other risks include inflammation of the pancreas, infection, and bleeding. Injury to the lining of the stomach, esophagus, or intestine, as well as abdominal pain and fever, can also occur.

Possible complications of ERCP include pancreatitis (inflammation of the pancreas), infection, bleeding, and perforation of the duodenum. Except for pancreatitis, such problems are uncommon. You may have tenderness or a lump where the sedative was injected, but that should go away in a few days.

Time required to do the test:
ERCP takes 30 minutes to 2 hours. You may have some discomfort when the physician blows air into the duodenum and injects the dye into the ducts. However, the pain medicine and sedative should keep you from feeling too much discomfort. After the procedure, you will need to stay at the hospital for 1 to 2 hours until the sedative wears off. The physician will make sure you do not have signs of complications before you leave. If any kind of treatment is done during ERCP, such as removing a gallstone, you may need to stay in the hospital overnight.

What happens after the Test is over
You will be monitored in the endoscopy area for 1-2 hours until the effects of the sedatives have worn off. Your throat may be a little sore for a day or two. You will be able to resume your diet and take your routine medication after you leave the endoscopy area, unless otherwise instructed.

Your surgeon will usually inform you of your test results on the day of the procedure. Biopsy results take several days to return, and you should make arrangements with your surgeon to get these results. The effects of sedation may make you forget what you were instructed after the procedure. Call your surgeon’s office for the results.

Resources:
https://www.health.harvard.edu/fhg/diagnostics/endoscopic-retrograde-cholangiopancreatography.shtml
http://digestive.niddk.nih.gov/ddiseases/pubs/ercp/
http://www.alabangmedicalcenter.ph/patientscorner/ERCP.htm

Percutaneous Transhepatic Cholangiography (PTCA)

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Definition:

Percutaneous transhepatic cholangiography (PTHC or PTC) is a radiologic technique used to visualize the anatomy of the biliary tract. A contrast medium is injected into a bile duct in the liver, after which X-rays are taken. It allows access to the biliary tree in cases where endoscopic retrograde cholangiopancreatography (ERCP) has been unsuccessful. Initially reported in 1937, the procedure became popular after a 1952 report in the English-language literature.

CLICK & SEE
It is an x-ray test that can help show whether there is a blockage in the liver or the bile ducts that drain it. Since the liver and its drainage system do not normally show up on x-rays, the doctor doing the x-ray needs to inject a special dye directly into the drainage system of the liver. This dye, which is visible on x-rays, should then spread out to fill the whole drainage system. If it does not, that means there is a blockage. This type of blockage might result from a gallstone or a cancer in the liver.

It is predominatly now performed as a therapeutic technique. There are less invasive means of imaging the biliary tree including transabdominal ultrasound, MRCP, computed tomography and endoscopic ultrasound. If the biliary system is obstructed, PTC may be used to drain bile until a more permanent solution for the obstruction is performed (e.g. surgery). Additionally, self expanding metal stents can be placed across malignant biliary strictures to allow palliative drainage. Percutaneous placement of metal stents can be utilised when therapeutic ERCP has been unsuccessful, anatomy is altered precluding endoscopic access to the duodenum, or where there has been separation of the segmental biliary drainage of the liver, allowing more selective placement of metal stents. It is generally accepted that percutanous biliary procedures have higher complication rates than therapeutic ERCP. Complications encountered include infection, bleeding and bile leaks.
Why the test is performed?
Bile is a by-product of protein metabolism. It is created in the liver and excreted into the intestines via the bile ducts. If bile cannot be removed from the body, it collects in the blood and is seen as a yellow discoloration of the skin and eyes (jaundice).

Also, the pancreas creates digestive fluids which drain via a common bile duct into the intestine, and thus obstruction can prevent the drainage of the fluids and may cause pancreatitis (inflammation of the pancreas).

A PTCA test can help identify whether a blockage is causing the jaundice and pancreatitis.

How do you prepare for the test?
Tell your doctor if you have ever had an allergic reaction to lidocaine or the numbing medicine used at the dentist’s office. Also tell your doctor if you could be pregnant. If you have diabetes and take insulin, discuss this with your doctor before the test.

Most people need to have a blood test done some time before the procedure, to make sure they are not at high risk for bleeding complications. If you take aspirin, nonsteroidal anti-inflammatory drugs, or other medicines that affect blood clotting, talk with your doctor. It may be necessary to stop or adjust the dose of these medicines before your test.

You will be told not to eat anything on the morning of the test so that your stomach is empty. This is a safety measure in the unlikely case you have a complication, such as bleeding, that might require repair surgery.

What happens when the test is performed?
You lie on a table wearing a hospital gown. An IV (intravenous) line is inserted into a vein in case you need medicines or fluid during the procedure. An area over your right ribcage is cleaned with an antibacterial soap. Then the radiologist may take a picture of your abdomen with an overhead camera. Medicine is injected through a small needle to numb the skin and the tissue underneath the skin in the area where the dye is to be injected. You may feel some brief stinging from the numbing medicine.

A separate needle is then inserted between two of your ribs on your right side. A small amount of xray dye is injected, and some pictures are taken that are visible on a video screen. Your doctor adjusts the placement of the needle until it is clear that the dye is flowing easily through the ducts (drainage tubes) inside your liver.

Because taking the x-ray pictures sometimes requires a significant amount of time, the doctor replaces the needle with a softer plastic tube. First, the syringe holding the dye is detached from the top of the needle, leaving the needle in place. The doctor then gently pushes a thin wire through the needle and into the duct where the needle has been sitting. Next the needle is pulled out, sliding over the outside end of the wire. The wire is left with one end inside the liver to hold the position where the needle had been. A thin plastic tube similar to an IV line is slid along the wire, like a long bead on a string, until it is in the same place where the needle was. The wire is then pulled out, and the dye syringe is attached to the tube.

More dye is injected through the plastic tube, and pictures are taken with the video camera as the dye spreads inside the liver. If there is no blockage, the dye drains out of the liver through the bile ducts and begins to show up on the x-ray in the area of your small intestine. Once all of the needed pictures have been taken, the plastic tube is pulled out, and a small bandage is placed over your side. The whole test usually takes less than an hour.

Risk Factors:
It is possible to have serious bleeding from this test. In some cases, blood leaks to the outside surface of the liver and causes a buildup of blood there. In other cases, blood can leak directly into the liver’s drainage system, in which case it might start showing up in your intestine, causing a bloody bowel movement. It is less likely that you could develop an infection after the test. The only soreness you are likely to have is at the skin surface where the needle went in. This should last for only a day or two.

In rare cases, the dye used in the test can damage your kidneys. This kidney effect is almost always temporary, but some people have permanent damage.

As with all x-rays, there is a small exposure to radiation. In large amounts, exposure to radiation can cause cancers or (in pregnant women) birth defects. The amount of radiation from the video x-ray in this test is very small-too small to be likely to cause any harm. (The people performing the test on you will wear lead shields, since they would otherwise be exposed to this radiation over and over, which could be more of a danger.)

Must you do anything special after the test is over?
Call your doctor right away if you have pain in your right abdomen or shoulder, fever, dizziness, or a change in your stool color to black or red.

How long is it before the result of the test is known?
You may be told a few early results of your test as soon as the test is done. It takes a day or two for the radiologist to review the x-rays more thoroughly and to give your doctor a full report.

RESULTS:-

Normal Result:-The bile ducts are normal in size and appearance for the age of the patient.

Abnormal Results:-The results may show that the ducts are enlarged, which may indicate the ducts are blocked. The blockage may be caused by infection, scarring, or stones. It may also indicate cancer in the bile ducts, liver, pancreas, or region of the gallbladder.

You may click & See:–
*Blocked bile ducts
*Cholangitis (infection in common bile duct)
Special considerations:-
A PTCA may be done if an endoscopic retrograde cholangiopancreatography ( ERCP) cannot be performed or has failed in the past.

An MRCP (magnetic resonance cholangiopancreatography) is a newer, non-invasive imaging method, based on MRI, which provides similar views of the bile ducts.

Resources:
https://www.health.harvard.edu/fhg/diagnostics/percutaneous-transhepatic-cholangiography.shtml
http://en.wikipedia.org/wiki/Percutaneous_transhepatic_cholangiography
http://www.healthline.com/adamcontent/percutaneous-transhepatic-cholangiogram

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