Minimally Invasive Care for Organs That Aid Digestion

During an ERCP procedure, a thin, flexible tube called an endoscope is inserted through the mouth and guided through the esophagus to the area of concern inside your body. Through the endoscope, your doctor can insert a small plastic tube called a catheter, inject contrast dye, take X-ray images and perform other treatments as necessary.

Therapeutic ERCP involves not only having X-ray images of your duct system taken, but also having certain treatments administered as needed. The duct system includes:

• Bile duct – drains the gallbladder and the liver
• Pancreatic duct – drains the pancreas and joins the bile duct to form a common opening called the papilla (sphincter of Oddi)
• Papilla – drains into the first part of the small intestine, or duodenum

Sphincterotomy

A sphincterotomy is a painless procedure done to enlarge the common opening to the duct system, called the papilla, in the small intestine. Sometimes a larger opening is required in order for your doctor to insert the instruments needed for treatment. Using a wire that has an electric current passing through it, your doctor will make a small incision (less than a half inch) to cut the papilla tissue and enlarge the opening.

Stone removal

Therapeutic ERCP can be used to remove stones that become lodged in your bile duct system. These stones usually travel to the bile duct after forming in gallbladder. But even after a gallbladder is removed, other stones can form in the bile duct. After performing a sphincterotomy, your doctor will use a catheter to pass various instruments through the papilla and into the duct. Using these specially designed instruments, your doctor can take the stones out either by pulling them out whole or crushing them into smaller pieces to be removed.

Tissue samples (biopsies)

Cancer can cause narrowing in your duct system. To determine if cancer is present, your doctor will collect a sampling of cells from the narrowed area to biopsy, using a special brush or other instrument.

Stent placement

Tumors or scar tissue can sometimes cause a narrowing in your pancreatic duct or bile duct. To allow the ducts to still drain properly, your doctor may insert a small drainage tube called a stent to bypass these narrowed areas. Two types of stents may be used, and your doctor will talk with you about which stent is required for your specific condition. A plastic stent, which is similar to a straw, is not permanent and can be removed easily. A metal stent is wider, flexible and can be left in permanently. Either stent may get clogged after a few months and need to be replaced or removed altogether.

Cholangioscopy (SpyGlass)

If a definitive diagnosis is not possible with X-ray imaging from the ERCP alone, your doctor may decide to perform a cholangioscopy. With a built-in camera to deliver clear pictures, the small SpyGlass catheter (only three millimeters in diameter) is passed through the ERCP endoscope. SpyGlass also has a tube that laser fibers can be passed through to crush large stones in the bile duct and another tube that can carry biopsy forceps to take biopsies. Used to treat a variety of bile-duct diseases, this procedure can last 30-90 minutes, depending on the treatment needed.

Doctors at the Orlando Health Digestive Health Institute were involved in the development of this technology as well as leading-edge clinical research studies to evaluate the role of SpyGlass in the treatment of bile duct stones and tumors.

Ampullectomy (papillectomy)

Endoscopic ampullectomy is an early-stage treatment for the removal of an ampullary growth — a tumor that develops in the papilla of Vater — during ERCP by using a type of noose on the tumor. As the point of opening of the common bile duct and pancreatic duct into the duodenum, a tumor in this location results in blockage of the bile duct and pancreatic duct. This can cause patients to develop jaundice, pancreatitis or abnormal liver tests. If not treated in the early stages, this tumor can become cancerous. Because ampullectomy has a 5-10 percent chance of causing pancreatitis, or inflammation of the pancreas, your doctor may insert a temporary stent in the pancreas to allow the flow of pancreatic juice, preventing pancreatitis. Other risks, such as bleeding and perforation, may occur in 1-5 percent of patients.

Treatment of sphincter of Oddi dysfunction
Endoscopic sphincterotomy is a procedure used to treat sphincter of Oddi dysfunction (SOD). The sphincter of Oddi is a muscular valve that encircles the opening of the bile duct and pancreatic duct into the duodenum (papilla). Normally closed, the sphincter opens when food enters, allowing digestive juices into the duodenum to mix with the food for digestion. In SOD, the sphincter is too tight, causing bile and pancreatic juices to back up and resulting in very high pressure. Symptoms of SOD can include severe abdominal pain, fever, diarrhea and nausea. Sphincter of Oddi manometry is used to diagnose SOD by measuring the sphincter pressure through a small catheter passed into the bile and pancreatic ducts. Endoscopic sphincterotomy provides complete relief in 60 to 70 percent of patients diagnosed with SOD. Risks include development of a hole in the intestine, which would need surgical repair and pancreatitis. To decrease the risk of pancreatitis, your doctor may insert a temporary stent in the pancreas after the sphincterotomy.

Radiofrequency ablation (RFA)

RFA is a technique in which electrical current produced by radio waves is used to treat bile duct cancer. A catheter is placed in the bile duct to produce radio waves to destroy tumor tissue as a palliative treatment option.

Single-use duodenoscopes

Doctors at the Orlando Health Digestive Health Institute were the first in the world to evaluate the use of a single-use (disposable) endoscope for performing an ERCP. If you are at high risk of developing infection after an ERCP, your doctor may use a single-use endoscope to perform your procedure. You may discuss this option with your doctor beforehand.

For a successful ERCP procedure, you will need to have an empty stomach. You cannot eat or drink anything for at least six hours prior to the procedure. It is important to discuss your medical history with your doctor before your procedure, including any heart or lung conditions. Be sure to tell your doctor about all medications you are taking as well as any medication allergies that you may have, especially iodine drug allergies, because of the dye used in an ERCP procedure. You can still have the procedure if you have an allergy, but it is important that your doctor knows about them.

Before the procedure begins, your doctor may spray your throat with a local anesthetic. Typically, you will receive intravenous (IV) sedatives to help you relax, or the procedure may be done under general anesthesia. The procedure will most likely begin with you lying on your stomach or left side. Once you have been sedated, your doctor will insert the endoscope through your mouth and guide it through the esophagus and stomach into the duodenum. You will be able to continue to breathe normally with the endoscope in place. Most patients find it to be only a little uncomfortable, and many fall asleep during the procedure.

After the ERCP procedure, your throat may feel somewhat irritated, and you may feel bit bloated because of the air and water that were introduced during the procedure. Because you received sedation, you will be kept in the recovery area and monitored until effects of the medication have diminished. Unless instructed otherwise, you will be able to eat after leaving the procedure area.

Typically, you will receive the results of the exam from your doctor on the same day. However, some tests may take several days to get the results.

You will not be allowed to drive after the procedure — even if you do not feel tired. Make sure you arrange for a ride home and someone to stay with you after the procedure; you may be feeling the effects of the sedatives you received for the rest of the day.

Because you may have to be admitted to the hospital for observation, depending on the treatment you receive during your procedure, you should come prepared for a hospital stay. Most likely, you will be discharged the next day, as long as you are feeling well. If you develop severe pancreatitis, you could be hospitalized longer.

With ERCP, possible complication risks depend on the initial reason for the procedure as well as what is discovered during it. Your doctor will go over the complication risks for your specific situation beforehand. Standard endoscopy is very safe. Your throat may feel sore for a day or two following the procedure; over-the-counter, anesthetic-type throat lozenges can help. While uncommon, complications from endoscopic procedures can include:

• Infection
• Perforation of the bowel
• Bleeding in the gastrointestinal tract
• Inflammation of the pancreas (pancreatitis)

Other potential but rare risks of ERCP include:

• An adverse reaction to the sedative given (This is very rare but is a concern for patients with severe heart or lung disease.)
• Aspiration of stomach contents into your lungs
• A puncture or tear in the lining of the intestine that may require surgical repair

Complications requiring hospitalization are very rare but can happen. These risks must be weighed against the expected benefits of the procedure as well as the possible risks of alternative approaches to diagnose and treat your condition.

Doctors at the Orlando Health Digestive Health Institute have developed a fluoroscopy (X-ray) system that uses artificial intelligence (AI) to reduce radiation exposure during ERCP procedures. This technology decreases radiation exposure to both patients and providers during ERCP and thereby minimizes adverse events. Also, your doctors are researching to find out whether AI can be used in ERCP to accurately diagnose and treat patients with pancreatic or biliary diseases.