Few of us associate pleasant things with bile, yet the fluid is an essential component of the process of digestion. It helps your body process fats and is stored in the gall bladder. In some people, however, the bile duct can become blocked and bile begins to build up in the liver resulting in the appearance of jaundice and ever higher levels of bilirubin in the blood. It is in cases like this, as well as for conditions such as chronic pancreatitis that a doctor might first consider using Endoscopic retrograde cholangio pancreatography or ERCP to examine and possibly treat the problem says Dr. Chandika Liyanage, Consultant Gastrointestinal and Hepatobiliary Surgeon.

In ERCP a specialised, lighted, side viewing flexible endoscope is inserted into the upper gastrointestinal (GI) tract. The procedure is often used in combination with x-rays. The doctor injects contrast medium or dye into the ducts. The dye appears on x-rays, allowing doctors to clearly examine a patient’s biliary system and where necessary the pancreatic duct. This endoscopic procedure allows doctors to study and in many cases, directly treat problems of the bile and pancreatic ducts.
These ducts are best visualised as a system of tubes that transport bile and pancreatic juice from the liver and the pancreas to the duodenum.

The bile ducts carry bile, a fluid that the body requires to break down fats and process certain vitamins, explains Dr. Liyanage. It is produced by the liver and is made up of cholesterol, bile salts, and waste products such as bilirubin. After a meal, it is released into the small intestine. Between meals bile is collected in the gallbladder. This smooth flow can be easily obstructed by gallstones, which range in size from a grain of sand to the size of golf balls.

There are two types – the more common variety are stones made of cholesterol, while less common are the kind made of bilirubin, also known as pigment stones.

Flowing through the pancreas is pancreatic juice, another fluid that helps our bodies process what we eat. A small network of pancreatic ducts in the pancreas channel the juice into the main pancreatic duct. Both the common bile duct and the main pancreatic duct meet before they empty their contents into the duodenum. A blockage anywhere along the line can have unpleasant consequences with pancreatitis which typically manifests with pain, fever or weight loss and digestive problems such as diarrhoea and vomiting.

When a doctor decides to conduct the ERCP procedure, it is done under a general anaesthetic, explains Dr. Liyanage, adding, “we can use this procedure to know if there is any pathology in the pancreatic or bile ducts.” These cover a range of issues he says – from stones to tumours and in the case of the pancreas a condition known as chronic pancreatitis. In such cases, an inflammation of the pancreas does not naturally subside or improve, worsening over time and often leading to permanent damage. This is bad news because the pancreas is the organ responsible for producing the hormones or enzymes – such as insulin and glucagon – which regulates sugar levels in blood and many digestive enzymes that we need to digest our food.
Extended inflammation and scarring of the pancreas are associated with permanent damage which can lead to the organ being unable to produce the right quantities of essential enzymes, compromising your health. In some cases, damage to the pancreas can result in a patient developing diabetes.

Dr. Liyanage explains that he would consider using ERCP when he believes a patient’s bile or pancreatic ducts may be narrowed or blocked by a tumour, gallstones that have formed in the gallbladder but are now stuck in the ducts and in the case of malfunctioning sphincters or valves in the ducts that will not open correctly. It can also be used to assess pseudocysts which are accumulations of fluid and tissue debris. Some of these problems, such as stones, can affect people of any age group, while tumours and pacreatitis are more likely to occur in the middle aged and the elderly.

The specialised endoscope allows the doctors many options, says Dr. Liyanage, explaining that in the cases of stones, various accessories can be used through this endoscope to crush them or use balloons that expand and force the stones out of the bile ducts. Pancreatic duct stones are often found in patients with chronic pancreatitis, however, their removal can give a patient a great deal of relief from the pain associated with chronic pancreatitis. It can also be used to place both temporary and permanent stents across malignancies as a form of treatment.

Stents are plastic or expandable metal tubes that have a variety of applications. Stents might also prove useful in case patients have been exposed to surgery or trauma that has not healed properly. An example of this is when ERCP is done after gallbladder surgery to address a suspected surgical bile leak. A doctor can find and stop the leak by plugging it with a temporary stent. By using this procedure accumulated liquids in either of the ducts can be drained neatly out and will help in relieving infections. The endoscope can also be used to perform a biopsy, collecting cells which are later examined under the microscope for signs of infection or cancer.

There are risks patients and doctors must weigh before going ahead with the procedure. Among them, Dr. Liyanage lists a 1 in 1000 chance of perforation as well as a 25% chance of developing pancreatitis if the pancreatic duct is entered. One should note that of the 25%, an estimated 5% develop a serious case of pancreatitis. For the rest, milder versions of the condition prove relatively easy to treat and overcome. Other problems include the risk of infection, allergic reaction to sedatives or tissue damage from radiation exposure.

Preparing to undergo an ERCP is a relatively uncomplicated process and most hospitals routinely provide a checklist for patients. For their part, patients must take care to inform their doctor about any medications they may be taking, particularly as they might be at risk if any of the drugs interfere with blood clotting or interact with sedatives.

This procedure will be done by a well-trained doctor who would have gone through specialised training on this. An anaesthetist, at least two trained nurse assistants and a radiographer will comprise the ERCP team.

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