SCHOOL OF MEDICINE

Department of Medicine

Endoscopic Retrograde Cholangiopancreatography

Possible ERCP Treatments

If x-rays illustrate a blockage of the papilla or the duct systems, the physician could possibly treat the problem immediately. Common treatments would include balloon dilation (stretching), sphincterotomy, stenting and positioning of drainage tubes.

Sphincterotomy

Sphincterotomy is when the muscular sphincter of the bile duct or pancreatic duct is cut. A sphincterotomy is usually performed to assist in bile duct stone removal, prior to placement of a stent or drainage tube to treat papillary stenosis and sphincter of Oddi dysfunction, and to facilitate stricture dilation and tissue sampling. A small incision (about ¼ - ½ inch long) is made in the papilla to expand the relevant opening. This incision is made with an electrical current (you can not feel) that also cauterizes the tissues to prevent bleeding. A special type of sphincterotomy, a precut sphincterotomy, is used as a last resort when the physician has experienced difficulty in trying to place the standard sphincterotome completely into the pertinent duct. This type of treatment is deemed somewhat more risky in certain situations.

Stone Removal

Stone removal is performed when stones are detected. The most common type of stone requiring removal is bile duct stone. Prior to stone removal, a biliary sphincterotomy (an incision is made to expand the opening of the bile duct) is usually performed. Once the incision is made, the physician can remove the stones with a special "basket" designed for stone removal or they may manipulate the stone by using an inflatable balloon device designed to sweep the duct. Stones will sometimes pass (into the duodenum) spontaneously after a sphincterotomy is performed; however, the physician will generally attempt removal. Larger stones may need to be crushed before a removal attempt can be successful. This type of procedural technique is called a mechanical lithotripsy. Stones detected in the pancreatic ducts can be successfully removed however this type of stone removal is technically more complex.

Nasobiliary Drainage

When unsuccessful attempts are made at removing a stone the physician may choose to place a nasobilary drainage tube (NBD). This type of stenting (a long tube that is put in the bile duct through the endoscope and comes out through your nose) is useful in the prevention or treatment of acute cholangitis, biliary decompression of an obstructed common bile duct, treatment of a post-operative biliary leak or when unsuccessful stenting (plastic stent that stays in the duct) has occurred. Once the tube is in place the patient will generally be required to stay in the hospital for monitoring purposes (usually a few days). Although the tube will cause some discomfort, a patient will be able to eat and drink while it is in place.

Stricture Dilation

A partial blockage or narrowing of the bile or pancreatic duct can be treated with hydrostatic balloon dilation (similar to that used in the arteries of the heart) during the ERCP procedure. The balloon is used to stretch and expand the duct. Dilation may also be achieved by using a graduated catheter passed over a guidewire.

Stenting

After successful dilation of a duct narrowing the physician may insert a small tube called a stent to keep the duct expanded or to aid with any duct drainage. There are plastic (polyethylene) stents and metal (metallic) stents. A plastic stent is most commonly used. Plastic stents are generally trouble-free; however, they tend to clog up, thus requiring an additional ERCP in order to remove the stent and replace it with a fresh stent. This type of stent is easy to use and can pass out of the body on it's own through your stool or it may require removal by the physician via another ERCP. Metal stents are permanent and expand to a larger diameter once in place. If this type of stent becomes clogged a plastic or another metal stent can be placed through the original stent. In expert hands, stent placement is very successful.