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ERCP & EUS

ERCP is a technique that combines the use of a specialized endoscope with X-ray to view the patient’s bile and/or pancreatic ducts. The functions of the common bile duct and the pancreatic duct are to drain the gallbladder, liver, and pancreas via the bile and the pancreatic duct, respectively through the papilla into the duodenum (the first part of the small intestine). The most common indication of an ERCP is blockage of the bile duct (often due to stones). Prior to ERCP, blood tests and imaging tests such as ultrasound, computed tomographic (CT) scan or magnetic resonance imaging (MRI) are performed to delineate the problem in detail.

The ERCP trained doctor will examine the bile and/or pancreatic ducts, looking for abnormalities such as blockages, narrowing of the bile or pancreatic ducts due to stones or tumor. If a problem is found, the endoscopist can often perform a procedure to repair or improve the condition; as a result. ERCP has replaced surgery in most patients with common bile duct and pancreatic disease.

Preparation

You need to be fasting for six to eight hours before ERCP and dose of your medications may need to be adjusted prior to the examination. Some medications need to be discontinued for several days; for example, if you are taking a blood-thinning medication, your doctor will determine how and when you should stop taking this prior to ERCP. If you are diabetic, adjustments will be made to your morning doses of medication (tablets or insulin) because you cannot eat anything before your ERCP.

Procedure

ERCP is performed in a room that contains X-ray equipment. You will lie on a special table during the examination, generally on your left side or stomach.

Although many people worry about discomfort from the endoscopy, most people tolerate it well and feel fine afterwards. Medications will be given through the IV line during the procedure. A plastic mouth guard is placed between the teeth to prevent damage to the teeth and endoscope. Many patients sleep during the test; others are very relaxed and not aware of the examination

Is it safe

ERCP is generally a safe procedure and serious complications are uncommon. If complications do occur, they are usually mild, and may include the following:

  • Pancreatitis (inflammation of the pancreas) is the most frequent complication, occurring in about 3 to 5 percent of people undergoing ERCP. When it occurs, it is usually mild, causing abdominal pain and nausea, which resolve after a few days in the hospital. Rarely pancreatitis may be more severe requiring prolonged hospitlization.
  • Bleeding can occur from a cut in the ampulla, but it is usually minimal and stops quickly by itself or can be controlled during the ERCP procedure.
  • The ERCP scope or other instruments can cause a tear or hole in the intestine being examined (called perforation). This is a serious condition, often requiring surgical intervention, although it occurs rarely.
  • Infection of the bile ducts (cholangitis)

What is EUS (Endoscopic Ultrasound)?

Endoscopic Ultrasonography (EUS) allows your doctor to examine the wall structures of your esophageal and stomach as well as your lower gastrointestinal tract. In addition to endoscopic view, this procedure allows the study of organ structures close to but outside the digestive tract thanks to the ultrasonic transducer placed at the distal end of the scope. Through detecting the reflected sound waves, EUS helps your doctor indentify stones, cysts, and small masses in the bile duct and pancreas and to evaluate other cancers of the digestive and respiratory systems. EUS also allows your doctor to identify affected lymph nodes, major blood vessels and other nearby important structures located outside the digestive tract.

Preparation

An empty stomach allows for the best and safest examination, so you should have nothing to eat or drink, including water, for approximately six hours before the examination. Your doctor will tell you when to start fasting as the timing can vary. You may be required to prepare your bowel with laxatives if the study involves the lower digestive tract.

Tell your doctor in advance about any medications you take; you might need to adjust your usual dose for the examination. Discuss any allergies to medications as well as medical conditions, such as heart or lung disease.

Routine blood tests may be required to ensure your fitness for the procedure. These blood tests are usually done a few days before the actual procedure.

EUS procedure

Your doctor will apply a local anesthetic agent to your throat and administer a sedative through your vein to ensure you are relax and comfortable. In some cases, an anesthesiologist may be required to administer the sedation. Some patients also receive antibiotics before the procedure.

You will usually be asked to lie on your left side for the examination. Just like gastroscopy or OGD, EUS procedure involved inserting a thin, flexible endoscope that has a built-in miniature ultrasound probe through your digestive tract under both endoscopic and ultrasonic guidance. This procedure takes about 30-45mins to complete and the instrument does not interfere with your breathing. Depending on your medical condition, tissue samples outside the digestive tract may be obtained using a long and thin needle through the scope. This will enhance the diagnostic accuracy in managing any suspicious growth found on scans. This tissue sampling process is generally painless and carries very little risk.

Is EUS safe?

EUS is a well-tolerated procedure when performed by doctors who are specially trained and experienced in the technique. Although complications requiring hospitalization can occur, they are uncommon. Complications include:

  1. Pancreatitis (inflammation of the pancreas) after FNA (fine needle aspiration) in 1-2%
  2. Bleeding in 1-2%
  3. Infection (especially with aspiration of cysts)1-4%
  4. Perforation (tearing of the small bowel wall) and death in <1%

Some patients can have an adverse reaction to the sedative used. At times, the procedure cannot be completed for technical reasons. Occasionally, repeat EUS/FNA may be required due to inconclusive results. In any case, your doctor will discuss with you other options to help with your condition.

The overall risks of EUS vary according to the reason for the study, what is found during the procedure, what therapeutic intervention is undertaken, and whether a patient has other major medical problems. Patients undergoing therapeutic EUS, such as pseudocyst drainage, face a higher risk than patients undergoing a diagnostic EUS. Your doctor will discuss your likelihood of complications before you undergo the procedure.