ERCP

By Tedler D. Depaynos, MD

The 54 years old patient has been complaining of severe abdominal pain which was diagnosed to be due to an inflamed gallbladder caused by a stone or in medical parlance, acute cholecystolithiasis. He underwent the simple removal of his gallbladder or open cholecystectomy. Recovery was uneventful and he returned to work and did his usual activities.
It was several weeks after when his wife noticed his eyes to be getting jaundiced and he started experiencing itchiness all over his body. He consulted another physician who did a worked up. Although his ultrasound was essentially normal except for a slight dilatation of the left hepatic duct, the experienced ultrasonologist gave the impression that there is an obstruction somewhere along the “biliary tree” which was draining the bile from the liver as it goes into the first part of the small intestine or specifically the duodenum. The obstruction may be due to a small stone which cannot be seen by ultrasound. He suggested that the patient consult the surgeon that did his surgery.
His surgeon together with his colleagues that assisted him reviewed their procedure and they were confident that they did well. In all the ultrasound results however, what is common before and after surgery was the slightly dilated portion of the left hepatic duct implying that there was probably an obstruction causing it. No stones were apparent however.
The liver is made up basically of 2 lobes and each has a hepatic duct (HD) drainage. They join together forming the common hepatic duct (CHD). This is then joined by the duct draining the gallbladder which is actually a bile reservoir to form the common bile duct (CBD). Any obstruction along the bile pathway, or “biliary tree” will eventually cause dilatation with time at the area proximal to it. In this patient there was obstruction probably in the left hepatic duct which was eventually dislodged after surgery. Since it must be very small, it must be stuck up at the opening of the common bile duct (CBD) into the duodenum called the “Ampulla of Vater” causing jaundice.
A CT Scan was required to confirm the diagnosis so that surgery could later be done to remove it. A better alternative nowadays, however, was to do an ERCP or Endoscopic Retrograde Cholangio-Pancreatography where a tube instrument containing a camera, suction and a “needle” that could be used for biopsy and injecting a dye or air is inserted thru the mouth, up to the opening of the CBD. Of course, the patient should be under sedation. The insertion is guided by the camera and the pictures are saved thru a connected computer. In this patient since the obstruction is probably at the opening or Ampulla of Vater and very small, this could be removed by suction.
The patient was referred to a Gastroenterologist MD and true enough there was a small stone obstructing the opening which was removed by suction.
If the stone was not seen because it is located higher up, a dye would have been injected in the biliary tree so that the obstruction could be confirmed and the location identified. Again extraction maybe attempted. If extraction cannot be done, a stent could be inserted to by-pass the obstruction.
The ERCP procedure is now routinely done by our young Gastroenterologists who trained in well-known Medical Centers in Metro Manila. Since the instrument passes thru the esophagus, stomach and the duodenum pathologic conditions in those areas could also be seen.
In this patient, a more stressful second abdominal surgery was prevented.
**