Failed ERCP

ERCP is a procedure in which an endoscope is inserted into the patient’s mouth and moved through the esophagus, stomach, and into the small intestine. This allows the physician to view the biliary and pancreatic ducts. ERCP is used for both diagnosis and treatment in cases where there is a restriction or blockage of these ducts. Although most ERCP procedures are successful, about three to five percent fail.

ERCP Failure

ERCP failure occurs when the physician cannot successfully insert the endoscope all the way through to the proper site. The Papilla of Vater, the place in the small intestine where the biliary duct and the pancreatic duct meet, is the site at which physicians stop the endoscope.

Reasons for Failed ERCP

Difficulties leading to a failed ERCP procedure may involve:

  • Blockage of passageways by tumors
  • Altered anatomy due to previous surgery
  • Duodenal stenosis, a rare birth defect causing a narrowing in the small intestine
  • Intestinal pocket

Alternatives after Failed ERCP

There are a variety of options when an otherwise healthy patient experiences an ERCP failure. The best alternative depends on the individual’s medical conditions. Specifically, the reason that the ERCP failed plays a major role in deciding the next diagnostic procedure or medical treatment.

MRCP Procedure

Magnetic Resonance Cholangiopancreatography, or MRCP, can be used in place of ERCP for diagnostic purposes. MRCP is a non-invasive procedure, so the risks of surgery are still avoided. During MRCP, magnetic images are taken of the biliary ducts in order to pinpoint obstructions or restrictions. There are mixed reviews on whether MRCP is as effective as ERCP.

Percutaneous Cholangiography

Percutaneous transhepatic cholangiography or percutaneous hepatic cholangiogram can be used to diagnose the same issues as an ERCP. During these procedures, a contrast medium is injected directly into the liver, causing it to flow through the biliary duct. If it is found that there is a blockage in the biliary duct, PTC can also be used to place a stent or temporary drainage tube until surgery can be performed. PTC carries a higher incidence of complications than ERCP, so it is typically used in the case of failed ERCP.

Endoscopic Ultrasound Guided Rendezvous

Endoscopic ultrasound (EUS) guided rendezvous is a procedure that involves threading a needle through the biliary duct and using it to guide a wire into the duodenum, whereupon ERCP can be performed. Although this procedure has shown to be safe and effective in most cases, the high cost of the procedure and the high skill level required are deterrent.

Surgery after ERCP Failure

In some cases of failed ERCP, surgery may be the best alternative. There are many different types of surgery available, depending on the specific issue. Laparoscopic surgery may also be an alternative to open surgery, reducing the invasiveness and risk factor.


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