ERCP in the Supine and Left Lateral Position

Abstract

Purpose: ERCP is an acronym for Endoscopic Retrograde Cholangiopancreatography. Traditionally, with the patient in prone position, an ERCP endoscope is passed through the mouth, esophagus and stomach into the duodenum. After the ampulla is identified, a catheter is passed through the endoscope into the pancreatic and biliary ducts, contrast material is then injected into the ducts and x-rays are taken. In skillful hands, ERCP can be very useful and life saving. Sometimes patients are very ill and require intubation before ERCP. In such patients, prone position is cumbersome, not possible or unsafe. We report three patients; two with successful ERCP in supine position, and one with successful ERCP in left lateral position. Methods: Case 1: 63 year old female morbidly obese, with significant past medical history of end stage renal disease on hemodialysis, diabetes mellitus, hypertension, presented with right upper quadrant abdominal pain, fever and jaundice. The total and direct billirubin were 20.4/17.8. AST, ALT, Alkaline Phosphatase were also elevated. Because of morbid obesity and poor respiratory status, patient could not be placed in prone position. ERCP was attempted in supine position, successful cannulation of common bile duct was achieved, billiary stricture was diagnosed and seven french 12 cm stent was placed successfully. Patient returned after 8 weeks and billiary stent was replaced again in supine position. Case 2: 63 year old male with significant history of COPD, coronary artery disease, pacemaker placement, presented with abdominal pain, fever, elevated LFTs and high white count. CAT scan revealed dilated common bile duct. Because of poor respiratory status, patient could not be placed in prone position. ERCP was attempted in left lateral position, ampulary mass with dilated common bile duct was diagnosed, a common bile duct stent was placed successfully. Case 3: 58 year old female with known history of cirrhosis, diabetes mellitus, renal stones, cholycystectomy, presented with abdominal pain, jaundice and elevated obstructive enzymes. Because of poor respiratory status, patient could not be placed in prone position. ERCP was attempted in supine position, common bile duct was cannulated successfully. Conclusions: Although the success is not guaranteed with these anecdotal case reports, one should not be dogmatic, but ought to attempt ERCP in the supine and/or left lateral position if needed.