ERCP Radiology Basics

R o b e r t M. M i t c h e l l , M B , B C h , a n d I a n S. G r i m m , M D

volt peak (kVp) measures the voltage across the X-ray tube. The
It may be tempting for the endoscopist performing endoscopic
retrograde cholangiopancreatography (ERCP) to ignore the basic
X-ray generator's power rating is the product of the kVp and the
principles underpinning good radiological technique. However, maximum mA allowed at 0.1 s at 100 kV. Only 5% of the
while a thorough understanding of the physics behind X-ray high-energy electron beam produces X-rays on striking the
production and image formation is not necessary, knowledge of rotating anode; the rest is wasted as heat. Adding filtration to
basic radiology and its application to ERCP is an advantage the X-ray beam increases the average energy of the beam and
when imaging the pancreatic and biliary systems. The endosco- therefore improves penetration. Changing the kVp affects the
pist must also aware of the safety issues involved in dealing with average and maximum energy of the X-ray beam. The half-
ionizing radiation. In this article, we have covered the important value layer (HVL) is the thickness of material that will reduce
radiological principles and safety issues as applied to ERCP, an X-ray beam to half of its original intensity. Typical diagnostic
identified common problems encountered by ERCPists, and X-ray beams have an HVL in tissue of about 5 cm, but in
endeavored to provide guidance in order to overcome these.
materials with a high atomic number, e.g. lead, the HVL is many
9 2003 Elsevier Inc. All rights reserved.
times less. Photoelectric absorption and Compton scattering
describe the interaction between the incident X-ray photon and
the atom. Photons undergoing Compton scattering retain most
Although endoscopic retrograde cholangiopancreatography
of their energy and can reduce the image contrast. Scatter can
(ERCP) has both radiologic and endoscopic aspects, those per-
be reduced, and resultant image quality improved, by using
forming the procedure are often focused primarily on the letter.
grids and keeping the field size small.
Attention to good radiologic techniques is essential to achiev-
ing studies of high quality; however, in this artice we review the
important radiologic principles pertaining to ERCP. Image Quality and Spatial Resolution
Variations in patient thickness and density, material composi-
Basic Radiology Principles tion, kVp and filtration result in differences in X-ray transmis-
sion known as subject contrast. Materials with high atomic
Properties of X-rays numbers, such as the contrast agents used in ERCP, have higher
contrast due to the photoelectric effect. Low kVp values result
X-rays, a form of electromagnetic radiation, travel at the speed in higher subject contrast due to the increased difference be-
of light, ie, 3 • 108 meters per second. Radiation exposure is tween areas of similar density. Therefore a low kVp increases
measured as coulombs per kilogram (C/kg) (the old unit was a contrast but decreases penetration. Spatial resolution measures
roentgen (1 R = 258 muC/kg)). The radiation dose ts the the minimum separation that can be distinguished between two
energy deposited on a body and is measured in grays (Gy); 1 Gy objects. It is measured in line pairs per millimeter (lp/mm), and
is one joule per kilogram (J/kg). The former unit of dose, the is related to pixel size in digital imaging, computed tomogra-
rad, is 1/100 the dose of 1 Gy. A sievert (Sv) is the measure of phy, and magnetic resonance imaging. Focal spot penumbra,
dose equivalence. The effective radiation dose is dependent on absorption blur, motion blur, and detector blur may all cause a
the characteristics of the part of the body exposed, and varies lack of sharpness in radiographs.
from tissue to tissue.

X-ray Production Fluoroscopy

After passing through the patient, X-rays interact with the input
An X-ray generator includes a high-voltage transformer, a rec-
phosphor o[ the fluoroscopy image-intensifier tube. The input
tifier that converts alternating current (AC) to direct current
phosphor converts the incident X-rays into visible light, and
(DC), and a filament supply to control the temperature of the
thereby causes the photocathode to emit electrons. These elec-
filament that produces the current in the X-ray tube, measured
trons are accelerated and focused by electrodes within the im-
in milliamps (mA). The efficiency and penetration of X-rays is
age intensifier onto the output phosphor to produce visible
higher as the voltage across the X-ray tube increases. The kilo-
output light that can be viewed on an optical or television
system. Fluoroscopic images can be recorded either on film or
From the Division of Gastroenterology, Duke University Medical Center on videotape. Dual-mode image intensifiers focus the image on
(DUMC), Durham, NC; and Division of Gastroenterology and Hepatology, the central viewing area, producing a magnified image of a
University of North Carolina, Chapel Hill, NC. smaller field at the expense of a higher patient dose.
Address reprint requests to lan S. Grimm, MD, Associate Professor of
Medicine, Division of Gastroenterology and Hepatology, University of
North Carolina, Chapel Hill, NC 27705; e-mail: [email protected]. Contrast Agents
9 2003 Elsevier Inc. All rights reserved.
1096-2883/03/0501-0003530.00/0 Contrast agents are organic iodides, either ionic or nonionic,
dei:l 0.1053/tgie.2003.50008 that depend on their iodine content for radiopacity (Fig 1).

Techniques in Gastrointestinal Endoscopy, Vol 5, No 1 (January), 2003: pp 11-16 11

 TABLE 2. Tips for Minimizing Fluoroscopy Time
1. Keep foot off pedal
2. Use guidewires with distance markers
3. Don't watch for curiosity's sake
4. Rapid exchange system

ease, hyperviscosity conditions (eg, macroglobulinemia, multi-

ple myeloma), and advanced dehydration. Although the risk of
contrast reactions is primarily related to intravenous adminis-
tration, idiosyncratic systemic adverse reactions to iodine-con-
taining contrast agents used during endoscopic retrograde
cholangiopancreatography (ERCP) have been reported 12 (Ta-
ble 1).
Prophylactic pre-medication for patients at risk is recom-
mended. At DUMC, we prescribe 20 mg of prednisone 6 hourly
Fig 1. Contrast agents in common use for ERCP. Isovue is a
for 5 doses prior to ERCP in "at risk" patients. The addition of
nonionic agent.
an antihistamine 1 hour prior to the procedure may be useful,
but does not replace the need for steroids. Likewise, intrave-
Ionic contrast agents are excreted almost entirely by glomerular nous steroids immediately prior to the procedure are not effec-
filtration. Nonionic media generally have fewer adverse effects tive; a longer period of pre-medication is essential.
than their ionic counterparts, but are considerably more expen-
sive. Dose ranges in adults are calculated according to body Radiation Safety
weight; in children, they are based on body surface area. The
dose may be decreased in thin patients and increased in obese In general, risks from radiation exposure are low in medical
patients. practice. The endoscopist is subject to radiation exposure from
Minor reactions to intravenous iodinated contrast, eg, urti- a variety of sources, namely the incident beam, scatter from the
caria, itching, nausea, and vomiting, are the most common, patient, and leakage from the X-ray machine. The factors that
with an incidence of about 5% to 10% for ionic agents. The limit radiation exposure are the ALARA principles (As Low As
incidence of minor reactions to nonionic agents is much less. Reasonably Achievable), ie, reducing the time exposed, increas-
Minor reactions are more common in patients who have a ing the distance from the source beam and adequate shielding.
history of allergy. An allergy to shellfish or dairy products, In addition, optimization of the beam characteristics and room
previously thought to be predictive of contrast allergy, is now set-up are important. Education and monitoring have been
recognized to be similar to that of other food allergies. Unfor- shown to decrease fluoroscopic time by nonradiologists, 3'a al-
tunately, skin testing or a test-dose challenge cannot predict though in ERCP practice it is often difficult to reduce the fluo-
adverse reactions. Also, it is not clear whether a history of a roscopy time. However, awareness of the potential risks is im-
minor reaction to a contrast medium is a risk factor for a portant.
subsequent life-threatening reaction. Severe reactions are rare Radiation exposure follows the Inverse Square Law, ie, the
and idiosyncratic and are reported in around 0.2% of patients exposure is inversely proportional to the square of the distance
given ionic agents, and in 0.04% of those given nonionic agents. from the source. This is easy to calculate from the beam, but
The corresponding mortality due to reactions to ionic contrast more difficult from scatter radiation which is not localized to
agents is about 1 in 40,000, and for nonionic contrast agents is one particular point. Shielding with lead aprons has been
1 in 168,000. Nonionic agents are usually reserved for patients shown to greatly reduce the exposure of the radiologist. 5 If
who have had previous contrast reactions, have a history of possible, wrap-around aprons with lead at the front and back,
allergy or asthma, have known cardiac dysfunction, or who are or at least the front and sides, should be used by the endoscopist
severely debilitated. Severe reactions often feature a sudden as it is usually not possible to always face the source of radia-
onset of cardiovascular, respiratory, or neurological collapse tion, and ERCPists rarely stand in the one position for long!
within 20 minutes of administration of contrast. Risk factors for Protective eyeglasses reduce direct radiation exposure and the
a severe reaction to intravenous contrast are a prior severe risk of cataract formation, but may not prevent scatter from the
reaction to contrast media, asthma, severe cardiac or renal dis- endoscopist's own head. 6 Thyroid collars can reduce the expo-
sure to the thyroid by nearly 50%. Mobile shields or protective
drapes placed close to the source beam are effective, and may
TABLE 1. Contraindications to (intravenous) Contrast reduce the occupational exposure risk by as much as 93%. 7,s An
Material increase in voltage, collimation of the beam size to include only
the area to be studied, and using digital rather than film radiol-
1. Known hypersensitivity to the contrast agent
2. Combined renal and hepatic disease ogy all reduce radiation from the source beam s,9 (Table 2).
3. Oliguria or serum creatinine > 2.5 to 3.0 mg/lO0 mL When the C-arm is used (Fig 2), scatter radiation may increase
4. IDDM in combination with renal insufficiency (serum creatinine significantly as the directed beam is at an angle to the patient and
greater than 1.5 mg/dL)
5. Multiple myeloma therefore the reflected beam is likely to be greater, especially if the
6. Personal history of severe allergy C-arm is close to the endoscopist. If possible, the source beam of
7. Use of metformin (Glucophage; Bristol-Meyer Squibb, Princeton, the C-arm should be on the opposite side of the patient from the
NJ) within the previous 48 hours (risk for severe lactic acidosis).
endoscopist to reduce exposure from scatter radiation.

12 MITCHELL AND GRIMM

 and hard copies cannot usually be produced. In a fixed fluoros-
copy set-up it is very useful to be able to tilt the table. Some of
the reasons for tilting and oblique views will be discussed later.

The Scout Film

The routine acquisition of a scout film prior to the injection of
contrast will verify proper X-ray exposure, identify radiopaque
structures in the field of view, eg, barium from a recent barium
enema or upper gastrointestinal series examination or ra-
diopaque materials above or beneath the patient, and identify
other possible relevant abnormalities, such as pancreatic calci-
fication and occasionally cholelithiasis.

Contrast Injection
The catheter should be flushed prior to injection of contrast to
Fig 2. Typical C-arm set up, The advantage of the C-arm is expel air. This procedure often needs to be repeated by the
that it is portable and maneuverable, assistant, because the tip of the catheter tends to fill with air in
a retrograde fashion as air is introduced through the scope.
Aspiration of bile prior to cholangiography will also minimize
One special circumstance when radiation exposure becomes
air bubbles.
especially problematic is in ERCP in pregnant women. Case
When first injecting contrast, the catheter tip should be just
series of pregnant patients undergoing ERCP have suggested
inside the papilla, and injection of contrast should be con-
that it is safe, ts although techniques such as ultra-short fluo-
trolled to avoid submucosal injection. Blind deep insertion of
roscopy and use of air as a contrast media may be of value in
the catheter may cause rupture of a pancreatic side-branch. The
minimizing exposure to the mother and the fetus.
patient, who is normally in the prone position, may need to be
tilted or rolled in certain circumstances, for instance, to sepa-
Radiation Monitoring
rate the views of the pancreatic duct and common bile duct
Radiation monitoring is vital, but compliance among medical staff (CBD). If the table tilts, this is easily accomplished; if not, the
is often poor, In one study, only half of interventional radiologists patient may have to be physically rolled. Multiple oblique views
always wore a dosimeter badge. 1~ Education of nonradiologists are also often helpful in defning difficult hilar anatomy. Depen-
has been shown to decrease radiation exposure.< H Badges should dent bile ducts fill first, and the patient may have to be tilted to
be worn on an area of the body that receives a representative fill particularly the right posterior intrahepatic ducts. Underfill-
radiation exposure. However, this may be difficult to judge in the ing of the tail of the pancreas may lead to misinterpretation;
case of an ERCPist who is rarely in one position during an entire turning the patient to the supine or left lateral decubitus posi-
procedure. The appointment of a member of the endoscopy staff to tion may help filling of the tail. In general, supine films are
act as a radiation awareness officer in order to enforce dosimeter helpful for pancreatic disease and hilar tumors. In the pancreas,
compliance should be helpful in an ERCP unit. excessive injection of contrast causes parenchymal opacifica-
tion, which is likely to increase the risk of post-ERCP pancre-
atitis. Therefore, a small volume of high concentration contrast
ERCP Radiology Technique
should be injected slowly into the pancreatic duct when a pan-
There are no set rules for determining who performs fluoros- creatogram is desired (eg, full strength, undiluted contrast,
copy during ERCP. In many units, the endoscopist also controls which is a 60% concentration). For cholangiography on the
the fluoroscopy pedal. In other units, eg, DUMC, a radiology
technician may be present to operate the fluoroscopy machine.
Some units may have a radiologist allocated to perform fluoros-
copy and help interpret films. Interpretation of fluoroscopic
images can produce a dilemma for the endoscopist whose at-
tention is divided between the endoscopic and fluoroscopic
images. Fluoroscopic images are rarely as high quality as "hard
films," and therefore subtle abnormalities may be missed if the
procedure is terminated before the films are developed. As a
general rule, the endoscope should not be withdrawn until the
films are developed and viewed. If digital imaging is available,
the images can be viewed on the screen obviating the need for
immediately developing hard copies.
Most units use fixed X-ray equipment in a dedicated fluoros-
copy suite (Fig 3). However, there are occasions when a C-arm
unit (Fig 2) may be useful, eg, road trips to the intensive care
unit. C-arms have the advantage over fixed units that oblique
views can be obtained without re-positioning the patient. How-
ever, the equipment is expensive and not generally available, Fig 3. The ERCP suite at DUMC,

ERCP RADIOLOGY BASICS 13

 Fig 5. Distance markers on a guidewire and catheter. These
are useful when measuring, eg, the length of a stricture.

B). It is important to avoid overfilling in the presence of biliary

obstruction or if there is a risk of cholangitis. This is achieved
by routinely aspirating bile prior to injection to prevent cholan-
gio-venous reflux, and to continue to exchange contrast for bile
during cholangiography. With most malignant strictures of the
distal bile ducts, it is not particularly helpful to fully opacify the
biliary tree above the stricture. Efforts should instead focus on
providing high quality images of the strictured area. Again, the

Fig 4. (A) Early bile leak from right hepatic duct. (B) Later
view of right hepatic duct,

other hand, a larger volume of a more dilute contrast (eg,

half-strength or 30%) should be used, so as not to obscure small
common bile duct stones. In the bile duct, the strength of
contrast used depends somewhat on the size of the bile ducts
and the expected findings. The more dilated the ducts, and if
small stones are suspected, the less concentrated the contrast
solution should be (30% contrast can sometimes be diluted
further using sterile water if required). For small duct disease,
such as primary sclerosing cholangitis or strictures, full
strength contrast provides better detail. Overlying gas, and air or
contrast in a diverticulum may also cause some difficulty. Suction-
ing and lavage are usually effective in clearing these up. If neces-
sary, oblique films may help to sort out overlying calcification, eg,
chondral calcification, from biliary or pancreatic stones.
It is generally useful to take a series of films early in the
injection process, as certain anatomical details are often ob-
scured by excessive contrast. This is particularly useful if a
small stone, a hilar obstruction, or a bile leak is expected. The
site of bile leakage can be very difficult to determine once a Fig 6. Radiopaque distance markers are also present on the
significant volume of contrast has been injected (Figs 4A and introducer for stent deployment.

14 MITCHELL AND GRIMM

Fig 7, (A) Filling defect on an early cholangiogram. (B) Filling
defect hidden behind the endoscope,

earliest images are often the most informative. However, there

is some debate as to optimal stent positioning in hilar obstruc-
tion and therefore a reasonable cholangiogram proximal to the
obstruction is mandatory. Some endoscopists prefer to drain
both left and right intrahepatic systems, while others favor a
single stem. At a minimum, the side that fills first should be
drained. Determining the required length of stent can usually
be achieved using either a wire or catheter with distance mark-
ers (Figs 5 and 6). Magnetic resonance cholangiography often
provides better imaging of hilar anatomy than ERCP and may
be helpful in showing isolated ducts and in planning stem
therapy prior to ERCP. Pre-ERCP magnetic resonance cholan-
giography may therefore minimize the introduction of contrast
(and bacteria) into isolated portions of the biliary tree, poten-
tially reducing the risk of cholangitis.
It is usually best to inject above the cystic duct when attempt-
ing to fill the intrahepatic ducts. At times, a balloon occlusion
cholangiogram may be necessary, particularly if a sphincterot-
omy has been performed, or if there is preferential filling of the
gallbladder. After the endoscope has been withdrawn further
films should be taken, usually with the patient in the "feet

Fig 8, (A) Stricture of mid bile duct hidden by duodeno-

scope. (B) With left torque and advancing duodenoscope the
mid-CBD is seen revealing a short stricture.

ERCP RADIOLOGY BASICS 15

down" position, to ensure adequate ductal drainage. These late
TABLE 4. Interpretive Pitfalls
films often provide the best views of the sphincter mechanism,
especially if sphincter peristalsis is monitored fluoroscopically. It 1. Pseudocalculus defects
may be necessary on occasion to repeat the films after 15-30 min- 2. Mistaken stone, eg, vascular impression, tumor
3. Stone mimicking tumor
utes or more, particularly if sphincter of Oddi dysfunction is sus- 4. CBD overlying PD or vice versa
pected and manometry is not performed to assess sphincter pres- 5. Transverse bands mimicking webs or strictures
sure. Although rarely performed, delayed upright gallbladder films 6. T-tube notch simulating retained CD stone
7. Intraductal defects misidentified as stones
taken after the patient has woken from sedation increase the sen- 8. Distortion of the intra- or extra-hepatic system
sitivity of ERCP for detecting gallbladder stones. 12
sometimes arises in the pancreas is the appearance of a stricture
CBD Stones or Air Bubbles?
at the junction between the dorsal and ventral portions of the
ERCP is considered the gold standard for diagnosis of CBD pancreatic duct. Other anatomic variations that commonly
stones, with a reported sensitivity of 90% to 100%. Air bubbles, cause confusion are prominent pancreatic duct side branches,
commonly recognized as a potential cause of a falsely positive loops or kinks in the pancreatic duct and a low cystic duct
ERCP, are differentiated from stones by their response to grav- take-off (Tables 3 and 4).
itational maneuvers: stones sink while air bubbles rise--thus,
the importance of having a tilting fluoroscopy table. However, Conclusions
on occasion, CBD stones may also rise and float, particularly if An understanding of basic radiology theory and techniques is
they have very high cholesterol content or contain gas-filled important for good ERCP practice. This review has attempted
clefts (Mercedes Benz sign). Dilute contrast, ie, 30% or less, and to address some of the issues which endoscopists encounter,
a low kVp reduce the chance of floating bile duct stones being and, hopefully, has provided some useful tips to improve imag-
misinterpreted as air or missed altogether especially in a dilated ing and interpretation.
CBD 13-16 (Figs 7A and B); alternatively, if full strength contrast
is used, it should be in combination with high-peak kilovoltage, References
ie, 100-110 kVp instead of the normal 75-80 kVp. 17 Other
1. Bilbao MK, Dotter CT, Lee TG, et al: Complications of endoscopic
means of distinguishing stones from bubbles include the obser-
retrograde cholangiopancreatography (ERCP). A study of 10,000
vation that stones are often faceted, whereas bubbles are round cases. Gastroenterology 70:314-320, 1976
and tend to coalesce. Small air bubbles can often be aspirated 2. Moreira VF, Moreno E, Larraona JL, et al: ERCP and allergic reac-
through the catheter. One final reminder is to look behind the tions to iodized contrast media. Gastrointest Endosc 31:293, 1985
duodenoscope. The scope can hide pathology as seen in Figure 3. Vehmas T: Hawthorne effect: shortening of fluoroscopy times during
radiation measurement studies. Br J Radiol 70:1053-1055, 1997
8A and when moved by torqueing to the left and pushing in to
4. McParland BJ, Lewall DB: Reductions in fluoroscopy screening
move the scope off the mid-CBD a stricture is seen Figure 8B times resulting from physician credentialing and practice surveil-
that turned out to be a pancreatic carcinoma. lance. Br J Radiol 71:461, 1998
5. Kicken PJ, Bos AJ: Effectiveness of lead aprons in vascular radiol-
Anatomic Variants in the Pancreas and Biliary Tree ogy: results of clinical measurements. Radiology 197:473-478, 1995
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u n c o m m o n and can cause confusion to the endoscopist and vest Radiol 22:688-692, 1987
7. Chen MY, Van Swearingen FL, Mitchell R, et al: Radiation exposure
potential catastrophe to the surgeon. Variant bile duct anatomy
during ERCP: effect of a protective shield. Gastrointest Endosc
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cannot be over-emphasized when performing subsequent patients and personnel during interventional ERCP at a teaching
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9. Baiter S: Radiation safety in the cardiac catheterization laboratory:
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Basic principles. Catheter Cardiovasc Interv 47:229-236, 1999
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is short, it arborizes normally, which differentiates it from the
are important after endoscopic retrograde cholangiography. Br J
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of a false negative endoscopic retrograde cholangiogram. J Clin
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TABLE 3. Technical Pitfalls in ERCP Radiology 14. Davies G, Butzelaar R. The missing stone. BrJ Radio153:496-498, 1980
1. Underfilling of the pancreatic or biliary (esp. intrahepatic) ductal 15. Machi J, Sigel B, Spigos DG, et al: Critical factors in the image clarity
system of operative cholangiography. J Surg Res 35:480-489, 1983
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3. Injected air bubbles mimicking stones pretation. Radiographics 7:1067-1105, 1987
4. False level of obstruction 17. Thompson WM, Halvorsen RA, Foster L, et al: Optimal cholangio-
5. Confusing lymphatic, perivascular and periductal patterns graphic technique for detecting bile duct stones. AJR Am J Roent-
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7. Lesions obscured in the oblique segment of the CHD 18. Jamidar PA, Beck GJ, Hoffman BJ, et al: Endoscopic retrograde
8. Ancillary technical maneuvers - use of glucagon, combined
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duodenography-cholangiography
1263-1267, 1995

16 MITCHELL AND GRIMM