Gastroenterology - Endoscopic Retrograde Cholangio-Pancreatogram (ERCP)

What is ERCP?

An ERCP allows us to examine the bile and pancreatic ducts. If a gallstone or blockage is found, then we may be able to treat this during the ERCP possibly avoiding the need for an operation.

Once you are sedated (drowsy), a thin flexible tube (endoscope) will be passed through your mouth down into your stomach and the upper part of your gut. This endoscope (duodenoscope) does not interfere with your breathing.

We will then insert a special dye down the duodenoscope so that the pancreas and bile ducts can be seen on an x-ray. If everything is normal, the duodenoscope is removed and the test is over.

If a gallstone is found in the bile duct during the test, it may be possible to remove this by widening the opening of the bile duct (sphincterotomy). This is done by making a small cut at the opening where the bile and pancreas duct open into the duodenum using an electrically heated wire (diathermy).

If it is not possible to remove the gallstone due to its size or because the bile duct is narrowed, then a small plastic tube (stent) may be left in the bile duct to allow it to drain.

Why do I need an ERCP?

An ERCP may be recommended for several reasons including:

• Help your doctors to make a diagnosis
• Treat jaundice caused by gall stones or a narrowing of the bile ducts
• Remove gall stones from the bile ducts or pancreatic duct
• Insert a plastic or metal tube to drain the bile (or the pancreatic juices) which is called a biliary stent
• Clear blockage of the bile flow
• ERCP is a less invasive procedure compared with surgery

Possible risks and complications of an ERCP

Complications can develop during or after the ERCP. Every effort is made to prevent, recognise and treat these when they do occur. An ERCP is a skilled procedure and is performed by a highly trained doctor who takes every care to reduce the risks.

• Problems do sometimes occur, which may lead to a longer stay in hospital and very rarely, an operation is necessary to treat a complication
• Acute Pancreatitis (the risk of inflammation of the pancreas is between 1- 5%). Most cases are mild but could result in 1% of cases requiring HDU/ICU admission). You may need to stay in the hospital for several days, sometimes longer. The main risk is inflammation of the pancreas gland (pancreatitis), which usually settles within a few days
• Bleeding (1 in 10 cases if a cut is made, but this almost always stops by itself). This can occur in 1 in 500 people but is 10 times more likely (10 in 500) if a cut has been made (sphincterotomy) to remove stones or to insert a stent. Bleeding can cause vomiting of blood which may be black, or the passing of black stools. The bleeding can often be stopped using special instruments that are passed through the duodenoscope. Very rarely, a blood transfusion or surgery is needed
• If gallstones or blockages are found and a widening of the lower bile duct is attempted, this will increase the risks with the procedure (rare for something to go wrong). The main complications of a sphincterotomy are bleeding or a perforation (hole in the bowel)
• Perforation occurs in 1 in 400 patients having ERCP
• If complications occur, you may need a blood transfusion, being kept off food for some days attached to an IV line (drip) and antibiotics, or very occasionally an operation to repair the damage
• Sedation related (being very drowsy or suppressed breathing)
• Infection
• On rare occasions the procedure leads to major complications and unfortunately there is a risk of death from ERCP

If you would like to discuss any of these issues with the consultant before the ERCP, please don’t be afraid to ask.

Benefits

The test gives a direct view and provides x-ray pictures of the bile duct and pancreas. At the same time therapeutic intervention (e.g., extracting a stone or inserting a stent) can be done. During the test we may need to take a sample which will allow us to confirm the diagnosis.

Alternatives

Open surgery is a potential alternative, but this may not be possible if you have multiple medical problems, due to the high list of complications. The other alternatives to ERCP would be Percutaneous Transhepatic Cholangiography (PTC) and an Endoscopic Ultrasound (EUS) guided approach wherever indicated. These are also invasive tests and carry complications.

Medication

If you take blood thinning tablets (anticoagulants e.g., Aspirin, Clopidogrel, Apixaban, Enoxaparin or Warfarin) please consult your consultant or the doctor who deals with your anticoagulant medication. Please make sure that the doctor requesting the procedure and the one performing the procedure are both aware that you have been on anticoagulants and what measures have been taken. If you are diabetic on medication or insulin, please contact your Diabetic Nurse for specific instructions.

If you take Clopidogrel, please consult your consultant or contact the Endoscopy Unit for specific instructions.

If you have a latex allergy, then please contact the Booking & Scheduling Team as your admission date/time might be affected.

You must keep taking any essential prescribed tablets.

How will I prepare for my ERCP?

Most patients undergoing an ERCP are admitted to a ward prior to the procedure where blood tests are undertaken. Some ERCPs may be undertaken as a day case procedure, or you may be required to stay in hospital overnight following the investigation, so please bring your nightclothes, slippers, toiletries and a towel with you. The decision is made on the requirements of individual patients (based on your existing medical issues).

Please follow the advice below carefully in preparation for your procedure:

Morning appointment – Do not eat from 12 midnight the previous evening. You may have sips of water up to 6 hours before your appointment time.

Afternoon appointment – Take a light breakfast at home, e.g., tea and toast before 7:00am on the day of the procedure. Do not eat or drink fluids after this time.

Please do not drink alcohol for 24 hours before the ERCP

• Regular medication should be taken as usual with sips of water
• Please bring medication and inhalers with you
• Please make sure that the doctor requesting the procedure and the one performing the procedure are both aware that you have been on anticoagulants and what measures have been taken
• Please wear loose comfortable clothing

Sedation

You will be given sedation to have an ERCP. This is not a general anaesthetic, but for your own safety please comply with the following:

• You should not drive, drink alcohol, or sign any legal documents for at least 24 hours after the procedure
• You will need to be accompanied home by a friend or relative in their car or a taxi.
• A friend or relative will need to stay with you for up to 24 hours after the procedure 

What happens when I arrive at the hospital unit?

Soon after you arrive you will be seen by the nurse, who will ask you a few questions about your medical condition and any past surgery or illness you have had. This is to confirm that you are fit enough to undergo the ERCP examination. If you have not had a blood test in the previous five days, we will take a blood sample. The nurse will record your heart rate, blood pressure and oxygen levels. If you are diabetic, your blood glucose level will also be recorded.

The nurse will also check that you understand the ERCP procedure (along with the risks and benefits) and you will be able to ask any further questions or raise any concerns you may have.

You will be asked to consent for the procedure and confirm you understand.

The nurse will also ask you about your arrangements for getting home after your ERCP. As you will be having sedation you must have someone with you when you travel home.

You will be asked to remove your clothes and to put on a hospital gown. You will need to remove all jewellery and metal (such as piercings), as this can interfere with x-rays and a special instrument called diathermy, which may be used during an ERCP.

An intravenous cannula (small plastic tube) will be placed in your right arm, so that we can give you the sedative medication during the procedure.

You may be given an anti-inflammatory suppository into your back passage (bottom) before or during the ERCP, to reduce the risk of developing pancreatitis (inflammation of the pancreas).

When the procedure is ready to start, you will be moved to the examination room in the radiology department. The endoscopist and the nurses will introduce themselves and you will have the opportunity to ask any final questions. A consultant will perform your examination. A nurse will also remain with you throughout the procedure.

We will give you a small plastic mouth guard to put between your teeth, to protect them during the examination. (If you have any dentures, you will be asked to remove them first). The nurse will then ask you to lie on the x-ray table and will place a probe on your finger to monitor your oxygen levels.

The sedative medication will be injected into the cannula and you will quickly become sleepy. A small plastic suction tube, rather like the one used at the dentist, will be used to remove any saliva or other secretions produced during the examination.

The endoscopist will put the duodenoscope into your mouth and will pass it gently down your oesophagus into your stomach, then into your duodenum (upper part of the small bowel). You will be able to breathe normally through your nose. The duodenoscope allows the doctor to see pictures of the inside of your intestine on a screen. A small amount of air will be blown into your stomach, to help the endoscopist to see clearly. This may be uncomfortable but shouldn’t cause you any pain.

The doctor will find the position of the valve where the pancreatic and bile ducts enter the duodenum. A very thin plastic tube will then be inserted down the duodenoscope into the bile or pancreatic duct, to inject a special dye, so that the pancreatic and bile ducts can be seen on x-ray images. The dye is later passed out of the body harmlessly.

The doctor will then carry out any treatments that are required.

If the ERCP shows that you have gallstones in the bile ducts, the doctor may treat these by cutting the opening of your bile duct (sphincterotomy) using an electrically heated wire (diathermy) that is passed down the duodenoscope. You will not feel anything when this is carried out. The doctor will then remove the gallstones using a special balloon or “basket”.

If there is a narrowing (stricture) of the bile duct, a short plastic or metal tube called a stent will be placed across the narrowing to drain the bile. You will not be able to feel the tube, which may remain in place permanently. There is a chance that the stent may become blocked after a few months. If this happens, it may be necessary to replace the stent by performing another ERCP.

X-ray images and /or photographs will be taken for your health record and documentation purposes. A biopsy (sample of tissue) or some bile may be collected and sent to the Pathology laboratory to be analysed.

Images from the ERCP and X-rays will be kept in your health record.

How long will I be in hospital?

The procedure usually takes between 30 minutes and 1 hour. However, you should expect to be in the department for most of the day. The ERCP Unit also deals with emergencies, and these will take priority over people with outpatient appointments, but we will try to keep any delays to an absolute minimum.  Unfortunately, on occasion your procedure might be cancelled on the day.

Depending on your health condition or whether you have a treatment or procedure during the ERCP, you might be admitted overnight.

How soon will I recover?

After the procedure, you will be taken to the endoscopy recovery area ward where you will be allowed time to recover, as you will feel a little drowsy and sleepy for a while. As soon as you are fully awake, you will be offered some light refreshment, although some patients are required to wait a little longer before eating and drinking.

The back of your throat may feel sore for a short while, your abdomen may feel a little bloated and you may feel a little discomfort in your stomach. This is quite normal and usually settles down quickly. The fine tube (cannula) will be removed from your hand and a dressing will be applied.

Following the procedure, the doctor will decide about the time of your discharge. You may be required to stay in hospital overnight. Before you are discharged home, your nurse will discuss your aftercare with you. If there were complications of ERCP then you will need to stay in the hospital longer and may require an operation.

When will I be told the results?

You should be informed of the result of the ERCP before you go home. If biopsies have been taken, then the results take several days. These will be sent to either your consultant or GP. You could even be sent an appointment to attend the outpatient department to see your consultant.

A copy of the ERCP report will be sent to your GP and we will also give you a copy to take home.

Will I need any medicines on discharge?

A letter will be sent to your GP giving information on the results of the ERCP and any medication that you may require. If you require a course of tablets, you should visit your own GP to arrange a supply.

Going Home

As you will have had sedation, it is essential that someone comes to the hospital to escort you home.

You should not do any of the following:

• Be left on your own for 24 hours
• Drive a car
• Ride a bike
• Operate machinery
• Sign any legally binding documents
• Drink any alcohol for 24 hours after the ERCP

After 24 hours most patients can resume to normal activities.

Please discuss any concerns you may have with the doctor. If you are unsure about returning to work, ask for advice before you go home. If we can be of any more assistance to you, then please contact the Endoscopy Unit on the telephone numbers listed below.

Serious post procedure signs and symptoms

If you experience any severe pain in your abdomen, chest or neck, this could be due to bleeding from a small operation that may have been necessary as part of the examination, or a perforation (a small hole made in the lining of your small bowel, stomach or oesophagus (food pipe)). You are advised to attend your nearest Accident and Emergency Department as soon as possible taking the report from your ERCP procedure with you.

Contact details

For more information on medication or cancellations, please ring either:

Booking & Scheduling Team (for cancellations) - 01706 906 788

The Royal Oldham Hospital Endoscopy Unit - 0161 627 8513/8217