Gastroenterology - A guide to having an ERCP (Endoscopic Retrograde Cholangio-Pancreatography)

To help treat a problem with your bile duct or pancreas, you have been advised by your doctor to have an ERCP (endoscopic retrograde cholangiopancreatography). The most common reasons to do an ERCP are jaundice (yellowing of skin or eyes), abnormal liver blood tests or if a scan (CT, endoscopic ultrasound, MRI or USS) shows a blockage of the bile ducts or pancreas. ERCP is usually used to treat blockages of the bile duct or pancreas.

This leaflet has been prepared from talking to patients who have had the procedure. It may not answer all your questions so if you have any worries please do not hesitate to ask. The staff who are performing the test will be available to answer any queries.

What is an ERCP?

ERCP is a procedure which allows the doctor to take detailed X- rays of the bile duct and/or pancreas. Nurses will attach monitors to your finger and maybe to your chest. Your throat will be sprayed with local anaesthetic. You will be given an injection of intravenous sedation before the doctor passes the tip of the endoscope through your mouth, into your stomach and round into the beginning of the small intestine (the duodenum).

The endoscope is a long flexible tube (thinner than your index finger) with a bright light at the end. By looking down the endoscope, the doctor can find the opening (papilla) where the bile duct and pancreatic duct empty into the duodenum. A small plastic tube is passed down the endoscope into this opening, through which dye is injected into the ducts, allowing x-ray pictures to be taken.

Endoscopic sphincterotomy

If the X-rays show a gallstone, the doctor will enlarge the opening of the bile duct. This is done with an electrically heated wire (diathermy) which you will not feel. Stones can be extracted from the duct with a balloon or basket and left to pass out with normal bowel movement.

Endoprosthesis

If the x-rays show a blockage in the bile duct the doctor may place a very small plastic or metal mesh tube (stent) inside the duct itself to help the bile drain into the intestine in the normal way. You will not be aware of the presence of the tube. It is usually necessary to replace the tube some months later to prevent it becoming blocked. Your doctor will advise if this is not the case.

Benefits

• By relieving the obstruction in your biliary system with a sphincterotomy, stone extraction or stent placement, the pain, jaundice or itching you may be suffering from should improve
• Tissue samples can also be taken either by a small biopsy (forcep) or brush

Alternatives

An operation may be an alternative to an ERCP. If you want more information about these alternatives, you can discuss them with your doctor.

What will happen if I decide not to have an ERCP?

Without appropriate treatment your problems may not get better.

What should you expect?

To allow a clear view, the stomach and duodenum must be empty. You will therefore be asked not to have anything to eat or drink for at least six hours before the procedure.

When you come to the hospital, the procedure will be explained, and a doctor will check that you have signed your consent form. This is to ensure that you understand the test and its implications. Please tell the nurse or doctor if you have had any previous endoscopy examinations, reactions to drugs or allergies. In some situations, antibiotics are given by injection before the procedure. If you have any worries or questions at this stage, do not be afraid to ask. The staff will want you to be as relaxed as possible for the test and will not mind answering your queries.

You will be asked to take off your clothes and to put on a hospital gown. It will also be necessary for you to remove any false teeth, contact lenses, jewellery or metal objects whenever possible. If they cannot be removed, they will need covering with insulating tape because they interfere with X-rays and a special instrument called a diathermy. Please leave any valuables at home.

During the procedure

In the examination room you will be made comfortable on an x- ray table, resting ideally on your front, or alternatively on your left side. X-ray equipment will be beside the couch and the room will be darkened. A nurse will stay with you throughout the procedure.

The staff will be wearing X-ray protective aprons because of their repeated exposure to X-rays. The number of X-rays you receive will be strictly controlled for your safety. The nurse will have administered a local anaesthetic on the back of your throat to help numb the area. We will usually give you pain killing suppositories (into your back passage) before the procedure to reduce your risk of pancreatitis. You will be given an injection to make you feel sleepy and relaxed.

Most patients have little, or no memory of the test being done. To keep your mouth lightly open and to protect the endoscope, a plastic mouthpiece will be put gently between your teeth. When the doctor passes the endoscope into your stomach it will not cause you pain. Nor will it interfere with your breathing. The test usually takes up to thirty minutes. The procedure itself should not be painful, although air blown into your duodenum to maintain endoscopic views may make you feel bloated.

After the test

You will be taken back to the ward to rest. The nurses will check your pulse and blood pressure regularly. You will not be able to have anything to eat or drink for a few hours. When you do start to eat you should keep to simple meals for a day or two.

For the first day you may feel some soreness at the back of the throat and also some bloating if air has remained in your stomach. The procedure can cause inflammation of the pancreas or bile duct, but this is rare.

It is important for you to tell the staff if you have any of the following symptoms after the procedure: persistent or worsening abdominal pain, fever, vomiting blood, passing black stools, severe neck/chest pain. As this could be a sign of sepsis following the procedure. If you have been discharged home, please seek medical attention immediately.

If a stent has been placed this is a temporary measure and will need to be removed or replaced after a period of time, and you will be sent an appointment for this to be done. If you have not received an appointment to have your stent removed or exchanged, it is important to contact the GI endoscopy unit.

Risks

ERCP is a form of endoscopic surgery and serious complications may occur (the procedure is only performed after careful consideration).

Risk of death 1 in 300. Inflammation of the pancreas (pancreatitis) may occur in around 4% (1 in 25) cases. Usually this is mild but requires treatment in hospital. Very occasionally pancreatitis can be severe and lead to the need for intensive care treatment. Bleeding may occur in 1-2% (up to 1 in 50) of cases after sphincterotomy. This usually stops without treatment, but occasionally requires blood transfusion, further endoscopy or even surgery. It is important to let the doctor performing the procedure know if you are taking any drugs such as warfarin or clopidogrel that may interfere with bleeding (usually you will have been asked to stop these for a period of time).

Infection occurs in 1-2% of cases and is usually treated with antibiotics but may require a repeat ERCP procedure. When indicated, antibiotics will be administered at the time of the procedure.

Perforation (tearing) of the bowel is a rarer complication (around 1 in 200 cases). Sometimes this will require an operation, but not usually.

If you are unsure about information given or have any other queries, please contact:

GI Endoscopy Unit – Salford Royal Hospital on 0161 206 5959 or 0161 206 5958.