What is an ERCP?
An ERCP (Endoscopic Retrograde Cholangio-Pancreatography) is a procedure performed on patients with suspected diseases of the bile ducts or pancreas. During the procedure a thin flexible tube (endoscope) with a small video camera at the end is passed into the mouth, down through the stomach and into the duodenum (first part of small intestine). The aim of the procedure is to obtain detailed X-ray images of the bile ducts, gallbladder and pancreas.
What do I need to know before admission?
Before you come into hospital you will be asked to attend for blood tests. It is very important that you come for the blood tests before the day of the ERCP. If for any reason you cannot have blood tests before the procedure please let the Endoscopy Unit know. You must not have anything to eat or drink for at least six hours before the procedure. Having your stomach and duodenum empty allows a clear view during the procedure.
Patients taking any prescribed medication or any anticoagulation medication (medication to thin your blood) e.g. Warfarin or Clopidogrel – Please inform us as soon as possible and before you come into the hospital. You can then be advised whether you should continue taking the medication before your procedure.
Women of childbearing age – Please inform us before you attend if there is any chance that you could be pregnant, or are breastfeeding.
What happens on admission?
Once you have arrived at the Endoscopy Unit a nurse will admit you and may ask you to put on a hospital gown. They will check your pulse, blood pressure and oxygen levels. They will also explain the procedure to you and answer any questions you may have.
The doctor will come to examine you and they will explain to you the procedure, inform you of the potential risks and complications of an ERCP, and also answer any questions you may have. The doctor will then ask you to sign the consent form for the procedure once you have read it carefully and understood it in full.
The doctor or the nurse will insert a cannula (thin plastic tube) into a vein in your hand or arm. This provides a route for the sedative drugs to be given before and during the procedure.
Dentures, glasses and contact lenses can be removed later on; the nurses will tell you when. Ideally any jewelry should be left at home as this will need to be taken off before the procedure.
Cancellations or delays
Please be aware that in some circumstances your procedure may have to be delayed or cancelled at short notice. If this occurs we apologise for any inconvenience caused and will aim to reschedule your appointment as soon as possible
What happens during the ERCP?
You will be taken to the X-ray Department for the procedure. The nurses will help you lay down in the correct position on the X-ray table. Your throat will be sprayed with a local anaesthetic and a fine soft tube will be placed into the nostrils to give you extra oxygen during the test.
A sedative drug will be injected via the cannula into your arm. This is not a full anaesthetic but it will make you very relaxed and sleepy. Once you are sedated the procedure will be carried out in three distinct phases:
Firstly, the endoscope is passed into the mouth, down through the stomach and into the duodenum (first part of small intestine) to visualise the openings from the bile duct and pancreas
The second stage can be described as the diagnostic phase of the procedure during which dye will be injected (through the endoscope) directly into the common bile duct and pancreas. The dye outlines the bile and pancreatic ducts, allowing these structures to be identified and any abnormalities detected.
The third stage can be described as the therapeutic phase. If abnormalities are detected; these are then treated during the ERCP where appropriate.The main procedures carried out are:
Where stones have been found in the common bile duct a small cut (sphincterotomy) may be made using cautery (electric current) this widens the opening of the bile duct into the duodenum. This allows a small balloon or basket to be inserted to grasp the stones and remove them.
• In some circumstances, a short plastic tube (stent) can be fitted which allows bile to drain into the duodenum. With time these tubes do become blocked however and so require replacing. The length of time before replacement is necessary is variable and depends upon individual circumstances
The procedure lasts from 20 minutes up to an hour and a half depending upon the procedures performed during the therapeutic stage of the ERCP.
What happens after the ERCP?
You will be taken back to the Endoscopy Unit on a trolley. The nursing staff will check your pulse, temperature, blood pressure and oxygen levels, and generally assess how you have recovered from the procedure. If you feel unwell at all please let the staff know. Some patients experience pain following the procedure. If you do, please inform the ward staff as soon as possible so you can be given some painkillers.
You will be seen by a doctor in the hours following the procedure. They will decide when you can begin to eat and drink and whether you are able to go home or are required to stay in hospital. If you are required to stay in hospital, the length of stay will depend upon what the procedure found and additional treatment given. Most patients are well enough to go home within one or two days of an ERCP, but some may be required to stay in hospital longer.
Discharge advice
If after your ERCP you are allowed home the same day it is essential that someone comes to collect you and stays with you overnight. Once home, it is important to rest quietly for the remainder of the day. Sedation can last in the system for up to 24 hours or maybe longer.
Furthermore you should avoid the following activities for at least 24 hours after the procedure:
• going to work
• driving
• operating machinery
• drinking alcohol
• signing any legally binding documents
• carrying out any activities involving heights
• caring for young children (sole responsibility)
If you start to feel unwell or feverish, or develop severe abdominal pain, you must contact your General Practitioner (GP) or the GP Emergency Centre (see phone number below) as soon as possible, it may be necessary to re-admit you to hospital.
Is there an alternative to an ERCP?
ERCP is usually a therapeutic procedure, the alternative is an operation to explore the bile duct through a laparoscopic (key hole ) operation or a open operation under general anaesthetic . This normal caries a higher risk of complications and a longer recovery time.
What are the risks and complications of ERCP?
It is very important that you are aware of the potential risks and complications of ERCP before giving your consent to the procedure. These include:
Pancreatitis (inflammation of the pancreas)
In most cases this is mild causing abdominal pain, usually lasts a few days and requires observation in hospital. However severe pancreatitis can occur following ERCP, this is treated in intensive care . Although it is rare, severe pancreatitis can be fatal (Less than 1 in 500 cases).
Infection
Infection may occur in the gallbladder (acute cholecystitis) or the bile ducts (acute cholangitis).
Internal bleeding
This may follow a procedure to widen the opening of the bile duct. The bleeding is usually resolved without any treatment but in a minority of cases may be serious.
Perforation
Damage to the wall of either the duodenum or common bile duct (perforation) may result in the leakage of intestinal contents or bile into the abdominal cavity. This can be a potentially serious complication, although it usually settles without surgery being necessary.
Every effort is made to reduce the risk of these complications occurring. If you are concerned about any of these risks and complications, please discuss this with the consultant or member of their staff before the procedure.
References used in the compilation of the leaflet
Bennet, J. R. (1981) Therapeutic Endoscopy. Chapman and Hall
Doctor Online (1999) ERCP http://www.doctoronline.nhs.uk
Gelton, P. and Williams, C. (1997) Practical Gastrointestinal Endoscopy. Blackwell Science Ltd
Hadley, A. and Martin, D. Having an ERCP: A Guide to the Test. Keymed
Johnson GK, Geenen JE, Beford RA, Johanson J, Cass O, Sherman S, Hogon WJ, Ryan M, Silverman W and Edmundowica S(1995) A comparison of nonionic verses ionic contrast media: results of a prospective, multicentre study. Gastrointestinal Endoscopy. 42(4): 312-6
Sherman S, Hawes RH, Rathgaber SW, Uzer MR, Smith MT, Khusro QE, Silverman WB, Earle DT and Lehman GA (1994) Post ERCP Pancreatitis: randomised, prospective study comparing a low and highosmolity agent. Gastrointestinal Endoscopy. 40(4): 422-7
Sherman S and Lehman GA (1991) ERCP- and endoscopic sphincterotomy-induced pancreatitis. Pancreas. 6(3): 350-67
Do you need further information?
If you have any questions or concerns, please contact the Endoscopy unit:
The Endoscopy Unit at Diana Princess of Wales
Normal Hours: 8am-7pm Monday to Friday and 8am-6pm Saturday
Endoscopy Pre-assessment Nurse: 03033 304343
Telephone the Unit direct on 03033 303353 between the hours of 8am until 6pm, Monday until Friday
Or Telephone Diana, Princess of Wales Hospital, Grimsby on 03033 306999 and ask for the Endoscopy Unit.
Out of Hours
After 6pm contact Ward C6 via the main switchboard on: 03033 306999 (Out of hours 6pm to 8am).
The Endoscopy Suite at Scunthorpe General Hospital
Normal Hours: 8am-6pm Monday to Friday and 8am-6pm Saturday
Telephone the Unit direct on 03033 302186.
Or Telephone the Endoscopy Unit at Scunthorpe General Hospital on 03033 302221.
Out of Hours
After 6pm contact your G.P. or phone the G.P. emergency Centre (01724) 290444
Department of General Surgery and Endoscopy, Goole Hospital
Telephone 03033 304119 or 03033 304123