Endoscopy : ERCP (Endoscopic Retrograde Cholangiopancreatography)

You have been advised by your doctor to have an Endoscopic Retrograde Cholangiopancreatography (ERCP) to help find the cause of your symptoms. This leaflet tells you how to prepare for your ERCP and will help you to understand what will happen during and after your procedure.

What is an ERCP?

An ERCP is an examination of your pancreatic and bile ducts (drainage tubes from the liver) using an endoscope (a thin, flexible tube) and x-ray. A special dye is injected down the endoscope so your pancreatic and bile ducts show up on x-ray.

An endoscope will be passed through your mouth and guided into your stomach and then into your duodenum (small intestine). Air will be pumped into your stomach and duodenum to allow your doctor to get a better view. The endoscope has a bright light and camera at the end that passes back a picture of the inside of your stomach and duodenum on to a monitor. Your doctor can then check if any disease, blockages or abnormalities (unusual areas) are present. Biopsies (small pieces of tissue) or brushings (a small brush to collect cells) can also be taken painlessly using instruments passed through the endoscope. Any biopsies or brushings taken will be sent to a laboratory for examination.

An ERCP may be useful in diagnosing and treating

•  Any narrowing of your pancreatic or bile duct
• Gallstones which are trapped in the main bile duct 
• Blockage of the pancreatic or bile duct 
• Jaundice, which turns the skin yellow; may cause itchiness and turns the urine dark 
• Undiagnosed upper abdominal pain 
• Cancer of the bile ducts or pancreas 
• Pancreatitis (inflammation of the pancreas).

 If the test shows gallstones, or any narrowing of your pancreatic or bile ducts, these can usually be treated during your ERCP procedure. Any narrowing of the ducts may be dilated (widened) or a stent (small tube) may be inserted to keep them patent (open).

What will happen during the procedure?

• Before the procedure begins, if you have any false teeth you will be asked to remove them. You will then be asked to lie down on a trolley on your tummy.
• Your pulse and oxygen levels will be checked before and during the procedure by putting a small plastic clip on to one of your fingers. You will be given extra oxygen to breathe through a soft plastic tube on your nose. A blood pressure cuff will be placed on your arm to allow your blood pressure to be monitored during your procedure.
• A small plastic guard will be put gently between your teeth to protect them.
• Do not worry, this is all routine and is not painful. A nurse will stay with you during your ERCP and make sure you are comfortable.
• Your throat will be sprayed with local anaesthetic. You will then be given a sedative and painkilling drug to make you feel comfortable and relaxed before the procedure starts. This involves injecting medication (drugs) through a cannula (a fine tube) inserted into a vein in the back of your hand or arm using a small fine needle. This is called conscious sedation. You will still be awake but will feel more comfortable and relaxed. When the sedation has taken effect your doctor will pass the endoscope through your mouth, into your stomach and into your duodenum. Air will be passed through the tube to inflate your stomach and duodenum so your doctor can see all parts. This can cause "windy" discomfort.
• During the procedure any extra saliva will be cleared from your mouth using a fine suction tube.
• A thin plastic tube is then passed down the endoscope and is directed into either your common bile duct or pancreatic duct. The tube allows a special liquid dye to be injected into these ducts.
• X-rays are then taken of the ducts. Any blockage, narrowing or widening of the duct can be seen on the monitor. If gallstones are found it may be possible for your doctor to remove them using miniature instruments passed through the endoscope.
• It is possible to widen narrowed ducts using a cut and to place stents in these areas to keep them open. A biopsy or brushing may be taken during your procedure and sent for testing in a laboratory.
• The procedure usually takes about 30 - 60 minutes. When the procedure is over the air is released and the endoscope is removed quickly and easily.
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What are the risks and possible complications of an ERCP procedure?

• ERCP is a very accurate examination but occasionally a problem may be missed. It is a safe procedure but does have some risks and possible complications. These will be discussed fully before you consent to the procedure. They must be compared to the benefits of having the procedure carried out. The doctor who advised you to have this procedure will have considered this. The most common risks and complications are:
• Discomfort-You may feel some discomfort during the procedure; we try to keep this to a minimum. A nurse will be with you throughout the procedure and if you show any signs of being uncomfortable steps will be taken to relieve this.
• Feeling bloated and sore throat-You may feel bloated for a few hours afterwards and have a sore throat for 24 - 48 hours.
• Damage to teeth or bridge-work- The endoscope can occasionally cause damage to teeth or bridge-work. This is rare, and a mouth-guard is used to lessen the risk.
• Pancreatitis (mild to severe inflammation of the pancreas).-This can be caused by a reaction to the x-ray dye that is passed into your bile and pancreatic ducts. This can happen to 5 patients in every 100.1 It can happen within 24 - 48 hours of an ERCP procedure. If you feel unwell, feverish, have upper abdominal pain or discomfort you must contact the hospital. (See contact numbers). With treatment it usually settles in a few days. 
• Bleeding-If any bleeding occurs during your ERCP steps will be taken to stop it. This can happen to 1 patient in every 100. If this happens you may need a blood transfusion or, rarely, an operation.
• Infection-You may be given antibiotics before your ERCP. If a blockage of your bile or pancreatic duct is found and released the fluid could be infected. This can happen to 1 patient in every 100.1 You may be given antibiotic treatment after your ERCP if your doctor thinks it is needed. If you feel unwell, feverish or feel sick you must contact the hospital or your GP. (See contact numbers)
• Perforation (hole)- Perforation in the intestinal wall or stomach. This can happen to 1 patient in every 250.1 If this happens you may need an operation to repair it.
• Adverse effects of conscious sedation (a drug which should make you feel comfortable and relaxed)- This can occasionally cause problems with your breathing, heart rate and blood pressure. Careful monitoring (checking) by a fully trained endoscopy nurse will make sure they are identified and treated quickly.
• Aspiration-If you are sedated and your stomach contains food or drink, it can leak into your lungs, affect your breathing and cause an infection. This is one of the reasons why you must not eat or drink for 6 hours before this procedure.
• Radiation-Risks from x-rays are very small with the dosages used in this procedure. The benefits of this test outweigh any small radiation risk.
• Unable to complete ERCP-Very occasionally your doctor may not be able to access (get into) your common bile duct or pancreatic duct during your ERCP. You may need to have a different x-ray procedure called a percutaneous transhepatic cholangiogram (PTC); your doctor will discuss this in more detail with you. This may need to be arranged on a different day.
• Other treatments- If any of the other treatments described earlier are needed the risks can increase.
• Procedure related mortality (death)- This can happen to 1 patient in every 250 undergoing this procedure.  

Are there any other tests that can be done instead of an ERCP?

You do not have to have any examination or tests you do not want, but the doctor who has requested the procedure has advised this is best for you. However, if you do not want this procedure an MRI scan may also help to find the cause of certain symptoms. This is not always appropriate as it does not allow treatment of any abnormality detected.

Who will do my ERCP?

Your ERCP will be carried out by a doctor who has specialist skills.

Where can I expect this to happen?

Your ERCP will be performed at the Cumberland Infirmary Carlisle

What will I have to do to prepare for my ERCP as an outpatient?

You will either have a face to face or a telephone pre-assessment before your procedure. They will explain the procedure and discuss the risks and possible complications.

You will be asked about your general health, medical history and medications that you take.

You will need to make the nurse aware of any blood thinning medications that you normally take, these can include; warfarin, Apixaban, Rivaroxaban, Dabigatran, Edoxoban, Clopidogrel, Prasugrel and Ticagrelor. Although if you are unsure of any medication please check with the nurse.

Your nurse will tell you if you need to stop taking any of your medications  before your ERCP. You may be given some tablets to take before your ERCP if it is decided that you need them.

You will need to have your bloods taken within 7 days of your ERCP.

As we give you sedation for this procedure you will need to make sure you have someone who can pick you up to take you home and have someone to stay with you for at least 24 hours.

Please bring the contact details of your escort for us to contact when you are ready to be collected and also  your next of kin details to update our records.

You need to be aware you will be with in the Endoscopy unit for a long period.

Bring an overnight bag as a precaution, that includes dressing gown and slippers and any medications that you normally take.

Leave any jewellery or valuables at home.

Do not eat anything after midnight the evening before you procedure.

You may have clear fluids up until 2 hours before.

On the day of your ERCP:

• Do not smoke
• Tie long hair back
• Nail varnish must NOT be worn
• Only a wedding ring should be worn
• Wear loose comfortable fitting clothes
• You may be given a suppository in your rectum, to help reduce the risk of pancreatitis.

Will it be painful?

No, not painful, but you may feel some discomfort. We try to keep this to a minimum. You can ask for the procedure to stop at any point if you wish.

What will happen after the procedure?

You will be taken on the trolley to a recovery area where you will be able to rest. Your pulse, blood pressure and oxygen levels will be checked regularly after your procedure. If you are an inpatient you will be returned to the ward.

Your nurse will tell you when you can start to eat and drink.

If you can go home you must have a responsible adult to take you home and stay with you for the first 24 hours after your sedation. This is because sedation may make you feel tired and will affect your judgement. Your nurse will tell you how long you need to follow this advice.

For the first 24 - 36 hours after sedation you

• must not go back to work
• must not drive a car, ride a bicycle or motorcycle. It is an offence to drive while unfit to do so because of drugs and it will probably invalidate your insurance policy.
• must not supervise children
• must not make any important decisions or sign any legal documents
• must not operate machinery or electrical appliances
• must not go near open flames or sources of high heat
• must not drink alcohol
• must not take sleeping tablets, tranquillisers or any drugs other than those prescribed to you by the hospital or your GP
• must not lock the toilet or bathroom door in case you need any help
• should not smoke.

How will I feel after my ERCP when you return home?

You may  

• have a sore throat for the first 24 - 48 hours feel bloated. This is due to the air put in your stomach and duodenum during your procedure. This usually settles within a few hours.
• have a light meal on the evening after your procedure, for example, soup and sweet. Do not have a heavy meal as it could make you sick.

 If you have any of these symptoms, you must contact the Endoscopy Unit:

• have severe pain in your neck, chest or abdomen (tummy)
• start vomiting (being sick) or develop nausea (feeling sick)
• your temperature is 38°C (100.4°F) or higher.                                       

If the Endoscopy unit is closed and you have an urgent problem up to 48 hours after your ERCP you should go to A&E

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For further information on confidentiality contact the Information Governance Team:

Information.Governance@ncic.nhs.uk | 01228 603961

Feedback

We appreciate and encourage feedback, which helps us to improve our services. If you have any comments, compliments or concerns to make about your care, please contact the Patient, Advice & Liaison Service:

pals@ncic.nhs.uk | 01228 814008 or 01946 523818

If you would like to raise a complaint regarding your care, please contact the Complaints Department:

complaints@ncic.nhs.uk | 01228 936302