An endoscopic retrograde cholagiopancreatography (ERCP) is a combined endoscopic and radiologic examination of the gallbladder, pancreas, liver, and the ducts (tubes) that drain these organs. Bile from the liver and pancreatic juices from the pancreas flow through tubes called ducts that drain into the small intestine through an opening in the upper small intestine (duodenum) called an ampulla.
The test will examine the gallbladder, pancreas, and these ducts, looking for blockages, irregularity in the tissue or disruptions in the flow of bile/pancreatic fluid, spasm of the ducts, stones, or tumors.
Some patients are admitted to the hospital afterward, depending upon the reason for ERCP or because a treatment was done during the procedure that requires overnight observation in the hospital.
REASONS FOR ERCP
The most common reasons for ERCP include the following:
- Preoperative or postoperative evaluation of patients who undergo laparoscopic gallbladder removal to detect and remove gallstones that might be blocking the ducts.
- Evaluation of pancreatitis (an inflammation of the pancreas)
- Evaluation of a possible pancreatic or bile duct cancer
- To remove gallstones that are not passing through the ducts into the small intestine. Some stones are too large to pass easily and get stuck in the ducts.
- Evaluation of abnormal or unclear findings in the biliary system on a CT or MRI examination
- Evaluation of chronic or acute abdominal pain when pancreatic or biliary disease is suspected
- Evaluation of jaundice (yellow skin) when bile duct disease is suspected
At the time of the procedure, the endoscopist may take tissue samples (biopsies), place drainage tubes to improve bile flow, or make a small incision in the tissues surrounding the bile or pancreatic ducts.
Specific instructions regarding how to prepare for the examination will be given before the procedure. These instructions are designed to maximize the patient’s safety during and after the examination and to minimize possible complications. It is important to read the instructions ahead of time and follow them carefully. Do not hesitate to call the physician’s office or the endoscopy unit if there are questions.
Patients will be asked not to eat or drink anything after midnight the night before (medications can be taken with sips of water). It is important for the stomach to be empty to allow the endoscopist to visualize the entire area and to decrease the possibility of food or fluid being vomited into the lungs while under sedation (called aspiration).
Patients may be asked to adjust the dose of their medications or to eliminate specific medications prior to the examination. Some medications need to be discontinued for several days. Patients should ask about their specific medications since some medicines are more important than others.
Patients will also be instructed to arrange for a friend or family member to escort them home after the examination. Although the patient will be awake by the time they are discharged, the medications used for sedation cause changes in the reflexes and judgment and interfere with the ability to drive or make decisions (similar to the effects of alcohol).
WHAT TO EXPECT IN THE ENDOSCOPY UNIT
ERCPs are done in the hospital endoscopy unit due to the special fluoroscopic equipment necessary for the procedure. Prior to the endoscopy, a nurse will ask questions to ensure the patient understands the procedure and the reason it is planned. A doctor will also review the procedure, including possible complications, and will ask patients to sign a consent form.
The nurse will start an intravenous line (insert a needle into a vein in the hand or arm) to administer medications. The intravenous line insertion feels like a pin prick, similar to having blood drawn. Most endoscopy units use a combination of a sedative (to help patients relax), and a narcotic (to prevent discomfort). Due to the complexity of the procedure, sedation will be provided by the Anesthesia service at the hospital, whom you will meet and be able to ask questions in the endoscopy unit before starting. The anesthesia service will give medicines through your IV to put you to sleep and then insert a temporary breathing tube (intubation) for the procedure, which will be removed immediately afterwards. The vital signs (blood pressure, heart rate, and blood oxygen level) will be closely monitored before, during, and after the examination. The monitoring is not painful. Patients will be given oxygen during the examination. For safety reasons, patients will be asked to remove dentures. Some patients will be given medication to gargle to numb the throat, or a numbing spray may be used.
ERCPs are performed in a room that contains x-ray equipment at the hospital. The patient will lie on an x-ray table during the examination. The ERCP will be performed while the sedated patient lies on their side or stomach.
Although patients worry about discomfort from the examination, most tolerate it well and feel fine afterwards. Medications will be administered through the intravenous line. A plastic mouth guard is placed between the teeth to prevent damage to the teeth and scope. For safety reasons, patients will be asked to remove dentures.
The ERCP scope is a flexible tube, approximately the size of a finger. It contains a lens and a light source that allows the endoscopist to view images on a monitor where it is magnified many times so the endoscopist can see small changes in the tissues. The ERCP scope also contains channels that allow the endoscopist to take biopsies and introduce or withdraw fluid, air and instruments.
The patient will be asked to swallow the tube; many patients do not remember this after the medications have taken effect. Many people sleep during the test; others are relaxed and generally not aware of the examination.
The scope in inserted through the mouth, and air is introduced to open up the esophagus, stomach, and intestine so the scope can be passed through those structures and to allow the endoscopist to see. When the scope reaches the duodenum, the first portion of the small intestine, the endoscopist will locate the ampulla, the opening into the ducts that drain the biliary system. A small cannula (tube) will be placed into the ampulla and, dye (a special contrast material that allows visualization of tissues by x-ray) will be injected through the cannula.
The length of the examination varies, but it generally takes about one hour.
After the ERCP, patients will be kept for observation while the anesthesia wears off. The most common discomfort after the examination is a feeling of bloating from the air introduced during the examination. Some patients also have a mild sore throat.
Most patients are able to eat a few hours after the examination. Many patients are tired afterwards or have difficulty concentrating (from the anesthesia) so it is usually advised not to return to work or drive that day. The first meal after ERCP should be light but most patients can eat their usual diet by the next day.
The endoscopist can usually tell the patient the results of their examination, but the effect of the anesthetic may cause the patient not to remember this discussion. If biopsies were taken the patient will be instructed to call back for results. Tissue removed is sent to a lab for analysis and it may take one to two weeks to receive the results. The endoscopy team can give guidelines about when the results will be available and whether further treatment will be necessary.
Serious complications are not common, but can occur:
- Pancreatitis (inflammation of the pancreas, an organ in the back of the abdomen) occurs in about 3 to 5 percent of people undergoing ERCP. When it occurs, it is usually mild, causing abdominal pain and nausea, which resolves after a few days in the hospital. Much less commonly, pancreatitis can be a severe and even life-threatening condition. (See “Patient information: Acute pancreatitis”).
- Aspiration of food or fluids into the lungs, the risk of which can be minimized by not eating or drinking for several hours before the examination. Aspiration can lead to pneumonia, but this is less likely to occur if the stomach is empty.
- The ERCP scope or other instruments can cause a tear or hole in the tissue being examined. This is a serious condition, but fortunately occurs very uncommonly.
- Bleeding can occur from biopsies or from a cut into the ampulla, but it is usually minimal and stops quickly by itself or can be controlled. Patients should let their endoscopist know if they have a bleeding disorder.
- Reactions to the medicines used for sedation; the endoscopy team (doctors and nurses) will ask about previous medication allergies or reactions and about health problems such as heart, lung, kidney, or liver disease. Providing this information to the team ensures a safer examination.
- The medications can also produce irritation in the vein at the site of the intravenous line. If redness, swelling, or warmth occur, warm to hot wet towels applied to the site may relieve the discomfort. If discomfort persists, notify the endoscopy unit.
- Infection is rare, but can occur.
If the doctor suspects complications, or if a drainage tube is placed into a duct or an incision made into the ampulla, the patient may be hospitalized overnight for observation.
After an ERCP, the following problems should be reported to us immediately:
- Severe abdominal pain (not just gas cramps)
- A firm, distended abdomen
- Difficulty swallowing or a severe sore throat
- A crunching feeling under the skin