ERCP
ERCP ('Endoscopic Retrograde Cholangiography and Pancreatography')*
Endoscopic removal of gallstones and insertion of stents to open up bile and pancreatic ducts
*NHS practice only
What this test involves
ERCP (understandably shortened from its full name given above) is a means of accessing the tubes (ducts) that drain the liver and the pancreas using an endoscope introduced through the mouth.
The type of endoscope (shown opposite) differs from other types of endoscopic instruments (such as in the picture above) in that the camera points sideways rather than out of the end. The reason for this is that the opening of the liver and pancreas ducts is on the sidewall of the upper small intestine (duodenum) and is not easily visualised using a gastroscope.
In the X-ray image at the bottom of this page, the endoscope itself is seen, and the normal ducts draining the liver (top left) and pancreas (to the right and below the scope) are shown opacified with contrast that shows up on the X ray. The cystic duct that drains the gallbladder is also shown.
Given the significant advances in imaging technology such as 'MRI', ERCP is nowadays only used for therapeutic purposes - commonly removing gallstones that have spilt out of the gallbladder and into the tubing draining the liver, or placing 'stents' (metal or plastic tubes) that open up ducts that are blocked, for instance by cancer.
In order to access the ducts, it is often necessary to make a small cut - called 'sphincterotomy' in the muscle that closes off their lower end as they join the intestine. This cut is only a few mms long and is painless as there are no pain receptors at this site.
The procedure is carried out under good sedation in order to make sure that it can be completed successfully and comfortably.
Risks and safety
ERCP is the endoscopic procedure that carries the most risk of complications and we therefore carefully consider the balance of risks and benefits before undertaking it. Nevertheless, over 95% of patients experience no adverse events after ERCP.
Adverse events have been described to occur 2-5 in every 100 cases. Whilst most are mild and can be managed conservatively (without surgery) serious complications can occur.
- As the camera passes through a mouthguard placed between the teeth, there is a risk of a sore throat for a day or so afterwards, and of damage to loose or wobbly teeth.
- Intravenous sedation carries a risk of impaired breathing and inhalation of stomach contents (hence we recommend that you are starved prior to the procedure). The sedatives used are short acting and have safe reversal agents. We monitor your oxygen levels and provide additional oxygen throughout the procedure in order to reduce any associated risks of sedation.
- The serious complications include perforation and bleeding as for other endoscopic procedures, but in the case of ERCP the risk of bleeding is higher, and there is an additional risk of causing pancreatitis (inflammation of the pancreas):
- Perforation - where the instrument accidentally passes through the wall of the organ - can occur in the throat, the oesophagus, stomach or duodenum. It is reported in around 1:1000. It can often be managed by clipping or closing the hole at the time, but may require a stay for observation in hospital and in rare circumstances may require surgery.
- Bleeding is described in about 1 in 100 cases but significant bleeding is rare and can usually be managed by treating through the endoscope but may require an X-ray procedure or surgery in very rare circumstances.
- Pancreatitis occurs in around 3-4 cases in every 100 and can require a stay in hospital for treatment. usually mild, in severe cases it can lead to long-term consequences.
Instructions and preparation for the test
You will be asked to attend the endoscopy department having not had anything to eat or drink for at least 6 hours prior to the time of the procedure. This ensures that your stomach is empty. It is quite alright to take essential medications with a small amount of water if necessary.
We will often (if it safe to do so) insert a suppository of an anti-inflammatory drug called indomethacin into the bottom prior to the procedure as this reduces the risk of developing pancreatitis afterwards.
We will discuss the procedure in detail with you on the day and answer any questions you may have, prior to asking for your consent to proceed.
Please make sure that you inform us prior to the procedure about:
- Medications - especially any medications that thin the blood ('anticoagulants') , or for diabetes
- Any severe cardiac or respiratory condition including a pacemaker device.
- Any allergies that you may have to medications (our procedures are latex-free).
- Any loose teeth, dentures, plates or crowns that might be at risk during the procedure.
SEE IMAGES BELOW
After the procedure
You will be taken to a recovery area (if you have had sedation) for us to monitor your blood pressure and oxygen levels whilst the sedation wears off. This can take a few minutes to half an hour or so.
If we have carried out any interventions such as a 'sphincterotomy' you will be monitored with regular measurements of your temperature, oxygen levels, blood pressure and pulse for four hours before we allow you to drink or eat. You will have an intravenous drip to provide fluids over this time.
Most complications such as perforation, bleeding or pancreatitis become apparent during this 4 hour observation period and it is safe to go home if you are well at the end of this time.
We would recommend that you do not use heavy machinery, drive a car or sign important documents for 24 hours after the procedure.
You will be informed of the outcome of the procedure when you are awake.
If you experience any significant symptoms within the hours or days after the test - including pain, fever, shivering, vomiting blood or passing black bowel motions then please contact the unit immediately for further advice - they will put you in touch with me.
