ERCP is short for…Endoscopic Retrograde Cholangio Pancreatography
Endoscopic refers to the use of an instrument called an endoscope - a thin, flexible tube with a tiny video camera and light on the end. The endoscope is used by a highly trained subspecialist, the gastroenterologist, to diagnose and treat various problems of the GI tract. The GI tract includes the stomach, intestine, and other parts of the body that are connected to the intestine, such as the liver, pancreas, and gallbladder.
Retrograde refers to the direction in which the endoscope is used to inject a liquid enabling X-rays to be taken of the parts of the GI tract called the bile duct system and pancreas.
The process of taking these X-rays is known as cholangiopancreatography. Cholangio refers to the bile duct system, pancrea to the pancreas.
ERCP may be useful in diagnosing and treating problems causing jaundice (a yellowing of the whites of the eyes) or pain in the abdomen. To understand how ERCP can help, it’s important to know more about the pancreas and the bile duct system.
Bile is a substance made by the liver that is important in the digestion and absorption of fats. Bile is carried from the liver by a system of tubes known as bile ducts. One of these, the cystic duct, connects the gallbladder to the main bile duct. The gallbladder stores the bile between meals and empties back into the bile duct when food is consumed. The common bile duct then empties into a part of the small intestine called the duodenum. The common bile duct enters the duodenum through a nipple-like structure called the papilla.
Joining the common bile duct to pass through the papilla is the main duct from the pancreas. This pathway allows digestive juices from the pancreas to mix with food in the intestine. Problems that affect the pancreas and bile duct system can, in many cases, be diagnosed and corrected with ERCP.
For example, ERCP can be helpful when there is a blockage of the bile ducts by gallstones, tumors, scarring or other conditions that cause obstruction or narrowing (stricture) of the ducts. Similarly, blockage of the pancreatic ducts from stones, tumors, or stricture can also be evaluated or treated by ERCP, which is useful in assessing causes of pancreatitis (inflammation of the pancreas).
Problems with the bile ducts or pancreas may first show up as jaundice or pain in the abdomen, although not always. Also, there may be changes in blood tests that show abnormalities of the liver or pancreas.
Other special exams that take pictures using X-rays or sound waves may provide important information for use along with that obtained from ERCP.
The endoscope does not cause problems with breathing unless you have lung or heart problems
Before the Procedure
Regardless of why ERCP has been recommended for you, there are important steps you can take to prepare for and participate in the procedure.
To properly prepare for your procedure, you may need to make certain changes to your daily medication routine.
- If you take insulin or diabetic tablets, consult with your physician about making any necessary changes in you daily regimen.
- You must tell your doctor what drugs you are taking, particularly: Aspirin products, Arthritis drugs, Blood thinners eg. Warfarin (anticoagulants). It may be necessary to stop taking them seven days before your procedure. They may increase your risk of bleeding after removal of a polyp or a biopsy during your upper GI endoscopy by interfering with the normal clotting of your blood. IF YOU ARE TAKING COUMADIN OR HEPARIN, YOU MUST CHECK WITH YOUR PRESCRIBING PHYSICIAN BEFORE CHANGING OR INTERRUPTING YOUR DAILY ROUTINE.
- Certain medications should be continued prior to your upper GI endoscopy. If you take cardiac (heart) or anti-hypertensive (high blood pressure) pills, take them as you normally do with small sips of water.
In addition to changes to your medication, you'll also need to:
- Bring a list of all your medications (prescription medications, over-the-counter medications and eye drops) with you on the day of your procedure. You may bring the medication bottles themselves.
- Be prepared to list and describe your ALLERGIES and REACTIONS to any medications.
Tell the doctor if you have: a pacemaker, a joint replacement, heart, lung or other medical conditions that may need special attention .
Tell your doctor if you have to take antibiotics before dental treatment. If so, you may also need antibiotics before an upper endoscopy
Because you will receive a relaxing medication during your procedure, you must arrange to have a responsible adult pick you up and/or accompany you home if you taking public transportation. You may not operate an automobile or other mechanical equipment until the day following your procedure.
Preparation for the Procedure
You must not eat or drink anything for at least six hours before the procedure. Ideally you must not eat or drink anything after midnight the night before your procedure. Food in the stomach will block the view through the endoscope and it could cause vomiting. ERCP can be done either as an outpatient procedure or may require hospitalization, depending on the individual case. The exception is medication taken with small sips of water.
During the Procedure
- On the day of your ERCP, please come directly to the requseted location at your scheduled arrival time and check in with the receptionist. Plan to spend several hours at the unit to allow time for your preparation, your procedure, and your recovery.
- Before the procedure, a nurse will greet you and assist you with changing into a hospital gown. An IV will be placed in your arm. You will receive relaxing medications through the IV during the procedure.
- Everything will be done to ensure your comfort. Your blood pressure, pulse, and the oxygen level in your blood will be carefully monitored. A sedative will be given through a vein in your arm. You will feel drowsy, but will remain awake and able to cooperate during the procedure.
- Although general anesthesia is usually not required, you may have the back of your throat sprayed with a local anesthetic to minimize discomfort as the endoscope is passed down your throat into your esophagus (the swallowing tube), and through the stomach into your duodenum.
- The doctor will use it to inspect the lining of your stomach and duodenum. You should not feel any pain, but you may have a sense of fullness, since air may be introduced to help advance the scope.
- In the duodenum, the instrument is positioned near the papilla, the point at which the main ducts empty into the intestine. A small tube known as a cannula is threaded down through the endoscope and can be directed into either the pancreatic or common bile duct. The cannula allows a special liquid contrast material, a dye, to be injected backwards - that is, retrograde - through the ducts.
- X-ray equipment is then used to examine and take pictures of the dye outlining the ducts. In this way, widening, narrowing, or blockage of the ducts can be pinpointed.
- Some of the problems that may be identified during ERCP can also be treated through the endoscope. For example, if a stone is blocking the pancreatic or common bile duct, it is usually possible to remove it.
- First, the opening in the papilla is cut open and enlarged. Then, a special device can be inserted to retrieve the stone. Narrowing or obstruction can also have other causes, such as scarring or tumors. In some cases, a plastic or metal tube (called a stent), can be inserted to provide an opening. If necessary, a tissue sample or biopsy can be obtained, or a narrow area dilated.
- Extra procedures that might become necessary during the procedure include:
- Biopsy (sample of tissue)
- Sphincterotomy (cutting incision into the bile duct)
- Dilatation of the bile duct (by a stent or a balloon)
- Insertion of a stent (drainage tube)
- Blood transfusion
Risks of this Procedure
Thanks to ERCP, these kinds of procedures may help you avoid surgery. Depending on the individual and the types of procedures performed, ERCP does have a five to ten percent risk of complications. In rare cases, severe complications may require prolonged hospitalization.
Mild to severe inflammation of the pancreas is the most common complication and may require hospital care, even surgery. Bleeding can occur when the papilla has to be opened to remove stones or put in stents. This bleeding usually stops on its own, but occasionally, transfusion may be required or the bleeding may be directly controlled with endoscopic therapy.
A puncture or perforation of the bowel wall or bile duct is a rare problem that can occur with therapeutic ERCP. Infection can also result, especially if the bile duct is blocked and bile cannot drain. Treatment for infection requires antibiotics and restoring drainage. Finally, reactions may occur to any of the medications used during ERCP, but fortunately these are usually minor.
Be sure to discuss any specific concerns you may have about the procedure with your doctor.
After the Procedure
When your ERCP is completed you will be cared for in a recovery area until most of the effects of the medication have worn off.
When your ERCP is completed on an outpatient basis, you will need to remain under observation until your doctor or healthcare team has decided you can return home. Sometimes, admission to the hospital is necessary.
Your doctor will tell you when you can take fluids and meals. Usually, it is within a few hours after the procedure.
Because of the air used during ERCP, you may continue to feel full and pass gas for awhile, and it is not unusual to have soft stool or other brief changes in bowel habits. However, if you notice bleeding from your rectum or black, tarry stools, call your doctor.
For your safety you must:
Be taken home by a responsible person
- Have a responsible adult care for you that day/night or be on hand in case of any problems
- Not drive a car or motorcycle (this is against the law) or operate machinery until the following day or for as long as your doctor or anaesthetist advises
- Not make any important decisions or sign any contracts within 24 hours of the procedure (the medication used may impair judgement)
- Not drink any alcohol for 24 hours post procedure
- Not drink any alcohol for 24 hours post procedure
Tell your doctor immediately if you:
- Feel generally ill with or without headache, chills or muscle aches
- Have a high temperature/fever
- Have trouble swallowing or severe abdominal pain
- Are dizzy, short of breath or feel faint or dizzy
- Start to get sharp pains in the throat, chest or stomach or begin vomiting
Your doctor will explain the results of the examination to you or arrange for you to come back to hospital and talk to you about the results.