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Endoscopic Retrograde Cholangio-Pancreatography

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Endoscopic Retrograde Cholangiopancreatography (ERCP)

What is an Endoscopic Retrograde Cholangiopancreatography (ERCP)?

An ERCP is a procedure used to diagnose and treat diseases of the gallbladder, bile ducts, pancreas, and liver. ERCP combines endoscopy and x-ray in order to gain access to bile ducts and pancreas to create detailed “road maps” and then use tiny instruments to fix problems found there.

How do I prepare for my procedure?

Your health care professional usually provides written instructions about how to prepare for ERCP. To begin, the upper GI tract must be empty. Generally, food is stopped 8 hours ahead and all liquids held for at least 2 hours. Patients should tell their clinician about all health conditions they have, especially heart and lung problems, diabetes, and allergies. A complete list of medicaitons and supplements is reviewed. You may be asked to temporarily stop taking medications that affect blood clotting or adjust other medications.

How is the procedure performed?

To begin, patients usually arrive at the outpatient endoscopy unit of a hospital, where a nurse will have you change into a hospital gown and start an IV. Sometimes limited blood tests are checked. Typically an anesthesia professional sees you and discusses the deep sedation medication (usually propofol) that will be given to keep you comfortable and unaware of the procedure. Sometimes an antibiotic is given. Doctors and other medical staff monitor vital signs while patients are asleep. Radiology equipment is prepared. During ERCP, patients lie on their back or side on an x-ray table. The doctor guides an endoscope down the esophagus, through the stomach, and into the duodenum. Video is transmitted to a monitor within the doctor’s view. When the doctor locates the small bile duct opening, a catheter is slid through the endoscope and guided into the ducts, contrast dye injected and this allows the duct systems to be seen. Based on what is then diagnosed, different procedures may be performed. Gallstones might be removed after cutting open the tiny ductal opening to make it wide enough (this is called sphincterotomy). Tumors or narrowings might be biopsied or cell samples taken (cytology). Strictures (blockages) might be dilated with ballon catheters. Plastic or metal stent tubes might be placed and left in place after the ERCP, to allow bile or pancreas juice to drain where a blockage has stopped their flow. Occasionally, ERCP is done after gallbladder surgery, if a surgical bile leak is suspected, to find and stop the leak with a temporary stent. These delicate “surgical” procedures all performed through an endoscope require our “therapeutic endoscopists” can maintain advanced endoscopic training and ongoing training in the newest techniques to a very high level of skill.

What can I expect after my procedure?

After the ERCP, patients are moved to a recovery room. Sedation gradually wears off. Sometimes patients may not remember initial conversations with health care staff, as the sedatives reduce memory of events during and right after the procedure. During recovery, patients may feel bloated or sometimes have nausea, which can be treated. Patients may also have a sore throat, which can last a day or two. Outpatients usually go home after the procedure, though after complex procedures may need to stay overnight for observation. Patients will likely feel tired and should plan to rest for the remainder of the day. Diet and medication instructions will be given.

When will I know the outcome of the ERCP?

Some ERCP results are available immediately after the procedure. Biopsy results are usually ready in a few days. Your doctor ordinarily will try to talk to you when you’re awake enough to recall the conversation, otherwise reaches you by phone for further discussion. If office followup is needed, you would be told when to seek an appointment.

How long does the ERCP take?

The ERCP takes from 30 minutes to 2 hours. After the procedure, you may need to stay at the hospital for 1 to 2 hours until the sedative wears off.

What precautions are taken to avoid infection from the duodenoscope used in ERCP?

In 2015, media widely reported a problem we’ve known of for a long time, namely that tiny hidden parts of the ERCP duodenoscope equipment can be hard to sterilize and so can rarely can result in an infection in a person who didn’t start out with one. In 2015 this became a more publicized issue when a very resistant bacteria (called CRE) turned up in a very tiny percent of people having ERCP. Eventually the scopes may be redesigned to eliminiate this problem, but in the meanwhile more strict sterilizing procedures are being followed by all quality centers where ERCP is done, including all of our centers, to minimize the chance of this risk. THIS PROBLEM DOES NOT EXIST FOR ROUTINE COLONOSCOPY AND UPPER ENDOSCOPY because these scopes don’t have these tiny recesses, but ALL endoscopic procedures involve meticulous techniques to disinfect scopes and we always follow all manufacturer and FDA, CDC recommendations to maintain optimal safety.

What are the risks involved with a ERCP?

Significant risks associated with ERCP include:

  • Infection, most commonly from bacteria already present in the bile ducts when they are blocked up. Relieving the blockage helps relieve infection.
  • Pancreatitis, a potentially VERY serious inflammation in the pancreas, which is usually mild when it occurs but can still cause a hospital stay of a few days to resolve. The most serious and potentially fatal ERCP complications are the complications of pancreatitis when a case becomes severe, which fortunately is very infrequent. All precautions possible are taken to avoid this happening
  • adverse reactions to sedatives, usually quite minor or brief
  • excessive bleeding, called hemorrhage, which is usually obvious right at the time and is treated, but sometimes is evident only after you’ve returned home (vomiting dark/black material or passing black tarry stools or blood clots in stool).
  • puncture of the GI tract or ducts, also rare but very serious potentially
  • death, in rare circumstances

When an experienced doctor performs ERCP, complications occur in about 6 to 10 percent of patients and these often require hospitalization. Patients who experience any of the following symptoms after ERCP should contact their health care provider immediately:

  • swallowing difficulties
  • throat, chest, or abdominal pain that worsens
  • vomiting
  • bloody or dark stool
  • fever

What are my alternatives to this procedure?

Radiologists sometimes perform invasive needle catheter procedures to gain access to bile ducts or obtain biopsies of deep tumors. Abdominal surgery to treat gallstones stuck in the duct system was the older method of treatment before ERCP became reliable and most always successful; the surgical procedure requires significant hospital stay and has more potential complications. NOT doing a recommended ERCP can result in death from infection, liver failure or serious progression of tumors if suspected.

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