Endoscopic Retrograde Cholangio Pancreatography (ERCP)

Before your appointment

All medications should be taken as normal with a little water.

• If you take Warfarin or Clopidogrel or other blood thinning medication please contact the endoscopy nurses when you receive this information on 01223 216515. You may need to stop your medication prior to your procedure. If you take Aspirin only please continue.
• If you have implanted cardiac device such as a Pacemaker or Implanted Cardioverter Defibrillator please contact the endoscopy unit on 01223 216515.
• If you have any questions about the procedure or find that you cannot keep this appointment, please contact the endoscopy office between 9:00 and 17:00 Monday to Friday on 01223 257080.

On the day

• Have nothing to eat for six hours and nothing to drink for four hours before your appointment.
• Please ensure you have arranged an escort home. We cannot sedate you if you do not provide details of your escort

At the hospital

• Please come to the endoscopy department on level 3 of the Addenbrooke’s Treatment Centre (ATC).
• Use the ‘Car Park 2’. The car park is busy early in the morning; please allow yourself enough time to arrive in time for your appointment. Take your parking ticket to the Endoscopy reception desk to have your ticket stamped; this will enable you to have discounted parking.
• Please note you need to arrive 30 minutes prior to your appointment time for your pre procedure check. The length of time you will be here will vary enormously but may be anything from two to four hours or more. Please ask your admitting nurse for further information during your admission check.
• You may be required to stay overnight in hospital, please ensure you bring anything required for an overnight stay in hospital.

What is an ERCP?

Your doctor has requested this procedure to help investigate your medical condition to aid your diagnosis and management. ERCP stands for 'endoscopic retrograde cholangio-pancreatography'. It is a procedure that allows the endoscopist to examine the tubes that drain bile from your liver and gall bladder and digestive juices from the pancreas.

Bile is made in the liver, which is in the upper right part of the abdomen. Bile passes from liver cells into tiny tubes called bile ducts; these join together like the branches of a tree. Bile constantly drips down the bile duct into the duodenum (the first part of the gut after the stomach). Bile helps to digest food, particularly fatty foods.

The gallbladder lies under the liver on the right side of the upper abdomen. It is like a pouch which comes off the bile duct. It is a 'reservoir' which stores bile between meals. It contracts (squeezes) when you eat, empting stored bile back into the bile duct.

The pancreas is a large gland that makes enzymes (chemicals); these enzymes flow into the duodenum. The pancreatic enzymes are vital to digest food.

Jaundice, which is yellowing of the skin and urine, occurs when the tubes draining the bile become blocked. ERCP procedures are undertaken to relieve this condition.

A duodenoscope is used; this is a flexible tube thinner than your index finger with a light at the end. It is passed into the mouth, through the stomach to the duodenum to find the small opening (called Ampulla of Vater) where the bile and digestive juices drain into the intestine. A tube is passed through the duodenoscope and up into the Ampulla so that contrast (dye that can be seen on an x-ray) can be injected. X-rays are then taken.

Sometimes we need to make a small cut in the Ampulla so that gallstones which are stuck in the bile duct can be removed; this is called a sphincterotomy and is painless.

In other cases we need to put a tube called a stent into an area where the bile duct is blocked to allow the bile to drain.

Sometimes it is helpful to take a biopsy - sample of the lining of the ducts. This is done by passing a small instrument called forceps through the duodenoscope to ‘pinch’ out a tiny bit of the lining (about the size of a pinhead) which is sent to the laboratory for analysis.

These procedures usually take about 15 minutes but times vary considerably. If it takes longer, you should not worry.

Getting ready for the procedure

Wear loose fitting washable clothing and leave valuables at home.

On arrival to the department

Please register your arrival with the receptionist, they will ask for your pre-procedure questionnaire. Some patients may arrive after you but be seen quicker; we have seven procedure rooms all undertaking different procedures therefore patients are not seen in arrival order.

Before your procedure you will meet one of the nurses who will ask you some health questions and explain the procedure to you.

Once this is completed, you will be escorted to a single sex changing area. You are able to wear your own clothes for this procedure. Your escort cannot wait with you from this point and can leave the department until you are ready to go home.

You can change your mind about having the procedure at any time.

Sedatives

ERCP is performed under sedation. You can also be offered anaesthetic throat spray so that you are as comfortable as possible during the procedure.

This will be administered via a plastic tube called a cannula which is inserted into a vein, and will make you feel relaxed and sleepy but not unconscious (this is not a general anaesthetic). This option means you may not be aware of the procedure. As you will require sedation, if you are going home:

• You will need to stay whilst you recover which may take up to an hour or more.
• You will need to be escorted home; your procedure will be cancelled if you do not have an escort.
• The injection will continue to have a mild sedative effect for up to 24 hours and may leave you unsteady on your feet for a while.

What happens during the procedure?

You will be collected from the changing room by the endoscopist and taken to a private bay to complete your consent form, when this has been completed they will escort you to the procedure room. The team in the procedure room will introduce themselves and ask you some questions; this is to confirm you are ready and prepared to continue with the procedure.

In the procedure room, we will ask you to remove false teeth, glasses and hearing aids in the left ear. We will make you comfortable on the x-ray table lying on your left side with your left arm behind your back. The endoscopist will give you the injection or throat spray. We will put a plastic guard into your mouth so that you do not bite and damage our instrument. We will also put a plastic ‘peg’ on your finger to monitor your pulse and oxygen levels. For your comfort and reassurance, a trained nurse will stay with you throughout.

As the tube is gently passed through your mouth you may gag slightly; this is quite normal and will not interfere with your breathing. During the procedure some air will be put in to your stomach so that the endoscopist will have a clear view. This may make you burp and belch a little, some people find this uncomfortable. Please note, however, that you should generally not be aware of the procedure because of the sedative drugs administered beforehand.

Minimal restraint may be appropriate during the procedure. However if you make it clear that you are too uncomfortable the procedure will be stopped.

Occasionally it is not possible to complete the procedure. This may be due to difficulty passing the endoscope through the stomach, difficulty gaining access to the bile duct or because of a problem in the bile duct that cannot be surpassed. The endoscopist will weigh up whether to persevere depending on the clinical need although safety is paramount.

Potential risks

This procedure involves x-rays; if you are pregnant, you should not have this procedure.

ERCP procedures carry a very small risk (5 in 1000 cases) of haemorrhage (bleeding) or perforation (tear).

If a cut is made into the bile duct there is a risk of 1 in 50 of significant bleeding. This can be treated straight away through the duodenoscope and rarely is a major complication, however if it is severe sometimes blood transfusion or surgery is needed.

Occasionally inflammation of the pancreas (pancreatitis) may develop (1 in 20); it can be painful and usually requires you to stay in hospital for a few days for intravenous fluids and painkillers. On very rare occasions, it may be more severe than this.

There may be a slight risk to crowned teeth or dental bridgework and you should tell the endoscopist if you have any of these.

Other rare complications include aspiration pneumonia (inflammation of the lungs caused by inhaling or choking on vomit) and adverse reactions to intravenous sedative drugs and, when used, antibiotic treatment.

You can be reassured that your doctors will only have recommended ERCP if the benefit to you from the procedure clearly outweighs these small risks.

After the procedure

We will take you to a recovery area while the sedation wears off. An intravenous antibiotic may be administered if the endoscopist feels this is appropriate. When you are sufficiently awake, we will give you a drink before you get dressed. You can then go home; this may be up to two hours following the procedure.

If you are being discharged from hospital we advise you not to drive, operate machinery, return to work, drink alcohol or sign legally binding documents for a 24-hour period after the procedure. We also advise you to have a responsible adult to stay with you for the next 12 hours. You can eat and drink as normal.

If you need to be admitted to a ward overnight, one of the nurses will escort you to the ward once a bed is available for you.

The back of your throat may feel sore for the rest of the day. You may also feel bloated if some air remains in your stomach. Both these discomforts will pass and need no medication.

We will always do our best to respect your privacy and dignity, e.g. with the use of curtains. If you have any concerns, please speak to the department sister or charge nurse.

When will I know the result?

The endoscopist or endoscopy nurse will tell you about the procedure in the recovery area when you are awake. If you would like more privacy, we will take you to a private room.

The endoscopist (particularly if admitted via the day-case ward) or the medical team looking after you will be able to inform you before you leave hospital. The result, as a written report, will be filed in your electronic notes before you leave the endoscopy department so the information is immediately available for the medical team on your ward.

The sedation can affect your ability to remember any discussion. If you would like someone with you when you talk to the endoscopist or endoscopy nurse please inform the nurse looking after you who will arrange for you to be seen in a private room with your escort when they arrive.

Details of the results and any further treatment should be discussed with the doctor who recommended you have this procedure. Usually, follow up arrangements are established before you leave hospital.

After discharge

We will provide you with an information sheet on discharge which will detail who to contact if you require any assistance after your procedure.

Alternatives

There are no real alternatives to therapeutic ERCP. In some cases, depending on individual factors such as the symptoms present and the condition being investigated, alternatives may be:

• Magnetic resonance cholangio-pancreatography (MRCP) – diagnostic only.
• Percutaneous transhepatic cholangiography (PTC) – through the skin and can sometimes be therapeutic in itself or to assist ERCP if failed.

For more information:

• Contact the endoscopy office between 09:00 and 17:00 Monday to Friday on 01223 216546.