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ERCP: Endoscopic retrograde cholangio pancreatogram

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An ERCP is an examination that uses an X-ray and a camera. 

During the procedure, a flexible tube (endoscope) with a camera on the end is put into your mouth, down your food pipe (oesophagus) and into your stomach and the first part of your small intestine.

An ERCP is used to look at, or treat, conditions of your biliary system.

Your biliary system includes the:

  • liver
  • gall bladder
  • pancreas
  • pancreatic ducts
  • bile ducts

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What is an ERCP?

An ERCP uses a camera, guided by an X-ray, to look at your biliary system. 

It can give more information about your pancreas and bile ducts.

The doctor can also take samples of your cells through brushings or biopsies during an ERCP. These will be examined in the laboratory to help diagnose any problems you are having.

You might have an ERCP if you have:

  • yellow skin, eyes and itchy skin (jaundice)
  • liver blood tests that need more investigation, and you have tummy (abdomen) pain
  • had a CT or ultrasound scan that shows a blockage in your bile duct or pancreatic ducts

Blockages can be caused by stones, narrowing of the bile duct, and growths or cancer of the pancreas or bile duct.

An ERCP can also be used to offer treatment to both the bile duct and the pancreas, especially to treat jaundice. This is a less invasive option than open surgery. 

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Having a stent during an ERCP

During an ERCP, small plastic or metal tubes called stents can be put into the bile duct.

This allows the bile blocking the bile duct to drain into the intestine.

Stents can also be put into the small intestine (duodenum). This helps people who have a blockage affecting the flow of food out of their stomach. 

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Risks of an ERCP

ERCP is generally safe, but there can sometimes be complications.

Your doctor will talk about all the risks with you before the procedure.

Although there are some risks, you will only have an ERCP if your doctor believes the possible risks of doing the procedure are better than doing another procedure, or doing nothing.

Possible minor complications

  • Mild discomfort in the tummy (abdomen), which might last a few days
  • A sore throat, which might last a few days.
  • Loose teeth, crowns and bridgework can move or fall out when the tube is put into your mouth. This does not happen often.
  • An ERCP can lead to inflammation of the pancreas (pancreatitis). This happens in about 5 in every 100 people having an ERCP. If you have pancreatitis you will have pain in your tummy (abdomen), which usually starts a few hours after the procedure and lasts for a few days. The pain can be controlled with painkillers. You will also be given fluids into a vein (intravenously) in hospital, to keep you hydrated.
  • In some cases, the doctor cannot get to the bile duct or pancreatic ducts to do the ERCP.
  • You might have a sore lump for a few days. This is due to irritation of the vein where medicine was given for the procedure. This is not common.

Possible major complications

  • Some people might get severe pancreatitis after an ERCP. This can be treated with medicine, or surgery. Although it is very rare, severe pancreatitis can be fatal in less than 1 in 500 cases.
  • Infection in the bile duct (cholangitis). Your doctor might suggest a course of antibiotics to treat the infection. You might have antibiotics in hospital, or at home.
  • If you had a small cut made in the bottom of the bile duct (a sphincterotomy) during an ERCP, there is a risk of bleeding. This usually stops quickly without treatment. If it does not stop by itself, you might have an injection of adrenaline through the endoscope tube. However, in severe cases, a blood transfusion, a special X-ray procedure or surgery might be needed to control the bleeding.
  • Very frail or elderly people can get pneumonia (swelling of the lung tissue) after the procedure. This is due to stomach juices getting into the lung. This happens in about 1 in 500 cases.
  • A hole might be made through the small intestine during an ERCP. This might be a sphincterotomy, or due to a tear made by the endoscope. This happens in less than 1 in 750 cases. You might need surgery to repair the hole. This can be serious, and sometimes fatal.  

Other treatment options

The only other treatment option is a percutaneous trans-hepatic cholangiogram (PTC). This is a procedure that puts a needle through the skin and into the liver. An X-ray is then used to look at the bile ducts. However, there are more complications with a PTC.

There are other options for diagnosing problems with your biliary system. However, the options below cannot be used to treat the problem, like an ERCP can. 

  • A CT scan can be used, but this is less sensitive and small growths (less than 1cm) can be missed. You also cannot get samples (biopsies) during a CT scan, or put a stent in to treat the problem.
  • An MRI scan can be used, but this does not allow direct vision of the bile ducts. You also cannot get samples (biopsies) during an MRI scan, or have a stent put in.
  • An ultrasound scan can give images of the biliary system. However, you cannot have a biopsy, or a stent put in during this scan.
  • An endoscopic ultrasound (EUS) can be used. However, you cannot make a cut (sphincterotomy) at the bottom of the bile duct during an EUS. 

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  • Asking for your consent

     

    We want to involve you in decisions about your care and treatment. If you decide to go ahead, you will be asked to sign a consent form to say that you agree to have the treatment, and you understand what it involves. If you would like more information about our consent process, please speak to a member of staff caring for you

Preparing for an ERCP

  • You will have a blood test to check the clotting of your blood, and your blood count.
  • It is important that you do not eat or drink any solid food for 6 hours before your procedure. This is so the doctor has a clear view with the camera. 
  • You can drink only water up to 3 hours before.
  • You will usually be given an antibiotic to take 1 hour before the ERCP. You can swallow this with a small amount of water.
  • If you are having sedation, and are going home within 24 hours, you must have someone to take you home and stay with you overnight. They must be over 18 years old. They should come with you for the appointment, or be contactable by phone when you are ready to leave.

If you do not have someone to take you home and stay with you overnight, your procedure might be cancelled.

If you cannot arrange for someone to collect you, please contact us to discuss alternative arrangements.

Your usual medicines

You will have chance to talk about any medicines you are taking with a doctor or nurse before your procedure.

  • Let them know if you are taking any regular medicines. This includes anything you buy yourself over the counter, or any herbal or homeopathic medicines.
  • Tell your doctor or nurse if you have any allergies to any medicines. 
  • Tell your doctor or nurse if you are taking antiplatelet or anticoagulant medicines to thin your blood or to prevent blood clots (such as, aspirin or clopidogrel, warfarin, rivaroxiban or dabigatran). You might need to stop taking these medicines for a short time before your procedure. 
  • Tell your doctor or nurse if you have diabetes, as you might need to change the dose of your diabetes medicine when you do not eat or drink for a short time (6 hours) before the ERCP.
  • You should keep taking all your medicines as usual, unless you have been told otherwise by the doctor or endoscopy nurse.

More information on stopping any medicines will be given to you when you come for pre-assessment appointment.

If you have any questions about any of your medicines, please talk to your medical team.

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When you arrive at the endoscopy unit

  • On arrival, please give your name to the receptionist.
  • You will be asked to wait in the waiting area until you are seen by an endoscopy nurse.
  • The nurse will ask you about your medical history. Please tell the nurse if you have had any reactions or allergies to other procedures or medicines in the past.
  • You will be asked to take off your jewellery. This is because you should not wear any metal during the procedure.
  • You might wish to leave any valuable jewellery at home, as we cannot be responsible for any valuables lost while in the unit.
  • You will be asked to remove all of your clothing and change into a gown and some disposable underwear.
  • You might want to bring your own dressing gown and slippers with you (we do supply non slip socks).
  • Once you are ready, you will be taken to the second waiting area, signposted ‘sub wait area.’
  • Your doctor will explain more about the procedure and answer any questions you have.

Waiting times

Our endoscopy teams run up to 5 procedure rooms at the same time. Therefore, a person who arrived after you, might be called in before you.

This does not mean you have been forgotten, but that the other person is on a different list to you.

We do everything we can to avoid you waiting any longer than necessary. However, because every procedure takes a different length of time, sometimes it is hard to give exact timings.

We will update you on how long you are likely to be with us.

Please be prepared to be with us for the whole morning or afternoon, depending on when your appointment time is. 

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During an ERCP

You will usually be given an antibiotic 1 hour before your procedure. You can swallow this with a small amount of water.

The procedure will take between 15 minutes to 1 and a half hours. The average time is 30 minutes.

  1. A nurse will attach monitors to one of your fingers. These record your pulse, oxygen level, blood pressure and heart rhythm.
  2. You might be given a local anaesthetic throat spray to help to numb your throat.
  3. You will need to lie on your left side.
  4. A plastic mouth guard will be placed in your mouth. This allows the tube to pass through your mouth.
  5. Oxygen to be given to you throughout the procedure.
  6. You will be given an injection of sedation and a painkiller through a small needle in your arm or the back of your hand. This will relax you and make you sleepy, but will not put you to sleep.
  7. You can hear what is said to you, and respond to any instructions given to you. A nurse will sit by your head and monitor you for the whole procedure.
  8. Once you are sleepy, a flexible tube (endoscope) with a camera on the end will be passed down your mouth, and into your stomach or the first part of your small intestine. 
  9. The doctor will put a fine wire through the endoscope into the bile ducts. 
  10. The doctor will inject a dye through the tube. The dye helps the biliary system (such as your bile duct) be seen on X-ray.
  11. X-rays of various parts of your biliary system will be taken.

If an ERCP is being done to remove stones from the bile or pancreatic duct, a small cut (sphincterotomy) might be made in the lower end of the bile duct to allow a fine tube to pass through. This allows stones to be removed, or any stones that might block the bile duct in future to pass into the intestine. 

Samples (biopsies) might be taken from the bile ducts using a small brush or forceps.

A plastic or metal tube (stent) might be put in to the bile duct to help with the drainage of bile or pancreatic juice.

Specialist ERCP procedures

You will be told if you will be having a SpyGlass ERCP.

A SpyGlass is a thin tube called a cholangioscope. This tube is passed through the endoscope tube being used, and into the bile duct. This allow a clearer view of the bile duct.

Special equipment can be used through the SpyGlass to break up bile or pancreatic duct stones, using methods not usually performed during a standard ERCP.

It also allows samples to be taken from any areas if there is a concern.

SpyGlass is a longer procedure, usually done under general anaesthetic. For this reason, there is a higher risk of side effects or complications.

Your doctor will talk to you about SpyGlass, and what is the best type of ERCP for you. 

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Pain

An ERCP is done with sedation, or general anaesthetic in some cases. 

You will also be given a pain killer before and during your procedure, to make you as comfortable as possible.

You might have cramps and tummy (abdominal) pain during or after the procedure. This is from the air that we use to inflate your small intestine.

You might also have short periods of discomfort or pain from certain parts of the procedure. This should not last long.

We will give you pain medicine into your bottom (a suppository) before the end of the procedure. This will also reduce the risk of pancreatitis.

After the procedure, you can take painkillers such as paracetamol.

Having peppermint (as peppermint tea or peppermint water) can help to pass the air.

Important. If you have severe tummy (abdominal) pain, tell your nurse straight away. If you are at home, contact your GP or go to the emergency department (A&E).

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After an ERCP

  1. The nurse will take you to the recovery area. They will check your observations regularly, and monitor you for any complications.
  2. You will usually be fully awake 1 hour after the ERCP.
  3. You will need to stay under observation for at least 6 hours after an ERCP. This might be done in the endoscopy unit, or you might be transferred by ambulance back to your own hospital. 
  4. Most of the time, you can eat as usual once you are fully awake. However, depending on the type of treatment you had during the procedure, you might be asked to not eat anything for 12 hours or more. 
  5. You should keep taking your usual medicines, unless you are told not to.
  6. If you have been asked to stop any medicines before the procedure, your doctor or nurse will tell you when you can start taking these again.

Your doctor or nurse will talk you through the results of the procedure, but you might be sleepy and not be able to remember the details. These results will be available to the doctor on the ward, or your GP, and they can explain it to you.

If a follow-up appointment is needed, it will be sent to you in the post. 

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When you go home

If you have had sedation or a general anaesthetic and are going home within 24 hours, you must have someone to take you home and stay with you overnight.

If you are going home within 24 hours, you should rest at home.

You should not:

  • drive a car, or ride a bicycle
  • operate machinery, or do anything needing skill or judgement
  • drink alcohol
  • take sleeping tablets
  • go to work
  • make any important decisions, sign contracts or legal documents

Important. If you develop any of these symptoms, contact your GP or go to the emergency department (A&E). 

  • Severe tummy (abdominal pain).
  • High temperature (fever).
  • Black poo.
  • Yellow, itchy skin (jaundice).
  • You cannot stop being sick.

Take your endoscopy report with you. 

It is important that you tell your GP or the emergency department doctor that you have had an ERCP. The team will need to contact the gastroenterology team for specialist advice. 

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Follow-up appointment

If your results suggest that you need a follow-up appointment, the Patient Access Team will contact you to arrange an appointment. 

If it is urgent, you will be given an appointment on the day of your procedure. 

You might be told after your procedure that your follow-up is a virtual clinic.

This is when the clinical team review your results without you being there. They will make a decision on next steps for you based on the results.

You and your GP will then get a letter from the clinic telling you if you need to return to the hospital, or if you can be discharged back to your GP.

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Resource number: 2559/VER4

Last reviewed: October 2018 | Next review: October 2021

A list of sources is available on request.


Where next?

 Contact us

If you need to change your appointment, or have any questions or concerns about your ERCP, contact the endoscopy unit.

Phone 020 7188 8887

Email Endoscopy AdmissionsTeam GSTT@gstt.nhs.uk

Nurse in charge     020 7188 7188 and ask for extension 54059

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