ERCP (Endoscopic Retrograde Cholangiopancreatography)

  • Reference Number: HEY-212/2018
  • Departments: Endoscopy

Introduction

This leaflet has been produced to give you general information about your procedure.  Most of your questions should have been answered by this leaflet.  It is not intended to replace the discussion between you and your doctor, but may act as a starting point for discussion.   If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team who has been caring for you.

Endoscopy Department contact numbers: Hull Royal Infirmary (01482) 674790 (direct line) Castle Hill Hospital (01482) 622069 (direct line)

  PLEASE DETACH THE INFORMATION CHECKLIST AND BRING IT WITH YOU

What is an ERCP?  

A slim flexible tube with a light on the end (duodenoscope) is gently passed from your mouth into your stomach. The view can be watched on a TV monitor.  The opening to the bile and pancreatic duct (papilla) can be seen.  A small plastic tube is passed down the duodenoscope into this opening.  Dye is then injected which shown up on the X-ray.

ERCP and sphincterotomy

If the X-rays show a gallstone blocking the bile duct, the doctor will enlarge the opening of the bile duct by making a small cut.  You will not feel this.  Any stones can be collected from the duct with a tiny basket or balloon, or left to pass out into the intestine, where they are passed out later in your stools.

If the doctor cannot get into your bile duct through the opening, a small cut may be made to the side to allow access.

ERCP and stent replacement

If the X-rays show a blockage in the bile or pancreatic duct, the doctor may place a small plastic or metal tube (stent) into the duct.  This allows bile to drain into the intestine again.  If you have had jaundice, this will relieve the jaundice and your itching.  Plastic tubes can be removed or replaced at a later date if necessary.

Why do I need an ERCP?

You have probably been troubled by some symptoms, which have led to your doctor advising an ERCP (Endoscopic Retrograde Cholangiopancreatography).  This is a procedure which helps to determine whether there is a problem with your bile duct system or pancreas.

Can there be any complications or risks?

Yes.  It is important to say that serious complications during ERCP are rare. ERCP is generally a well tolerated procedure and is performed by doctors who have had special training and experience in this technique. Major complications requiring hospitalisation can occur but are uncommon during ERCP.  The commonest is pancreatitis (inflammation of the pancreas – a gland in the tummy which helps with digestion) which occurs in 5% of cases.  If it occurs, the patient is admitted to the ward and given a drip.  It usually settles in 24 – 48 hours.

Other complications include perforation (making a hole in the wall of one of the areas viewed with the endoscopy), infection and bleeding.  Usually these complications settle without surgery although occasionally it may be required.  Another possible risk of ERCP is an adverse reaction to the sedative used.

The risks of the procedure vary and depend on the reason for the test, what is found during the procedure, whether any therapy is undertaken and the presence of other major medical problems, e.g. lung or heart disease.  Your doctor will tell you the likelihood of complication before undergoing the test.

Sedation

Some people, for reasons we still do not fully understand, are particularly sensitive to this drug. The breathing can be too shallow and too slow. In these cases we stop the examination, give more oxygen and if required we can give an antidote, which reverses the effect of the sedation. This is usually all that is needed and the person recovers with no ill or lasting effects.

In some cases, when people have another serious illness e.g., heart disease, stroke, unstable angina, severe asthma or chronic bronchitis, the sedation drug can cause difficulty in breathing. This is rare and is why we monitor breathing and heartbeat throughout; and why we give oxygen by nasal tubes.

The risks must be balanced against the potential benefits of ERCP.  Alternative treatments like surgery may have higher risks.

How do I prepare for the ERCP?

Please read the information leaflet.  Share the information it contains with your partner and family (if you wish) so that they can be of help and support.  There may be information they need to know, especially if they are taking care of you following this examination. Complete the health questionnaire sent/given to you as fully as possible.

How long will I be in hospital?

Generally you can expect to be in hospital for at least 3 hours.  Some patients may need to stay overnight.  You will usually be notified of this in your appointment letter; however it is best to bring a small overnight bag with you. To allow for a clear view, your stomach and first part of your intestine needs to be empty.

You should not have any thing to eat and drink for at 6 hours before your test.

If you have diabetes (especially taking insulin) or you have serious heart, lung or kidney problems, or concerned that a health problem you have may be affected, then contact the Endoscopy Department at the hospital you are having your examination (see contact numbers).

WARFARIN – These are blood thinning tablets and usually have to be stopped for a period of time before your test, please contact your Endoscopy Department for advice.

LATEX – Please inform the department if you have a confirmed latex allergy as this will affect your appointment time.

Creutzfeldt-Jakob disease/variant Creutzfeldt-Jakob disease (CJD) commonly known as mad cow disease – Please inform the department if you have been notified that you are at risk of CJD/vCJD for public health reasons.

CLOPIDOGREL (PLAVIX) – Please inform the department if you are taking these tablets as these may need to be stopped prior to your procedure.

 PREGNANCY – It is important that you inform us if there is a possibility that you may be pregnant.  Any information you share with us will be kept strictly confidential.

If you take any of the following blood thinning tablets please contact the Endoscopy Department before your appointment for further advice: APIXABAN, RIVAROXABAN, DABIGATRAN, ARGATROBAN, OR EDOXABAN.

What happens to me in the Endoscopy Department?

Our friendly reception staff will greet you on arrival. They will let a nurse know that you have arrived.  Occasionally there may be a delay in your appointment time due to an emergency taking place.  Occasionally there may be a delay in your appointment time.  If there are any delays you will be notified as soon as possible and be kept informed.

A nurse will collect you from the waiting room and explain what will happen next. You will be given an approximate time of when you may be collected to go home. It is advisable to leave any valuables at home. We will ask you questions about your general health and work through the health questionnaire you have completed for us. Please feel free to ask questions.

The endoscopist will meet you and explain the test to you. You will both sign a consent form. This is to show you understand what will happen and agree to the procedure being performed.  At any point during the procedure you can withdraw your consent and ask for the procedure to stop. If this happens the endoscopist will stop the test and take the scope out.  If you have any queries or worries, please tell us.

You will require a blood test before the procedure.  This will be done usually on the day before or just before the procedure. Some patients also have antibiotics given before the procedure, especially if they are jaundiced (yellow appearance). We will check your blood pressure, pulse and oxygen levels before your test. If you wear glasses or dentures, you will be asked to remove them.

You will be taken to the examination room and asked to lie on your left-hand side.   You will see the X-ray and endoscopy equipment around you and the staff wearing X-ray aprons.  The amount of X-rays you receive are strictly controlled.

Once in position, a probe will be placed on your finger to monitor your oxygen levels and pulse rate throughout and after the examination.  If you are having sedation it will be given now and you will feel sleepy. Sedative drugs make your breathing slow and shallow; therefore we give you a little oxygen via tubes placed in the nostrils.

To keep your mouth open, a plastic mouth guard will be placed between your teeth.  A fine plastic tube will rest by your nostrils to give you some extra oxygen. Sometimes diathermy (gently cutting with an electrically heated wire) will be used.  A special pad will be placed on your leg for safety. The test usually takes 30 minutes.

Do I need sedation?

Yes. People have sedation to keep them comfortable while the doctor carries out the test. Sedation is given through a needle in the back of your hand. It makes you feel sleepy and relaxed but does not put you to sleep. You can still respond to what is happening. 

Do I really need someone with me after sedation?

Yes, this is very important as sedation can have side-effects, which last some 24 hours after the test. You can become forgetful and also sleepy again. Your test may be cancelled if you do not arrange to have someone to collect you and stay with you for the next 24 hours.

We strongly recommend that for the next 24 hours you:

  • Do not drive
  • Do not return to work or operate machinery
  • Do not sign any important/or legal documents
  • Are not left alone, you may be at risk of injuring yourself
  • Are not left alone to care for children

If you are an outpatient, the person accompanying you will be contacted to collect you.  If you are an inpatient you will be transferred back to your ward.

What will the test feel like?

You may feel the tube gently slide over your tongue and down your gullet. It will not be painful, or interfere with your breathing. If you get a lot of saliva, the nurse will clear it with a sucker. You may feel the tube move around in your stomach. Some air will be passed down the tube to inflate your stomach and duodenum to allow a clear view.

How can I help myself?

You can help by listening to the instructions your nurse gives you. By staying calm and relaxed, the test goes quickly and easily. Try to control your breathing by taking slow deep breaths. This helps stop you wanting to retch.

What happens when the ERCP is finished?

When the ERCP is finished, you will be transferred to the recovery room on a trolley to rest for about an hour.  When you have recovered, you will be helped to a chair and given a drink. Please take care because the sedative may make you feel dizzy and a little confused when you get off the examination trolley.

It is for these reasons that, when having sedation, someone must bring you and take you home.  If you live alone or do not have anyone who can be with you, please contact your Endoscopy Department so that other arrangements can be made. It is quite likely that the back of your throat will feel sore for the rest of the day. You may feel bloated if some air remains in your stomach. Both discomforts usually pass without any medication; you may find it helpful to eat light meals for the next 24 hours.

When do I get the results?

The Recovery nurse will explain your test results to you and (if you wish) the results will be told to your carer. These will be written on your discharge form with any instructions that you need to follow. Your own doctor and hospital doctor will receive a copy of the results.

Will I ever need an ERCP again?

This will depend on the reason for the ERCP, what is found and whether it was possible to complete the test. It may be necessary to repeat the test after a few weeks, if stones have been removed, to check the ducts are clear. If it was necessary to insert a stent (tube) into the duct during the test, it may be need to be changed or removed at some time. Your nurse will keep you informed of any further appointments.

Further information

If you require further information about your test your GP, consultant, and the Endoscopy Department is a valuable source of information. Further information about your rights with regards to consent can be found in the following documents. These are free of charge.

  • Department of Health (2001), Guide to Consent for Examination or Treatment.
  • Department of Health (2001), Consent – What you have a right to expect.
  • A Guide for Adults. (Available from the Endoscopy Department)
  • A Guide for Relatives and Carers. (Available from the Endoscopy Department)

Visit the Department of Health’s website at: www.doh.gov.uk and for consent: www.doh.gov.uk/consent

Useful contact numbers:

The Endoscopy Department, Castle Hill Hospital (01482) 622069 (direct line) Monday – Friday 8.00am – 5.00pm

The Endoscopy Department, Hull Royal Infirmary (01482) 674790 Monday – Friday 8.00am – 5.00pm

Ward 100 Hull Royal Infirmary Out of hours  (01482) 674860

What do the words in the leaflet mean?

  • Bile: A fluid produced in the liver and passed into the gut via the bile ducts.
  • Biopsy: A sample of tissue is taken for analysis.
  • Consent: This is the agreement between you and the endoscopist.  You are agreeing to have investigations or treatment and that you understand the purpose, benefits, alternatives and risks. You and the endoscopist during this process usually sign a consent form.
  • Duodenum: The part of the gut leading from the stomach.
  • Endoscopy Department: The place where your procedure takes place.
  • Endoscope: A tube for looking inside the body.
  • Endoscopist: This can either be your consultant, an experienced and trained doctor or an experienced and specially trained practitioner.
  • ERCP: Endoscopic Retrograde Cholangiopancreatography.
  • Gall Stones: Stones usually formed from crystals of cholesterol in the gall bladder.
  • Oesophagus: The gullet. The pipe leading from the mouth to the stomach.
  • Pancreas: Gland which delivers enzymes into the duodemum for the digestion of food.
  • Pancreatitis: Inflammation of the pancreas.
  • Stent: A plastic or metal tube inserted in your bile or pancreatic duct.
  • Sphincter: A muscular valve.
  • Sphincterotomy: Cutting an opening into the bile duct.
  • Stricture: Narrowing.
  • Therapeutic: Something done or given that will treat illness.

This leaflet has been written with the help, support, advice and collaboration of:

  • Consultants of the Department of Gastroenterology
  • Consultants of the Surgical Department
  • Staff of the Endoscopy Department
  • Patients attending the Endoscopy Department

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

  • you must be able to give your consent
  • you must be given enough information to enable you to make a decision
  • you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.