Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

The nature of the test, including possible side-effects and complications, will be discussed with you before the test. If you wish to have more information please advise your doctor before the test.

What is the Purpose of ERCP?

To examine the bile ducts and pancreatic ducts, to remove gallstones from the bile ducts, to dilate strictures in the bile ducts, to dilate or cut strictures due to a tumour of the duodenum, pancreas or bile ducts, and to keep open a stricture by the use of a plastic or metal tube called a stent. The procedure also allows samples of tissue (biopsies) to be taken for examination by a pathologist.

Sphincterotomy

Sphincterntomy involves making a small cut in the lower part of the bile duct where the duct opens into the duodenum. This is done using an instrument passed through the endoscope. You do not feel the cut. This procedure allows better access into the bile duct, removal of gallstones, and other procedures to be performed.

How are you Prepared?

Prior to the procedure you will asked not to eat or drink, usually for 8 hours. This is to allow a satisfactory examination and to minimise the risk of vomiting during the test. You will be asked to come to the hospital before the test to complete admission procedures, be admitted and checked for any medical problems, have an intravenous line inserted, and have any premedication and antibiotics if required.

How is ERCP Done?

The test is done in the X-Ray Department (you will be taken there from the Ward). After the sedation is given, a long, thin flexible tube is passed into the stomach via the mouth and a thin plastic tube inserted into the bile and pancreatic ducts. In about 5% of patients this is not successful. The procedure takes up to 45 minutes and your are under intravenous sedation throughout (Midazolam, Fentanyl, and sometimes Propofol). Reactions to these medications are rare. After the procedure you must not drive or use machinery until the next day, or longer if you feel unsteady or tired the next day. If you object to the use of sedation please discuss with your doctor.

Are there Alternatives to ERCP?

Similar information can be obtained by Percutaneous Cholangiography which is done by a Radiologist. This is generally a more difficult procedure with a slightly higher risk of complications. Removal of gallstones and treatment of strictures and tumours also can be done by open surgery, which involves an operation under general anaesthetic, a much longer stay in hospital, and higher risk of complications. If gallstones are left in the bile ducts, or if blockage of the bile ducts is not relieved, life-threatening problems may occur.

Sometimes ultrasound, CT cholangiography, and MRI cholangiography can give very similar information to that provided by ERCP, however these investigations do not allow therapeutic procedures to be performed. Your doctor will discuss these investigations with you if you wish.

Complications

ERCP, sphincterotomy, and stent insertion are normally safe procedures and are only done when other methods of diagnosis or treatment have failed. Complications (mostly minor) occur in about 5% of patients, including:

  • Reaction or sensitivity to medication used for sedation (this may affect your breathing briefly)
  • Pancreatitis (inflammation of the pancreas) (mild pancreatitis occurs in about 1 patient in 20)
  • Bleeding following sphincterotomy (about 1 patient in 100)
  • Perforation (puncture) of the lining of the duodenum or bile duct (about 1 patient in 1000)
  • Infection of the bile ducts, blood, and other organs
  • Incomplete removal of gallstones due to impaction, or to an instrument impacting in the bile duct
  • Stent displacement with damage to bowel wall including perforation & bowel obstruction
  • Heart attacks, cardiac arrest, and breathing problems (very rare)
  • There are other very rare complications - please advise if you wish to be given more details

Everything will be done to minimise the risk of these complications. There are ways of detecting these complications early and specific treatments are available if they do arise. Very rarely there may be a need for hospitalisation, major surgery, intravenous feeding, or blood transfusion. Although death can result from complications of ERCP this is rare.

ERCP is a technically difficult procedure and in about 5% of patients there is a need to repeat the procedure at a later date for a variety of reasons e.g. to check that gallstone extraction has been successful, or to remove residual gallstones.

Special Precautions will need to be taken:

  • if you suspect or know you are pregnant (x-rays are used in this test) or if you are breastfeeding
  • have severe heart, lung, or kidney disease
  • have lymphoma, leukaemia, or you are receiving chemotherapy
  • if you have had heart valve disease, a pacemaker, aortic graft or other blood vessel graft
  • if you bleed very easily or if you take blood thinning tablets (warfarin), aspirin, or arthritis tablets
  • if you are allergic or sensitive to any medication, including iodine

Some useful links providing further information:

ASGE policy and procedure manual on GI endoscopy
http://www.asge.org/gui/patient/index.asp

General information about colonoscopy
http://www.gastro.com/html/colonoscopy.html