Endoscopic Retrograde Cholagiopancreatography
An examination of the ducts (tubes) that drain the liver, pancreas and gallbladder.
Small ducts from the gallbladder and pancreas flow into a larger duct that drains bile from the liver (common bile duct). The common bile duct drains into the small intestine through an opening called an ampulla. An endoscopist (a doctor who has special training in the use of endoscopes) will examine these ducts, looking for blockages, irregularity in the tissue or disruptions in the flow of bile/pancreatic fluid, spasm of the ducts, stones, or tumors.
It normally requires overnight observation in the hospital after the procedure.
REASONS FOR ERCP
The most common reasons for ERCP include the following:
- Preoperative or postoperative evaluation of patients who undergo laparoscopic gallbladder removal to detect gallstones that might be blocking the ducts.
- Evaluation of pancreatitis (an inflammation of the pancreas)
- Evaluation of a possible pancreatic cancer
- To remove gallstones that are not passing through the ducts into the small intestine. Some stones are too large to pass easily and get stuck in the ducts
- Evaluation of abnormal or unclear findings in the biliary system on a CT or MRI examination
- Evaluation of chronic or acute abdominal pain when biliary disease is suspected
- Evaluation of jaundice (yellow skin) when bile duct disease is suspected
At the time of the procedure, the endoscopist may take tissue samples (biopsies), place drainage tubes to improve bile flow, or make a small incision in the tissues surrounding the bile or pancreatic ducts.
Specific instructions regarding how to prepare for the examination will be given before the procedure. These instructions are designed to maximize the patient’s safety during and after the examination and to minimize possible complications.
Patients will be asked not to eat or drink anything for six to eight hours before the test. It is important for the stomach to be empty to allow the endoscopist to visualize the entire area and to decrease the possibility of food or fluid being vomited into the lungs while under sedation (called aspiration).
Patients may be asked to adjust the dose of their medications or to eliminate specific medications prior to the examination. Some medications need to be discontinued for several days. Patients should ask about their specific medications since some medicines are more important than others.
WHAT TO EXPECT IN THE ENDOSCOPY UNIT
Prior to the endoscopy, a nurse will ask questions to ensure the patient understands the procedure and the reason it is planned. A doctor will also review the procedure, including possible complications, and will ask patients to sign a consent form.
The nurse will start an intravenous line (insert a needle into a vein in the hand or arm) to administer medications. Most endoscopy units use a combination of a sedative (to help patients relax), and a narcotic (to prevent discomfort).
The vital signs (blood pressure, heart rate, and blood oxygen level) will be monitored before, during, and after the examination. The monitoring is not painful. Patients will be given oxygen during the examination. For safety reasons, patients will be asked to remove dentures. Some patients will be given medication to gargle to numb the throat, or a numbing spray may be used.
ERCPs are performed in a room that contains x-ray equipment. The patient will lie on an x-ray table during the examination. The ERCP will be performed while the patient lies on their side or stomach.
Although patients worry about discomfort from the examination, most tolerate it well and feel fine afterwards. Medications will be administered through the intravenous line. A plastic mouth guard is placed between the teeth to prevent damage to the teeth and scope.
The ERCP scope is a flexible tube, approximately the size of a finger. It contains a lens and a light source that allows the endoscopist to view images on a monitor where it is magnified many times so the endoscopist can see small changes in the tissues. The ERCP scope also contains channels that allow the endoscopist to take biopsies and introduce or withdraw fluid, air and instruments.
The patient will be asked to swallow the tube; many patients do not remember this after the medications have taken effect. Many people sleep during the test; others are relaxed and generally not aware of the examination.
The scope in inserted through the mouth, and when the scope reaches the duodenum, the first portion of the small intestine, the endoscopist will locate the ampulla, the opening into the ducts that drain the biliary system.
A small cannula (tube) will be placed into the ampulla and, dye (a special contrast material that allows visualization of tissues by x-ray) will be injected through the cannula.
Patients may experience a mild discomfort as air distends the tissue. This is not harmful and belching may relieve the sensation. The endoscope does not interfere with breathing. Taking slow, deep breaths during the procedure may help a patient to relax.
The length of the examination varies, but it generally takes at least one hour.
After the ERCP, patients will be kept for observation while the anesthesia wears off. The most common discomfort after the examination is a feeling of bloating from the air introduced during the examination. Some patients also have a mild sore throat.
Most patients are able to eat a few hours after the examination. The first meal after ERCP should be light but most patients can eat their usual diet by the next day.
The endoscopist can usually tell the patient the results of their examination, but if biopsies were taken the patient will be instructed to call back for results. The endoscopy team can give guidelines about when the results will be available and whether further treatment will be necessary.
ERCP is a safe procedure and serious complications are rare, but can occur:
- Pancreatitis (inflammation of the pancreas, an organ in the back of the abdomen) occurs in about 3 to 5 percent of people undergoing ERCP. When it occurs, it is usually mild, causing abdominal pain and nausea, which resolves after a few days in the hospital. Much less commonly, pancreatitis can be a severe and even life-threatening condition.
- Aspiration of food or fluids into the lungs, the risk of which can be minimized by not eating or drinking for several hours before the examination. Aspiration can lead to pneumonia, but this is less likely to occur if the stomach is empty.
- The ERCP scope or other instruments can cause a tear or hole in the tissue being examined. This is a serious condition, but fortunately occurs very uncommonly.
- Bleeding can occur from biopsies or from a cut into the ampulla, but it is usually minimal and stops quickly by itself or can be controlled. Patients should let their endoscopist know if they have a bleeding disorder.
- Reactions to the medicines used for sedation; the endoscopy team (doctors and nurses) will ask about previous medication allergies or reactions and about health problems such as heart, lung, kidney, or liver disease. Providing this information to the team ensures a safer examination.
- The medications can also produce irritation in the vein at the site of the intravenous line. If redness, swelling, or warmth occur, warm to hot wet towels applied to the site may relieve the discomfort. If discomfort persists, notify the endoscopy unit.
- Infection is rare, but can occur.
The following symptoms should be reported immediately:
- Severe abdominal pain (not just gas cramps)
- A firm, distended abdomen
- Difficulty swallowing or a severe sore throat
- A crunching feeling under the skin