ERCP (Endoscopic retrograde cholanglopancreatography)

An ERCP is an endoscopic procedure utilized to examine the pancreas and gallbladder, specifically the tubes or ducts that connect these organs to the small intestine. The procedure uses a long thin flexible tube which is placed in the mouth, travels down the esophagus into the stomach and then into the duodenum. In the duodenum is an opening where fluid from the bile ducts is drained.  Dye will be injected in a retrograde fashion into this opening, and an XRAY will be taken as the ducts are filled with dye. This allows for an XRAY roadmap of your bile ducts to be obtained. Pathology of these ducts can be investigated through this procedure, such as stones in the duct, strictures or narrowing of the ducts, or tumors within the duct.

Some patients are brought into the hospital afterward. This will be determined after the procedure depending on the difficulty of procedure and what was done therapeutically.

The most common reasons for ERCP are the following:
To determine a cause for chronic pancreatitis, to remove stones lodged within this duct system, to evaluate a ductal or pancreatic cancer, to evaluate abdominal pain when blood work shows that the source is within the biliary system, to evaluate yellowing of the skin or jaundice and to evaluate abnormal findings on CT, ultrasound or MRI tests.

At the time of the procedure, the endoscopist may take biopsies or brushings of the ducts, remove stones with special tiny tools, make a cut at the end of the drainage tube for large stones to pass, and may even place a stent to keep the bile duct open.

Preparing for the Exam
One week before the exam, you may need to stop any medications which cause your blood to be thin. These include aspirin, ibuprofen products, plavix or coumadin. Before stopping any medication please discuss this with your doctor.

The day before the exam you will be allowed to eat anything you desire and take all your medications, but you must not eat or drink anything, even water, after midnight the night before your procedure.

You will arrive for your exam at the endoscopic center with a responsible adult who will drive you home. You will not be able to drive after your procedure, because you will receive sedatives during the procedure to make you comfortable. It is also important to know that you will not be able to operate heavy machinery, such as a lawn mower; and you will not be able to make life-altering decisions for 24 hours, such as changing your will or selling your home, after you have received sedatives. Plan on resting on the couch at home after your procedure for the reminder of the day; and do not plan on going to work for at least 16-24 hours. Most people feel no adverse effects 24 hours after the procedure and are able to return to work without any difficulty.

As you arrive for your exam with your driver, you will be checked in and will meet the nursing staff. The nurse will take a brief medical history including a current medication list. Please bring your current medication list written on a piece of paper. Include the dosage and frequency of ingestion of all medications in addition to over the counter medications. Please let the nursing staff know if you have any medication allergies or if you have had adverse reactions to sedative medications in the past.

You will change into a gown and an intravenous line will be placed in your arm or hand. This line will allow IV fluids and medications to be given to you during the procedure. These medications are like valium and morphine and will relax you and take away any pain. You will be placed on a monitor that will monitor your blood pressure, heart rate and oxygen level in the blood, from the time you have your IV placed, throughout the whole procedure and during the whole recovery process. As long as your vital signs are stable and similar to your pre-procedure vital signs, then you will be allowed to head home.

Next, a doctor and nurse will review the examination with you, including possible complications, and will ask you to sign an informed consent form. The doctor will answer any questions you have before you receive any sedatives or pain killers.

The ERCP exam
The ERCP will be performed with you lying on your stomach. Sedative drugs will be administered through the IV line. Many people sleep during the examination; and others are very relaxed, comfortable and not aware of the examination.

A numbing medication will be sprayed in the back of the throat which you may swallow, and a mouth guard is placed in your mouth to facilitate placing of the scope in your esophagus.

The long thin flexible endoscope (tube) will be placed in the back of the throat, and it will move into the esophagus with ease. Some people will be asked to swallow the tube, when it is in the back of the throat. Please do not try to talk during the procedure, as it makes the procedure more difficult. The best advice is to close your eyes, relax and take deep breaths through your nose. The endoscopist will move the tube through your esophagus and into your stomach and then into the duodenum.

An examination of the bile ducts, gallbladder and pancreas will then take place. Any diagnostic or therapeutic interventions will occur at that time. A simple ERCP usually takes ½ hour; but if more diagnostic or therapeutic interventions are required, it may take more than an hour and sometimes even longer. You will receive sedative medications throughout the whole procedure to keep you comfortable.

Recovery
After the ERCP, you will be taken to Recovery to allow the medication to wear off and for you to wake up after the procedure. You will be met in Recovery by your driver. The doctor will explain the results of the test to you and your driver. It is important that your driver write down the results of the test, because the amnestic effect of the medication may cause you to forget what the endoscopist has said. During the Recovery room period, which usually lasts from a half hour to an hour, you may feel bloating and cramping. Belching relieves air that was placed in your stomach and will take away some of the discomfort. This is why after your procedure, you should plan on spending the day at home, relaxing on your couch or taking a nap. You may eat a regular diet as tolerated after your procedure. You will likely resume all your medications after the procedure, but if you are on any blood thinners such as aspirin, plavix or coumadin, ask your doctor when it is safe to resume these medications.

Occasionally after a complicated procedure, when the risk of post procedure complication is moderate to high, the doctor will bring you into the hospital for observation. This observation is usually only for one night; and if you are walking and eating the next day, with minimal pain, you will be allowed to go home.

Complications from this procedure are rare, but may occur; and you have to be aware that they exist.
Bleeding may occur from trauma from the scope or after biopsies are taken. Bleeding may occur if the end of the duct is cut to allow stones to pass. Pancreatitis is a complication that may occur in 5-10% of ERCP procedures. Usually this is self-limiting and requires no intervention. Occasionally pancreatitis can be so bad that it requires a stay in a medical intensive care unit and may even be life-threatening in very rare instances. A tear in the bowel wall, also called a perforation may occur. If a tear were to occur, you will need to come into the hospital; and you may even need surgery to sew the tear. Swallowing of oral secretions or stomach contents into the lungs may occur during the procedure. This is called aspiration and may result in pneumonia.

Please feel free to ask questions of your doctor or nurse about anything relating to the procedure while you are in the unit. If you should develop horrible abdominal pain (not just cramping), fevers or you vomit blood, please call your physician. If your physician is unavailable, an on-call physician will be available to answer any questions.