• Individuals with stones, tumors, strictures or other abnormalities of the bile ducts, gall bladder, or pancreas
• Individuals with evidence of blockage of the bile duct identified by ultrasound, CT scan or other diagnostic test
• Individuals with unexplained recurrent pancreatitis
• Individuals with unexplained jaundice
• Individuals with unexplained abnormalities of liver chemistries
• Individuals being considered for liver transplantation

WHAT IS ERCP?

ERCP or Endoscopic Retrograde Cholangio Pancreatography is a technique in which the gallbladder, bile ducts, and pancreatic ducts are injected with x-ray dye and x-ray pictures are taken.  When these x-ray pictures show stones or obstructions, they can often be treated during the same ERCP examination.  Thus, ERCP is a useful method for both diagnosis and treatment, but it is complex and can result in complications. It is important to understand exactly what is being proposed, the potential benefits and risks, and alternative methods which might be used.

WHAT WILL HAPPEN DURING YOUR ERCP?

The ERCP procedure involves passing a flexible tube (endoscope) through the mouth, esophagus, and stomach into the first part of the small intestine (the duodenum) where the drainage opening for the bile and pancreatic ducts is located.  The doctor then passes a small plastic tube (catheter) through a channel in the endoscope and out into view in the duodenum and inserts it into this small opening.  A contrast solution (dye) is then injected through the catheter into the bile and pancreatic duct system(s), and x-rays are taken. These can be viewed immediately so that the doctor can make a diagnosis.

The doctor may take specimen samples for analysis if the x-rays (and any previous tests) suggest the possibility of cancer.  Tiny wire brushes are used to scrape the duct lining and retrieve cells for microscopic examination.  Small pinching biopsy forceps can be used to take larger pieces of tissue.  Bile or pancreatic juice can be retrieved and sent to the laboratory to check whether there is any infection or to look for disturbance of the normal digestive constituents.

POSSIBLE ERCP TREATMENTS

If x-rays show a blockage of the papilla or the duct systems, the doctor may be able to treat it immediately.  Common treatments include sphincterotomy, balloon dilatation (stretching), stenting, and placement of drainage tubes.

• Sphincterotomy means cutting the muscular sphincter of the bile duct or pancreatic duct.  A small cut (about 1/4 inch long) is made in the papilla to enlarge the opening. This cut is made with electrical current (which you do not feel), so as to cauterize the tissues to prevent bleeding.
  
• Stone removal. The most common reason for performing a biliary sphincterotomy (cutting the opening of the bile duct) is to remove bile duct stones.  Although stones can pass spontaneously after a sphincterotomy into the duodenum (and through the intestines), doctors usually remove them directly at the same time using a basket-shaped grasper or by sweeping the duct with a small balloon on the end of a catheter.  Large stones may need to be crushed before removal, a technique called lithotripsy.  Special devices such as lasers may be needed occasionally to break particularly hard stones. Stones can also be removed from the pancreatic ducts, but they are often harder, and technically more difficult to remove.
  
• Papillary stenosis and sphincter dysfunction. Sphincterotomy (of the bile duct and/or pancreatic orifice) is used also when there is scarring of the papilla (papillary stenosis) or evidence of overactivity (spasm) of the muscular valve. This is called sphincter of Oddi dysfunction. Sphincterotomy is more hazardous in this context than when used for stones.
  
• Duct dilatation and stenting. ERCP x-rays may show partial blockage or narrowing of the bile duct or pancreatic duct. This narrowing can be stretched (dilated) using a sausage shaped balloon catheter. Often a small tube (stent) is left behind to maintain the stretch, and allows the duct to drain more easily.
  
• Nasobiliary drainage. Sometimes, instead of a plastic stent which stays in the duct, the doctor will choose to leave a longer tube for drainage after ERCP.  This is also placed through the endoscope during ERCP, but the end of the tube comes out through your nose after the procedure is finished.  The tube may be a little uncomfortable, but you will be able to eat and drink normally while it is in place (usually for one to three days).

SPECIFIC PREPARATIONS FOR YOUR ERCP

Your doctor will want to know if you have any allergies, or general health problems (e.g. heart, lung or kidneys) which might effect your response to ERCP and its treatment.  The contrast dye contains iodine.  If you have had allergic reactions to iodine (or shellfish), the doctors may wish to take special precautions against dangerous reactions.  When doctors suspect a bile duct or pancreas blockage, they may recommend starting antibiotics before ERCP.

If there is any possibility of treatment during ERCP (especially cutting or sphincterotomy), the doctor will want to make sure that your blood can clot satisfactorily.  Thus, it is important for you to report if you (or close family members) have had any major bleeding problems, and whether you are taking any medicines to reduce blood clotting (especially anticoagulants such as Coumadin).  Aspirin and nonsteroidal antiinflammatory drugs (NSAIDS) can effect blood clotting. They should be avoided for one week prior to the procedure, and afterwards if treatment has been performed.

ERCP is performed with sedation, which means that you will not be able to drive until the next day.  Make sure a friend or relative is available to take you home.  Be aware that you may need to be admitted to the hospital after the ERCP, either because observation is needed after an ERCP treatment, or because a complication has occurred.

You will need to have an empty stomach when the ERCP is performed, so have nothing to eat or drink for at least six hours prior to the test (apart from a small sip of water to help you swallow any essential regular medications).  Do not take antacids, which can obscure the stomach lining.

The physician will review the procedure with you and ask you to sign a standard consent form.  This authorizes your doctor to perform the test.  Please read this and be sure you understand it to your satisfaction.  Be sure you have all your questions and concerns answered by the doctor before signing it.  You will put on a hospital gown, and will need to remove any eyeglasses, contact lens or dentures.  An IV tube will be placed into a vein in your arm, and fluids will be given to prevent dehydration during the test.  During the ERCP the IV line will also be used to administer sedative medicines to make you relaxed and sleepy. General anesthesia is sometimes used.

IN THE ERCP ROOM

You will be taken into a special room that has an x-ray machine. You will lie down on a padded table and be covered with a sheet.  Local anesthetic medicine will be sprayed onto the back of your throat, to make it numb.  A plastic guard will be placed in your mouth to protect your teeth.  Small monitoring devices will be placed on your skin so that the nurse can measure your pulse, blood pressure and blood oxygen as necessary during ERCP.

When you are sleepy, the doctor will place the thin flexible tube (endoscope) through the mouth guard.  When you swallow, the doctor will gently move the endoscope down the esophagus.  The doctor can see with a small video camera on the end of the endoscope.  The endoscope will not interfere with your breathing.  You will not feel the doctor doing the diagnostic maneuvers and any treatments.  The contrast dye which is injected will pass out of your body naturally. The ERCP procedure takes between 30 and 90 minutes.

After ERCP you will be sleepy for up to a few hours and will not be able to eat or drink during that time.  Once you are awake, the doctor will discuss the results of the ERCP with you and the person accompanying you (since your memory may be dulled by the medicines).  You will need to be driven home.  Once home, you should rest quietly until the next day, having only  very light meals with plenty of fluids.  You will probably feel slightly bloated (because of the air inserted into your stomach during the examination).  This is normal and will pass spontaneously.  Your throat may be slightly sore for a day or two.

Call your doctor if you have concerns about your progress during the next few days especially if you have severe pain, vomiting, passage or vomiting of blood, or fever above 101 degrees or chills.

If the ERCP involved treatment or was difficult, you may be admitted to the hospital overnight.  The IV fluids will be continued.

RISKS OF ERCP

ERCP has become popular because it can provide a diagnosis and treatment more safely and easily than other options such as surgery.  However, ERCP is not without risk, and you must understand what can happen.

Taking x-rays involves a small dose of radiation no greater than other standard x-ray tests.  You could have an allergic reaction to the sedatives such as nausea or skin reactions such as reddening and hives.  A tender lump may form in the vein where the IV was placed.  This will usually settle spontaneously, but you should call your doctor if redness or swelling develops or persists.

Specific complications of ERCP occur in 5-10% of patients.  The precise risk depends on the particular patient, disease, and type of ERCP procedure.  Make sure you understand the likely risks in your particular case.

Pancreatitis (swelling of the pancreas) is the most common complication of ERCP; it occurs in 3-5% of ERCPs.  It can occur even in the most expert hands.  Pancreatitis usually resolves in one to three days, but you will need to be in the hospital with IV fluids and analgesics (pain medicines).  More serious cases of pancreatitis occur in less than 1% of ERCP procedures.  Severe pancreatic damage can result in formation of a pseudocyst or abscess, which may require a prolonged stay in the hospital.  Rare fatal cases of pancreatitis related to ERCP have been reported.

Other important complications are less common, and occur mainly after treatments such as sphincterotomy.  This may provoke bleeding, which can usually be controlled by the doctor during the ERCP.  Rarely it is necessary to give a blood transfusion or other treatment such as surgery.  Sphincterotomy can also result in perforation when the cut extends into the tissues behind the duodenum and pancreas.  Some perforations can be treated medically (with IV fluids, antibiotics, and a nasogastric tube); other cases may require surgery and prolonged hospital treatment.

Very rarely, the endoscope itself can perforate (make a hole) in the lining of the esophagus, stomach or duodenum.  This type of perforation usually requires surgical treatment.

Infection can occur in the bile ducts or pancreas after ERCP, especially when there is duct obstruction which cannot be treated by the ERCP procedure.  Antibiotics will be required, and possibly another type of drainage procedure such as surgery.

Because education is an important part of comprehensive medical care, you have been provided with this information to prepare you for this procedure. If you have any questions about your need for an ERCP procedure, alternative tests, the cost of the procedure, methods of billing, or insurance coverage, do not hesitate to speak to your doctor or doctor's office staff about it. The physicians of Digestive Health Network are highly trained specialists and welcome your questions regarding their credentials and training. If you have questions that have not been answered, please discuss them with the nurse or your physician before the examination begins.