What is an ERCP

 

 

What is ERCP?


Your doctor has recommended that you have a medical procedure called an ERCP.

This brochure will help you understand why ERCP is performed and what you can expect from the procedure.

ERCP is short for…

Endoscopic
Retrograde
Cholangio
Pancreatography

Endoscopic refers to the use of an instrument called an endoscope - a thin, flexible tube with a tiny video camera and light on the end. The endoscope is used by a highly trained subspecialist, the gastroenterologist, to diagnose and treat various problems of the GI tract. The GI tract includes the stomach, intestine, and other parts of the body that are connected to the intestine, such as the liver, pancreas, and gallbladder.

Retrograde refers to the direction in which the endoscope is used to inject a liquid enabling X-rays to be taken of the parts of the GI tract called the bile duct system and pancreas.

 

The process of taking these X-rays is known as cholangiopancreatography. Cholangio refers to the bile duct system, pancrea to the pancreas.

ERCP may be useful in diagnosing and treating problems causing jaundice (a yellowing of the whites of the eyes) or pain in the abdomen. To understand how ERCP can help, it’s important to know more about the pancreas and the bile duct system.

 

Bile is a substance made by the liver that is important in the digestion and absorption of fats. Bile is carried from the liver by a system of tubes known as bile ducts. One of these, the cystic duct, connects the gallbladder to the main bile duct. The gallbladder stores the bile between meals and empties back into the bile duct when food is consumed. The common bile duct then empties into a part of the small intestine called the duodenum. The common bile duct enters the duodenum through a nipple-like structure called the papilla.

 

Joining the common bile duct to pass through the papilla is the main duct from the pancreas. This pathway allows digestive juices from the pancreas to mix with food in the intestine. Problems that affect the pancreas and bile duct system can, in many cases, be diagnosed and corrected with ERCP.

 

For example, ERCP can be helpful when there is a blockage of the bile ducts by gallstones, tumors, scarring or other conditions that cause obstruction or narrowing (stricture) of the ducts. Similarly, blockage of the pancreatic ducts from stones, tumors, or stricture can also be evaluated or treated by ERCP, which is useful in assessing causes of pancreatitis (inflammation of the pancreas).

Problems with the bile ducts or pancreas may first show up as jaundice or pain in the abdomen, although not always. Also, there may be changes in blood tests that show abnormalities of the liver or pancreas.

 

Other special exams that take pictures using X-rays or sound waves may provide important information for use along with that obtained from ERCP.

 

How to Prepare for the Procedure

Prior to having ERCP, there are a number of things you will need to remember:

  • First, don’t eat or drink anything for at least six hours beforehand or after midnight if your ERCP is scheduled for first thing in the morning.
  • Be sure to tell your doctor all the medication you are taking, including aspirin, aspirin-containing drugs, or blood thinners.
  • Identify any allergies or any reactions you have had to drugs, particularly antibiotics or pain medications.
  • Follow all of your doctor’s instructions regarding preparation for the procedure.

ERCP can be done either as an outpatient procedure or may require hospitalization, depending on the individual case. Your doctor will explain the procedure and its benefits and risks, and you will be asked to sign an informed consent form. This form verifies that you agree to have the procedure and understand what’s involved.

 

What Can You Expect During an ERCP?

Everything will be done to ensure your comfort. Your blood pressure, pulse, and the oxygen level in your blood will be carefully monitored. A sedative will be given through a vein in your arm. You will feel drowsy, but will remain awake and able to cooperate during the procedure.

Although general anesthesia is usually not required, you may have the back of your throat sprayed with a local anesthetic to minimize discomfort as the endoscope is passed down your throat into your esophagus (the swallowing tube), and through the stomach into your duodenum.

The doctor will use it to inspect the lining of your stomach and duodenum. You should not feel any pain, but you may have a sense of fullness, since air may be introduced to help advance the scope.

 

In the duodenum, the instrument is positioned near the papilla, the point at which the main ducts empty into the intestine. A small tube known as a cannula is threaded down through the endoscope and can be directed into either the pancreatic or common bile duct. The cannula allows a special liquid contrast material, a dye, to be injected backwards - that is, retrograde - through the ducts.

 

X-ray equipment is then used to examine and take pictures of the dye outlining the ducts. In this way, widening, narrowing, or blockage of the ducts can be pinpointed.

 

Some of the problems that may be identified during ERCP can also be treated through the endoscope. For example, if a stone is blocking the pancreatic or common bile duct, it is usually possible to remove it.

 

First, the opening in the papilla is cut open and enlarged. Then, a special device can be inserted to retrieve the stone. Narrowing or obstruction can also have other causes, such as scarring or tumors. In some cases, a plastic or metal tube (called a stent), can be inserted to provide an opening. If necessary, a tissue sample or biopsy can be obtained, or a narrow area dilated.

 

What are the Possible Complications from an ERCP?

Thanks to ERCP, these kinds of procedures may help you avoid surgery. Depending on the individual and the types of procedures performed, ERCP does have a five to ten percent risk of complications. In rare cases, severe complications may require prolonged hospitalization.

Mild to severe inflammation of the pancreas is the most common complication and may require hospital care, even surgery. Bleeding can occur when the papilla has to be opened to remove stones or put in stents. This bleeding usually stops on its own, but occasionally, transfusion may be required or the bleeding may be directly controlled with endoscopic therapy.

 

A puncture or perforation of the bowel wall or bile duct is a rare problem that can occur with therapeutic ERCP. Infection can also result, especially if the bile duct is blocked and bile cannot drain. Treatment for infection requires antibiotics and restoring drainage. Finally, reactions may occur to any of the medications used during ERCP, but fortunately these are usually minor.

Be sure to discuss any specific concerns you may have about the procedure with your doctor.

 

What Can You Expect after Your ERCP?

When your ERCP is completed on an outpatient basis, you will need to remain under observation until your doctor or healthcare team has decided you can return home. Sometimes, admission to the hospital is necessary.

 

When you do go home, be sure you have arranged for someone to drive you, since you’re likely to be sleepy from the sedative you received. This means, too, that you should avoid operating machinery for a day, and not drink any alcohol.

 

Your doctor will tell you when you can take fluids and meals. Usually, it is within a few hours after the procedure.

Because of the air used during ERCP, you may continue to feel full and pass gas for awhile, and it is not unusual to have soft stool or other brief changes in bowel habits. However, if you notice bleeding from your rectum or black, tarry stools, call your doctor.

 

You should also report vomiting, severe abdominal pain, weakness or dizziness, and fever over 100 degrees. Fortunately, these problems are not common.

 

ERCP is an effective and useful procedure for evaluating or treating a number of different problems of the GI tract.

HOW ERCP WORKS
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ercp1.gif (11190 bytes)
Your doctor may determine that a stone is blocking a common duct.
ercp2.gif (13772 bytes)
An endoscope will be lowered down your esophagus, through the stomach, and into the duodenum. A small tube will be threaded down into the duct.
ercp3.gif (12651 bytes)
A dye will be injected backwards through the ducts, allowing X-rays to be taken.
ercp4.gif (13261 bytes)
Your doctor will be able to remove the stone that is blocking the duct with the endoscope.
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A Question on ERCP's

I read a response from Henry regarding ERCP's that in my opinion explains the procedure to the letter.

 

From the message board. Ann wrote

I'm hoping to find some info on the ERCP experience from some folks who have actually been through it. I'm scheduled for an ERCP in two weeks (since I wasn't a heavy drinker and they couldn't find any stones with 2 CAT Scans, or an ultrasound. I'm a bit frightened of the ERCP but don't exactly see any other option. Is it painful? Does it take long to recover from it? Please share any ERCP experiences good or bad. I am a single mother of two.

Yours truly, Ann (scaredy cat in Hawaii)

 

Henry's reply:

Dear Ann,

Hi! I'm Henry from the group and welcome to this fine family of pancreas patients and their caregivers! Sorry you have pancreatitis, but you've come to a nice, friendly supportive group of folks who are happy to help. Some background to introduce my self, and my case may be helpful for you. My goodness, what a terrible thing to have happen on your birthday, and it has to be hard with your children.

I'm 38- years-old and was diagnosed with chronic pancreatitis in early 1992 when I was 29. I had been having symptoms of pancreatitis for about eight months or so before the first major acute attack. I've had the Puestow surgery and the Whipple in 1998, and 2000, respectively and gal bladder removal in 1995.

 

Since you've never had an ERCP before I thought you might want to know what the experience is like from a patient's standpoint. I will try my best to describe what the ERCP experience has been like for me to help give you an idea of what it's like if that is helpful for you.

 

I have had over 20 ERCPs over eight years. One reason I had so many was that I was at a teaching hospital, The Medical University of South Carolina (MUSC), as part of a stent study they sere conducting so my treatments were free mostly. In my case they asked me to take nothing by mouth after midnight on the day of the procedure. (NPO) they call it. I came into the clinic in the morning and they took me into a cubicle with a cot in a large room and changed into a gown then they started an I.V. with saline. Then they wheeled me into a small surgical suite and had me lie on my left side and turned down the lights. They will put a nasal, oxygen tube under your nose. Then they began administering the anesthesia. In my case this was usually 100 milligrams of Demerol, or 20-30 milligrams of Morphine, and I forget how many milligrams of Verced (which induces relaxation and can produce an amnesia affect so that hopefully will help you not remember the procedure. They refer to this type of anesthesia as a "twilight sleep." They want to be able to communicate with you if necessary, but for you to be as comfortable as is possible and relaxed. Since I have a high tolerance to anesthesia, this didn't usually work and I often was awake for the procedure, though somewhat groggy during and after. I worked out a system with the anesthesiologist where I would tap my fingers to signal him if I felt I needed more meds since you cannot speak with the tube down your throat during the ERCP. Next they numb your throat with an unpleasant tasting substance that comes out of a spray bottle. Then they put a mouthpiece in and began introducing the tube that goes into your mouth and down your esophagus into your stomach and past to the small bowel where the pancreatic ducts are located. They will slowly introduce the tube and ask you to begin swallowing the tube. The hardest part of this is getting it past the back of your throat and down into the esophagus.

 

They had some difficulty with me at the ducts because I was born with pancreas divism (Latin for divided pancreas), and my ducts were small. They have a light and a camera on the end of the tube and can pass wires and cutting instruments and stents, (little plastic or rubber tubes that help the pancreas drain), through the tube. The tube is black and smaller in diameter than a garden hose, although I don't know the exact diameter. They do various things such as a cut on the duct to widen it and insert various size stents. I have had some pain with the cuts, (spinterotomies), but the Demerol, (or Morphine) helps some with this pain. They want you to lie very still so they don't risk puncturing bowel. In my case the procedure usually lasted about an hour or so depending on what they were doing on a given procedure. The longest ones were about two hours when they had to remove stones from my pancreas. When they are finished, they would rub my shoulder and say, "It's over Henry, we're finished! You did great!" or some such thing. Then they would help me off the operating table onto a stretcher and wheel me back to the recovery room where I would lie for about an hour. After this it would be time for me to go home unless I had to stay the night.

 

I don't like ERCPs, but when I think about what people had to go through before they had the ERCP such as surgery to widen ducts, remove stones, then it seems like a good alternative. I hope that this helps some. If you have any other questions for me please feel free to e-mail me. There are a lot of good folks here who can answer your questions and know more about this than I do.

 

I always enjoy receiving e-mail and it's great to meet all the new folks who have joined the "family." I hope you are doing reasonably well and that I will hear from you again soon! There is another pancreas patient named Rich who lives in Hawaii here too. God Bless.

 

Your New Pancreas Pal,

Henry, from SC

 

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