ERCP (Endoscopic Retrograde Cholangio Pancreatography)

This information is for patients who are having an ERCP. It explains what is involved and the risks of the procedure.

If you do not attend your appointment without telling the Endoscopy Unit in advance you may be removed from the waiting list.

Students and trainees (supervised by qualified staff) may be involved in your care. If you do not want students and trainees to be present, please tell the endoscopist or nurse in charge. 

The time stated is your booking-in time, please tell those accompanying you that this is not your procedure time. The test itself takes on average 30 minutes, and may take longer if we need to carry out any treatment during the ERCP. Occasionally, if there are emergency cases or very complex cases, the start of your procedure may be delayed.

What is an ERCP?

An ERCP is a test that allows your doctor to diagnose and treat problems with the tubes (ducts) draining your gallbladder, pancreas, and liver into the upper small intestine (duodenum).

1. 
   Endoscope passing through the mouth, gullet, stomach, and duodenum
2. 
   The bile duct and pancreatic duct

To do this test an endoscope (a thin flexible tube approximately the size of an index finger) is passed through your mouth, via your gullet and stomach, and into the duodenum.

A catheter (a thin plastic tube) is then passed through the endoscope and into the opening of the bile duct, and pancreatic duct if necessary. X-ray dye is gently injected and x-ray pictures are taken to check for problems (abnormalities).

How do I prepare for my examination?

• Before your ERCP you will need to have a blood test, (+/- a COVID swab) and a further medical assessment, if needed.

• Usually you will be asked not to eat for six hours before your procedure and drink only clear fluids (such as water) up to two hours before your procedure. The Endoscopy Unit will advise you when to begin this period of nil by mouth.

• If you are a diabetic or have clotting or bleeding disorders, please phone the Endoscopy Unit for specific advice.

• If you might be pregnant, please tell us as soon as possible.

• If you are taking blood thinning medications like clopidogrel, ticagrelor (Brilique), warfarin, dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Lixiana), or any other blood thinning medications, please tell us as soon as possible.

• If you have a pacemaker or ICD, please tell us at least one week before your test.

• Continue to take your medications with a sip of water. Please bring a list of them with you to the Unit. If you have any queries about your medication please ring the Endoscopy Unit.

• It is especially important to remember to bring any asthma inhalers or angina sprays with you.

• If you have been diagnosed with sleep apnoea and use a CPAP machine, please bring this with you to your appointment and tell the nurse on arrival.

• Please remove nail polish and all types of false nails before coming to hospital for your procedure. Bring a dressing gown, slippers, and something to do during your stay.

• Do not bring any valuables to the Unit. East Kent Hospitals accepts no responsibility for the loss or damage to personal property, unless the property had been handed in to Trust staff for safe-keeping.

• Remember you can withdraw your consent for treatment at any time.

What will happen when I arrive at the hospital?

• Please report to the reception of the Endoscopy Unit.

• A nurse will check your details, blood pressure, and pulse. If you are taking any medication or are allergic to anything (medications, plasters, latex) please tell the nurse.

• You will be asked to remove any jewellery, spectacles, contact lenses, tongue studs, and false teeth before your examination.

• Please tell the nurse if you have a pacemaker, replacement joints, pins, or plates.

• You may receive antibiotics before your procedure to help prevent infection. Usually you will also be given a painkiller suppository before your procedure, this reduces the risk of pancreatitis (inflammation of the pancreas).

• The endoscopist performing your test will explain the procedure and discuss the risks and benefits of the procedure before asking you to sign a consent form. This confirms that you understand the examination and agree to go ahead with it. Please do not hesitate to ask any questions you may have.

• You will need to change into a hospital gown.

• A nurse will stay with you throughout your examination.

What does the examination involve?

• Your throat may be sprayed with a local anaesthetic that has a numbing affect; this has a slightly bitter taste.

• A small needle will be inserted into a vein and a sedative and painkiller given before your examination; this will help you feel more relaxed and sleepy. (This needle will be left lightly strapped to your hand / arm until you are recovered from the procedure).

• You will be asked to lie on your left side with your left arm behind your back and then turned partly onto your stomach for the test. A guard will be placed in your mouth to protect your teeth.

• A small device for recording your pulse and breathing will be attached to your finger and you will be given oxygen.

• A cuff will be placed on your arm to monitor your blood pressure.

• Three small ECG pads will be placed on your back to monitor your heart during the procedure.

• Once you are sleepy, the endoscopist will begin the test.

• Your stomach and duodenum will be gently inflated with air to expand it, so the lining can be seen more clearly. The air is sucked out at the end of the test.

• The nurse may need to clear excess saliva from your mouth using a small suction tube.

• If a narrowing is found in your bile duct, a tube (stent) may be inserted to allow the bile to drain. This may stay in place permanently or be removed at a later date. If the endoscopist finds a gallstone in your bile duct during ERCP, the opening of your bile duct may be enlarged with a cut using an electrical current (diathermy), which will allow the stones to be removed. If the stone is very large, or if there are a lot of stones, it may not be possible to remove all in one go. In this case, a stent is left in your bile duct and a further appointment will be arranged.

• A biopsy (a small sample of the lining of your bowel) may be taken during your examination to be sent to the laboratory for more tests. You cannot feel this. (A video recording and / or photographs may be taken for your records).

• In about one in 15 cases, it will not be possible to treat your problem at ERCP. For example, the opening of your bile duct may be too narrow to allow the catheter to be inserted. If this happens, then further treatment options will be discussed with you after your procedure.

What happens after my examination?

• You will return to the recovery area to rest.

• You may still have a little wind but this will pass naturally.

• In some cases you will be discharged home after a period of observation (up to four hours). If the procedure was complex, or you are at increased risk of complications, you may be admitted overnight for observation.

• You may also be kept nil by mouth for up to 24 hours. However, if your procedure was straightforward you can usually eat some light food and drink once you are fully awake and the local anaesthetic spray in your throat has worn off.

• You will be told of the result of your examination. If biopsies have been taken, the results take about a week to come back.

• A letter will be sent to your GP.

What happens when I go home?

The decision to allow you to go home will be made after your procedure.

• You must have a friend or relative with transport to collect you from the Unit and stay with you at home for 24 hours until you are fully recovered.

• You must not drive, drink alcohol, operate machinery, or sign important documents for 24 hours following the sedative.

• You may have a mild sore throat, but this will pass after a few days.

• You may feel a little bloated from some air left in your stomach, again this will pass.

Are there any significant risks?

ERCP is generally a well-tolerated procedure but there are significant risks.

• Damage to crowned teeth or dental bridgework.

• Cardiovascular (heart and blood vessels) or respiratory (lung and breathing) complications can happen as a result of the sedatives and painkillers you need during your procedure.

• Inflammation of the pancreas called pancreatitis, which causes abdominal pain and usually needs some days in hospital for intravenous fluids and painkillers. On rare occasions, it may be severe and a patient may need to be admitted to Intensive Care.

• Infection of the bile duct or gallbladder can happen, although often ERCP is done to provide drainage of infection.

• Bleeding: if a cut is made into your bile duct to remove a gallstone or place a stent, there is a risk of bleeding. Bleeding can often be treated immediately, or during a later endoscopy procedure, and a blood transfusion may be needed. If bleeding is severe, it may need occlusion of the bleeding vessel by a radiologist (usually by accessing groin blood vessels) or surgery.

• Perforation is a tear in the wall of your bowel. This is usually managed with intravenous fluids and feeding, antibiotics, and nil by mouth, occasionally surgical repair is needed.

• You may have a sore throat after your procedure, but this normally clears up in a few days.

The European Society of Gastroenterology published a guideline of ERCP related adverse events in 2019. The incidence of adverse events was summarised and is shown below.

It is important to realise that the risks listed below are for all patients, including patients who are very sick and might be on an Intensive Care Unit. In general the severity and outcome of a complication depends on how fit the patient is before they have their ERCP.

ERCP is often the least invasive way to drain bile ducts, remove bile duct stones, and treat sepsis.

The risks include all adverse events from mild to severe, and are approximate. The overall risk of death, attributable at least in part to the ERCP, is one in 200; this includes some very unwell patients undergoing urgent procedures.

• Frequency of ERCP related adverse events (ESGE Clinical Guideline, Endoscopy 2019)

  -  Pancreatitis: affects one in 20 patients.

  -  Infection of bile ducts or gall bladder: affects one in 30 patients.

  -  Bleeding: affects one in 30 patients.

  -  Significant perforation: affects one in 300 patients.

Please discuss risks and benefits of the procedure with your endoscopist.

Further information

Please phone the Endoscopy Unit. The Units are open Monday to Sunday 8am to 6pm:

• Kent and Canterbury Hospital (K&C), Canterbury                          
  Telephone: 01227 783058 (not always staffed at weekends)

• Queen Elizabeth the Queen Mother (QEQM) Hospital, Margate      
  Telephone: 01843 234370

• William Harvey Hospital (WHH), Ashford                                           
  Telephone: 01233 616274

If you need urgent advice following ERCP, between 6pm and 8am Monday to Sunday, then contact the Emergency Department on:

• Emergency Department, Queen Elizabeth the Queen Mother (QEQM) Hospital, Margate
  Telephone: 01843 23 50 30

• Emergency Department, William Harvey Hospital (WHH), Ashford           
  Telephone: 01233 616207

A short film outlining what patients can expect when coming to hospital for an endoscopy is available on the East Kent Hospitals web site.  

If you develop any severe pain in the neck, chest, or abdomen within the first 24 hours of your procedure, please phone the Emergency Department (see telephone numbers above). You will be given a leaflet after your ERCP which will give you more details on possible risks when you go home and general advice.

Our Units are regularly inspected and audited; please ask if you want any information about our performance standards. You can also visit the Care Opinion web site.