What is endoscopic retrograde cholangiopancreatography?
ERCP is a way to examine your pancreas, the pancreatic duct, the common bile duct, the bile ducts inside the liver, the gallbladder (if present), and/or the sphincter of Oddi.

Your doctor uses a long narrow tube called an endoscope to look at these parts of your body and he or she may use contrast (dye) and x-rays to highlight them. Your doctor may also use ERCP to treat any stones or blockages he or she may find.

Your common bile duct connects your liver, gallbladder, and pancreas to your small intestine. Your pancreatic duct connects your pancreas to the intestine (duodenum). Its outflow is shared with the common bile duct. The sphincter of Oddi is a circular muscle where your common bile and pancreatic duct enter your small intestine. It opens and closes to allow fluid to pass into your small intestine to help with digestion.

When is it used?
The doctor may suggest this procedure if:

• You have particular forms of jaundice.
• He or she suspects you have a stone lodged in the common bile duct.
• You have a blockage (stricture) in the bile duct or pancreatic duct.
• You have a sphincter of Oddi that may be too tight.
• You have or are suspected of having a growth of tissue in the bile duct, liver, or pancreas

Examples of alternatives are:

• Having an ultrasound or compute tomography (CT) scan of the abdomen.
• Having similar x-rays done through a needle placed in the bile duct through the liver (a procedure called a percutaneous transhepatic cholangiogram).
• Having a surgical common bile duct exploration.
• Choosing not to have treatment, while recognizing the risks of your condition.

You should ask your doctor about these choices.

How do I prepare for an ERCP?
Follow the doctor’s instructions. Eat a light meal the night before the operation and do not eat or drink anything after midnight the night before the procedure. Plan for care and recovery time after the operation is over (average of one to two hours).

Patients with a history of allergy to IV contrast agents or iodine require 24 hours of steroid preparation. Please alert the doctor if you believe you require this steroid prep. Our staff will also need to know if you have an allergy to Lostex or antibiotics.

What happens during the procedure?
You will be given intravenous sedation to relax you. You will be offered local anesthesia (1 percent lidocaine) to numb your throat. Please let us know if you do not want this (especially if you are allergic).

The doctor will insert a tube into your throat and down your esophagus (swallowing tube) and guide it through your stomach and small intestine until it reaches the point at which the common bile duct and pancreatic duct open into the intestine (the sphincter of Oddi).

The doctor will pass a smaller tube (cannula) through the endoscope and guide it into the common bile duct to look for stones, narrow places, or blocked portions. The doctor will use fluoroscope, a motion picture x-ray, to guide the tube.

The doctor may inject some contrast (dye) into your common bile duct and/or pancreatic duct to highlight any abnormal growths or structures on an x-ray.

If the x-ray or tube uncovers stones, the doctor may use a look to break them and move them into the intestine.

The doctor may also enlarge the opening of the sphincter of Oddi by cutting into the muscle (sphincterotomy) to allow the stones to pass into the intestine more easily.

What happens after the procedure?
You will be observed for about one hour and then may go home. Because you should not drive or do anything that requires coordination or quick response you must arrange for an adult who can drive to pick you up from the hospital. We regret that we cannot send unescorted patients home by taxi, or offer to admit them to the hospital for recovery if an escort is not arranged…if you anticipate a problem of this kind, please notify us ahead of time, as your procedure may need to be rescheduled.

In the past, patients who had the sphincter muscle cut (sphincterotomy) were routinely observed overnight in the hospital. We no longer require this, as our statistics show that very few patients develop problems that are delayed beyond the usual recovery period.

In certain circumstances, we may request that a patient stay for additional tests or therapy (e.g., intravenous antibiotics for infection). We may also suggest that you stay nearby overnight (i.e., in a hotel or motel), so that if problems do arise they can be dealt with quickly. Any patient coming for ERCP should bring a bag of toiletries and night wear in case admission to the hospital is necessary.

Prior to leaving the Endoscopy Unit, one of the physicians on the team will review the findings of the ERCP with you and your escort, and tell you what further treatment, tests or clinic review may be required. After sedation, it can be difficult to retain this information, which is why we often request that you come for a clinic follow-up. A discharge information sheet is provided, with “do’s” and don’ts” and contact telephone numbers in case of problems.

What are the benefits of this procedure?
Your doctor may understand your problem better and be able to suggest further care.

You may get relief from the problem. If you have an obstruction, the doctor may relieve it without having to resort to abdominal surgery or other invasive procedures.

What are the risks associated with this procedure?

• Your esophagus, stomach, intestine and/or common bile duct may be hurt or punctured. All medical procedures carry some risk. ERCP is no exception. Your doctor is very experienced and works to keep your risk of complications as low as possible. However, complications can and do occur, and your doctor is trained to manage them.

All endoscopies carry a small risk of problems related to medication, including allergy. Administration of sedation and antibiotics through an IV catheter can also cause chemical irritation of the vein (phlebitis). Your doctor will tell you how to recognize and treat this. We monitor patients very carefully during endoscopy to ensure normal heart and lung function (breathing).

When problems arise during sedation, the procedure is usually discontinued and measures taken to correct the problem. Rarely, this may require help from anesthesiology or other specialists. Whenever an endoscope is passed into the stomach and intestine, a tear or perforation is possible. Fortunately, this is a rare complication that is seen in less than 1:1000 cases. A tear or perforation may require surgery to repair, to prevent infection from leakage of gut contents into other body cavities.

• You may develop inflammation in the liver, common bile duct, or pancreas. Pancreatitis (inflammation of the pancreas) is the commonest complication of ERCP, occurring in 3 to 5 percent of cases (the risk is increased in certain specific conditions; your doctor will alert you to these). Pancreatitis causes upper abdomen and back pain associated with nausea and (sometimes) vomiting. It is usually obvious within one hour of finishing the ERCP, but may be delayed as long as six to 12 hours.

If you develop ERCP-related pancreatitis, we will ask you to stay in the hospital so we can treat it (IV fluids, painkillers) until you can eat and drink normally again. Ninety percent of cases are “mild”, which means that patients can go home after one to three nights in the hospital. Occasionally, pancreatitis can be more severe, resulting in a prolonged stay in the hospital and further procedures (sometimes including surgery).

• The procedure may not work. If there is a blockage or if you have stones, your doctor may not be able to clear either one.
• There is a risk of infection and bleeding. Bleeding is a rare (less than 1 percent) complication of ERCP. The risk increases if you are on anticoagulants or other blood-thinners, such as aspirin, non-steroid analgesics (e.g., ibuprofen, Advil) or Ticlid. Please alert your doctor if are taking any of these medications, or you have a known bleeding disorder.

Bleeding during ERCP usually follows sphincterotomy (electrical cutting of the sphincter muscle). Most bleeding of this kind can be stopped using local methods, such as cautery (heat) or adrenaline injection. It is rare for bleeding to continue despite these interventions.

Occasionally, blood transfusion, interventional radiology or surgery may be required. Blood transfusion causes a small risk of allergy (transfusion reaction) and transfer of viruses that can cause hepatitis (liver inflammation). All blood used at Duke is screened for HIV (the virus that causes AIDS). Please notify your doctor before the procedure if you have known problems with transfusion (i.e., previous reactions) or you do not wish to receive blood or blood products (e.g., if you are a Jehovah’s Witness).

Infection may complicate ERCP if the bile duct or pancreas is obstructed. We reduce the risk of infection by giving IV antibiotics before ERCP. Please tell your doctor if you have antibiotic allergies (e.g., Penicillin). Also, if you have an artificial (prosthetic) heart valve, antibiotic coverage may be appropriate to reduce the risk of infection caused by bacteria entering the bloodstream (e.g., endocarditis).

You should ask your doctor how these risks apply to you.

When should I call the doctor?
Call the Biliary Service doctor-on-call if:

• You develop abdominal pain that is severe enough to require painkilling injections.
• You have nausea and or vomiting, sufficient to stop your drinking fluids.
• You develop a persistent fever of 38.0°C (99.5°F) or higher.
• You think you are bleeding from the gut (vomiting blood or passing dark stools).

We would much rather hear from a patient with concerns or problems after ERCP than have anyone “suffer in silence”. The discharge sheet provides both daytime and out-of-hours contact numbers. There is always a physician on-call with whom you can discuss problems. There is no such thing as a “stupid” question!

Call the Biliary Office (919-684-3708) office hours (7:30 a.m. to 4 p.m.) if:

• You have questions about the procedure or its result.
• You want to make another appointment.

This article is intended as a resource for patients receiving their cancer care at Duke University Hospital or Duke Clinic. It is not intended to substitute for medical advice from your health care team. If your doctor’s instructions differ from the information in this article, please talk with your doctor before making any changes.

Source: Duke Cancer Patient Education Program / Patient & Family Education Committee 8/00