ERCP (Endoscopic Retrograde Cholangio-Pancreatography)

ERCP (Endoscopic Retrograde Cholangio-Pancreatography) image

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ERCP (Endoscopic Retrograde Cholangio-Pancreatography)

Why do I need an ERCP?
ERCP stands for ‘Endoscopic Retrograde Cholangio-Pancreatography. It has been recommended for you to have an ERCP to help diagnose and treat the cause of your symptoms. The aim of the procedure is to assess the bile duct and the areas around it and the pancreatic duct. We may well find that we have to either make a small cut to release trapped gallstones or insert a plastic/metal tube to relieve the blockage in the bile duct (jaundice).

What is an ERCP?

  • An ERCP is an examination that allows the doctor to look directly at the opening where the bile duct and the pancreas drain into the duodenum (the first part of your small bowel).
  • To perform the examination, an endoscope is passed gently through your mouth, over the back of your tongue, into your oesophagus (gullet), through your stomach and into your duodenum. The endoscope is a long flexible tube with a bright light on the end, which is about the thickness of your index finger.
  • An X-ray dye will then be injected down the endoscope into the bile ducts, which can then be seen on X-ray films. It allows us to see if there is anything wrong or if any of the ducts are blocked. If everything is normal the endoscope is removed and the test is complete. The dye is passed out of your body harmlessly.
  • If the examination shows gallstones in the bile duct, we will usually enlarge the opening of the bile duct (Sphincterotomy) with an electrically heated wire (diathermy), and you should not feel anything. Any gallstones will be removed by the endoscope, or left to pass naturally.
  • If we find that the duct has narrowed, we can improve how the bile duct drains by leaving a short plastic or metal tube (stent) in place. You will not be aware of the presence of the tube. Occasionally, it may be necessary to replace the tube if it becomes blocked. Sometimes we may take a biopsy, this is a sample of the lining of your intestine, and this will be examined in the laboratory. We will remove this small piece of tissue painlessly using tiny forceps through the endoscope.

What do I need to do to prepare?
Before the examination you will be welcomed and assessed by an Endoscopy Nurse. Please bring your medicines or prescription. You may have been given a patient health questionnaire to fill in at home (please bring this back with you) alternatively, you will be asked to complete this with a nurse on arrival. We will need to know if you suffer from any other medical conditions, allergies or past operations etc.

Eating/Drinking:

  • You must NOT eat, chew gum or suck boiled sweets for six hours before the procedure.
  • This allows us to see clearly inside your stomach, it must be completely empty of food and fluid.
  • If it is not, we may not be able to see certain areas of your stomach and we may have to repeat the procedure.
  • You may take one or two sips of water up to two hours before the procedure.

Medication:

  • Continue to take your normal medicines up to and including the day of your procedure.
  • If you are taking Warfarin, Phenindione, Clopidogrel (Plavix), Rivaroxaban, Apixaban, Dabigatran, Edoxaban, Prasugrel, Ticagrelor or any other blood thinning agents (anti-coagulant) please contact the unit as our Doctors may decide that it is necessary for you to stop taking your tablets for a limited time before the procedure. Please ring the department directly on: 01905733085
  • Please bring a list of any medications you are taking and any medication you may need to take after your procedure.
  • We will need to know if you feel unwell when you are due to come into hospital for your procedure. Depending on your illness and how urgent your investigation is, your procedure may need to be delayed.
  • If you have diabetes, please read pages 7 and 8 carefully.

IF YOU TAKE LONG TERM STEROIDS OR HYDROCORTISONE FOR ADRENAL INSUFFICIENCY PLEASE RING THE RELEVANT DEPARTMENT AND SPEAK TO A NURSE IF THIS HAS NOT ALREADY BEEN ADDRESSED.

General Information:

  • If you are pregnant or breast feeding, please contact the Endoscopy Unit for advice.
  • Please remove any body piercings and jewellery before you leave home.
  • Please do not bring valuables or money with you as Worcestershire Acute Hospitals NHS Trust cannot accept responsibility for these items.
  • Please do not wear any nail varnish, lipstick or false nails. Please do not use any fake tan or body lotion on the day of your procedure.
  • Due to the nature of this procedure, you may find wearing loose-fitting casual clothes more comfortable to travel home in.
  • Our aim is to run the Endoscopy lists as close as we can to time, however the time taken to complete procedures can vary. We also deal with emergencies which can arise without warning. These can take priority over your appointment, meaning we may have to ask you to wait or possibly postpone your ERCP to a later date.

What will happen on the day of my procedure?
Before the procedure you will be welcomed and assessed by an Endoscopy Nurse. Please bring your medicines or prescription and the patient health questionnaire. We will need to know if you suffer from any other medical conditions, allergies or past operations etc. The nurse will discuss the procedure with you, take your pulse, blood pressure and confirm that you wish to go ahead with the procedure. Your appointment time takes into account the time required to admit you to the unit by the nurse. You should expect to be with us for around 3-4 hours including waiting and recovery time.

Sedation:
We usually give you a sedative drug by injection through a small tube (venflon) in the back of your hand, to help make sure that you are relaxed and comfortable during the procedure. This is NOT a general anaesthetic, the sedative will not put you to sleep but helps to relax you; it is known as conscious sedation and as such you should be able to respond to verbal commands. Some Consultants may also administer throat spray or a local anaesthetic to numb the back of the throat.

Please be aware you cannot have sedation unless you have a responsible adult who will accompany you home and care for you for a minimum of 12 hours. If you fail to make appropriate arrangements for someone to accompany you home, we may have to cancel your procedure.

What will happen during my ERCP?

  • In the X-Ray room you will be made to feel comfortable on a trolley, resting on your left side. A nurse will stay with you throughout the procedure.
  • A nurse will attach a small device to your finger to monitor your pulse rate and general condition during the procedure. We will then give you a sedative injection and oxygen throughout the procedure, along with a pain relief injection.
  • You will also be given indometacin or diclofenac as a suppository (medication given in the rectum) prior to the procedure. These medications are given to reduce the risk of pancreatitis following ERCP.
  • A metal plate may be attached to your thigh this is for the use of the diathermy
  • To keep your mouth in a comfortable position, we will insert a plastic mouthpiece between your teeth and gums.
  • The Consultant will gently push the endoscope down your oesophagus (gullet) into the duodenum, air is passed through it to expand the area, this may make you feel full and want to belch.
  • The procedure generally takes between 30 and 60 minutes to complete.
  • If necessary, we will take small tissue samples (biopsies) through the endoscope and send them to the laboratories for analysis.

What will happen after my ERCP?
After the procedure is over, we will take you back to the Endoscopy unit recovery area, where you will need to recover for a minimum of two hours, your pulse, blood pressure and temperature will be checked regularly, if after a few hours you are considered well enough you will be allowed to eat and drink then most people are ready to go home. During your recovery time, you may be given an antibiotic suppository, but you will be made aware of this prior to discharge home.

You may feel a little bloated with wind pains but these usually settle quite quickly. A member of the Endoscopy Team will discuss the finding of this procedure with you and the person taking you home. On occasion some patients may require an overnight stay.

Leaving the hospital:

  • Once you get home, it is important to rest quietly for the rest of the day. This is very important if you have been sedated, sedation lasts longer than you think.
  • You should not be left alone for 12 hours after the procedure.
  • You must be accompanied home from the hospital by a responsible adult. You must not drive yourself for 24 hours.

For 24 hours after the procedure, you should not:

  • Drive a car
  • Sign any legally binding documents
  • Take sleeping tablets
  • Work at heights – including ladders
  • Use machinery
  • Drink alcohol

The effects of the procedure and injection should wear off within 24 hours, when most patients are able to carry out normal activities again. If you work, we do advise you to have the following day off.

What complications can occur?
Most ERCPs are usually done without any problem; however, the benefit of this procedure needs to be weighed up against the risk of complications. According to our national guidance there is a risk of:

  • Bloating or abdominal discomfort (this is not unusual for a few hours following the procedure);
  • The back of your throat may feel a little sore for 24 hours after your procedure;
  • Possible damage to any teeth which are loose in your mouth;
  • Vomiting of blood
  • Reaction to medications given
  • Difficulty in breathing
  • Raised temperature/fever

Significant problems may occur after therapeutic ERCP. Risk to life occurs approximately 1 in 100 and usually related to complications arising in patients with significant underlying health problems.

Pancreatitis: Pancreatitis results from inflammation of the pancreas. This may be relatively mild and involve mild abdominal pain. Sometimes perhaps 1 in 20 cases this will be more severe and will require you to stay in hospital for several days until the pancreatitis resolves.

Bleeding: During a Sphincterotomy a small cut is made. In about 1 in 50 cases this is associated with bleeding. Whilst this often settles spontaneously and requires little more than a blood transfusion, in very rare cases an operation is required to stop the bleeding.

Cholangitis: Infection of the bile ducts may occur after ERCP. This requires treatment with antibiotics. It occurs in less than 1 in 50 cases and maybe more common if a stent has been put in or if there is a stone which cannot be removed.

A puncture or perforation of the bowel wall or bile duct is a rare problem that can occur in 1 in 50 patients.

Sometimes, surgery is needed to put right these types of complications.

Finally, other complications may occur but are extremely uncommon. The consultant responsible will discuss these risks with you prior to the procedure.

You will be cared for by a skilled team of doctors, nurses and other health-care workers who are involved in this type of procedure every day. If problems arise, we will be able to assess them and deal with them appropriately.

If any of the following serious problems above happen within 72 hours after the ERCP you should seek help from own GP, or out of hours GP, or the nearest A&E department or NHS 111 and say that you have had a ERCP

If you have diabetes:
If you monitor your blood glucoses, please monitor your blood glucoses every 2 hours on the day of your procedure.

If your diabetes is treated with lifestyle measures only (diet and exercise), you don’t need to take special precautions.

Upper Gastrointestinal Endoscopy (OGD) in Patients with Insulin-Treated Diabetes

Basal-Bolus regimens (Injections 3 or more times a day)

Instructions for on the day of the procedure:
Before the procedure
For those taking long-acting insulin (e.g.Lantus®, Levemir®) in the morning, reduce dose by 20%.

For those taking a rapid acting insulin (e.g. Novorapid®, Humalog®) with breakfast, the rapid acting insulin should be omitted.

Capillary blood glucose should be checked at least every two hours until the end of the procedure.

If on an afternoon list, and therefore able to eat breakfast, give usual dose of rapid acting insulin with breakfast, but omit the lunchtime dose.

After the procedure
Usual insulin treatment should be resumed.

Twice daily regimens
Mixed insulin injections twice a day (e.g. Novomix 30®, Humalog Mix 25® or50®)

Before the procedure
Half the usual morning dose of insulin should be given. Capillary blood glucose should be checked at least every two hours until the end of the procedure.

After the procedure
Usual insulin treatment should be resumed.

Once daily regimens
Injections once a day (e.g. Insulatard®, Humulin I®)
If taken in the morning, half the usual dose of insulin should be given. If taken in the evening, the usual dose of insulin should be given. Capillary blood glucose should be checked at least every two hours until the end of the procedure.

If there is any doubt or concern, the local diabetes specialist nurse or consultant should be contacted for advice.

If more than one meal is to be missed, or there are two consecutive blood glucose levels above 15mmol/l, consider commencing CVRIII.

Upper Gastrointestinal Endoscopy (OGD) In Patients With Diabetes Treated With Tablets and/or GLP-1 Agonists

Instructions for on the day of the procedure.
Omit the morning dose of the diabetes drug. Take the usual dose of the diabetes drug when able to eat after the procedure. It is recommended that capillary blood glucose is checked every 2 hours from waking until the test.

If there is any doubt or concern, the local diabetes specialist nurse or consultant should be contacted for advice.

Contact details:
If you have any specific concerns that you feel have not been answered and need explaining, please contact the following.

Alexandra Hospital, Redditch

  • Booking Office –01527 505751
  • Endoscopy Nursing staff – 01527 512014

Worcestershire Royal Hospital

  • Booking Office – 01905 760856
  • Endoscopy Nursing staff – 01905 733085

Other information
The following internet websites contain information that you may find useful.

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you.

Feedback
Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: wah-tr.PALS@nhs.net

Opening times:
The PALS telephone lines are open Monday to Thursday from 8.30am to 4.30pm and Friday: 8.30am to 4.00pm. Please be aware that a voicemail service is in use at busy times, but messages will be returned as quickly as possible.

If you are unable to understand this leaflet, please communicate with a member of staff.

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