ERCP is a safe procedure that will give your doctor information other tests may not be able to give. An ERCP is an examination of a part of the gastrointestinal system that includes the gallbladder and pancreas and the ducts (tubes) that drain those organs and the liver. Small ducts from the gallbladder and pancreas flow into a large duct (common bile duct) that drains into the small intestine through an opening called an ampulla.

An endoscopist (a doctor who has special training in the use of endoscopes) will examine the gallbladder, pancreas, and these ducts, looking for blockages, irregularity in the tissue or flow of bile/pancreatic fluid, spasm of the ducts, stones, or tumors. X-ray equipment and a medical dye will be used during ERCP.

Some patients are admitted to the hospital afterward depending upon the reason for ERCP and on what was done during the procedure. The length of the examination varies, but generally takes at least an hour.

INDICATIONS FOR ERCP — The most common reasons for ERCP are the following:

• Preoperative or postoperative evaluation of patients who undergo laparoscopic gallbladder removal to detect gallstones which might be blocking the ducts
• Evaluation of pancreatitis (an inflammation of the pancreas)
• Evaluation of a possible pancreatic malignancy
• To remove gallstones that are not passing through the ducts into the small intestine. Some stones are too large to pass easily and get stuck in the ducts.
• Evaluation of abnormal or unclear findings in the biliary system on a CT examination
• Evaluation of chronic or acute abdominal pain when biliary disease is suspected
• Evaluation of jaundice (yellow skin) when bile duct disease is suspected

At the time of the procedure, the endoscopist may take tissue samples (biopsies), place drainage tubes to improve bile flow, or make a small cut into the main bile duct (common bile duct) to remove stones or to improve flow.

PREPARATION — Your doctor will provide you with specific instructions on how to prepare for the examination. The instructions are designed to maximize your safety during and after the examination and to minimize possible complications. It is important that you read the instructions ahead of time and follow them carefully. Call your doctor or the endoscopy unit if you have questions.

You will be asked not to eat or drink anything for six to eight hours before the test. It is important for your stomach to be empty at the time of the examination to allow the endoscopist to visualize all of the structures and to decrease the possibility of food or fluid being vomited into your lungs (called aspiration) while you are sedated.

Medications — You may be asked to adjust doses of your medications or to eliminate specific medications prior to the examination. Some need to be eliminated for several days, so read the instructions when you receive them. Be sure to ask your doctor specifically what you should do about your particular medications since some medications are more important than others, and your doctor may want you to take them despite the examination.

Escort — You will also be instructed to arrange for a responsible person to escort you safely home after the examination. Even though you will be awake by the time you are discharged, the medications used to sedate you cause changes in reflexes and in judgment that will leave you feeling well, but interfere with your ability to drive or make decisions coherently, similar to the effects of alcohol in your body.

WHAT TO EXPECT IN THE ENDOSCOPY UNIT — Prior to the ERCP, a nurse will prepare you for the examination. The nurse will take a history from you to determine what you already know about the procedure and whether you understand why the examination is being done. The nurse will ask questions to determine if you are properly prepared, such as:

• Have you been fasting?
• Do you have an escort to take you home?
• What medications you take?
• Do you have any medical problems, such as heart disease, lung disease, etc?
• Do you have allergies to any medicines, Latex, or dyes used in medical procedures? If you alert the nurse to a previous adverse reaction to medical dyes, a special dye will be used during the ERCP and you will probably be given medication before the examination to minimize the possibility of a reaction.
• Have you had any previous adverse reactions to sedation medications or narcotics?

The nurse will start an intravenous line (put a needle in a vein in your arm) so that medications can be administered to help you relax and keep you comfortable during the examination. This is just a pin prick, no worse than having your blood drawn. Your vital signs will be monitored during the examination and for a time after the ERCP is over. The nurse will check your blood pressure and pulse either manually or with a machine that continuously monitors your heart rate and rhythm, oxygen level, and blood pressure. The monitoring devices are not painful. You may also be given oxygen during the examination.

A doctor will review the examination with you, including possible complications, and will ask you to sign a consent form. Do not hesitate to ask questions you may have about the examination.

You will be given medication to gargle to numb your throat, or, a numbing spray might be used. For safety reasons you will be asked to remove dentures.

THE PROCEDURE — ERCPs are performed in a room that contains x-ray equipment. You will be lying on an x-ray table for the examination. The ERCP will be performed with you lying on your side or stomach. Medications will be administered through the intravenous line. Most endoscopy units use a combination of a sedative to help you relax and a narcotic to diminish any unpleasant sensations. A plastic mouth guard will be placed between your teeth to prevent damage to your teeth and to the scope. You will be asked to swallow the tube when it is introduced into your mouth, though you may not remember doing this once the medications have taken effect. Many people sleep during the test; others are very relaxed, comfortable, and generally not very aware of the examination.

The ERCP scope is a flexible tube, approximately the size of your finger. It contains a lens and a light source that allows the endoscopist to either look into the scope or at a TV monitor. If the image is reflected on a TV monitor, it is magnified many times so the endoscopist can see minute changes in tissue.

The ERCP scope also contains channels that allow the endoscopist to take biopsies and introduce or withdraw fluid and air. The scope in inserted through your mouth, and air is introduced to open up the esophagus, stomach, and intestine so the scope can be passed through those structures and to allow the endoscopist to see. When the scope reaches your duodenum, the first portion of the small intestine, the endoscopist will locate the ampulla, the opening into the ducts that drain the biliary system. A small cannula (tube) will be placed into the ampulla and, dye (a special contrast material that allows visualization of tissues by x-ray) will be injected through the cannula.

If you experience any sensations at all, you may experience a mild discomfort from the air as it distends the tissue. It is not harmful to you, and you may belch to relieve the sensation. It is important to remember that the ERCP scope does not interfere with your breathing, and that, in fact, concentrating on taking slow deep breaths during the procedure may help you relax further.

RECOVERY — After the ERCP, you will be kept for a time for observation while some of the medicine wears off. The most common discomfort after the examination is a feeling of bloating from the air introduced during the examination. Some patients also have a mild sore throat.

Unless you are given other instructions, you should be able to eat a few hours after the examination. Many patients are tired afterwards or have difficulty concentrating (from the medicines) so it is usually advised not to return to work that day.

The endoscopist can usually tell you the results of your examination, but if biopsies have been taken you will be instructed to call back for results. Tissue removed is sent to a lab for analysis and may take several days for a report.

COMPLICATIONS — ERCP is a safe procedure and serious complications are rare, but can occur:

• Pancreatitis (inflammation of the pancreas, an organ in the back of your abdomen) occurs in about 3 to 5 percent of people (about one in thirty to one in twenty people) undergoing ERCP. When it occurs it is usually mild causing abdominal pain and nausea, which resolve after a few days in the hospital. Much less commonly, the pancreatitis can be severe and be a serious or even life-threatening condition.
• Aspiration of food or fluids into the lungs, the risk of which can be minimized by having you refrain from eating or drinking for several hours before the examination.
• The ERCP scope or other instruments can cause a tear or hole in the tissue being examined. This is a serious condition, but fortunately occurs very uncommonly.
• Bleeding can occur from biopsies or from a cut into the ampulla, but it is usually minimal and stops quickly by itself or can be controlled.
• Reactions to the medicines used to sedate you are possible, so the endoscopy team (doctors and nurses) will ask you about previous medication allergies or reactions and about health problems such as heart, lung, kidney, or liver disease. Providing this information to the team ensures a safer examination.
• The medications can also produce irritation in the vein at the site of the intravenous line. If redness, swelling, or warmth occur, warm to hot wet towels applied to the site may relieve the discomfort. If discomfort persists, notify your doctor or the endoscopy unit.
• Infection is rare, but can occur.

If the doctor suspects complications, or if a drainage tube is placed into a duct or a cut made into the ampulla, you may be hospitalized overnight for observation.

The following symptoms should be reported immediately:

• Severe abdominal pain (not just gas cramps)
• A firm, distended abdomen
• Vomiting
• Fever
• Difficulty swallowing or a severe sore throat
• A crunching feeling under the skin

AFTER ERCP — Although patients worry about discomforts of the examination, most tolerate it very well and feel fine afterwards. Fatigue after the examination is common. You should plan to take it easy and relax the rest of the day. The first meal after ERCP should be light but you should be able to eat your usual diet by the next day.

You should contact your doctor about the results of your test if you have any questions and especially if biopsies were taken. The endoscopy team can give you some guidelines as to when your doctor should have all the results and whether further treatment will be necessary.