Endoscopic Retrograde Cholangiopancreatography

(ERCP, ERCP of the Biliary and Pancreatic Ducts)

Procedure overview

What is endoscopic retrograde cholangiopancreatography?

Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic procedure that allows the doctor to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. The procedure combines X-ray and the use of an endoscope--a long, flexible, lighted tube. The scope is guided through the patient's mouth and throat, then through the esophagus, stomach, and duodenum (first part of the small intestine). The doctor can examine the inside of these organs and detect any abnormalities. A tube is then passed through the scope, and a dye is injected which will allow the internal organs to appear on an X-ray.

Other related procedures that may be used to diagnose problems of the liver, gallbladder, and pancreas include abdominal X-rays, computed tomography (CT scan) of the abdomen, CT scan of the liver and biliary tract, CT scan of the pancreas, cholecystography, gallbladder scan, liver scan, pancreas scan, abdominal ultrasound, and abdominal angiogram. Please see these procedures for more information.

The liver and biliary system

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The liver is the largest internal organ in the body. It is located in the upper right side of the abdomen, beneath the diaphragm, and on top of the stomach, right kidney, and intestines. Shaped like a cone, the liver is a dark reddish-brown organ.

The liver holds about one pint (13 percent) of the body's blood supply at any given moment. The liver consists of two main lobes, each made up of thousands of lobules. These lobules are connected to small ducts that connect with larger ducts to ultimately form the hepatic duct. The hepatic duct transports the bile (fluid that helps break down fats and gets rid of wastes in the body) produced by the liver cells to the gallbladder and duodenum (the first part of the small intestine).

The liver carries out many important functions, such as:

• Making bile. Fluid that helps break down fats and gets rid of wastes in the body
• Changing food into energy
• Clearing the blood of drugs and other poisonous substances
• Producing certain proteins for blood plasma
• Regulating blood clotting

The biliary system consists of the organs and ducts (bile ducts, gallbladder, and associated structures) that are involved in the production and transportation of bile.

The pancreas is an elongated, tapered organ located across the back of the abdomen, behind the stomach. The pancreas has digestive and hormonal functions. The enzymes secreted by the exocrine tissue in the pancreas help break down carbohydrates, fats, proteins, and acids in the duodenum. The hormones secreted by the endocrine tissue in the pancreas are insulin and glucagon (which regulate the level of glucose in the blood), and somatostatin (which prevents the release of the other two hormones).

Reasons for the procedure

ERCP may be performed to assess the liver, gallbladder, biliary tree, and/or pancreas for the cause of unexplained abdominal pain or jaundice (yellowing of the skin and eyes due to bile pigments in the blood). ERCP may be used to obtain further diagnostic information in the presence of pancreatitis or cancer of the liver, pancreas, or bile ducts.

Blockages and/or stones in the bile ducts, fluid leakage from the bile or pancreatic ducts, obstructions or narrowing of the pancreatic ducts, or tumors may be found with ERCP.

There may be other reasons for your doctor to recommend an ERCP.

Risks of the procedure

You may want to ask your doctor about the amount of radiation used during the procedure and the risks related to your particular situation. It is a good idea to keep a record of your past history of radiation exposure, such as previous scans and other types of X-rays, so that you can inform your doctor. Risks associated with radiation exposure may be related to the cumulative number of x-ray examinations and/or treatments over a long period of time.

If you are pregnant or suspect that you may be pregnant, you should notify your doctor. Radiation exposure during pregnancy may lead to birth defects.

Patients who are allergic to or sensitive to medications, contrast dyes, iodine, or latex should notify their doctor.

As with any invasive procedure, complications can occur. Some possible complications may include, but are not limited to, the following:

• Pancreatitis (inflammation of the pancreas) and/or cholecystitis (inflammation of the gallbladder)
• Infection
• Bleeding
• Perforation (a tear in the lining) of the duodenum (the upper section of the small intestine, connected to the stomach by the pyloric valve), esophagus, or stomach
• Biloma (collection of bile outside the biliary system)

ERCP is contraindicated when previous gastrointestinal (GI) surgery has obstructed the ducts of the biliary tree, when esophageal diverticula (pouches) are present, or when acute pancreatitis is already present.

There may be risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Barium within the intestines from a recent barium procedure may interfere with an ERCP.

Before the procedure

• The doctor will explain the procedure and offer you the opportunity to ask any questions that you might have about the procedure.
• You may be asked to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if something is not clear.
• Notify your doctor if you have ever had a reaction to any contrast dye, or if you are allergic to iodine.
• Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents (local and general).
• You will be asked not to eat or drink liquids for eight hours before the procedure, generally after midnight. You may be given additional instructions about a special diet for one to two days prior to the procedure.
• If you are pregnant or suspect that you are pregnant, you should notify your doctor.
• Notify your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
• Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, ibuprofen, naproxen, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
• Your doctor will instruct you about specific ways to prepare your bowel for the procedure. You may be asked to take a laxative, undergo an enema, use a rectal laxative suppository, and/or drink a special fluid that helps prepare your bowel.
• Patients with diseases of the heart valves may be given antibiotics before the procedure.
• You will be awake during the procedure, but a sedative will be given before the procedure. You will need someone to drive you home afterwards.
• Based on your medical condition, your doctor may request other specific preparation.

During the procedure

An ERCP may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your doctor's practices.

Generally, an ERCP follows this process:

1. You will be asked to remove any clothing, jewelry, or other objects that may interfere with the procedure.
2. You will be asked to remove clothes and put on a gown prior to the procedure.
3. An intravenous (IV) line will be inserted in your arm or hand.
4. You may receive oxygen through a nasal cannula (tube) during the procedure.
5. You will be positioned on your left side on the X-ray table.
6. Numbing medication will be sprayed into the back of your throat to prevent gagging as the endoscope is passed down your throat into your stomach. You will not be able to swallow the saliva that may collect your mouth during the procedure due to the endoscope in your throat. The saliva will be suctioned from your mouth from time to time.
7. A mouth guard will be placed in your mouth to keep you from biting down on the endoscope and to protect your teeth.
8. Once your throat is numbed and you are sufficiently relaxed from the sedative, the doctor will ask you to swallow the endoscope. By using the endoscope's camera system, the doctor will guide the endoscope down the esophagus into the stomach and through the duodenum until it reaches the ducts of the biliary tree.
9. When the endoscope is in place, you will be asked to lie flat on your back.
10. A small tube will be passed through the endoscope to the biliary tree, and contrast dye will be injected into the ducts. Air may be injected prior to the injection of the contrast dye. Injection of air may cause you to have a sense of fullness in your abdomen.
11. Various X-ray views will be taken. You may be asked to change positions during this time.
12. After X-rays of the biliary tree are taken, the small tube for dye injection will be repositioned to the pancreatic duct. Contrast dye will be injected into the pancreatic duct, and X-rays will be taken. Again, you may be asked to change positions while the X-rays are taken.
13. If needed for your specific situation, samples of fluid and/or tissue may be taken at any time during the procedure. Other procedures, such as the removal of gallstones or other obstructions, may be performed while the endoscope is in place.
14. After the X-rays and any other procedures have been completed, the endoscope will be withdrawn.

After the procedure

After the procedure, you will be taken to the recovery room for observation. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room or discharged to your home. If this procedure was performed as an outpatient, you should plan to have another person drive you home.

You will not be allowed to eat or drink anything until your gag reflex has returned. You may notice some soreness of your throat and pain with swallowing for a few days. This soreness is normal.

You may resume your usual diet and activities after the procedure, unless your doctor advises you differently.

Notify your doctor to report any of the following:

• Fever and/or chills
• Redness, swelling, or bleeding or other drainage from the IV site
• Abdominal pain, nausea, and/or vomiting
• Black, tarry, or bloody stools
• Swallowing difficulties
• Throat or chest pain that worsens

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.