Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

The vast majority of ERCP tests are performed for therapeutic reasons. The tests are most commonly done with sedation, in the x-ray department.


Common reasons for the test:

1. to relieve obstruction from gallstones in common bile duct (CBD) causing pain, infection (cholangitis) and/or jaundice
2. to relieve obstruction from narrowing (stricture) in CBD causing pain, infection (cholangitis) and/or jaundice. A stricture may be due to a growth (tumour) in the bile duct or pancreas, or surrounding enlarged lymph nodes
3. to remedy a bile leak complication following a cholecystectomy (surgery to remove gallbladder)


Alternatives

The alternatives to ERCP for reasons 1 & 2 above include a procedure that involves percutaneous (through the skin) needle puncture into the liver to access the bile duct (also called PTC) or bypass surgery. These may not be feasible when patients are unfit, unstable or have advanced tumour stage.


Preparing for the test

Stop clopidogrel (7 days) or warfarin (5 days) before the test if instructed, and temporary heparin injection may be necessary

On the day of test

Report any known allergy to iodine or x-ray dye, or the possibility of pregnancy
Clotting (INR) blood test is checked
Blood sugar (BM) is checked in patients with diabetes mellitus
A cannula (small plastic tube) is inserted into a vein, preferably in the right hand


In the endoscopy/x-ray room


A monitoring probe is attached to a finger
A nasal cannula is attached to a nostril for oxygen supplementation
Denture (if present) is removed
Plastic mouth guard is applied
Endoscope is introduced into the mouth


Drugs commonly used for the test

Topical spray - Local anaesthetic throat spray
Injection - Sedatives (benzodiazepine, midazolam)
- Pain killer (morphine, commonly pethidine or fentanyl)
- Antibiotics (Tazocin or cefuroxime, oral ciprofloxacin)
- Buscopan
Oxygen


Patient position during the test


Prone or semi-prone (see picture 1)
Left lateral (sometimes)

Picture 1

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Can I watch the test?


This is not feasible as the head position faces away from the video and x-ray (fluoroscopy) monitors and the moderate deep sedation administered during ERCP.


Pain/discomfort


A stent (made of plastic or flexible metal mesh) is an internal drainage tube that may be placed to treat a stricture in the bile duct. This does not cause any discomfort. The opening of the bile duct may be enlarged to allow removal of gallstones or passage of a stent. This may involve an electrically heated wire (diathermy) or a balloon device passed through the endoscope. You may experience some discomfort from dilation with a balloon device, and sometimes during the removal of gallstones.

Supplementary injection of sedative or painkiller (morphine) drugs will be given as necessary during the tests for adequate control of pain or discomfort.


Specific complications


There is a 1-2% risk of inflammation of pancreas (pancreatitis), which may be higher with some patient and procedure related risk factors. Due to the therapeutic nature of most ERCP tests, they are associated with complications of perforation (as with any therapeutic endoscopy test) and bleeding (about 2%). In severe cases of perforation or bleeding, surgery may become necessary.

If there is any suspicion of the above complications during or straight after the test (in recovery), patients will be admitted for close monitoring and/or treatment.