ERCP is a procedure which combines the use of endoscopy and fluoroscopy (X-ray) to diagnose and treat certain problems of the biliary (bile duct) or pancreatic (pancreas) duct systems.

ERCP is carried out by or under the supervision of a trained endoscopist. It involves the use of a scope (a long flexible tube with a camera) which is  inserted through your mouth to reach your small bowel (duodenum). Different equipment can be inserted through the channel of the scope, as required.

The procedure can be uncomfortable however ‘conscious sedation’ can be given alongside a local anaesthetic throat spray which helps to numb the back of your throat and dull down the sensation of the scope to reduce gagging.

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Supporting diagnosis

An ERCP allows staff to diagnose and get more information about conditions that affect your biliary system.

During an ERCP staff can also take samples of your cells using a small brush or by taking pieces of tissue (biopsies). These samples can then be examined in a laboratory to support diagnosis.

You might need an ERCP if:

• you have yellow skin or eyes and itchy skin (jaundice)
• your liver blood tests need to be investigated and you have pain in your tummy (abdomen)
• you had a CT or ultrasound scan that shows a blockage in your bile ducts or pancreatic ducts

Possible causes of blockages are:

• stones in the pancreas
• narrowing of the bile ducts
• growths or cancer of the pancreas or bile ducts

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Treatment

Staff can do an ERCP to treat conditions that affect the bile ducts, small intestine and pancreas. It is a less invasive procedure than surgery.

• Bile ducts: during an ERCP staff can put small plastic or metal tubes called stents into the bile ducts if they are blocked. This unblocks the bile ducts and allows bile to drain into the small intestine.
• Small intestine: staff can also put stents into the small intestine (duodenum). This helps if you have a blockage that affects the flow of food out of your stomach.
• Pancreas: sometimes staff can use an ERCP to help remove stones in the pancreas or to put a stent into a narrowed pancreatic duct to help reduce pain.

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Medication advice

Addison’s disease

• If you take hydrocortisone for pituitary problems or Addison disease, please call the Endoscopy Unit on 01324 567518 in advance as you will require additional treatment prior to your ERCP. You must also double your normal dose of hydrocortisone the day before, the day of and the day after your procedure.

Anticoagulants

• Direct oral anticoagulants (DOACs): e.g. Rivaroxaban, Apixaban, Edoxaban, Dabigatran, dose should be stopped for 72 hours (three days) before the procedure.
• Warfarin should be stopped for 7 days before procedure. INR should be checked before the procedure.

Antiplatelet drugs

• P2Y12 receptor antagonist antiplatelet agents: e.g. Clopidogrel, Prasugrel, Ticagelor should be stopped for 5 days before the procedure.
• Aspirin should be continued.
• Diabetic medication: see advice listed below for patients with diabetes.

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Before the procedure

• Do not eat anything for midnight the night before the ERCP. Your stomach and small intestine must be empty for the endoscopist to have a clear view with the camera.
• Do not drink anything for four hours before your appointment. However, you can have small sips of water for up to two  hours before the appointment.
• Remove any nail polish, BIAB or acrylic nails before attending the appointment so staff can obtain accurate readings during your time in the Endoscopy Unit.
• Remove and leave any metal jewellery at home.

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What happens on the day of the procedure?

Nursing staff will meet you in the waiting area and take you into the Endoscopy Unit where they will check your details and observations.

You will be asked to change into a hospital gown and to remove any metal jewellery if you have not left this at home. A cannula will be inserted into a vein and a blood sample may be taken to check your blood clotting levels. If you are diabetic, your blood sugar will also be checked.

In the procedure room the endoscopist will introduce themselves and you will have the opportunity to ask any questions before the procedure. Your details will be checked.

If you are having throat spray, this will be administered. You will then be asked to lie more or less flat on your chest with you left hand behind you by your hip, and right hand by your face looking towards your right hand side. Your right knee can be bent slightly – similar to the recovery position.

A probe will be placed on your finger to monitor your oxygen levels and pulse; you may also have your blood pressure checked too. A plastic mouth guard will be inserted into your mouth to protect your teeth and the scope. Sedation is given via a cannula and you will be given oxygen via your nostrils.

The scope will be passed into your mouth, down your gullet, stomach and the first part of your small bowel.  Air is used to inflate the stomach so you may feel bloated or have some windy type stomach pains. The feeling of the scope at the back of your throat can sometimes make you gag. You are able to breathe through your nose or mouth at all times. Staff will remain close to you to provide reassurance and suction any saliva that builds up in your mouth.

During the procedure, staff may take tissue samples (biopsies) for examination. Any treatment required will be undertaken, if planned, and photographs may also be take.

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After the procedure

After an ERCP you will recover in a ward if you are an inpatient or wait within the Endoscopy Unit if you are an outpatient.  Recovery time for outpatients is around 6 hours and you can then be collected by a friend or relative. However, occasionally, it may be necessary to stay in hospital overnight.

You may have a sore throat and feel bloated after an ERCP as some air may remain in your stomach however this should ease quite quickly.

Sedation can remain in your body for about 24 hours so you can feel drowsy with lapses of memory. You will need a responsible adult to pick you up from the Unit, take you home and stay with you for the next 24 hours. The Endoscopy Unit closes at 6pm so please arrange for someone to collect you before then.

Staff will send a report of the procedure to the doctor who is responsible for your care and your GP Practice. The doctor responsible for your care may write to you to advise you of any results and further investigations, if required.

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Risks of ERCP

An ERCP like all medical procedures carries a risk of complications. The benefits must outweigh the risks of having the procedure and staff need to make you aware of the risks so you can make an informed decision and give your consent to have the procedure.

Possible minor (small) complications

• Abdominal discomfort or a sore throat
• Damage to loose teeth, crowns and dental bridgework, this does not happen often
• In some cases, the endoscopist cannot access the bile or pancreatic ducts to do the ERCP
• Reactions to the sedative medication – which can usually be reversed and staff will monitor you throughout the procedure

Possible major (big) complications

• There is a risk of infection in the bile ducts (cholangitis). Your doctor might suggest antibiotics, which you can have in hospital or at home, to treat the infection.
• If you had a small cut in the bottom of your bile duct (a sphincterotomy), there is a risk of bleeding. This usually stops quickly without treatment. If the bleeding does not stop, you might need further treatment to stop the bleeding.
• Very frail or older people can get pneumonia (inflammation of the lung tissue) after an ERCP. This is because of stomach juices getting into the lung and happens in about 1 in 500 cases.
• A hole (perforation) might be made in the wall of the small intestine during an ERCP. This can be due to a sphincterotomy or a tear made by the endoscope tube and may require surgery to repair the hole. This happens in less than 1 in 750 cases and can be serious and sometimes fatal.

Pancreatitis (inflammation of the pancreas)

• An ERCP can cause mild inflammation of the pancreas (pancreatitis). This happens to about 5 in every 100 people who have an ERCP. To reduce the risk of this you will be given a Diclofenac suppository at the end of your procedure.
• If you have pancreatitis, you will have abdominal pain. This usually starts a few hours after the procedure and lasts for a few days. Painkillers can be taken to reduce the pain and fluids can also be inserted into a vein in hospital to help keep you hydrated.
• Some people get severe pancreatitis after an ERCP. Although it is rare, severe pancreatitis can result in a prolonged stay in hospital and can be fatal in less than 1 in 500 cases.

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Advice for patients with diabetes undergoing an ERCP

Adjusting your diabetic treatment could upset your blood glucose levels because of the changes in your routine. Please do not worry about this as the levels should return to normal within 24 to 48 hours after the procedure.

If you normally check your blood glucose levels with a meter, please continue to do so. You may need to test them more often. It is recommended that you test before each meal, before going to bed and whenever you feel that your blood glucose levels are falling (hypoglycaemia or ‘hypo’).

Symptoms and signs of hypoglycaemia can include:

• Sweating
• Drowsiness
• Shaking
• Light headedness
• Blurred vision
• Slurred speech
• Extreme hunger
• Muddled thinking

If your blood glucose level falls below 4 mmol/L take something sugary immediately, such as:

• Three to five glucose tablets
• Three jelly baby sweets
• 150mls (quarter pint) smooth orange juice (no bits)

Wait 15 minutes and re-test your blood glucose levels. If they remain below 4mmol/L repeat the initial hypo treatment.

On the day of your appointment please bring your diabetes tablets and/or insulin with you so that you can continue with it as soon as possible after your procedure.

If you have any further questions or are unclear about any aspects of the diabetes advice then please call the diabetes team on 01324 566929 for advice.

If your diabetes is managed by diet alone then no changes are required.

If you use tablets and/or non-insulin injectable medications (e.g. Liraglutide, Exenatide, Dulaglutide, Lixisenatide)

• The day before: please take medication as usual
• On the day, if your procedure is in the MORNING: Stop taking any oral diabetic medication (tablets) and non-insultation injectables
• On the day, if your procedure is in the AFTERNOON: take your usual diabetes medication with a light breakfast
• After the procedure: once you are allowed to eat and drink normally, resume your usual diabetes treatment at the usual doses.

If you use insulin to manage your diabetes follow the instructions in the table below.

If you have any further questions or are unclear about any aspects of this advice then please call the diabetes team in advance on 01324 566929.

• Your normal insulin dose can be resumed the day after the procedure (assuming you are able to eat and drink normally).
• If managed by personal insulin pump – please inform your specialist pump team before the  procedure.
• The day before: No changes but avoid solid foods after 21.00. If you normally have a bedtime snack, please take this by 21.00.
• On the day: continue with usual basal rates (or temporary ‘reduced’ rate if you have been previously trained to set this for fasting states) and continue to bolus as you normally do once you resume oral intake.