Endoscopic Retrograde Cholangio-pancreotography (ERCP) Examination of the bile duct and pancreas

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1 Endoscopic Retrograde Cholangio-pancreotography (ERCP) Examination of the bile duct and pancreas This is a procedure to look at the bile duct which drains the bile from your liver into the small bowel. Sometimes the Pancratic duct which drains digestive juices from the pancreas into the small bowel can also be examined. The procedure is performed by a specially trained doctor called an endoscopist. Why do I need an ERCP? An ERCP may be advised for a number of reasons; To find out what is wrong (diagnosis) Remove gallstones trapped within the bile duct Treat yellow jaundice caused by blockage of the bile duct by inserting a plastic or metal tube, (stent), to open up the blockage and allow bile to flow through. Seal leaks in the bile duct that sometimes (rarely) occur following gall-bladder surgery. What are the alternatives? Computerised tomography, (CT scanner) and magnetic resonance imaging, (MRI scanner) can also provide pictures of the internal organs, but no treatment can be given during these procedures. Many patients may have had these tests prior to an ERCP. Surgery (having an operation) is also an option to treat bile duct stones but is generally a higher risk procedure How long will I be in the hospital? Some patients have an ERCP as a day-case procedure, other patients, who may have suffered a complication from their gallstones or jaundice, may already be in hospital. Patients admitted for a day-case procedure will attend the day-case ward on the morning of their procedure where they will be met by a nurse who will ask you a few questions about your general health and check your heart rate and blood pressure. If you have diabetes, we will also check your blood sugar. The nurse will then perform a blood test to ensure your blood clots properly. Before the procedure you will need to get undressed and put on a hospital gown. Jewellery or metal objects will also need to be removed as they interfere with x-rays, used to take pictures during the procedure. You will then be taken to x-ray where the procedure is performed. The procedure takes approximately 30 minutes. Following the procedure you will return to either the day-case ward or the in-patient wards to monitor your condition for a few hours. If you feel well, you will be able to eat and drink and day-case patients usually go home later that evening. It is advisable to bring an overnight bag with you, in case we need to monitor your condition in hospital overnight

2 Preparation: Eating and drinking: You must not eat or drink for 6 hours before the procedure. This usually means nothing to eat or drink after 7:30am on the morning of your procedure. This is because the endoscopist passes the endoscopic camera through your mouth and down into your stomach to get to the bile duct. If food is in the stomach, this will prevent us from getting a clear picture. It also increases the risk of inhaling stomach contents into the lungs during the procedure, which can result in pneumonia. Preventative medication: You will be given a suppository of an anti-inflammatory agent known as diclofenac just before you go down for the procedure. Please let the staff know if you are allergic to this medication or similar medications such as aspirin. The agent has been demonstrated to reduce the risk of pancreatitis (see risks and complication section) following ERCP Medications: You should continue on all of your normal medications unless you have been previously been asked to stop these before the procedure. Medications for diabetes and blood thinning medication are usually stopped before the procedure. Patients with diabetes: As you will need to starve before the procedure, you will usually be asked to omit all of your diabetes medications before the procedure. The doctor who organised the procedure will give you advice regarding this. Alternatively discuss this with your usual diabetic practitioner (e.g. GP, practice nurse, or diabetes nurse specialist). Anticoagulants: Warfarin must be stopped 5 days prior to the procedure. The doctor who organised the procedure should have given you advice regarding this. If not please ensure you ring the endoscopy department at least a week before the procedure to discuss what to do Clopidogrel/ Prasugrel need to be stopped 7 days before the procedure. Please discuss with the doctor who organised the procedure if you are on these drugs and the reason why you are taking these. It is safe to take your Aspirin Sedation: ERCP is usually performed with sedation. The sedation will be injected into a vein in your hand or arm and will make you feel drowsy and relaxed. This is not a general anaesthetic and therefore you will not be unconscious. The sedation is to minimise your discomfort. It is likely that you will remember little if anything after the procedure. During sedation, we monitor your breathing, heart rate and oxygen levels in the blood with a finger clip device (probe) connected to a small monitor. After the sedation you will not be permitted to drive home or use public transport. You need to arrange for a family member or friend to collect you. As the effects of the sedation can last for 12 hours, we ask that a family member or friend remains with you for this time period. What happens during the ERCP examination? You will be transferred via a trolley to the X-ray department. There you will have the opportunity to ask any final questions. We will give you a small plastic mouth guard to put between your teeth to protect them during the examination, (any dentures need to be removed prior to the examination). You will then be asked to transfer to the x-ray table and the finger a probe will be attached

3 The sedation will be injected into your vein and you will quickly become drowsy. A small plastic suction tube, rather like the one used at the dentist, will be placed in your mouth to remove any fluid (saliva or other secretions) produced during the procedure The endoscopist will put the endoscope camera into your mouth and pass it gently down your oesophagus (gullet) into your stomach and then on into your duodenum, (upper part of the small bowel). You will be able to breath normally through your nose. The endoscope camera allows the doctor to have a direct view of the inside of the small bowel on a TV screen. A small amount of air is blown into the small bowel to help the doctor see what is going on. Once the doctor has found the position where the bile and pancreatic ducts drain into the small bowel, they will then insert a thin plastic tube through the endoscope into the bile duct. The doctor injects X-Ray dye into the bile duct, which highlights any problems within the bile duct, such as stones or blockages If the x-rays show gallstones within the bile duct, the doctor may enlarge the opening of the bile duct, (sphincterotomy) using an electrically heated wire, (diathermy) to make the opening wide enough to remove the stones. You will not feel any discomfort during this procedure. The stones are then removed using a special balloon or basket to ease the stones out of the bile duct If there is a narrowing, (stricture) of the bile duct, a short plastic or metal tube called a stent, is placed across the narrowing to drain the bile. You will not be aware of the presence of the tube X-ray films are taken during the procedure What are the risks and complications? Sometimes patients may experience discomfort and / or a sore throat for a few days. This can be relieved by paracetomol Acute pancreatitis: This is inflammation of the pancreas which can cause abdominal pain and vomiting. This affects between 2-5% of patients undergoing this procedure. Pancreatitis requires hospital admission for a few days until this settles and patients usually have to rest the pancreas by avoiding eating and usually require strong pain killers and anti-sickness medication Bleeding: This can occur in 1 in 500 patients but is 10 times more frequent if a cut has been made, (sphincterotomy) to remove gallstones. Bleeding can often be stopped during the procedure using the endoscope. Very rarely blood transfusions are required. Uncontrolled bleeding can lead to vomiting blood or passing blood in the motions, which often appear black Perforation: A tear in the gastrointestinal wall or bile system occurs very rarely, (1 in 1000 procedures). This would require admission to hospital and antibiotics. Such perforations are often small and may heal spontaneously but occasionally need an operation to repair the perforation There is a small risk abnormalities will be missed. Adverse reaction to the sedation or the x-ray dye. Damage to teeth, crowns or bridgework is rare.

4 After the examination: Following the procedure you will return to your ward or day-case unit where a nurse monitors you for several hours while the sedation wears off. You might experience a sore throat and bloating if there is still some air left in your stomach. A doctor will review you after the procedure on the day-case ward to assess whether we can discharge you home. Inpatients are usually kept in overnight. The doctor will explain the results of the ERCP and discuss any further treatment needed. As the sedation can make you forgetful for a short time afterwards, it is useful to have someone with you at this time. A copy of the ERCP report will be sent to your G.P. As the sedation has some effect for at least 12 hours, you need a family member or friend to take you home and stay with you for at least 12 hours. Once home it is important to rest for the remainder of the day and have light meals. For 24 hours following the procedure Do not drive a car Do not operate machinery Do not drink alcohol Do not sign legal documents Do not be left alone to care for children. The effects of the test and sedation will usually have worn off after 24 hours after which you can resume normal activities.

5 Leaflet Title Here ERCP Version 1 Chesterfield Royal Hospital NHS Foundation Trust Reviewed Date: February 2016 Next Planned Reviewed Date: February 2017 Directorate: Endoscopy