Endoscopic retrograde cholangiopancreatography (ERCP)

ERCP (Endoscopic Retrograde Cholangio-Pancreatography) Patient Information from SAGES

Endoscopic retrograde cholangiopancreatography (ERCP)

(Endoscopic Retrograde Cholangio-Pancreatography)

ERCP is a procedure that enables your physician to examine the pancreatic and bile ducts.

A bendable, lighted tube (endoscope) about the thickness of your index finger is placed through your mouth and into your stomach and first part of the small intestine (duodenum).

In the duodenum a small opening is identified (ampulla) and a small plastic tube (cannula) is passed through the endoscope and into this opening. Dye (contrast material) is injected and X-rays are taken to study the ducts of the pancreas and liver.

Why is an ERCP Performed?

ERCP is most commonly performed to diagnose conditions of the pancreas or bile ducts, and is also used to treat those conditions.

It is used to evaluate symptoms suggestive of disease in these organs, or to further clarify abnormal results from blood tests or imaging tests such as ultrasound or CT scan.

The most common reasons to do ERCP include abdominal pain, weight loss, jaundice (yellowing of the skin), or an ultrasound or CT scan that shows stones or a mass in these organs.

ERCP may be used before or after gallbladder surgery to assist in the performance of that operation. Bile duct stones can be diagnosed and removed with an ERCP.

Tumors, both cancerous and noncancerous, can be diagnosed and then treated with indwelling plastic tubes that are used to bypass a blockage of the bile duct.

Complications from gallbladder surgery can also sometimes be diagnosed and treated with ERCP.

In patients with suspected or known pancreatic disease, ERCP will help determine the need for surgery or the best type of surgical procedure to be performed. Occasionally, pancreatic stones can be removed by ERCP.

What Preparation is Required?

Your stomach must be empty, so you should not eat or drink anything for approximately 8 hours before the examination. Your physician will be more specific about the time to begin fasting depending on the time of day that your test is scheduled.

Your current medications may need to be adjusted or avoided. Most medications can be continued as usual.

Medication use such as aspirin, Vitamin E, non-steroidal anti-inflammatories, blood thinners and insulin should be discussed with your physician prior to the examination as well as any other medication you might be taking.

It is therefore best to inform your physician of any allergies to medications, iodine, or shellfish. It is essential that you alert your physician if you require antibiotics prior to undergoing dental procedures, since you may also require antibiotics prior to ERCP.

Also, if you have any major diseases, such as heart or lung disease that may require special attention during the procedure, discuss this with your physician.

To make the examination comfortable, you will be sedated during the procedure, and, therefore, you will need someone to drive you home afterward. Sedatives will affect your judgment and reflexes for the rest of the day, so you should not drive or operate machinery until the next day.

What Can Be Expected During the ERCP?

Your throat will be sprayed with a local anesthetic before the test begins to numb your throat and prevent gagging. You will be given medication intravenously to help you relax during the examination.

While you are lying in a comfortable position on an X-ray table, an endoscope will be gently passed through your mouth, down your esophagus, and into your stomach and duodenum. The procedure usually lasts about an hour, but this may vary depending on the planned intervention.

The endoscope does not interfere with your breathing. Most patients fall asleep during the procedure or find it only slightly uncomfortable. You may feel temporarily bloated during and after the procedure due to the air used to inflate the duodenum.

As X-ray contrast material is injected into the pancreatic or bile ducts, you may feel some minor discomfort.

What Happens after ERCP?

You will be monitored in the endoscopy area for 1-2 hours until the effects of the sedatives have worn off. Your throat may be sore for a day or two. You will be able to resume your diet and take your routine medication after you leave the endoscopy area, unless otherwise instructed.

Your physician will usually inform you of your test results on the day of the procedure. Biopsy results take several days to return, and you should make arrangements with your physician to get these results. The effects of sedation may make you forget what you were instructed to do after the procedure. Call your surgeon’s office for the results or any further questions.

What Complications Can Occur?

ERCP is safe when performed by physicians who have had specific training and are experienced in this specialized endoscopic procedure. Complications are rare, however, they can occur.

Pancreatitis due to irritation of the pancreatic duct by the X-ray contrast material or cannula is the most common complication. A reaction to the sedatives can occur.

Irritation to the vein in which medications were given is uncommon, but may cause a tender lump lasting days to a few weeks. Warm moist towels will help relieve this discomfort.

If your ERCP included a therapeutic procedure such as removal of stones or placement of a stent (drain), there are additional small risks of bleeding or perforation (making a hole in the intestine or bile duct).

Blood transfusions are rarely required.

It is important for you to recognize the early signs of possible complications and to contact your physician if you notice symptoms of severe abdominal pain, fever, chills, vomiting, or rectal bleeding.

This brochure is not intended to take the place of a discussion with your surgeon about your need for an ERCP.

If you have any questions about your need for an ERCP, alternative tests, billing and insurance coverage, or your surgeons training and experience, do not hesitate to ask your surgeon or his/her office staff about it.

If you have questions about the exam or subsequent follow-up, please discuss them with your surgeon before or after the examination.

Some images courtesy of Amy Cha,MD; Penn PresbyterianMedical Center, Philadelphia, PA

Source: https://www.sages.org/publications/patient-information/patient-information-for-ercp-endoscopic-retrograde-cholangio-pancreatography-from-sages/

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP)

Linkedin Pinterest Liver Gallbladder and Pancreas

Endoscopic retrograde cholangiopancreatography, or ERCP, is a procedure to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. It combines X-ray and the use of an endoscope—a long, flexible, lighted tube.

Your healthcare provider guides the scope through your mouth and throat, then down the esophagus, stomach, and the first part of the small intestine (duodenum). Your healthcare provider can view the inside of these organs and check for problems. Next, he or she will pass a tube through the scope and inject a dye.

This highlights the organs on X-ray.

You may need ERCP to find the cause of unexplained abdominal pain or yellowing of the skin and eyes (jaundice). It may be used to get more information if you have pancreatitis or cancer of the liver, pancreas, or bile ducts.

Other things that may be found with ERCP include:

  • Blockages or stones in the bile ducts
  • Fluid leakage from the bile or pancreatic ducts
  • Blockages or narrowing of the pancreatic ducts
  • Tumors
  • Infection in the bile ducts

Your healthcare provider may have other reasons to recommend an ERCP.

You may want to ask your healthcare provider about the amount of radiation used during the test. Also ask about the risks as they apply to you.

Consider writing down all X-rays you get, including past scans and X-rays for other health reasons. Show this list to your provider. The risks of radiation exposure may be tied to the number of X-rays you have over time.

If you are pregnant or think you could be, tell your healthcare provider. Radiation exposure during pregnancy may lead to birth defects.

Tell your healthcare provider if you are allergic to or sensitive to medicines, contrast dyes, iodine, or latex.

Some possible complications may include:

  • Inflammation of the pancreas (pancreatitis) or gallbladder (cholecystitis). Pancreatitis is one of the most common complications and should be discussed with your provider ahead of time. Keep in mind, though, that ERCP is often performed to help relieve the disease in certain types of pancreatitis.
  • Infection
  • Bleeding
  • A tear in the lining of the upper section of the small intestine, esophagus, or stomach
  • Collection of bile outside the biliary system (biloma)

You may not be able to have ERCP if:

  • You’ve had gastrointestinal (GI) surgery that has blocked the ducts of the biliary tree
  • You have pouches in your esophagus (esophageal diverticula) or other abnormal anatomy that makes the test difficult to perform. Sometimes the ERCP is modified to make it work in these situations.
  • You have barium within the intestines from a recent barium procedure since it may interfere with an ERCP

There may be other risks depend your condition. Be sure to discuss any concerns with your healthcare provider before the procedure.

How do I get ready for ERCP?

Recommendations for ERCP preparation include the following:

  • Your healthcare provider will explain the procedure and you can ask questions.
  • 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.
  • Tell your healthcare provider if you have ever had a reaction to any contrast dye, or if you are allergic to iodine.
  • Tell your healthcare provider if you are sensitive to or are allergic to any medicines, latex, tape, or anesthesia.
  • Do not to eat or drink liquids for 8 hours before the procedure. You may be given other instructions about a special diet for 1 to 2 days before the procedure.
  • If you are pregnant or think you could be, tell your healthcare provider.
  • Tell your healthcare provider of all medicines (prescribed and over-the-counter) and herbal supplements that you are taking.
  • Tell your healthcare provider if you have a history of bleeding disorders or if you are taking any blood-thinning medicines (anticoagulants), aspirin, ibuprofen, naproxen, or other medicines that affect blood clotting. You may be told to stop these medicines before the procedure.
  • If you have heart valve disease, your healthcare provider may give you antibiotics before the procedure.
  • You will be awake during the procedure, but a sedative will be given before the procedure. Depending on the anesthesia used, you may be completely asleep and not feel anything. You will need someone to drive you home.
  • Follow any other instructions your provider gives you to get ready.

What happens during ERCP?

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

Generally, an ERCP follows this process:

  1. You will need to remove any clothing, jewelry, or other objects that may interfere with the procedure.
  2. You will need to remove clothes and put on a hospital gown.
  3. An intravenous (IV) line will be put in your arm or hand.
  4. You may get oxygen through a tube in your nose during the procedure.
  5. You will be positioned on your left side or, more often, on your belly, on the X-ray table.
  6. Numbing medicine may be sprayed into the back of your throat. This helps prevent gagging as the endoscope is passed down your throat. You will not be able to swallow the saliva that collects in your mouth during the procedure. It will be suctioned from your mouth as needed.
  7. A mouth guard will be put 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 relaxed from the sedative. Your provider will guide the endoscope down the esophagus into the stomach and through the duodenum until it reaches the ducts of the biliary tree.
  9. 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 before the contrast dye. This may cause you to feel fullness in your abdomen.
  10. Various X-ray views will be taken. You may be asked to change positions during this time.
  11. 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.
  12. If needed, your provider will take samples of fluid or tissue. He or she may do other procedures, such as the removal of gallstones or other blockages, while the endoscope is in place.
  13. After the X-rays and any other procedures are done, the endoscope will be withdrawn.

What happens after ERCP?

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

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

Many times, a rectal suppository of a certain medicine is given after the ERCP to decrease the risk of pancreatitis.

You may go back to your usual diet and activities after the procedure, unless your healthcare provider tells you otherwise.

Tell your healthcare provider if you have any of the following:

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

Your healthcare provider may give you other instructions after the procedure, your situation.

Next steps

Before you agree to the test or the procedure make sure you know:

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • What results to expect and what they mean
  • The risks and benefits of the test or procedure
  • What the possible side effects or complications are
  • When and where you are to have the test or procedure
  • Who will do the test or procedure and what that person’s qualifications are
  • What would happen if you did not have the test or procedure
  • Any alternative tests or procedures to think about
  • When and how will you get the results
  • Who to call after the test or procedure if you have questions or problems
  • How much will you have to pay for the test or procedure

Source: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/endoscopic-retrograde-cholangiopancreatography-ercp

About Endoscopic retrograde cholangiopancreatography (ERCP)

ERCP has been used for the diagnosis and treatment of pancreatic diseases for over 20 years. This procedure is performed on an outpatient basis under sedation (rarely under general anesthesia).

Using a “side-viewing” endoscope, called a duodenoscope, the duodenal “papilla”-(a mound- structure that houses the opening of the common bile duct and the pancreatic duct)- is identified and manipulated.

The scope contains a working channel through which flexible instruments are passed into the bile and/or pancreatic ducts to diagnose and treat pancreatic diseases.

ERCP: Its Uses

ERCP plays a role in gallstone pancreatitis and complicated acute and chronic pancreatitis. Randomized trials have proven that ERCP will decrease morbidity and have suggested a decrease in mortality for certain patients with gallstone pancreatitis.

Groups benefiting from ERCP include patients with an impacted stone in the common bile duct and those in whom removal of the gallbladder will be delayed. ERCP is also valuable in detecting and treating main pancreatic duct leaks with transpapillary stenting (i.e. placement of a plastic tube across the papilla).

Symptomatic pseudocysts, essentially walled-off pancreatic or peripancreatic fluid collections seen in either acute or chronic pancreatitis, may be drained via the papilla if they connect with the pancreatic duct. If they do not, drainage can be achieved by creating a cystogastrostomy or cystoduodenostomy (i.e.

a hole connecting the stomach or small intestine with the cyst) utilizing a needle-knife papillotome. Pancreatic fistulas, connections between the pancreatic duct and other structures, also respond to transpapillary drainage.

Pancreatic ascites, a large collection of abdominal fluid attributed to pancreatic duct rupture, is effectively treated through similar means.

In patients with recurrent acute or chronic pancreatitis, ERCP may detect common bile duct stones or duct narrowing not seen by other imaging modalities, focal narrowing of the pancreatic duct (termed a stricture), other manifestations of chronic pancreatitis suggesting that surgery may be of benefit (e.g.

duct dilation), or evidence of a tumor. Common bile duct stones can be removed. Bile duct and pancreatic duct strictures are temporarily treated with a stent as a bridge to surgery. In certain cases, removal of stones from the pancreatic duct may alleviate abdominal pain in the setting of chronic pancreatitis.

Pancreatic cancer diagnosis and palliation (symptomatic treatment) can be achieved via ERCP as well. A variety of methods can achieve a tissue diagnosis of pancreatic cancer including brush cytology, intraductal biopsy and fine needle aspiration.

However, due to the low sensitivity of duct brushings, and the potential morbidity associated with ERCP, endoscopic ultrasound-(where available)-has largely supplanted ERCP in the diagnosis of this malignancy.

The palliative management of biliary obstruction with transpapillary stents has simplified management of this difficult problem.

The use of ERCP to detect occult anatomical or physiologic abnormalities (i.e. pancreas divisum and sphincter of Oddi dysfunction, respectively) and treatment with biliary and pancreatic sphincterotomy (i.e. cutting of the circular muscle controlling ductal drainage) remains controversial.

Pancreas divisum occurs when the ducts from the two embryonic portions of the pancreas, termed the ducts of Wirsung and Santorini, fail to completely fuse. Many people have this anatomic variant without pancreatitis. There is some inconclusive data suggesting that decompression of one of these ducts may reduce the risk of recurrent pancreatitis.

The sphincter of Oddi is the circular muscle that controls drainage from the bile and pancreatic ducts. In some cases where the muscle exhibits high pressures, determined by measurement with a pressure-measuring catheter (i.e. manometry), there may be a benefit to sphincterotomy. The number of patients with this problem treated in published series is too small to draw definitive conclusions.

With that said, we believe that sphincter of Oddi manometry should be considered in the patient with recurrent acute pancreatitis of otherwise unknown cause.

ERCP Risks

ERCP is associated with a 5%-10% risk of pancreatitis. The risk is increased in those cases where cannulation of the ducts is difficult, the pancreas is normal, or when a sphincterotomy is performed in the setting of sphincter of Oddi dysfunction.

A prior history of ERCP-induced pancreatitis is also a risk factor. Other less common risks include bleeding, infection and perforation. Particularly in the setting of pancreatic disease, it is a specialized procedure that should be performed only by experienced endoscopists.

Many of the techniques discussed above require special training and consistent use to maintain expertise. Such individuals tend to migrate to tertiary referral centers such as ours at the University of Cincinnati (see www.ucpancreas.org).

Improvements in technology and instrumentation target enhanced performance with reduced morbidity.

Charles D. Ulrich, II, M.D., FACP, FACG and Stephen P. Martin, M.D. are pancreatologists and Associate Professors in the Department of Medicine at the University of Cincinnati (UC). Dr. Ulrich is Director of Research and Dr. Martin a Co-Director of the UC Pancreatic Disease Center. Dr. Ulrich is also a Director of the National Pancreas Foundation.

Source: https://pancreasfoundation.org/ercp-endoscopic-retrograde-cholangiopancreatography/

Endoscopic Retrograde Cholangiopancreatography (ERCP) | NIDDK

Endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that combines upper gastrointestinal (GI) endoscopy and x-rays to treat problems of the bile and pancreatic ducts.

What are the bile and pancreatic ducts?

Your bile ducts are tubes that carry bile from your liver to your gallbladder and duodenum. Your pancreatic ducts are tubes that carry pancreatic juice from your pancreas to your duodenum. Small pancreatic ducts empty into the main pancreatic duct. Your common bile duct and main pancreatic duct join before emptying into your duodenum.

Why do doctors use ERCP?

Doctors use ERCP to treat problems of the bile and pancreatic ducts. Doctors also use ERCP to diagnose problems of the bile and pancreatic ducts if they expect to treat problems during the procedure.

For diagnosis alone, doctors may use noninvasive tests—tests that do not physically enter the body—instead of ERCP.

Noninvasive tests such as magnetic resonance cholangiopancreatography (MRCP)—a type of magnetic resonance imaging (MRI)—are safer and can also diagnose many problems of the bile and pancreatic ducts.

Doctors perform ERCP when your bile or pancreatic ducts have become narrowed or blocked because of

How do I prepare for ERCP?

To prepare for ERCP, talk with your doctor, arrange for a ride home, and follow your doctor’s instructions.

Talk with your doctor

You should talk with your doctor about any allergies and medical conditions you have and all prescribed and over-the-counter medicines, vitamins, and supplements you take, including

Your doctor may ask you to temporarily stop taking medicines that affect blood clotting or interact with sedatives. You typically receive sedatives during ERCP to help you relax and stay comfortable.

Tell your doctor if you are, or may be, pregnant. If you are pregnant and need ERCP to treat a problem, the doctor performing the procedure may make changes to protect the fetus from x-rays. Research has found that ERCP is generally safe during pregnancy.1

Arrange for a ride home

For safety reasons, you can’t drive for 24 hours after ERCP, as the sedatives or anesthesia used during the procedure needs time to wear off. You will need to make plans for getting a ride home after ERCP.

Don’t eat, drink, smoke, or chew gum

To see your upper GI tract clearly, you doctor will most ly ask you not to eat, drink, smoke, or chew gum during the 8 hours before ERCP.

How do doctors perform ERCP?

Doctors who have specialized training in ERCP perform this procedure at a hospital or an outpatient center. An intravenous (IV) needle will be placed in your arm to provide a sedative. Sedatives help you stay relaxed and comfortable during the procedure.

A health care professional will give you a liquid anesthetic to gargle or will spray anesthetic on the back of your throat. The anesthetic numbs your throat and helps prevent gagging during the procedure. The health care staff will monitor your vital signs and keep you as comfortable as possible.

In some cases, you may receive general anesthesia.

You’ll be asked to lie on an examination table. The doctor will carefully feed the endoscope down your esophagus, through your stomach, and into your duodenum. A small camera mounted on the endoscope will send a video image to a monitor. The endoscope pumps air into your stomach and duodenum, making them easier to see.

During ERCP, the doctor

  • locates the opening where the bile and pancreatic ducts empty into the duodenum
  • slides a thin, flexible tube called a catheter through the endoscope and into the ducts
  • injects a special dye, also called contrast medium, into the ducts through the catheter to make the ducts more visible on x-rays
  • uses a type of x-ray imaging, called fluoroscopy, to examine the ducts and look for narrowed areas or blockages

The doctor may pass tiny tools through the endoscope to

  • open blocked or narrowed ducts.
  • break up or remove stones.
  • perform a biopsy or remove tumors in the ducts.
  • insert stents—tiny tubes that a doctor leaves in narrowed ducts to hold them open. A doctor may also insert temporary stents to stop bile leaks that can occur after gallbladder surgery.

The procedure most often takes between 1 and 2 hours.

What should I expect after ERCP?

After ERCP, you can expect the following:

  • You will most often stay at the hospital or outpatient center for 1 to 2 hours after the procedure so the sedation or anesthesia can wear off. In some cases, you may need to stay overnight in the hospital after ERCP.
  • You may have bloating or nausea for a short time after the procedure.
  • You may have a sore throat for 1 to 2 days.
  • You can go back to a normal diet once your swallowing has returned to normal.
  • You should rest at home for the remainder of the day.

Following the procedure, you—or a friend or family member who is with you if you’re still groggy—will receive instructions on how to care for yourself after the procedure. You should follow all instructions.

You will receive instructions on how to care for yourself after ERCP. You should follow all instructions.

Some results from ERCP are available right away after the procedure. After the sedative has worn off, the doctor will share results with you or, if you choose, with your friend or family member.

If the doctor performed a biopsy, a pathologist will examine the biopsy tissue. Biopsy results take a few days or longer to come back.

What are the risks of ERCP?

The risks of ERCP include complications such as the following:

  • pancreatitis
  • infection of the bile ducts or gallbladder
  • excessive bleeding, called hemorrhage
  • an abnormal reaction to the sedative, including respiratory or cardiac problems
  • perforation in the bile or pancreatic ducts, or in the duodenum near the opening where the bile and pancreatic ducts empty into it
  • tissue damage from x-ray exposure
  • death, although this complication is rare

Research has found that these complications occur in about 5 to 10 percent of ERCP procedures.2 People with complications often need treatment at a hospital.

If you have any of the following symptoms after ERCP, seek medical attention right away:

  • bloody or black, tar-colored stool
  • chest pain
  • fever
  • pain in your abdomen that gets worse
  • problems breathing
  • problems swallowing or throat pain that gets worse
  • vomiting—particularly if your vomit is bloody or looks coffee grounds

References

[1] ASGE Standard of Practice Committee, Shergill AK, Ben-Menachem T, et al. Guidelines for endoscopy in pregnant and lactating women. Gastrointestinal Endoscopy. 2012;76(1):18–24.

[2] Szary NM, Al-Kawas FH. Complications of endoscopic retrograde cholangiopancreatography: how to avoid and manage them. Gastroenterology and Hepatology. 2013;9(8):496–504.

Source: https://www.niddk.nih.gov/health-information/diagnostic-tests/endoscopic-retrograde-cholangiopancreatography

Diagnosing Digestive Diseases with ERCP

Endoscopic retrograde cholangiopancreatography (ERCP)

ERCP (short for endoscopic retrograde cholangiopancreatography) is a procedure used to diagnose diseases of the gallbladder, biliary system, pancreas, and liver. The test looks “upstream” where digestive fluid comes from — the liver, gallbladder, and pancreas — to where it enters the intestines. In addition, ERCP can be used to treat problems in these parts of the digestive system.

During an ERCP, a gastroenterologist (doctor who specializes in treating diseases of the gastrointestinal system), uses a special endoscope (a long, flexible tube with a light and camera at the end) to examine the inside of the digestive system.

The doctor identifies the place where the bile duct comes into the intestine and then feeds a tiny catheter (a plastic tube) into the duct and squirts in a contrast agent while X-rays are taken.

The contrast agent allows the doctors to see the bile ducts, the gallbladder, and the pancreatic duct on the X-rays.

Once the source of the problem is identified, the doctor may then treat it by performing one of the following procedures.

  • Sphincterotomy. This involves making a small incision (cut) in the opening of the pancreatic duct or the bile duct, which can help small gallstones, bile, and pancreatic juice to drain appropriately.
  • Stent placement. A stent is a drainage tube that is placed in the bile duct or the pancreatic duct to hold the duct open and allow it to drain.
  • Gallstone(s) removal. ERCP can remove gallstones from the bile duct, but not from the gallbladder itself.

An ERCP is considered a low-risk procedure; however, complications can occur. These can include pancreatitis, infections, bowel perforation, and bleeding.

Patients undergoing an ERCP for treatment, such as for gallstone removal, face a higher risk of complications than patients undergoing the test to diagnose a problem.

Your doctor will discuss the risks of possible complications before the test.

Before having ERCP, let your doctor know about any special medical conditions you have, including:

  • Pregnancy.
  • Lung conditions.
  • Heart conditions.
  • Allergies to any medications.

If you have diabetes and use insulin. You may need to adjust the dosage of insulin the day of the test. Your diabetes care provider will help you with this adjustment. Bring your diabetes medication with you so you can take it after the procedure.

If you are taking blood-thinning medications such as aspirin, clopidogrel (Plavix), dipyridamole (Persantine), enoxaparin (Lovenox), or warfarin (Coumadin), your primary doctor may ask you to hold these medications or prescribe an alternate method for thinning your blood before the procedure.

Do not discontinue any medication without first consulting with your primary or referring doctor.

Do not eat or drink anything for eight hours before the procedure.

You may be drowsy for some time after sedation, so you should ask for help from a responsible adult who can take you home after the procedure. You should not drive or operate machinery for at least eight hours because the medication given during the procedure may cause drowsiness.

You may need to stay overnight in the hospital after the procedure, so pack personal items you may need.

You will stay in a recovery room for about 1-2 hours for observation. You may feel a temporary soreness in your throat. Suck on throat lozenges to relieve the pain.

A responsible adult must take you home after the procedure. It is also recommended that someone stay with you for 24 hours after the procedure.

Do not drive or operate machinery for at least eight hours.

Stay overnight within a 30-minute drive of the hospital so you can get to the emergency room quickly to be evaluated, if necessary.

The results will be sent to your primary or referring doctor, who will discuss them with you. If the results of the procedure indicate that prompt medical attention is needed, the necessary arrangements will be made and your referring doctor will be notified.

If you have any of the following symptoms within 72 hours after ERCP, call your doctor and seek emergency care:

SOURCES: The National Institute of Diabetes and Digestive and Kidney Diseases.

© 2019 WebMD, LLC. All rights reserved.

Source: https://www.webmd.com/digestive-disorders/digestive-diseases-ercp

Endoscopic Retrograde Cholangiopancreatography (ERCP): Background, Indications, Contraindications

Endoscopic retrograde cholangiopancreatography (ERCP)

Before ERCP, all of the patient’s previous abdominal imaging findings (from CT, magnetic resonance imaging [MRI], US, and cholangiography or pancreatography) should be reviewed; this can facilitate location of the pathology during ERCP, as well as help pinpoint any changes that occurred since the previous imaging was performed.

A scout radiograph should be obtained while the patient is on the fluoroscopy table and before insertion of the duodenoscope; this image can act as a baseline for comparison with subsequent fluoroscopic images taken after contrast injection.

The patient's surgical history should be reviewed before the procedure to determine whether there is anything in the surgical anatomy that may be a contraindication for ERCP.

To minimize the patient's exposure to radiation, fluoroscopic images should be obtained only as necessary during the procedure; some fluoroscopy machines can be adjusted to minimize the frequency of image acquisition.

Deep sedation is desirable during ERCP because a stable endoscopic position in the duodenum is important for proper cannulation, therapeutic intervention, and avoidance of complications.

If the pancreatic duct is cannulated several times or if contrast is injected into the pancreatic duct, placement of a temporary pancreatic duct stent or rectally administered nonsteroidal anti-inflammatory drugs (NSAIDs; eg, indomethacin or diclofenac) should be considered in order to decrease the risk of PEP. [18] These two prevention modalities have proved effective for PEP prophylaxis. Numerous other pharmacologic agents have been studied, including gabexate, somatostatin, octreotide, steroids, heparin, allopurinol, and nitroglycerin, but with disappointing results. [19]

Multiple randomized controlled trials and meta-analyses have shown rectally administered NSAIDs to be effective in reducing the incidence of PEP, the occurrence of moderate-to-severe pancreatitis, and the length of hospital stay in high-risk patients who develop PEP.

[20, 21, 19, 22, 18]  Indirect comparative effectiveness studies suggested that rectal NSAIDs alone may be superior to pancreatic duct stenting in preventing PEP as a simple, easily administered, safe, inexpensive, and effective treatment modality, [22]  but there remains a need for further studies to help confirm these results through direct comparison with prospective randomized controlled data.

Whether rectal NSAIDs should be given to all patients or employed selectively in high-risk patients is a topic of debate among experts.

Widespread adoption of this simple strategy may minimize the incidence of PEP and modulate its severity, resulting in major clinical and economic benefit.

[19, 18]  NSAIDs have been shown to inhibit prostaglandin synthesis, phospholipase A2 activity, and neutrophil/endothelial cell attachment, which are all believed to play a key role in the pathogenesis of the initial inflammatory cascade of acute pancreatitis. [20, 23, 24, 19]

Single-dose administration is not associated with enhanced risk of bleeding or renal insufficiency. Rectal administration seems to work better than other routes, including oral, intramuscular (IM), intravenous (IV), and intraduodenal. [19]

In a prospective randomized study (N = 162) designed to compare the efficacy of single-dose (n = 87) and double-dose (n = 75) rectal indomethacin administration for preventing PEP, Lai found that although the incidence of PEP was lower in the latter group, the difference was not significant. [25] They concluded that in the general population, single-dose rectal indomethacin immediately after ERCP is sufficient for prevention, but they noted that in cases of difficult cannulation, the incidence of PEP frequency may rise as high as 15.4% even when rectal indomethacin is used.

The optimal timing of administering rectal NSAIDs has not been clearly defined. Two meta-analyses found no difference in efficacy between giving the medication before the procedure and giving it immediately afterward. [19, 18]

A pilot study suggested that aggressive IV hydration with lactated Ringer solution (LR) may reduce the development of PEP and is not associated with volume overload. [26]

In a subsequent prospective randomized, double-blind, placebo-controlled trial, 192 patients at high risk for PEP received standard normal saline solution (NS) plus placebo (n = 48), NS plus indomethacin (n = 48), LR solution plus placebo (n = 48), or LR solution plus indomethacin (n = 48).

[27] The primary outcome was PEP; secondary outcomes were severe acute pancreatitis, localized adverse events, death, length of stay, and readmission.

The combination of LR solution and indomethacin led to reductions in PEP incidence and readmission rate as compared with the combination of NS and placebo.

The first step in preventing post-ERCP complications is to identify those patients who are most ly to experience adverse events. Factors that place patients at higher risk for PEP, the most common serious complication associated with this procedure, may be broadly grouped as follows:

  • Patient-related factors

  • Procedure-related factors

  • Operator-dependent factors

  • Underlying disease or indication for performing ERCP

It is important to distinguish between asymptomatic postprocedural pancreatic enzyme elevations of serum amylase and lipase, which can be seen in more than half of all patients undergoing ERCP in the first 24 hours after the procedure, and true clinical pancreatitis induced by the ERCP, which presents with pancreatic-type pain or cross-sectional imaging confirming inflammation. [24]

Proposed underlying mechanisms that can induce PEP include the following [20, 24] :

  • Thermal injury from electrocautery

  • Hydrostatic injury from overinjection of the pancreatic duct

  • Enzymatic injury from intestinal contents or contrast

  • Mechanical injury from prolonged manipulation around the papillary orifice causing edema

Patient-related factors include the following [20, 23, 24, 28] :

  • Younger age (< 50 years)

  • Female sex

  • History of acute or recurrent pancreatitis

  • History of PEP

  • Preexisting biliary-type pain

  • Presence of bile duct stones

  • Normal serum bilirubin

  • Documented or suspected SOD (especially type III dysfunction with normal bile duct size and normal liver tests)

The term SOD is used to define motility abnormalities caused by stenosis or dyskinesia of the sphincter of Oddi. [20]  A history of chronic calcific pancreatitis seems to confer a protective effect on the risk of developing PEP. [24]

Procedure-specific risk factors for PEP include the following [20, 22, 23, 24, 29] :

  • Difficult cannulation of the ampulla of Vater (>10 attempts)

  • Cannulation of the pancreatic duct

  • Injection of contrast into the pancreatic duct (>2 times)

  • Pancreatic duct sphincterotomy

  • Pancreatic acinarization (opacification of acini)

  • Pancreatic duct tissue sampling/brushing

  • Pneumatic dilation of an intact biliary sphincter

  • Precut sphincterotomy

  • Ampullectomy

Data support the use of prophylactic pancreatic duct stents or the administration of rectal NSAIDs in patients at increased risk for pancreatitis, because it has been shown to reduce the incidence of PEP in this high-risk cohort of patients. [30, 20, 23, 24, 21, 19, 22]

Operator-dependent factors include the following:

  • Low case volume

  • Lack of experience

  • Lack of good technique

The significance of low case volume in this setting was challenged by a multicenter prospective study showing that the risk of PEP was not associated with the case volume of either the single endoscopist or the center. [29]

Those at higher risk for post-ERCP hemorrhage include patients with either a pathologic or an iatrogenic coagulopathy.

Anticoagulant or antithrombotic therapy should be discontinued before elective ERCP (generally 5-7 days beforehand), and the prothrombin time (PT) and partial thromboplastin time (PTT) should be evaluated on the day of the procedure.

If the PT and PTT are significantly abnormal, the procedure should be rescheduled if it is not an emergency. If there is an urgent need for ERCP, reversal of the coagulopathy with fresh frozen plasma may be required.

Routine use of prophylactic antibiotics in elective ERCP is controversial. The infectious risks of ERCP (ie, bacteremia and cholangitis) are most ly to occur in patients who present with biliary obstruction.

The 2015 ASGE guidelines for antibiotic prophylaxis for gastrointestinal endoscopy recommend antibiotic therapy in all patients presenting with bile duct obstruction and acute cholangitis. [31]  They also recommend antibiotics in cases where drainage with ERCP is incomplete or is achieved with difficulty (eg, in patients with hilar cholangiocarcinoma and primary sclerosing cholangitis).

A Cochrane analysis of nine randomized clinical trials found that the rates of bacteremia and cholangitis were lower in patients who received prophylactic antibiotics before elective ERCP than in those who did not, though subgroup analysis demonstrated that the effect of antibiotics was less evident in patients who underwent uncomplicated ERCP with successful biliary drainage. [32]

In March 2015, the American Gastroenterological Association suggested the following recommendations for reducing endoscope-associated infections in ERCP [33] :

  • Treat all elevator-channel endoscopes the same, including both fine-needle aspiration echoendoscopes (endoscopic ultrasound) and duodenoscopes

  • Track elevator-channel endoscopes by patient and by device serial number to facilitate retrospective identification in case of infection

  • Use a two-phase infection surveillance program that tracks all patients who have had a procedure with an elevator-channel endoscope, and periodically collect culture surveillance of all elevator-channel endoscopes; a positive culture should trigger a review of reprocessing techniques

  • Use a standard device reprocessing training program, and require reprocessing staff to demonstrate competency every 6 months

  • Immediately contact the Centers for Disease Control and Prevention to aid in investigation of any suspected breach or infection

Most mucosal perforations occurring during ERCP are periampullary and are associated with sphincterotomy.

Periampullary perforations are usually retroperitoneal and can often be managed with supportive care rather than immediate surgical intervention.

This complication can be prevented in many cases by following proper landmarks while performing sphincterotomy and by taking care to not cut beyond the intraduodenal portion of the CBD.

Perforations occurring away from the ampulla are typically due to traumatic endoscope passage, often related to limited visualization of the lumen.

As a general rule, the duodenoscope should never be forced against significant resistance during insertion. The forceps elevator should be in the closed position during passage of the endoscope down the lumen because it may lacerate the adjacent tissue if left in the open position.

Source: https://emedicine.medscape.com/article/1829797-overview

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