ERCP is a procedure that uses an endoscope and X-rays to look at the bile duct and the pancreatic duct. ERCP can also be used to remove gallstones or take small samples of tissue for analysis (a biopsy).
Note: the information below is a general guide only. The arrangements and the way tests are performed, may vary between different hospitals. Always follow the instructions given by your doctor or local hospital.
What is an ERCP?
ERCP stands for 'endoscopic retrograde cholangiopancreatography'. ERCP is a very useful procedure, as it can be used both to diagnose and to treat various conditions, such as gallstones, acute pancreatitis (inflammation of the pancreas that develops quickly over a few days) and chronic pancreatitis (inflammation of the pancreas that is more persistent).
An endoscope is a thin, flexible, telescope. It is passed through the mouth, into the gullet (oesophagus) and down towards the stomach and the first part of the gut after the stomach (the duodenum). The endoscope contains fibre-optic channels which allow light to shine down so the doctor can see inside.
Cholangiopancreatography means X-ray pictures of the bile duct and pancreatic duct. These ducts do not show up very well on ordinary X-ray pictures. However, if a dye that blocks X-rays is injected into these ducts then X-ray pictures will show up these ducts clearly. Some dye is injected through the papilla back up into the bile and pancreatic ducts (a 'retrograde' injection). This is done via a plastic tube in a side channel of the endoscope. X-ray pictures are then taken.
The bile ducts and nearby structures
Bile is made in the liver. The liver is in the upper right part of the tummy (abdomen). Bile passes from liver cells into tiny tubes called bile ducts. These join together (like the branches of a tree) to form the common bile duct. Bile constantly drips down the common bile duct,and through an opening called the papilla (see diagram, below) into the first part of the gut after the stomach (the duodenum).
The gallbladder lies under the liver on the right side of the upper abdomen. It is like a pouch which comes off the common bile duct. It is a 'reservoir' which stores bile between meals. The gallbladder squeezes (contracts) when you eat. This empties the stored bile back into the common bile duct. The bile passes along the remainder of the common bile duct into the duodenum. Bile helps to digest food, particularly fatty foods. The pancreas is a large gland that makes chemicals (enzymes). These flow down the pancreatic ducts, into the main pancreatic duct,and through the papilla into the duodenum. The pancreatic enzymes are vital in order to digest food. (The pancreas also makes some hormones such as insulin.)
What happens during an ERCP?
The doctor may numb the back of your throat by spraying on some local anaesthetic, or may give you a lozenge to suck. You will usually be given a sedative by an injection into a vein in the back of your hand or arm. The sedative makes you drowsy and relaxed but it does not 'put you to sleep'. It is not a general anaesthetic.
You lie on your side on a couch. The doctor will ask you to swallow the first section of the endoscope. Modern endoscopes are quite thin (thinner than an index finger) and quite easy to swallow. The doctor then gently pushes it down your oesophagus into your stomach and duodenum.
The doctor looks down the endoscope via an eyepiece or on a TV monitor which is connected to the endoscope. Air is passed down a channel in the endoscope into the stomach and duodenum to make the lining easier to see. This may make you feel 'full' and want to belch.
The endoscope also has a 'side channel' down which various tubes or instruments can pass. These can be manipulated by the doctor who can do various things. For example:
- Inject a dye into the bile and pancreatic ducts. X-ray pictures taken immediately after the injection of dye show up the detail of the ducts. This may show narrowing (stricture), stuck gallstones, tumours pressing on the ducts, etc.
- Take a small sample (biopsy) from the lining of the duodenum, stomach, or pancreatic or bile duct near to the papilla. The biopsy sample can be looked at under the microscope to check for abnormal tissue and cells.
- If the X-rays show a gallstone stuck in the duct, the doctor can widen the opening of the papilla to let the stone out into the duodenum. A stone can be grabbed by a 'basket' or left to be passed out with the stools (faeces).
- If the X-rays show a narrowing or blockage in the bile duct, the doctor can put a stent inside to open it wide. A stent is a small wire-mesh or plastic tube. This then allows bile to drain into the duodenum in the normal way. You will not be aware of a stent, which can remain permanently in place.
The endoscope is gently pulled out when the procedure is finished. An ERCP can take anything from 30 minutes to over an hour, depending on what is done.
What preparation do I need to do?
You should get instructions from the hospital department before an ERCP. The sort of instructions given include:
- You should not eat for several hours before the procedure. (Small sips of water may be allowed up to two hours before the procedure.)
- Advice about medication which you may need to stop before the procedure.
What can I expect after an ERCP?
If the procedure was done just to obtain X-ray pictures then most people are ready to go home after resting for a few hours. You should not drive, operate machinery or drink alcohol for 24 hours after having the sedative. If you go home on the same day as the procedure you will need somebody to accompany you home and to stay with you for 24 hours until the effects of the sedative have fully worn off.
Most people are able to resume normal activities after 24 hours. Because of the effect of the sedative, most people remember very little about the procedure. You may require a short hospital stay if you had a procedure such as removing a gallstone or inserting a small wire-mesh or plastic tube (a stent).
Are there any side-effects or complications from having an ERCP?
Most ERCPs are done without any problems. Some people have a mild sore throat for a day or so afterwards. You may feel tired or sleepy for several hours, caused by the sedative. Uncommon complications include the following:
- There is a slightly increased risk of developing a chest infection following an ERCP.
- Occasionally, the endoscope causes some damage to the gut, bile duct or pancreatic duct. This may cause bleeding, infection and, rarely, perforation. If any of the following occur within 48 hours after an ERCP, consult a doctor immediately:
- Tummy (abdominal) pain - in particular, if it becomes gradually worse and is different or more intense to any 'usual' indigestion pains or heartburn that you may have.
- Raised temperature (fever).
- Difficulty breathing.
- Bringing up (vomiting) blood.
- Inflammation of the pancreas (pancreatitis) sometimes occurs after ERCP. This can be serious in some cases.
The risk of complications is higher if you are already in poor general health. The benefit from this procedure needs to be weighed up against the small risk of complications.
Let your doctor know if you think you could be pregnant. It may still be possible to perform ERCP if you are pregnant, providing certain precautions are taken. Alternatively, it may be possible to delay it or use another type of procedure.
Further reading & references
- Bahr MH, Davis BR, Vitale GC; Endoscopic management of acute pancreatitis. Surg Clin North Am. 2013 Jun;93(3):563-84. doi: 10.1016/j.suc.2013.02.009. Epub 2013 Apr 13.
- Mesenas SJ; Does the advent of endoscopic ultrasound (EUS) sound the death knell for endoscopic retrograde cholangiopancreatography (ERCP)? Ann Acad Med Singapore. 2006 Feb;35(2):89-95.
- Zaheer A, Anwar MM, Donohoe C, et al; The diagnostic accuracy of endoscopic ultrasound in suspected biliary obstruction and its impact on endoscopic retrograde cholangiopancreatography burden in real clinical practice: a consecutive analysis. Eur J Gastroenterol Hepatol. 2013 Jul;25(7):850-7. doi: 10.1097/MEG.0b013e32835ee5d0.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Rachel Hoad-Robson
Dr Laurence Knott
Dr Adrian Bonsall