CPRE

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.

• Pancreatite aguda - inflammation of the pancreas that develops quickly over a few days.

• Pancreatite crônica - inflammation of the pancreas that is more persistent.

An endoscope is a thin, flexible tube. 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 (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 contrast 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 an opening called '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.

Prior to having an ERCP, blood pressure, heart rate, respiration and oxygen levels will be recorded. If a person has diabetes, the blood sugar level will also be checked and recorded. Blood tests may also be needed prior to the ERCP. The procedure will be discussed in detail and a consent form signed once the procedure is fully understood.

CPRE

The doctor may numb the back of the throat by spraying on some local anaesthetic, or may give a lozenge to suck. A sedative will usually be given by an injection into a vein in the back of the hand or arm. The sedative causes drowsiness and relaxes but it is not like a general anaesthetic.

While lying on n a couch, lying on one side, the first section of the endoscope is swallowed. Modern endoscopes are quite thin (thinner than an index finger) and quite easy to swallow. The doctor then gently pushes it down the oesophagus into the 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 the first part of the duodenum. This enables the lining to be seen more easily. It often causes a feeling of 'fullness' and wanting 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 opening called 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. The stent can remain permanently in place without being aware that it is there.

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.

Instructions will be provided by the hospital department before an ERCP. The sort of instructions given include:

• Not eating for six hours before the procedure. (Small sips of water may be allowed up to two hours before the procedure.)

• Advice about any usual medication that should be stopped before the procedure.

• Taking antibiotics before the procedure. This depends on the reason for having this test done.

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. Driving, operating machinery or drinking alcohol must be avoided for 24 hours after having the sedative.

If going home on the same day as the procedure, it is important to have somebody to accompany home and to stay with 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. A short hospital stay may be needed following a procedure such as removing a gallstone or inserting a small wire-mesh or plastic tube (a stent).

Most ERCPs are done without any problems. Some people have a mild sore throat for a day or so afterwards. Feeling tired or sleepy for several hours, caused by the sedative, is common.

Uncommon complications include the following:

• 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, a doctor should be contacted immediately:

  • Tummy (abdominal) pain - in particular, if it becomes gradually worse and is different or more intense to any 'usual' indigestion pains or heartburn.

  • Raised temperature (fever).

  • Dificuldade para respirar.

  • Bringing up (vomiting) blood.

• Inflammation of the pancreas (pancreatite) sometimes occurs after ERCP. This can be serious in some cases.

The risk of complications is higher if already in poor general health. The benefit from this procedure needs to be weighed up against the small risk of complications.

It may still be possible to perform ERCP during pregnancy, providing certain precautions are taken. Alternatively, it may be possible to delay it or use another type of procedure.