Endoscopic Retrograde Cholangiopancreatogram (ERCP)

Test Overview

An endoscopic retrograde cholangiopancreatogram (ERCP) is a procedure that combines the use of a flexible, lighted scope (endoscope) with X-ray pictures to examine the tubes that drain the liver, gallbladder, and pancreas.

The endoscope is inserted through the mouth and gently moved down the throat into the esophagus, stomach, and duodenum until it reaches the point where the ducts from the pancreas (pancreatic ducts) and gallbladder (bile ducts) drain into the duodenum.

ERCP can treat certain problems identified during the procedure. If an abnormal growth is seen, an instrument can be inserted through the endoscope to obtain a sample of the tissue for further testing (biopsy). If a gallstone is present in the common bile duct, the doctor can sometimes remove the stone with instruments inserted through the endoscope. A narrowed bile duct can be opened by inserting a small wire-mesh or plastic tube (called a stent) through the endoscope and into the duct.

Why It Is Done

ERCP is done to:

• Check persistent abdominal pain or jaundice.
• Find gallstones or diseases of the liver, bile ducts, or pancreas.
• Remove gallstones from the common bile duct if they are causing a problem such as blockage (obstruction), inflammation or infection of the common bile duct (cholangitis), or pancreatitis.
• Open a narrowed bile duct or insert a drain.
• Get a tissue sample for further testing (biopsy).

How To Prepare

Do not eat or drink for 8 hours before having the test.

Tell your doctor if you:

• Have hay fever, hives, food or medication allergies, or asthma.
• Are allergic to shellfish (shrimp, scallops, lobster), the iodine used in the contrast material for X-ray tests, or any other substance that contains iodine.
• Have had a digestive tract study that used barium, such as a barium enema, within the last week.
• Are taking blood-thinning medicines, such as aspirin or warfarin (Coumadin).

Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will indicate. To help you understand the importance of this test, fill out the medical test information form (What is a PDF document?) .

You will be asked to empty your bladder and remove any dentures, jewelry, or contact lenses before having an ERCP.

How It Is Done

An endoscopic retrograde cholangiopancreatogram (ERCP) is done by a doctor trained in endoscopy, usually a doctor who specializes in diseases of the digestive system (gastroenterologist). A thin, flexible fiber-optic endoscope is used.

ERCP is done in the hospital. You may have to stay overnight if your doctor removes gallstones or places a stent during the procedure. Otherwise, you will be allowed to go home after the procedure.

An ERCP usually takes between 30 and 60 minutes. You will be in the recovery room 1 to 2 hours.

Your throat may be numbed with an anesthetic spray, gargle, or lozenge to relax your gag reflex and make it easier to insert the endoscope. Shortly before the procedure begins, an intravenous (IV) line will be placed in a vein in your arm. You will be given pain medicine and sedative through the IV during the procedure. You may also be given an antibiotic through the IV.

You will be asked to lie on your left side with your head tilted slightly forward. A mouth guard may be inserted to protect your teeth from the endoscope. The lubricated tip of the endoscope will be guided into your mouth while the doctor gently presses your tongue out of the way. You may be asked to swallow to help move the tube along. The instrument is no thicker than many foods you swallow. Once the endoscope is in your esophagus, your head will be tilted upright to help the scope slide down.

Your doctor will slowly move the endoscope into your stomach and duodenum. Your doctor looks at your esophagus, stomach, and duodenum as the scope moves forward. When the endoscope reaches your duodenum, you will be turned over to lie flat on your abdomen. See an illustration of the placement of an endoscope during ERCP .

A small amount of air will be injected through the scope to make it easier for the doctor to see. The endoscope is moved forward until it reaches the point where the ducts from the pancreas and gallbladder drain into the duodenum (the papilla). A thin tube called a catheter is then passed through the endoscope into the papilla, and contrast material is injected into the bile or pancreatic ducts. Several X-rays are taken. You will remain on your abdomen while the X-rays are developed. If necessary, additional X-rays may be taken.

Surgical instruments, called biopsy forceps or brushes, may be inserted through the endoscope to collect samples. If a gallstone is seen during the procedure, the doctor can sometimes remove it. A narrowed bile duct can be held open by inserting a small wire-mesh or plastic tube called a stent through the endoscope and into the duct.

When the procedure is completed, the endoscope is slowly withdrawn.

After the procedure

After the ERCP is completed, you will be observed in a recovery room for 1 to 2 hours. If your throat was numbed before the test, you will not be allowed to eat or drink until your throat is no longer numb and you are able to swallow without choking. You can then resume eating and drinking normally.

Unless you are staying in the hospital, you will need to have someone drive you home after the procedure. You will not be allowed to drive or to return to work for 24 hours.

Your doctor will make sure you do not have any signs of complications before you go home. If your doctor removed a gallstone or placed a stent during the procedure, you may need to stay in the hospital overnight.

How It Feels

You may notice a brief, sharp burning or stinging sensation when the IV is started in your arm. The local anesthetic sprayed into your throat usually tastes slightly bitter and will make your tongue and throat feel numb and swollen. Some people report feeling as though they cannot breathe sometimes because of the tube in their throat. This is a false sensation caused by the anesthetic. There is always plenty of breathing space around the tube in your mouth and throat. Remember to relax and take slow, deep breaths.

You may gag, feel nauseated or bloated, or have mild abdominal cramping as the tube is moved. If the discomfort is severe, alert your doctor with an agreed-upon signal or tap on the arm. Even though you won't be able to talk during the procedure, you can still communicate.

The IV medicines will make you feel sleepy, and you may not be able to remember much of what happens during or for several hours after the test. You may have heavy eyelids, difficulty speaking, a dry mouth, or blurred vision for several hours after the procedure.

You may have a flushing sensation when the contrast material is injected.

After the test

After the procedure, you may have gas and feel bloated for a while. You may also have a tickling, dry throat, slight hoarseness, or a mild sore throat for several days. Throat lozenges and gargling with warm saltwater can help relieve your throat symptoms.

Because of the IV medicines used during this procedure, do not drink alcohol, drive, or sign any legal documents for 24 hours after the procedure.

Risks

An endoscopic retrograde cholangiopancreatogram (ERCP) is generally a safe procedure. Although not common, complications can include:

• Inflammation of the pancreas (pancreatitis).
• Bleeding, which may occur if the pancreatic or bile ducts are enlarged or if biopsies are taken during the ERCP.
• Infection of the bile ducts, which may occur if gallstones were removed.
• An abnormal heart rhythm.
• A puncture of the esophagus, stomach, duodenum, bile duct, or pancreatic duct. If this happens, you will need to have surgery to repair the puncture.

After the procedure

After the test, call your doctor immediately if you:

• Vomit blood, whether it is fresh and red or is old and looks like coffee grounds.
• Have new or increased pain.
• Develop a fever or chills.
• Feel short of breath.
• Are dizzy or feel like you may faint.

People with serious heart disease and older adults with other chronic diseases have a greater chance of having problems from this procedure. Although complications are uncommon, talk to your doctor about your specific risks.

Results

An endoscopic retrograde cholangiopancreatogram (ERCP) is a procedure that combines the use of a flexible, lighted scope (endoscope) with X-ray pictures to examine the tubes that drain the liver, gallbladder, and pancreas.

Your doctor may be able to discuss some of the findings with you immediately after the test. But the medicines used to relax you for an ERCP may impair your memory. So your doctor may tell you to call the next day for your results.

What Affects the Test

Barium contrast material in the intestines (from a barium enema procedure) can interfere with ERCP results.

What To Think About

• Other less invasive and less expensive tests, such as a CT scan, MRI scan, or an abdominal ultrasound, may be done before ERCP to evaluate abdominal pain or jaundice.
• An imaging test, a magnetic resonance cholangiopancreatogram (MRCP), can be used to view the bile ducts and to diagnose medical conditions. MRCP doesn't allow biopsies or treatments to be done during the procedure.
• Another test, endoscopic ultrasound (EUS), uses a small ultrasound probe at the end of the endoscope and may offer a more detailed view of parts of the digestive tract than ERCP. EUS also allows the doctor to see certain organs of the body adjacent to the digestive tract, such as the pancreas and bile ducts. EUS may help diagnose noncancerous (benign) or cancerous (malignant) tumors of the esophagus, stomach, pancreas, and bile ducts.
• If your doctor removes a gallstone or places a stent during your ERCP, you may need to stay in the hospital overnight.
• Because air is used during ERCP to open the bile and pancreatic ducts, you may feel bloated and notice a temporary change in your bowel habits. Notify your doctor if you experience bleeding from the rectum or your stools look black or bloody.
• Depending on the ERCP results, you may need other tests, such as angiography or laparoscopy, to confirm a diagnosis. Surgery may be needed to treat a problem found with ERCP.

References

Other Works Consulted

• Chernecky CC, Berger BJ, eds. (2004). Laboratory Tests and Diagnostic Procedures, 4th ed. Philadelphia: Saunders.

• Fischbach FT, Dunning MB III, eds. (2004). Manual of Laboratory and Diagnostic Tests, 7th ed. Philadelphia: Lippincott Williams and Wilkins.

• Pagana KD, Pagana TJ (2006). Mosby's Manual of Diagnostic and Laboratory Tests, 3rd ed. St. Louis: Mosby.

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