Endoscopic Retrograde Cholangiopancreatography (ERCP) combines the flexible viewing capabilities of an endoscope with real-time X-ray imaging, known as fluoroscopy. This technique allows physicians to diagnose and treat conditions affecting the body’s drainage system, including the bile ducts and the pancreatic duct. ERCP accesses the ducts that carry digestive fluids from the liver and pancreas into the small intestine, primarily to address blockages, narrowings, or leaks. It often replaces the need for more invasive surgical procedures.
Preparing for the ERCP
Preparation focuses on ensuring the digestive tract is clear. Patients must fast for at least six to eight hours before the scheduled time. This nil per os (NPO) status is necessary to empty the stomach and minimize the risk of inhaling food or fluid into the lungs during sedation.
A review of current medications is required. Medications affecting blood clotting, such as blood thinners, often need to be stopped several days prior to reduce bleeding risk. Diabetic patients must receive specific instructions on adjusting insulin or oral medications due to fasting. An intravenous (IV) line is placed to administer fluids and sedative medications. Informed consent is also obtained, ensuring the patient understands the procedure and its potential risks.
Performing the Procedure
The ERCP begins with the administration of sedation, which may range from monitored anesthesia care to general anesthesia, depending on the patient and the complexity of the anticipated intervention. The patient is positioned on an X-ray table, often lying on their stomach, to facilitate endoscopy and fluoroscopy. Once sedated, the physician guides the endoscope through the mouth, down the esophagus and stomach, and into the duodenum, the first part of the small intestine.
The physician locates the ampulla of Vater, where the bile and pancreatic ducts join and enter the small intestine. A narrow plastic tube, known as a catheter or cannula, is passed through the endoscope into this opening to access the ductal system. Contrast dye is injected through this catheter, and fluoroscopy (real-time X-ray) highlights the ducts, revealing blockages, stones, or strictures.
If a problem is identified, the ERCP transitions into a therapeutic intervention using specialized instruments passed through the endoscope. A sphincterotomy involves making a small incision in the muscle surrounding the duct opening to widen it. This allows for the removal of gallstones. Narrowed sections (strictures) can be stretched open using a balloon, and a small plastic or metal tube called a stent may then be placed to keep the duct open and allow proper fluid drainage.
Immediate Recovery and Discharge
After the procedure, the endoscope is removed, and the patient moves to a recovery area for close monitoring. The recovery team watches the patient’s vital signs, including heart rate, blood pressure, and oxygen saturation, and assesses their level of consciousness as the effects of the sedation begin to wear off. Patients may experience minor side effects, such as a mild sore throat from the endoscope insertion or a feeling of bloating and gas due to the air introduced to inflate the digestive tract during the procedure.
Before discharge, the patient must be fully awake and able to tolerate liquids or soft food. A responsible adult must escort the patient home, as sedative medications impair judgment and coordination. Patients are instructed not to drive, operate heavy machinery, or make important decisions for at least 12 to 24 hours following the procedure. Follow-up instructions are provided, including when to resume medications and how to schedule any necessary follow-up appointments.
Recognizing and Addressing Complications
While ERCP carries a higher risk of complications compared to standard endoscopy, the most common is Post-ERCP Pancreatitis (PEP). PEP is an inflammation of the pancreas that occurs in three to five percent of patients and can range from mild to severe, sometimes requiring a short hospital stay. Bleeding is another risk, especially if a sphincterotomy was performed, and it can occur immediately or in the hours following the procedure.
Rarely, the procedure can lead to a perforation (a small tear in the wall of the digestive tract or bile duct) or an infection in the bile ducts. Patients must be aware of specific warning signs that necessitate immediate medical attention after discharge. These symptoms include severe or worsening abdominal pain not relieved by standard medication, fever and chills, or bloody or black stools. Recognizing these signs and seeking prompt care is important for safely managing the recovery period.