ERCP

Endoscopic retrograde cholangiopancreatography or ‘ERCP’ is procedure that treats blockages and other problems in the bile duct and pancreatic duct, using a flexible scope passed through the mouth and X-ray guidance. This technique has replaced older methods of accessing these areas by surgery or other more invasive means.

What it is for

The bile duct carries bile from the liver and gallbladder to the intestine. The pancreatic duct carries digestive fluid from the pancreas. Both drain through a small opening in the wall of the duodenum called the papilla.

The common reasons for performing ERCP include:

  • Removing stones from the bile duct — the single most frequent indication

  • Relieving a blockage causing jaundice, whether from a stricture, a tumor, or scarring

  • Placing a stent to keep a duct open

  • Treating a bile leak after gallbladder surgery

  • Sampling tissue from a narrowed area, or inspecting the duct directly with a miniature camera

  • Treating pancreatic duct problems, including stones and strictures

ERCP is now almost entirely a treatment procedure rather than a diagnostic one. MRI scans or endoscopic ultrasound are often used as alternatives to ERCP when less invasive, diagnostic testing is required. Because ERCP involves real risks, it is typically only performed when a clear abnormality needs to be fixed.

Where this is being done

Beth Israel Deaconess Medical Center is one of the largest and most experienced ERCP centers in the country. This matters more here than for most endoscopic procedures.

ERCP is technically demanding and highly operator-dependent, and outcomes vary considerably between endoscopists and between hospitals. Our interventional endoscopy team performs a high volume of these procedures, including complex and repeat cases, in a dedicated unit with a team that does this work every day.

Before the procedure

Nothing to eat or drink for a period beforehand — you will be given specific timings.

Tell us about blood thinners and antiplatelet medications, as some are held beforehand. Also tell us about diabetes medications, allergies (including to iodine contrast), pregnancy, and any implanted devices.

If you have had abdominal surgery that rearranged your anatomy — a gastric bypass, or a Whipple procedure — tell us, as it changes how the procedure is done.

The procedure

ERCP is performed under deep anesthesia. You will be asleep and will not feel or remember it.

  1. A specialized ‘side-viewing’ scope is passed through the mouth, down the esophagus and stomach, into the duodenum.

  2. The papilla is located and a fine catheter and guidewire are threaded into the duct, this step is called cannulation.

  3. Contrast dye is theninjected and X-ray pictures show the anatomy of the duct and the problem within it.

  4. The treatment is carried out: the muscle at the duct opening may be widened with a small cut (sphincterotomy) or a balloon, stones removed with a basket or balloon, a stent placed, or tissue sampled.

Most procedures take between 30 and 90 minutes, sometimes longer for complex cases.

Preventing pancreatitis

The main risk of ERCP is inflammation of the pancreas afterward. Several measures are taken routinely at BIDMC to reduce it, and they work.

  • An anti-inflammatory suppository (indomethacin) is usually given at the time of the procedure. This roughly halves the risk and is standard for essentially everyone who can take it.

  • Intravenous fluids are given generously before, during, and after.

  • A temporary small pancreatic stent may be placed in higher-risk cases. It passes on its own, usually within a couple of weeks, and is checked with an X-ray if it does not.

The overnight stay

For a first ERCP, we plan on an overnight stay in the hospital. The reason for this is that pancreatitis and bleeding, the two complications that matter most, do not always declare themselves in the recovery room. Most problems appear within the first several hours, but sometimes complications can show up in a delayed fashion.

Staying overnight means that if something does develop, it can be recognized more quickly, by a team already familiar with exactly what was done. It also allows blood tests the following morning and a check that eating is tolerated before discharge.

Most people stay one night and go home the next day, feeling essentially normal.

For subsequent ERCPs, when the anatomy is known, the duct opening has already been widened, and the first procedure went smoothly, same-day discharge is often appropriate. That decision is made case by case.

Risks

These are real, and higher than for a standard endoscopy. They are also, in the great majority of cases, treatable.

Pancreatitis is the most common complication after ERCP, affecting roughly 5-10 in 100 people overall. It causes upper abdominal pain, often going through to the back, with nausea and vomiting. Most cases are mild and settle with fluids, pain control, and a few days in the hospital. A small proportion of pancreatitis cases can be severe or even life threatning.

Pancreatitis risk is higher in younger patients, in women,, when cannulation is difficult, and in those who have had post-ERCP pancreatitis before. Where the risk is high, that is discussed beforehand and extra measures may be used.

Bleeding occurs after roughly 1 to 2 in 100 ERCPs, almost always related to the sphincterotomy. It can appear several days later, as black stools or vomiting blood. Most bleeding can be treated endoscopically.

Infection of the bile duct (cholangitis) occurs after about 3 in 100 ERCP procedures, more often when a bile duct could not be fully drained. Antibiotics may be given when this is anticipated.

A tear in the wall of the intestine or duct (perforation) is very uncommon, occuring in far less than 1 in 100 ERCPs. Many perforations can managed without surgery, but sometimes surgery is needed to fix the area.

Anesthesia and heart or lung complications carry their own small risk, discussed as part of consent.

Death attributable to ERCP is rare, in the range of 1 to 2 per 1000.

A sore throat and some bloating for a day is normal and is not a complication.

Afterward

Diet is restarted once things look stable, usually starting with liquids.

Mild upper abdominal soreness is common. Pain that is severe, worsening, or persistent is not, and should be reported immediately rather than waited out.

What happens next

Results of the procedure are usually explained the same day, though tissue samples take a week or two.

If a stent was placed, this is important: many stents are temporary and are removed or exchanged, typically within a few months. A blocked stent causes fever and jaundice and needs prompt attention. Make sure the follow-up appointment for stent removal is arranged before you leave, and keep it — this is the most common thing to fall through the cracks.

Some conditions need a planned second ERCP, for instance when stones could not all be cleared in one session. That is a common and expected part of treatment rather than a failure of the first procedure.

Suggested reading

The American Society for Gastrointestinal Endoscopy maintains plain-language patient information on ERCP, including what to expect before and after the procedure: https://www.asge.org/list-pages/patient-informations/understanding-ercp