Endoscopic retrograde cholangiopancreatography

Why am I having the procedure?

The most common reasons to do an ERCP are jaundice (yellowing of the skin or eyes) or abnormal liver blood tests, especially if you have pain in the abdomen, or if a scan (ultrasound or CT scan) shows a blockage of the bile or pancreatic ducts. Blockages can be caused by stones, narrowing of the bile ducts (strictures), and growths or cancers of the pancreas and bile ducts. During ERCP your Doctor will aim to relieve your blockage, either by removing what is blocking it i.e a stone or by placing a stent (small plastic or metal tube) to allow the bile to drain past the blockage.

To perform an ERCP the doctor passes an endoscope, a thin flexible tube with a bright light at the end, through your mouth and down into the first part of the intestine called the duodenum. It is here that the ducts or tubes from the liver and pancreas drain through a small nipple called the ampulla. A fine plastic tube is placed inside the ampulla and liquid (X ray contrast) is injected into these tubes and X rays are taken. If necessary to remove stones or place a tube through a narrowing in these ducts, a small cut can be made by an electrically heated wire. This is called a sphincterotomy. An ERCP usually takes 30-40 minutes but times can vary considerably.

A video recording and /or photographs may be taken for your records.

Using newer technology we are now able to directly visualise your bile duct for diagnostic and therapeutic (treatment) applications. Spyglass DS is designed to optimize procedural outcomes for patients with indeterminate strictures (unknown cause of narrowing in the bile ducts) or large difficult stones in the bile duct.

Strictures in the bile ducts

When conventional methods of diagnosing the nature of strictures in the bile duct prove inconclusive, SpyGlass DS can be used to directly view the abnormality and also allow the endoscopist to take targeted biopsies via the endoscope helping with diagnostic accuracy.

Stones in the bile ducts

Sometimes stones in the bile duct cannot be removed via conventional ERCP due to reasons such as size, quantity, shape or ductal anatomy. SpyGlass DS has a therapeutic application whereby complex bile duct stones can be broken up using electrohydraulic lithotripsy often shortened to EHL or laser therapy under direct vision.

What are the alternatives?

The same information can be gained by putting a needle into the liver to inject x-ray contrast but this has higher risks and is more uncomfortable. Magnetic resonance scans can also show much of the necessary information without discomfort, but no treatment can be applied.

What are the possible complications of ERCP?

• Bloating and abdominal discomfort is not unusual for a few hours
• You may have a sore throat for 24 hours
• About one in 20 patients suffer from inflammation of the pancreas (called pancreatitis) after the procedure. This usually requires admission to hospital for several days, but occasionally may require longer stays. To reduce this risk, before we start your procedure you will be given an anti-inflammatory suppository into your back passage
• Perforation of the oesophagus or duodenum is a rare complication and would mean a stay in hospital and you may require an operation to repair the damage.
• If you have a sphincterotomy (a small cut in the bottom of the bile duct) performed, there is a risk of bleeding which usually stops quickly by itself. If it does not stop by itself we may inject you with adrenalin through the endoscope. However, in severe cases, blood transfusion, a special x-ray procedure or an operation may be required to control the bleeding.
• Using sedation can cause breathing complications in up to one in 200 procedures, which usually are not serious.
• Other rare complications include aspiration pneumonia, damage to loose teeth or to dental bridgework.
• In about ten% the procedure is technically unsuccessful and alternatives are required.
• No test is 100% accurate and abnormalities may be missed, including cancers.
• The procedure has a one in 500 mortality (death) rate.

If you are having this procedure performed under anaesthetic (Propofol sedation) the following risks apply:

• using propofol sedation can cause breathing complication which may require us to take over your breathing temporarily
• hypotension (low blood pressure)
• a feeling of pain at the site of the injection (while the injection is being given, before you fall asleep) approx. 10%

Are there any increased risks with SpyGlass™ DS?

The risks are very similar to that of ERCP however, there is a higher risk of cholangitis developing (inflammation of the bile duct caused by infection) when having the Spyglass procedure. To help protect you from this and/or lessen the severity should you develop it, your doctor will prescribe antibiotics for you, which will be given to you via your vein, before your procedure commences.

The person doing the test will discuss any questions you have about the risks associated with this procedure.

Preparing for a ERCP

Please read the information enclosed carefully. If you have any queries or worries, contact the unit where you will be having your procedure.

If you are diabetic, on any blood thinning medication i.e warfarin, clopidogrel, rivaroxaban, apixaban, or dabigatran please contact the unit for further information. Please bring any medication you are currently taking e.g. inhalers, insulin with you to your appointment. If you are taking a number of tablets, please bring your repeat prescription sheet with you.

To allow a clear view the stomach must be empty, so please follow these instructions:

• do not have anything to eat for at least six hours before the test
• do not drink milk for four hours before your test. Milk will line the stomach and not allow a clear view of the lining
• you may drink clear fluids (water, black tea or black coffee) up to two hours before the time of the appointment
• you may take medication for heart conditions, high blood pressure or asthma with a small sip of water.

Please report to the reception desk where a receptionist will check your details and direct you to the waiting area. Please be aware the appointment time you have been given, will be your admission time. Your procedure will be carried out as near to this time as possible however on occasions due to emergency patients being seen, this may be delayed.

• Please do not bring any valuables to the hospital with you
• Please do not wear any nail varnish, lipstick or jewellery (tongue studs must be removed
• Please bring slippers and a dressing gown.
• Please bring a contact number of a relative or friend with you

A nurse will then call you through to the admissions area of the unit. During your admission the nurse will check all of your details and also your Blood Pressure, Pulse and Oxygen levels. They will explain the procedure to you and answer any questions you may have. You will then be given an anti-inflammatory drug (suppository), which will be inserted into your back passage. Research has shown this to be helpful in reducing the risk of developing pancreatitis following the procedure, please see above in the complications section.

Following this both the Doctor performing your procedure and an Anaesthetist (if you are having a GA for your procedure) will talk to you. The Doctor will want to make sure you understand the

benefits, possible risks and their implications of having the procedure done before asking you to sign a consent form.

The consent form is confirmation that you fully understand the procedure you are about to have done and also includes any additional procedures that may be necessary during the procedure, i.e taking tissue samples (biopsies) that may be helpful in diagnosing your problem and administration of any medication you may require. There is an option of allowing tissue samples to be used for research on the consent form but you can decline this.

If you are deaf and require a sign language interpreter on the day of your procedure, please contact the unit where you will be having the test, as soon as possible.

Please note, relatives/friends or children should not be used as interpreters when you are required to sign your consent form. You should contact the Endoscopy Unit who will arrange for an interpreter to be present.

During the test

You will not have to get undressed but we will give you a gown to wear. You are advised to wear very loose clothing i.e. track suit and avoid any clothing that contains metal i.e. belts, under wired bras. You will have to remove dentures, glasses, contact lenses and loosen any tight clothing around the neck.

In the examination room you will be made comfortable on the couch, resting on your left side.

with your left arm behind your back. A nurse will stay with you throughout the procedure. To keep your mouth slightly apart, a plastic mouthpiece will be put gently between your teeth or gums. When the person doing the test passes the endoscope into your stomach it will not cause pain, nor will it interfere with your breathing. The whole examination usually takes less than 40 minutes. During the procedure you will be rolled onto your stomach and sometimes onto your back.

Sedation

The procedure is normally done with sedation and a painkilling injection is also often used. If you know of drugs that you do not tolerate, please tell the person doing the test. Sedation will be given through a small needle in the back of your hand or in your arm. Sedation will make you slightly drowsy and relaxed but not unconscious. You will be in a state called co-operative sedation. That means that although drowsy you will still hear what is said to you and therefore will be able to follow simple instructions during the procedure. You will be given oxygen through small tubes placed gently in your nostrils or through the plastic guard in your mouth. A clip will be attached to a finger or ear-lobe so that the levels of oxygen in the blood can be monitored. Your blood pressure may also be measured during the procedure automatically using a cuff around your arm.

Please note that we will not be able to give you sedation if you do not have a responsible adult to collect you and stay with you for 24 hours following your procedure.

After the test you will remain in the unit to rest for a while (about four hours). Occasionally an x-ray of the abdomen will be taken before you are allowed to drink or sent back to your ward. You may not be able to have a drink for up to two hours.

Going home

It is essential that a responsible adult comes to pick you up from the unit and accompanies you home by car or taxi – public transport is not suitable. Please note the unit closes at 18:00. Your relative/friend should arrive no later than 17:30 to collect you.

When you arrive home, it is important to rest quietly for the remainder of the day, with someone to look after you for 24 hours. It is advisable to have the following day off work.

For the first 24 hours following sedation do not:

• drive a car
• drink alcohol
• take sleeping tablets
• operate any machinery or electrical items – even a kettle
• sign any legally binding documents
• work at heights (including climbing ladders or onto chairs)

Both forms of sedation can impair your reflexes and judgement. The effect of the sedation will have worn off by the next day and most patients will be able to resume normal activities.

You will be able to eat and drink normally.

When will I know the results?

Before discharge from the unit, the nurse who has been looking after you will be able to give you a brief outline of the test results. A copy of the report will be sent to your GP or the doctor who referred you for the procedure. If a biopsy has been taken, the laboratory results will take longer, about 4 weeks. You will be given a copy of the report to take home with you.