Having an ERCP (Endoscopic Retrograde Cholangio-Pancreatography) Patient Information Important please read now Ninewells Hospital Clinical Investigation Unit Telephone: 01382 632494 Page 1 of 10
Please read this booklet and complete the enclosed consent form in the middle before you arrive. Introduction This booklet aims to give you enough information: To give properly informed consent for the procedure. To help you prepare for the procedure. To guide you through the procedure. To make appropriate arrangements afterwards. To answer frequently asked questions. What is an ERCP? ERCP (also known as Endoscopic Retrograde Cholangio-Pancreatography) is a procedure which allows the doctor to take detailed x-rays of your bile duct and/or pancreas. If required, further treatment can be carried out on your bile duct. Why is an ERCP performed? The most common reason to perform an ERCP is jaundice (yellowing of the skin or eyes) or abnormal liver blood tests, or if a scan (ultrasound, CT or MRI 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. An ERCP can give more information about the pancreas and bile ducts, brushings and biopsies (specimens of cells for analysis) can be taken and, if required, a stent can be inserted. What happens during the ERCP? You will be taken to the examination room where you will meet the doctor and other staff who will remain with you during the procedure. The endoscopist may ask you about your symptoms and treatment and you can discuss with them any questions you have about your condition and the procedure itself. You may be given a local anaesthetic throat spray to help to numb your throat. You will need to lie on your front, and a mouth guard will be placed in your mouth. Before the procedure starts, a nurse will attach a monitor to one of your fingers to record your pulse and oxygen level. Oxygen will be administered to you throughout the examination. You will be given an injection of intravenous sedation and painkiller through a small needle in the back of your hand or arm. These medicines (known as conscious sedation), will relax you and may make you drowsy but will not necessarily put you to sleep. You will hear what is said to you and be able to respond to any instructions given to you. A nurse will sit by your head and monitor you for the whole of the procedure. You may experience some discomfort as the endoscope touches the back of your throat and you may gag briefly at this point. This will not interfere with your breathing. The endoscope will go down your gullet, into your stomach and the first part of your small bowel (duodenum). Air will be passed through the endoscope to gently inflate the duodenum to allow a clearer view. During the procedure you may burp some air up but please do not feel embarrassed, as it is quite normal to do this. Page 2 of 10
Any saliva in your mouth will be removed with a small suction tube. When the endoscope is removed, most of the air is removed as well to make you comfortable again. During the procedure, the doctor will insert a fine wire, which shows up on x-ray into the bile ducts. Contrast dye will be passed down the endoscope so that x-rays images of the pancreas and bile duct may be obtained. The dye is passed out of your body harmlessly. Additional procedures (that may be performed during the ERCP) These include: 1. Sphincterotomy/Balloon sphincterplasy This is a cut to/or stretch of the duct to help pass a gallstone, widen a narrow duct, or insert a plastic tube (a stent). 2. Stone Removal Balloon clearance: If a gallstone or debris is identified in the bile duct a cannula with a deflated balloon can be passed up the duct and inflated above the stone. This is then withdrawn down the duct removing the stone and debris. Basket clearance: An instrument can be passed up the bile duct onto the stone to crush it and remove it. 3. Stent insertion If there is a narrowing, or if the stone cannot be removed, then a tube called a stent can be inserted to allow drainage of bile and relieve any jaundice (yellowing discolouration of your skin). 4. Biopsy/Cytology Sample Small pieces of tissue may be taken for further examination in the laboratory. This is not painful and is performed through the endoscope. How long does an ERCP take? The actual procedure lasts between 15 and 40 minutes. To ensure comfort your medication may be topped up throughout the procedure. You may be out of the ward for up to 1½ hours. Will I feel any pain or discomfort? You may experience some mild stomach cramps, these will soon disappear. Prior to the procedure you will be given an IV sedative and pain killer. This may make you forgetful, so you might not remember details of the test. The effects of sedation last in your system for 24 hours. We will give you pain killing suppositories (into your back passage) prior to the procedure these also help prevent pancreatitis. Afterwards, simple pain relief, for example, paracetamol, may be taken. Taking peppermint (for example as peppermint tea or peppermint water) can help to pass the air. What are the risks? ERCP is generally safe but complications can sometimes occur. Minor complications: Mild discomfort in the abdomen and a sore throat, which may last up to a few days. Loose teeth, crowns and bridgework can be dislodged, but this is rare. Mild inflammation of the pancreas (pancreatitis). This can happen in approximately five in100 people. If pancreatitis happens, you will have pain in the abdomen, usually starting a few hours after the procedure and lasting for a few days. The pain can be controlled with painkillers and you will be given an intravenous (into a vein) infusion of fluids in hospital to keep you hydrated until the pain subsides. Page 3 of 10
Irritation to the vein in which medications were given is uncommon, but may cause a tender lump lasting for a couple of days. Ascending cholangitis this is an infection within the bile duct. This is more likely if the duct is blocked. Possible major complications: Severe pancreatitis can occur following an ERCP. We can treat this with medication or surgery. Although it is very rare, severe pancreatitis can be fatal (less than one in 500 cases). If sphincterotomy (a small cut in the bottom of the bile duct) is performed, there is a risk of bleeding which usually stops quickly by itself. If it does not stop by itself we can treat this through the endoscope. However, in severe cases, blood transfusion, a special x- ray procedure or an operation may be required to control the bleeding. Very frail and/or elderly patients can get pneumonia from stomach juices getting into the lung (approximately one in 500 cases). A hole may be made in the wall of the duodenum (perforation), either as a result of sphincterotomy or due to a tear made by the endoscope. This happens in less than one in 750 cases. It might require surgery to put right and may occasionally be fatal. A very rare complication is a reaction to one of the sedative drugs used. Risks of sedation: Sedation can occasionally cause problems with breathing, heart rate and blood pressure. If any of these problems do occur, they are normally short lived. Is there an alternative to ERCP? Percutaneous transhepatic cholangiogram (PTC), an ultrasound guided PTC can be performed under x-ray guidance, is the only alternative which allows therapeutic intervention (treatment). However PTC does not allow us to see the bile ducts directly. Cholecystectomy an operation may be performed to remove your gall bladder and gallstones at the same time. However, this is not always successful at removing gallstones and an ERCP may still be needed. CT (computerised tomographic) scan can be performed, but the investigation is less sensitive, small growths (less than 1cm) can be missed, no biopsies can be obtained, and no stents can be inserted. MRI (magnetic resonance imaging) scan can be performed, but the investigation does not allow direct vision of the bile ducts, no biopsies can be obtained and no stents can be inserted. Also, you cannot have an MRI scan if you have some internal metalwork (for example, pacemaker, and joint replacements). An ultrasound scan can provide ultrasonic images of the biliary system, but a biopsy cannot be obtained and no stents can be inserted. An endoscopic ultrasound can be performed, but stones cannot be removed, a sphincterotomy (cut at the base of the bile duct) cannot be performed, and no stents can be inserted. MRCP (Magnetic Resonance Cholangio Pancreatography) this visualises the gallbladder and ducts showing if stones or strictures are present. An ERCP may still be needed to treat the problem. Once you have read and understood this information please complete enclosed consent form. The endoscopist will confirm the consent before your procedure. On very rare occasions we must take special precautions with endoscopes if there is a possibility you have been at risk of variant CJD. Page 4 of 10
We therefore ask all patients undergoing any endoscopy procedure if they have been told that they are at increased risk of CJD. This helps prevent the spread of CJD to the wider public. A positive answer will not stop your procedure taking place, but enables us to plan the procedure to minimise any risk of transmission to other patients. What happens on the day of your appointment? For a morning appointment, eat no food after midnight. You may drink water only up until 2 hours before your appointment. For an afternoon appointment, you may have tea/coffee and toast before 7.00 am. After 7.00 am, only drink water up until 2 hours before your appointment. You should take any prescribed medication with a little water at the usual time (except diabetic medicines). Bring any insulin and/or diabetes tablets with you. Bring the appointment letter and this booklet (with a list of your medications with you). Do not wear nail varnish or false nails as this interferes with the monitor we use. Do not bring valuables or large quantities of money into hospital, as we cannot accept responsibility for them. What happens when I arrive at the ward? When you arrive in the ward, a nurse will check your details and confirm your transport and aftercare arrangements with you. The ward nurse and doctor will take some relevant details and answer any questions you have. A healthcare professional will see you and take blood samples and a small plastic needle will be placed in your vein in your arm or hand. You will be given a hospital gown to wear. We will take you to the X-ray department where the procedure will take place. Prior to the procedure you will be given a pain killer suppository which reduces the risks of pancreatitis. If you have a pacemaker or ICD (Implantable Cardioverter Defibrillator) please contact the department where you are having your test for further advice. What about my medication? If you have diabetes take clopidogrel take warfarin have Addison s disease please see the specific instructions below and on the next page. What if I have diabetes? Important information for people who have diabetes (read prior to the procedure) Fasting for a procedure can potentially cause your blood sugar levels to be low. The guidelines on the next page will help you reduce the risk of problems. Page 5 of 10
If you have diabetes treated with tablets: On the morning of your procedure, do not take your tablets for diabetes. Bring your diabetes tablets with you to your appointment. You can take your diabetes tablets as prescribed with food following the procedure. If you have diabetes treated with insulin: If you normally take insulin before each main meal and long acting insulin once daily, continue to take your long acting insulin as usual daily (Lantus, Levemir, Insulatard, Humulin I). On the morning of your procedure, do not take your mealtime breakfast insulin. Bring your insulin with you to your appointment. You can take your insulin as prescribed with food following the procedure. If you are restarting your insulin late in the morning or before lunchtime, then it is advisable to take half of your normal breakfast insulin dose at this late time. If you have any doubt about managing or adjusting your diabetes medicine before or after your procedure, please contact the diabetes healthcare professional or the Diabetes Specialist Nurses on the telephone contact number: Diabetes Specialist Nurse contact details: Monday Friday, 9.00 am 5.00 pm Ninewells Hospital Telephone: 01382 632293 Perth Royal Infirmary Telephone: 01738 473476 Further details: http://taysidedn.dundee.ac.uk/handbook/preprationspriorprocedures4.aspx What if I take Warfarin, Clopidogrel/Plavix and/or Aspirin? If you are on Clopidogrel and do not have a heart stent: Stop your Clopidogrel 5 days before your appointment. If you are on aspirin, continue this at your present dose. If you are not on aspirin your referring doctor/specialist may want you to have aspirin for the period of time you have stopped your clopidogrel, please check with your doctor/specialist to verify this. Restart clopidogrel on the evening after your procedure has been completed. If you are on Clopidogrel and have a heart stent: You must phone the department as soon as possible before your procedure date, as we will need to confirm with the doctor who implanted the heart stent whether or not you are able to stop your clopidogrel. Continue taking aspirin. What if I take Warfarin? If you are on warfarin you must telephone the department as soon as possible before your procedure date, as we will need to discuss with the doctor who has sent you for your test, to verify whether by stopping your warfarin 5 days before the procedure, you need to commence heparin treatment or not. Page 6 of 10
If you are asked to stop taking warfarin 5 days before your test but not commence heparin, please follow these instructions: Stop taking warfarin 5 days before your procedure. After the procedure is completed you can take your normal dose of warfarin that day. 5 7 after the procedure days you should have a blood test done by the GP practice nurse or warfarin clinic to check your blood levels. Please bring your INR record book with you to your appointment. If you are asked to stop warfarin 5 days before your test and commence heparin: Heparin will start 2 days after stopping your warfarin. Do not take your dose of heparin on the day of your procedure. Your warfarin should be re-started on the evening of your test with your daily dose. Restart heparin and warfarin the day after your procedure and continue until your INR returns to adequate levels. You should have a blood test done by the GP practice nurse or warfarin clinic 2 4 days after the procedure. They will inform you when to stop the heparin. What if I take Rivaroxaban (Xarelto), Dabigatran (Pradax) or Apixaban? These new blood thinning tablets should be omitted for 48 hours prior to your appointment time. If you have any questions about any other of your medicines, please discuss with your GP, or contact the number on the front of this leaflet. What if I have Addison s disease? If you have Addison s disease, please let us now so that other arrangements can be made for you. If you need further advice, please telephone the ward. Going home/discharge advice It will be decided after the procedure if you will be allowed home the same day. If you are discharged then you are required to have someone collect you and stay with you overnight or until the effect of the sedation has worn off. You may be required to stay in hospital overnight following your procedure. After sedation You may get some bruising at the site of the venflon. You may feel slightly woozy and forgetful for the rest of the day. You must have a responsible adult collect you from the department/ward to take you home and have someone stay with you for at least 12 hours following the procedure. You must not use electrical equipment or kitchen appliances such as cookers or kettles for 12 hours. You must not take sleeping tablets on the night after the procedure For 24 hours following sedation you must not: drive operate machinery drink alcohol return to work Page 7 of 10
breast feed be responsible for looking after young children sign any legally binding documents If you develop severe or continued pain in your neck, chest or abdomen a high temperature black loose faeces (melaena) jaundice (yellowing of the eyes or skin) are unable to stop vomiting (being sick) any swelling, tenderness or redness of the injection site please inform your nurse immediately. If you have gone home, please consult your GP or contact NHS 24 (Tel 111). It is important that you tell your GP/NHS 24 or the doctor treating you that you have had an ERCP. Checklist I have read this booklet I have completed the health questionnaire Please tick Developed by Endoscopy staff and has been reviewed by other staff and patients Revised: 09/2017 Review: 09/2019 LN0321 Page 8 of 10
Patient demographic label Barcode NHS Tayside Consent Form Name of procedure(s): Endoscopic Retrograde Cholangio-Pancreatography (ERCP) Inspection of the gall bladder, pancreas and adjoining ducts using x-ray and flexible endoscope (with or without biopsy and photography/video) Biopsy specimens will be retained. Statement of patient You have the right to change your mind at any time, including after you have signed this form. I have read and understood the information in the attached booklet including the benefits and any risks. I agree to the procedure described in this booklet and on the form. I understand: That any procedure in addition to those described above will only be carried out if it is necessary to save my life or to prevent serious harm to my health. That you cannot give me a guarantee that a particular person will perform the procedure. The person will however, have appropriate experience. Information, including digital information (video and/or photographic material) may be stored as part of the patients medical records and may be stored on computer databases. The University of Dundee is very active in medical research: donations of excess body tissues and agreement to the use of images are a valuable resource for researchers and clinical scientists. Please tick () the appropriate box if you agree to: Excess body tissue not required for diagnosis or future treatment being used for medical research Digital images (for example such as described above) being used for research, education and teaching in presentations (for example conferences or websites) and in publications. Whenever relevant, such images will be anonymised to protect patient privacy. (If consent is withdrawn at a later date, it may not be possible to withdraw images that are already in the public domain.) NB: Medical staff you must complete the appropriate clinical photography forms. Page 9 of 10
Have you ever been notified that you are at increased risk of CJD or vcjd for public health purposes? (Please tick) Yes No Patient Signature:.. Date: Name (print in capitals):. If you would like to ask further questions please do not sign the form now. Bring it with you and you can sign it after you have talked to the healthcare professional. Please remember to bring this booklet and form with you when attending for your appointment. Confirmation of consent (To be completed by a health professional when the patient is admitted for the procedure) I have confirmed that the patient/parent understands what the procedure involves including the benefits and any risks. I have confirmed that the patient/parent has no further questions and wishes the procedure to go ahead. Signed:.. Date: Name (print in capitals): Job title:.. Additional discussions with patient Endoscopist signature: Date: Page 10 of 10