Having an ERCP A guide to the test Information for patients Endoscopy
Welcome to the Endoscopy Unit Introduction You have been advised by your doctor to have a procedure called ERCP (Endoscopic Retrograde Cholangio-Pancreatography) to help find the cause of your symptoms. This booklet has been prepared to help answer some of the concerns you may have about the procedure. It may not answer all your questions so if you have any worries please don't hesitate to ask. The staff involved in doing your test will be able to answer any queries. You will be admitted into hospital for a short stay that may be overnight. If you have any questions please do not hesitate to ask. The Endoscopy booking number is: Northern General Hospital: 0114 226 9174 You may get an answer machine, if so please leave a message and contact number and someone will get back to you. page 2 of 16
What is an ERCP? Endoscopic Retrograde Cholangio-Pancreatography is a procedure which allows the doctor to take detailed X-rays of the bile duct and/or the pancreas. The bile duct is the tube connecting the liver and gall bladder to the intestine and allows bile to drain, the pancreas is a gland important in digesting food. ERCP is done when there is a problem with drainage of bile (for example, due to gallstones), inflammation of the pancreas, or cancer around the opening of the ducts. The instrument we use to do this procedure is called a duodenoscope (endoscope). The endoscope is passed through your mouth, into your stomach and round into the beginning of the small intestine (the duodenum). liver stomach gall bladder bile duct pancreas papilla pancreatic duct duodenum page 3 of 16
The endoscope is a long flexible tube (thinner than your finger) with a bright light at the end. Using the endoscope we can see pictures of your duodenum on a television screen. Being able to see these pictures enables the doctor to find the opening (papilla) where the bile duct and pancreatic duct empty into the duodenum. A small plastic tube is passed down the endoscope into the papilla. Dye is then injected into the ducts and X-ray pictures are taken. If the X-rays show a gallstone, the doctor may enlarge the opening of the bile duct. This is done with an electrically heated wire (diathermy) which you will not feel. Any small stones can be left to pass out of the duct naturally; larger ones may be pulled out using special equipment. If the X-rays show a blockage in the bile duct the doctor may place a plastic tube called a stent (or endoprosthesis) inside the duct itself, allowing the bile to drain into the intestine in the normal way. This is to relieve any jaundice and itching from which some patients may be suffering. You will not be aware of the tube, which may have to stay in permanently. If this is the case for you, you may find that occasionally it is necessary to replace the tube because it has become blocked. page 4 of 16
Can there be complications or risks? ERCP is generally a well-tolerated procedure. The risk of complications is higher in an ERCP where additional procedures are needed (for example cutting an opening in the bile duct, stone removal). There is a small risk of the following: A reaction to the sedative. The sedative can affect your breathing, making it more slow and shallow. Damage to crowned teeth or dental bridgework. Inflammation of the pancreas: This is called pancreatitis. It can be painful, causing abdominal pain and sickness, and usually requires some days in hospital for intravenous fluids and painkillers. On very rare occasions it may be very severe. The risk of pancreatitis occurring is 1 to 2%, (which is 1 in 50 to 100 patients). Bleeding: If a cut is made into the bile duct to remove a gallstone, there is a risk of bleeding. This risk is approximately 2% (which is 1 in 50 to 100 patients). Bleeding can often be treated immediately through the endoscope and is rarely a major complication. If severe it may require a blood transfusion or surgery. Perforation, which is a little tear in the wall of the bowel; this is rare. This would require a short stay in hospital and treatment with antibiotics, or very occasionally may require surgical repair. The risk of complications is higher if you are already in poor general health. The benefit from this procedure needs to be weighed up against the small risk of complications. If you are worried about any of these, talk to one of the doctors or nurses about it during your visit. page 5 of 16
The consent form Before a doctor or healthcare professional examines or treats you, they will need to gain your consent. This will be required in writing. If you later change your mind, you are entitled to withdraw consent even after signing. A copy of the consent form will be offered to you. What should I know before deciding? The endoscopist or health professional will ensure you know enough information about the procedure to enable you to decide about your treatment. They will write this information on the consent form as well as discussing choices of treatment with you. We encourage you to ask questions and inform us of any concerns that you may have. It may be helpful for you to write these down as a reminder. What are the key things to remember? It's your decision. It's up to you to choose whether or not to consent to what is being proposed. Ask as many questions as you like and please express any concerns about medication, allergies or past medical history. Can I find out more about giving consent? For further information on consent you may wish to look at the NHS Choices website as follows: www.nhs.uk/conditions/consent-to-treatment Training at the hospital Sheffield Teaching Hospitals Trust is a teaching organisation and has a responsibility to ensure that students (both medical and nursing) receive a high standard of training. Occasionally there may be students or junior doctors to observe a procedure, or the endoscopist may be a trainee page 6 of 16
under the supervision of an experienced endoscopist. In each case you will be informed beforehand and it is your right to decline anything you are not comfortable with. This will not affect your treatment in any way. Medication If you are taking anti-blood clotting medicines such as Warfarin, Rivaroxaban, Apixaban, Dabigatran or Clopidogrel (Plavix) please contact the Endoscopy Suite as soon as possible as these may need to be stopped before your procedure. If you are diabetic, please refer to the Managing your diabetes booklet which you received with your appointment letter. Before you come into hospital you should: Bring with you any letters or cards you have received from the hospital. Bring any tablets you are currently taking. It is especially important to remember any asthma inhalers, angina sprays or diabetic medication. If you are suffering from a sore throat, cold or chest infection you should contact the Endoscopy Suite as it may be necessary to postpone your test because of the risks from sedation. You should not bring valuables or large amounts of money into hospital. We cannot accept responsibility for them. Follow all instructions included with this booklet. page 7 of 16
Preparation for the test You may be admitted on to a ward the day before your procedure or directly to the endoscopy department on the day of your procedure. To allow the doctor a clear view, the stomach and duodenum must be empty, so you will be asked not to eat for at least six hours before your procedure. You may be allowed to drink water until a couple of hours before, but not other liquids. When you arrive at hospital You will be seen by a doctor who will explain the procedure and ask you to sign a consent form. You should make sure you understand the test and its risks and benefits before you sign the form. Please feel free to ask questions if you do not understand. It is usual for antibiotics to be given before the procedure. These are generally given as an injection. In order to give you sedative injections and other drugs during the procedure a plastic needle called a cannula is usually placed into your right arm. You will have to wear a hospital gown for the procedure. You may keep your underwear on but anything with metal fastenings (for example, bras) must be removed. The procedure is done in the X-ray department. You will be taken there by trolley when it is time for your test. It is necessary to remove any false teeth. You may do this immediately before the test and they will be kept safe until you are fully recovered afterwards. It is also advisable to remove contact lenses and hearing aids. page 8 of 16
The staff who will be working in the room where you have your test will all be wearing protective aprons because of their repeated exposure to X-rays. You should not be worried since the amount of X-rays you will receive is strictly controlled for your safety. If you are a woman of childbearing age and have not been sterilised it is important to be sure that you are not pregnant. It may be necessary to do a pregnancy test on the day. What happens during the test? In the X-ray examination room you will sit up on an X-ray table. Once there, we will give you a local anaesthetic spray into your throat. This helps the endoscope pass easily into the gullet. At the beginning of the test we will place a plastic mouth guard between your teeth to keep your mouth open. We will also give you oxygen via tiny tubes in your nose. During the test, we will monitor your pulse rate and oxygen levels by attaching a small device to your finger. You will also have a cuff on your arm to monitor your blood pressure. Usually we will give you an injection to make you feel relaxed. This does not put you to sleep but keeps you as comfortable as possible and most patients do not remember the test. We advise you to refrain from taking any sleeping tablets on the day of your procedure if you have had sedation. Once you are comfortable on the table we can begin the test. To start with we will ask you to lie on your left side but eventually we will need you to turn onto your stomach. Once the procedure is under way, we will turn down the lighting in the room. page 9 of 16
Please be assured that the procedure will not hurt so when the doctor passes the endoscope into your stomach it will not cause any pain or interfere with your breathing. Some people do find that when the dye is put into the ducts it causes some discomfort but most people feel nothing. The test usually lasts 20 to 30 minutes. When the examination is finished the endoscope is removed quickly and easily. We may take additional X-rays after we remove the endoscope. What happens after the test? After the test you will be taken back to the ward to recover. You will probably feel sleepy for some time afterwards. Your blood pressure and pulse may be checked regularly. You will not be able to eat or drink for a few hours. When you do start to eat you should keep to simple meals for a day or two. For the first day you may feel some soreness at the back of your throat and also some bloating if air has remained in your stomach. Sometimes the air causes stomach discomfort and occasionally, pain; however this rarely lasts for more than an hour. Once you are fully recovered you may be able to go home but the effects of the sedation can last for at least 24 hours. If you are allowed to go home on the day of your test you should rest quietly for the remainder of the day. You will need someone to collect you from hospital and they should stay with you overnight. It is important that you do not: Drive a car Operate machinery or domestic appliances page 10 of 16
Drink alcohol Sign legally binding agreements Take sleeping medication for 24 hours Getting your results The results of the test may not be available straight away, especially if you are allowed home the same day. When possible a doctor will tell you about the test and what treatment has been given before you go home, otherwise it will be discussed at your next outpatient appointment. If at any time you would like more information about the results of the procedure please ask your GP as we will send all the details on to them. page 11 of 16
Frequently asked questions and answers If my symptoms have stopped before the ERCP, should I still come for the test? Yes. It is important that you still come for the test. Your doctor has organised this test to identify any problems in your bile duct and/or pancreas. Although your symptoms may have gone, it is important to have a look to ensure all is clear. Will it hurt? No, these examinations are not painful. You may feel some discomfort from the air that is pumped into the stomach so that the endoscopist can view the lining adequately. Some patients find the air used to inflate the stomach slightly uncomfortable. It should not hurt. Can I drive home after the procedure if I choose to have sedation? If you have sedation you will not be allowed to drive home and must arrange for someone to accompany you and drive you home. Medication given during the test will prohibit you from driving until 24 hours after your examination. Please do not plan to take public transport home. If you are unable to arrange transportation we can arrange a taxi to take you home, however, you are responsible for the fare. You will need a responsible adult with you for at least 12 hours. Will I get my results on the day? Upon completion you will return to the ward. Where possible the findings will be discussed with you before you go home, otherwise it will be discussed at your next outpatient appointment. A copy of the procedure report will be sent to your referring doctor and your GP. page 12 of 16
Can I park at the hospital? Yes. We have car parks at both hospitals; these are indicated on the enclosed maps. The rates are as follows*: Northern General Hospital 0-4 hours = 2.40 4 hours + = 3.70 All disabled parking bays around the Northern General Hospital are free of charge. *Car parking charges are correct at time of printing. Please ensure you check the rates before parking. Can I get public transport to the hospital? Yes. You may use public transport. See below for details of how to find out which bus routes serve the Endoscopy Suite you are visiting. Please remember: if you have sedation you will not be able to travel home using public transport. Traveline: 01709 515151 www.travelsouthyorkshire.com/ Are there facilities for my relatives/friends to obtain refreshments? Yes. There is an AMT Coffee Shop in the Huntsman main entrance (C floor) page 13 of 16
Please use this space to make a note of any questions you may have about your test page 14 of 16
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Produced with support from Sheffield Hospitals Charity Working together we can help local patients feel even better To donate visit www.sheffieldhospitalscharity.org.uk Registered Charity No 1169762 Alternative formats can be available on request. Please email: alternativeformats@sth.nhs.uk Sheffield Teaching Hospitals NHS Foundation Trust 2017 Re-use of all or any part of this document is governed by copyright and the Re-use of Public Sector Information Regulations 2005 SI 2005 No.1515. Information on re-use can be obtained from the Information Governance Department, Sheffield Teaching Hospitals. Email infogov@sth.nhs.uk PD2555a-PIL103 v5 Issue Date: August 2017. Review Date: August 2019