Endoscopic retrograde cholangiopancreatography (ERCP)
Endoscopy is an established and reliable method of investigating the body’s internal organs. An endoscope is a long, flexible fibre optic tube with a tiny camera and a light on the end. ERCP is an endoscopic procedure that is valuable in both examining your biliary and pancreatic structures. It can identify problems with the biliary tree, cystic duct obstruction, gallstones, narrowings and tumours. As a treatment ERCP can drain pus as well as dislodge, break down and remove gallstones.
You should get instructions from the hospital where your ERCP has been scheduled. These will provide you with guidelines on what preparations you need to make before the procedure. It is important for you to know how long before the procedure you will need to stop eating and drinking and about any possible changes in your medication.
At the beginning of the procedure, the doctor will spray the back of your throat with a local anaesthetic to make it feel numb. Sometimes a local anaesthetic lozenge is used, or you will be given a sedative injection through the drip (venflon) in your hand or arm. This will make you drowsy so that you can put up with the discomfort of having a tube passed into your gullet. You will be positioned on your side to follow the curvature of your gut.
The doctor will ask you to swallow the first section of the endoscope. After this the doctor will push it further down your gullet into your stomach and duodenum. The doctor will look at images on a TV monitor which come from the endoscope’s camera which is filming the procedure.
Air is also passed into the tube into your gut to make it easier to see the lining of the gut. This may make you feel bloated.
The endoscope has a side attachment down which small instruments and tubes can pass.
It has many uses:
- Contrast dye can be placed into the bile and pancreatic ducts. X-ray pictures are taken immediately after the dye has been given. This may show narrowings (strictures), any gallstones that might be stuck, tumours pressing on the ducts etc.
- A small tissue sample (biopsy) from the lining of the gut can be taken to check for abnormal tissue or cells. The sample is used for two types of test, histology and pathology
- If the X-rays show a gallstone obstructing the bile duct the doctor can widen the duct by making a cut to let the stone into the duodenum. This is called a sphincterotomy.
- If there is a narrowing in the bile duct the doctor can place a stent to open it up and keep it from collapsing. The stent can remain in place to help to drain away bile into the duodenum.
The endoscope is gently pulled out when the procedure is completed. It takes around 30 minutes to one hour, depending on what is done.
Your aftercare will depend on the findings of the ERCP. You might be booked in for an overnight stay if you have received a stent or had gallstones removed. You should not drive for 24 hours after receiving a sedative. Ask a friend or relative to drive you home from hospital. Also make sure that someone can stay with you for the first 24 hours after discharge from hospital. The hospital will also provide you with information when you are discharged that will help with any problems that might arise after an ERCP procedure.
Endoscopic techniques are also used to treat bleeding varices (small, protruding veins in the stomach and gullet). These techniques are called Injection Sclerotherapy and Banding.
In this technique a special chemical material called a sclerosant is injected into the veins of the gullet. This is done after you have been given some sedationand an endoscope has been passed into your gullet. A very fine flexible needle is passed through the endoscope to inject the sclerosant material into the oesophageal veins or the tissue nearby.
This kind of injection causes the blood within the varix to clot and will also encourage some scarring to reduce the likelihood of varices returning. Side effects are rare in elective sclerotherapy. In emergency situations some pain and ulceration may occur.
After you have been sedated a single vein (varix) is sucked into a small chamber attached at the end of the endoscope. A small band is then placed around the base of the varix (ligation).Like injection sclerotherapy, banding is usually performed as day surgery. The procedure may cause some mild pain and discomfort.
Injection sclerotherapy and banding are complementary procedures and both may be used if necessary. They each have advantages and disadvantages which you might discuss with your endoscopist.
Transjugular intrahepatic portosystemic shunts (TIPSS)
This technique, which connects two veins to change the direction of blood flow in the liver, is usually done by a radiologist with the help of ultrasound and other imaging technology to guide them. It is not classed as surgery and is commonly used for complications of portal hypertension. Portal hypertension is a complication of cirrhosis where you have too high a pressure in your portal vein which normally carries blood from your bowel and spleen to your liver.
To lower the pressure in your portal vein a stent is passed across your liver to make a shunt, or bypass, causing blood to travel straight into the hepatic vein which carries the blood from your liver. This is done using a needle guided by a catheter inserted through a tiny puncture in your neck. This is not painful in itself and will be performed under a general or local anaesthetic.
The hospital will advise you on how to prepare for this procedure. This will include requiring you not to eat on the day before, what to bring with you etc. You can expect to stay in hospital overnight or perhaps two or three days. You will be given a sedative (in some cases this may be a general anaesthetic) for your discomfort and monitored closely. Possible complications include internal bleeding and later encephalopathy (mental confusion and memory loss) resulting from the blood flow to the liver being bypassed. This usually responds to laxatives (such as lactulose) but your liver specialist will discuss this with you before the procedure.
This procedure is usually indicated when bleeding from varices is uncontrolled. It may also be used when ascites does not respond to treatment with diuretics.
In the following weeks you will be required to have further imaging tests so that doctors can be sure the shunt is working properly.