ERCP Procedure - Steps, Video, Complications, Recovery Time

ERCP, or Endoscopic Retrograde Cholangiopancreatography, is a procedure that uses two techniques, i.e. X-Ray and endoscopy. It aids the gastroenterologist in examining the bile duct and pancreatic ducts and imaging the gallbladder and hepatic duct. 

Here, endoscopy is combined with fluoroscopy, backed with radiography, to offer the gastroenterologist the finest details of the delicate internal organs. The endoscope is a thin tubule-like structure equipped with a lens and light. A dye is used as a fluorescing element, further enhancing the endoscope's details. Lastly, an X-ray captures the inner intricacies of the internal organs.

Endoscopy combined with fluoroscopy helps the medical practitioner view the inner details better. This increases the chances of a more precise diagnosis with a clearer medical picture which in turn aids in an appropriate treatment simultaneously or later.

Anatomy and Physiology of Bile Ducts

1. The bile ducts are the tubes that carry bile (a fluid that aids digestion) from the liver and gallbladder to the upper part of the small intestine, i.e., the duodenum. In a way, it's a connection between the liver and the small intestine. 
2. Similarly, the pancreatic duct connects the pancreas and the small intestine, carrying pancreatic juices to the duodenum for digestion.
3. The bile duct and pancreatic duct may remain separate or merge at a point to form a common duct. However, this differs from person to person (depending on their medical condition). 

The ERCP procedure facilitates a gastroenterologist with the scope to reach the internal organs, particularly the GI tract while diagnosing the medical condition. Thus, along with being a good diagnostic tool, it also exists as an efficient technique for treatment. Given below are some of the conditions that can be treated with ERCP:

Removing Stones

When an individual is suffering from the accumulation of stones in the bile duct, pancreatic duct, or gallbladder,  ERCP can be used to remove these stones.

Treating Blockage or Leakage  

Medical practitioners prefer ERCP stent placement in case of patients detected with blockage in the ducts. The stent acts as a device that helps in opening the blocked passage. Also, it can resolve the problem of fluids leaking in the ducts

Treating Adenomas and Biliary Duct Diseases

ERCP ampullectomy and sphincterotomy are the treatment procedures that can be adopted when the surgeon or specialist detects the presence of adenoma in the duodenal area. This involves making a small incision on the muscular valve to widen the opening of the duct. Removal of adenomas using the ERCP techniques is successful to some extent. 

ERCP procedure is used for diagnosing or treating the problems of the pancreatic and bile duct; it is evident that the patients with the associated discomfort are suitable candidates for it. Following are some symptoms an individual can show if he or she is suffering from pancreatic or bile duct issues. 

1. Recurrent abdominal pain.
2. Abnormal colour of urine and stool. 
3. Yellowing of the skin and eyes 
4. Swelling on the body. 

ERCP is considered by the practitioner when the cause of these symptoms, accompanied by other distinct symptoms, stays unknown even after trying other non-invasive diagnostic methods.

The following may need this procedure include candidates:

1. Suffering from pancreas problems, such as acute or chronic pancreatitis. This is for knowing the presence or the size of the blockage. At times, it also resolves the blockage simultaneously. 
2. Who has recently faced trauma or complications during the surgical procedure. Here, the medical practitioner looks for the reason for this distress through ERCP.
3. Diagnosed with tumours in the bile duct, pancreatic duct, or gallbladder. Through ERCP, doctors can diagnose if the tumour is progressing or shrinking, i.e., to judge the effectiveness of the cancer treatment. 
4. Diagnosed with an infection in the bile duct can be asked to undergo ERCP to check for improvement in their condition.
5. Who are already diagnosed or suspected to have stones in the gallbladder, bile duct, or pancreatic duct.

The ERCP procedure can be performed on both in-patients and out-patients, and it's a minimally invasive procedure, taking about 1-2 hours to complete. It is a therapeutic and diagnostic method that requires accuracy and has no place for errors. Thus, it must be accomplished with extreme care. Read below to know how it's performed. 

1. The IV is placed on the patient's arm to introduce the sedative. This is done to keep the patient relaxed and comfortable throughout, as the ERCP procedure is invasive and painful. 
2. The patient is asked to gargle the liquid anaesthesia so that the throat becomes numb and the tube insertion does not hurt. Alternatively, the medical practitioner can spray the anaesthesia on the back of the patient's throat. Some patients can even be given general anaesthesia to make them fall asleep completely (depending on the patient's medical condition).  
3. Then, the patient is advised to lie on the left side of the belly over the x-ray or examination table.
4. An endoscope, i.e., a thin tubule-like structure, is inserted carefully by the doctor into the mouth of the patient. It is made to pass through the oesophagus, running down to the duodenum (the start of the small intestine).
5. This endoscope is equipped with light and a lens (camera lens) to view the structures from where it is made to pass. The doctors can see the video image on the monitor screen. 
6. With the help of this camera, the opening of the bile and pancreatic duct that connect to the duodenum is located. Then, a small tube-like structure, known as a catheter, can be inserted through the endoscope. 
7. The catheter is made to reach the bile and pancreatic duct. A fluorescing dye, a contrast medium, is injected into the ducts via a catheter. This is done to increase the visibility of the ducts on the x-ray images.
8. Fluoroscopy, a type of X-Ray imaging, is used to examine if the duct is narrow or has blockages. 

When the gastroenterologist prefers opting for treatment through ERCP, the above procedure can also have a few additional steps. They are as follows: 

1. A tiny tool can be introduced through the endoscope to remove or break the stones in the bile duct, pancreatic duct, or gallbladder. This tool can also widen the duct, i.e., remove the blockage.
2. The inserted tool can also remove the existing tumour on the ducts. It can even facilitate performing a biopsy (if a more detail-oriented diagnosis of the condition is required). 
3. ERCP Stent is another treatment procedure that can open narrow ducts.  
4. For individuals who have undergone gallbladder surgery, there are chances of bile leakage. This can also be fixed with a temporary ERCP stent placement procedure. 

It is always better to be aware that no medical procedure is versatile, and numerous factors must be considered before choosing a particular diagnostic tool or treatment. Likewise, ERCP, though it is an efficient method, it is essential to know that the medical history of the patient and the doctor's opinion play a crucial role in deciding its applicability.   

ERCP is an invasive procedure that intrudes on the internal body organs. Thus it is vital to know specific instructions or precautions the patient should observe. Here, we shall highlight the aspects to remember or follow before or on the day of the procedure.  

Before ERCP

Following are some of the essential details of the ERCP procedure that a patient must know so that they know the procedure well and stays prepared for it: 

1. The patient must seek all the information about the procedure from their healthcare provider (in detail). ERCP test cost, the time taken for the procedure, when they can expect the results (in case of diagnosis), when they can book the appointment, etc.  
2. Before the ERCP test, the doctor may also suggest investigations such as CBC (Complete Blood Count) and several biochemistry blood tests to know the patient's current health status. 
3. The patient is asked if they are allergic to contrast dyes such as iodine. Also, the doctor may inquire if they have ever experienced an allergic reaction to certain types of drugs, tapes, latex, anaesthesia, etc. 
4. It is essential to take the patient's medical history before the procedure, i.e. if they have heart disease or any other disease, prescribed antibiotics or other drugs, and so on. Also, in the case of female patients, the medical practitioner should check if they are pregnant or suspect pregnancy. 
5. The patients should be advised not to eat or drink anything for at least 8 hours before the ERCP procedure. They can even take a proper diet chart for eating light for 1-2 days before the procedure day. This is because an empty stomach helps the doctor to visualise the details better. Also, there would be less discomfort on the patient's part as they would not feel like vomiting. 
6. The patients are recommended to avoid smoking, chewing gums, and eating candies, as all this can contribute to increasing saliva, which is not desired for the ERCP procedure. 
7. It is essential to check if the patient is taking blood thinners and medicines for blood pressure and diabetes. Some medicines can interfere with the sedative or affect blood clotting. In this case, the doctor advises the patients to stop taking such drugs for a few days before ERCP. 

On the day of ERCP

1. On the day of ERCP, the medical practitioner ensures the patient has followed the instructions, along with checking the medical history and other necessary components. Read below to know what happens on the day of the procedure. 
2. The patient is given a consent form asking for permission to do the test. They are expected to sign the document after carefully reading each consent point. Also, if the patient has any questions or doubts regarding the procedure, they must clear it before signing. 
3. Metal objects can interfere with the process. Thus, the patient is asked to remove jewellery or any metal object. Also, the patient would need to remove their clothes and wear the gown given by the hospital. 
4. An IV line would be placed on the patient's arm or hand. The doctor ensures that the patient receives sufficient oxygen throughout the procedure; thus, a tube is put in the nose to regulate the oxygen supply. 
5. The patient would be asked to lie on the X-Ray table either on the left side or primarily on their belly. In pregnant women, the doctors can advise them to lie on the left or other appropriate positions so that the baby stays unaffected by the X-Ray.
6. After conducting the procedure, the patient is put under observation, i.e. they are shifted to the recovery room and then to their regular room in the hospital or discharged home (in case of outpatients).
7. The results of ERCP (as a diagnostic procedure) can take up to 30-40 minutes after the completion of the procedure. Most of the time, the doctor performing ERCP writes the reports straight away but only authenticates them after a final review. The entire thing can take up to 1 or 2 hours maximum. 

There needs to be more than just knowing the purpose and procedure of ERCP. One must also know what happens after the procedure to understand its impact, consequences, or effect. Read below to learn about the ERCP aftercare: 

The recovery process in the hospital

1. The patient is kept in the hospital, i.e., in the recovery room, for about 1 to 2 hours after the procedure is completed.
2. The parameters such as blood pressure, pulse rate, and breathing are monitored, and attempts are made to stabilise them. 
3. After the effect of sedation and anaesthesia subsides, the patient gains alertness. Until then, it is advised to let them rest in the hospital room. Also, in some cases, doctors even advise patients to stay overnight in the hospital after ERCP (depending on one's medical condition). 

Recovery process/expectation after hospital discharge

The time and type of recovery depend on the type of medical procedure performed on the individual. Also, it depends on the patient's medical history, which the doctors consider and instruct about. Given below are some of the primary recovery aspects of ERCP. 

1. Minimal side effects such as bloating, fatigue, and soreness in the throat can prevail. Such signs are expected after a short procedure, and the patient can return to their routine lifestyle or eating habits once they can swallow adequately. 
2. It is advised by the medical practitioner not to drive for at least 24 hours after the ERCP procedure. For the in-patients, it's not a problem as they are shifted to their regular wards. However, for the outpatients, bringing family or friends along is usually suggested so they can drive home.
3. Once the patient returns home after the hospital discharge, they are advised to rest well for a whole day at least. 
4. It is essential to be attentive to what the patient eats after the surgery. Mostly, it is preferred to have a low-fat diet minimum for a week to avoid problems such as stomach upset or complications of ERCP. 

First follow-up appointment

1. Each condition needing ERCP as a diagnostic tool or treatment entity differs. Thus, it entirely depends on the doctor's opinion about when to see him next for a follow-up.
2. In the case of ERCP as a surgical procedure, the doctor would ask the patient to watch for specific symptoms to know the presence of structural changes or scarring of tissues in the bile duct (if any). 

The recovery time 

1. In such cases, it is essential to seek follow-ups more frequently (religiously stick to the follow-up routine and medication as prescribed by the healthcare provider) 

Every medical procedure's utility depends on its advantages over the other methods. ERCP is a unique and advanced procedure that gastroenterologists prefer for the several benefits it serves, which are mentioned below:  

1. As doctors can perform diagnosis and treatment simultaneously during ERCP, this procedure can efficiently bridge the gap between diagnosis and treatment. Early diagnosis and treatment are the most important for the successful recovery of a gastrointestinal problem, which ERCP can suffice well. 
2. It is a minimally invasive and non-surgical procedure with a high success rate. Moreover, it prevents the patient from experiencing abdominal scars, external drains and even major surgeries. 
3. Biliary and Pancreatic duct blockages can be treated quickly with minimum or no complications.
4. Treatment procedures of ERCP, such as sphincterotomy, stone removal, etc., prevent these conditions' recurrence

ERCP is a low-risk procedure, and the success rate is between 70-95%. When performed by a skilled and experienced gastroenterologist, ERCP is expected to feature the least complications or side effects. 

1. Pancreatitis (inflammation of the pancreas) is one of the most common ERCP side effects. The reason behind this is the irritation to the pancreas caused by injecting the dye during the procedure.
2. Irregular heart rate can be caused due to sedation which can also result in a heart attack; however, this happens in rare cases.
3. Minute tears in the duodenum lining, oesophagus or stomach can be introduced during the procedure. 
4. Infection in the biliary duct or gallbladder 
5. Excessive internal bleeding (haemorrhage) due to wrong or erroneous incision.
6. Damage to the internal tissues due to x-ray exposure

When is consultation with the doctor needed?

1. Problems after ERCP, such as nausea, bloating, and sore throat, are expected to disappear within 2-3 days maximum; however, if they prevail for longer, one must consider seeking medical help. 
2. If one observes symptoms like blood in vomiting, abnormal stool colour, chest pain, severe abdominal pain, difficulty swallowing and breathing, throat pain, etc., in that case, consult a doctor urgently

Delaying a medical procedure can pose a risk to the patient's life. However, this depends on the patient's medical condition and treatment. Can delayed ERCP be dangerous? Keep reading to know. 

1. Patients suffering from acute cholangitis should receive ERCP as early as possible. This is because a delay by even a single day can significantly increase the risk of organ failure.
2. Acute biliary pancreatitis, or ABP, is a condition that leads to severe biliary obstruction over time, which can even lead to death. Thus, an early ERCP should be performed in such patients.

Having a fair estimate of the medical procedure expenses is always a better idea as it helps an individual to stay prepared financially. The essential ERCP test cost ranges between ₹35,000-₹55,000; however, it may vary from city to city and hospital to hospital. 

Several factors are also considered while taking out the cost of the procedure. Some of the important ones include the doctor's expertise, consultation charges, hospital charges, the treatment procedure of ERCP (Stent placement, stone removal, etc.), and the patient's medical history. 

No medical procedure is risk-free; hence, looking for the most proficient source of skilled and experienced medical professionals is essential. HexaHealth has everything to call itself one of the best in healthcare. We are committed to offering the best medical advice, treatment, or therapies at affordable prices. So do not wait anymore. Get in touch with us to seek the best of healthcare!