Informed consent for endoscopic retrograde cholangiopancreatography (ERCP), a combined endoscopic and fluoroscopic procedure of the bile ducts and pancreatic duct, including risks of pancreatitis and perforation.
The ERCP Informed Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers consent, gastroenterology, ercp, endoscopy, biliary, pancreas. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# ERCP Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor risks/benefits/alternatives to the patient and your institution's protocols and state law. **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number:** ___________ **Ordering Physician / Endoscopist:** ___________ **Scheduled Procedure Date:** ___________ --- ## 1. Description of the Procedure Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that combines upper endoscopy with real-time X-ray imaging (fluoroscopy) to examine and treat conditions affecting the bile ducts, gallbladder, and pancreatic duct. A side-viewing flexible instrument (duodenoscope) is passed through the mouth, esophagus, stomach, and into the duodenum, where the opening of the bile and pancreatic ducts (the ampulla of Vater) is located. A small plastic catheter is then guided through the ampulla into the duct system. Contrast dye is injected to outline the ducts on X-ray. Depending on the findings, one or more of the following therapeutic maneuvers may be performed: - **Sphincterotomy:** Controlled incision of the ampullary sphincter muscle to allow passage of stones or instruments - **Stone extraction:** Removal of stones from the bile duct using a basket or balloon catheter - **Stent placement:** Insertion of a plastic or metal stent to drain an obstructed bile or pancreatic duct - **Stent removal or exchange** - **Dilation of strictures** - **Tissue sampling (biopsy or brushings)** for cytology or histology - **Ampullectomy:** Removal of ampullary adenomas - **Lithotripsy:** Mechanical, electrohydraulic, or laser fragmentation of large stones The procedure is performed under intravenous sedation (often deep sedation or general anesthesia) and requires fluoroscopic guidance. You will be positioned prone (face-down) or in left lateral decubitus on an X-ray-capable table. **Indication(s) for this procedure:** ___________ ---