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 Endoscopic Retrograde Cholangiopancreatography ERCP

RATIONALE: To visualize and assess the pancreas and common bile ducts for occlusion or stricture.

PATIENT PREPARATION FOR ERCP

 There are no activity restrictions unless by medical direction. Instruct the patient to fast and restrict fluids for 4 to 8 hr, or as ordered, prior to the procedure. Fasting is ordered because an empty stomach provides better visualization and as a precaution against aspiration related to possible nausea and vomiting. The patient may be instructed to prepare the bowel with a laxative or enema the night before or morning of the procedure, by medical direction.

 If iodinated contrast medium is scheduled to be used in patients receiving metformin or drugs containing metformin for type 2 diabetes, the drug may be discontinued on the day of the test and continue to be withheld for 48 hr after the test.

Patients with heart valve disease may be premedicated with antibiotics.

Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulants, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken.

Patients on beta-blockers before the surgical procedure should be instructed.to take their medication as ordered during the perioperative period. Protocols may vary among facilities.

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Ensure that this procedure is performed before an upper gastrointestinal GI) study or barium swallow.

NORMAL FINDINGS OF ERCP

• Normal appearance of the duodenal papilla

• Patency of the pancreatic and common bile ducts.

CRITICAL FINDINGS AND POTENTIAL INTERVENTIONS OF ERCP

OVERVIEW: (Study type: Endoscopy combined with X-ray, special/contrast; related body system: Digestive system.) Tissue specimens collected during the procedure should be placed in appropriate containers, properly labeled, and promptly transported to the laboratory. Endoscopic retrograde cholangiopancreatography (ERCP) allows direct visualization of the pancreatic and biliary ducts with a flexible endoscope and, after injection of contrast material, with x-rays. It allows the healthcare provider (HCP) performing the procedure to view the pancreatic, hepatic, and common bile ducts and the ampulla of Vater. ERCP and percutaneous transhepatic cholangiography (PTC) are the only procedures that allow direct visualization of the biliary and pancreatic ducts. ERCP is less invasive and has less morbidity than PTC. It is useful in the evaluation of patients with jaundice because the ducts can be visualized even when the patient’s bilirubin level is high. (In contrast, oral cholecystography and IV cholangiography cannot visualize the biliary system when the patient has high bilirubin levels.) With endoscopy, the distal end of the common bile duct can be widened, and gallstones can be removed and stents placed in narrowed bile ducts to allow bile to be drained in jaundiced patients. During the endoscopic procedure, specimens of suspicious tissue can be taken for pathological review, and manometry pressure readings can be obtained from the bile and pancreatic ducts. ERCP is used in the diagnosis and follow-up of pancreatic disease; it can also be used therapeutically to remove small lesions called choleliths, perform sphincterotomy (biliary or pancreatic repair for stenosis), perform stent placement, repair stenosis using dilation balloons, or accomplish the extraction of stones using dilation balloons.

INDICATIONS OF ERCP

• Assess jaundice of unknown cause to differentiate biliary tract obstruction from liver disease.

• Collect specimens for cytology.

• Identify obstruction caused by calculi, cysts, ducts, strictures, stenosis, and anatomic abnormalities.

• Retrieve calculi from the distal common bile duct and release strictures.

• Perform therapeutic procedures, such as sphincterotomy and placement of biliary drains.

CONTRAINDICATIONS OF ERCP

1. Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.

2. Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are asked specifically if they have a known allergy to iodine or shellfish (shellfish contain high levels of iodine), it has been well established that the reaction is not to iodine; an actual iodine allergy would be problematic because iodine is required for the production of thyroid hormones. In the case of shellfish, the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium, the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative non-contrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.

3. Patients with conditions associated with preexisting renal insufficiency (e.g., chronic kidney disease, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycosides and NSAIDs), because iodinated contrast is nephrotoxic.

4. Patients who are chronically dehydrated before the test, especially older adults and patients whose health is already compromised, because of their risk of contrast-induced acute kidney injury.

5.Patients with bleeding disorders or receiving anticoagulant therapy, because the puncture site may not stop bleeding.

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6. Patients with an acute infection of the biliary system (cholangitis, pancreatitis, or possible pseudocyst of the pancreas), pharyngeal or esophageal obstruction.

Factors that may alter the results of the ERCP study?

• Gas or feces in the GI tract resulting from inadequate cleansing or failure to restrict food intake before the study.

• Retained barium from a previous radiological procedure.

• Previous surgery involving the stomach or duodenum, which can make locating the duodenal papilla difficult.

• Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.

• Inability of the patient to cooperate or remain still during the procedure, because movement can produce blurred or otherwise unclear images.

Other considerations for ERCP

• Blood specimens for bilirubin, amylase, or lipase, if ordered, should be collected before the procedure; results will be elevated after the procedure.

POTENTIAL MEDICAL DIAGNOSIS: CLINICAL SIGNIFICANCE OF RESULTS OF ERCP

Abnormal findings related to

• Anatomical deviations of biliary or pancreatic ducts

• Biliary cholangitis

• Cancer of the bile ducts

• Duodenal papilla tumors 

• Gallstones

• Pancreatic cancer

• Pancreatic cysts or pseudocysts

• Pancreatic fibrosis

• Pancreatitis

• Stenosis of biliary or pancreatic ducts

NURSING IMPLICATIONS OF ERCP

Problem

 • Nausea (related to pain, inflammation, blockage)

Signs and Symptoms 

 • Self-report of pain; facial grimace; crying; restlessness; diaphoresis; nausea; vomiting; guarding; social withdrawal; elevated blood pressure, heart rate, respiratory rate; pallor.

BEFORE THE STUDY: PLANNING AND IMPLEMENTATION 

Teaching the Patient What to Expect 

➧ Inform the patient this procedure can assist in assessing the bile ducts of the gallbladder and pancreas.

➧ Explain that prior to the procedure, laboratory testing may be required to determine the possibility of bleeding risk (coagulation testing) or to assess for impaired kidney function (creatinine level and estimated glomerular filtration rate) if use of iodinated contrast medium is anticipated.

➧ Pregnancy is a general contraindication to procedures involving radiation. Explain to the female patient that she will be asked the date of her last menstrual period. Pregnancy testing may be performed to determine the possibility of pregnancy before exposure to radiation.

➧ Review the procedure with the patient. Address concerns about pain and explain that there may be moments of discomfort or pain experienced when the IV line or catheter is inserted to allow infusion of fluids such as saline, anesthetics, sedatives, contrast medium, medications used in the procedure, or emergency medications; no pain should be experienced during the procedure because a narcotic will be given prior to the procedure and a sedative will be given to promote relaxation, but there may be moments of discomfort when the endoscope is inserted. IV glucagon or anticholinergics can be administered to minimize duodenal spasm and to facilitate visualization of the ampulla of Vater.

➧ Explain that contrast medium will be injected, by catheter, at a separate site from the IV line.

➧ Inform the patient that the procedure is performed in a GI lab or radiology department, usually by an HCP, with support staff, and takes approximately 30 to 60 min. If the procedure is done in an outpatient setting, the patient must make arrangements for someone to drive him or her home.

➧ An x-ray of the abdomen is obtained to determine if any residual contrast medium is present from previous studies. The oropharynx is sprayed or swabbed with a topical local anesthetic to help prevent gagging as the endoscope is passed down the throat.

➧ Positioning for the study will be in the left lateral position (Sims) or on the stomach. A protective guard is inserted into the mouth to cover the teeth. A bite block can also be inserted to maintain adequate opening of the mouth and to protect the teeth. Record baseline vital signs, and continue to monitor throughout the procedure. Protocols may vary among facilities. 

➧ The endoscope is passed through the mouth with a dental suction device in place to drain secretions such as saliva that collects in the mouth during the procedure. A side-viewing flexible fiberoptic endoscope is passed into the duodenum to the biliary tree, and a small cannula is inserted into the duodenal papilla (ampulla of Vater). The duodenal papilla is visualized and cannulated with a catheter. Occasionally, the patient can be turned slightly to the right side to aid in the visualization of the papilla.

➧ ERCP manometry can be done at this time to measure the pressure in the bile duct, pancreatic duct, and sphincter of Oddi at the papilla area via the catheter as it is placed in the area before the contrast medium is injected.

➧ When the catheter is in place, contrast medium is injected into the pancreatic and biliary ducts via the catheter, and fluoroscopic images are taken. Biopsy specimens for cytological analysis may be obtained.

➧ Explain that once the study is completed, the needle or catheter is removed, and a pressure dressing is applied over the puncture site.

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Potential Nursing Actions 

 ➧ Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

➧ If iodinated contrast medium is scheduled to be used in patients receiving metformin or drugs containing metformin for type 2 diabetes, the drug may be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Protocols may vary among facilities.

➧ Provide mouth care to reduce oral bacterial flora, as appropriate. Ensure that the patient has removed dentures, jewelry, and external metallic objects in the area to be examined prior to being transported for the procedure.

AFTER THE STUDY: POTENTIAL NURSING ACTIONS 

Avoiding Complications 

➧ Cholangiography, establishing an IV site, and injection of contrast medium are invasive procedures. Complications are rare but include risk for allergic reaction (related to contrast reaction), bleeding from the puncture site (related to a bleeding disorder or the effects of natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties), extravasation of bile, hematoma (related to blood leakage into the tissue following needle insertion), infection (which might occur if bacteria from the skin surface is introduced at the puncture site), tissue damage (related to extravasation or leaking of contrast into the tissues during injection), nerve injury or damage to a nearby organ (which might occur if the needle strikes a nerve or perforates an organ), nephrotoxicity (a deterioration of renal function associated with contrast administration), pancreatitis (the most common post-procedural complication of ERCP; also associated with significant morbidity and mortality), perforation, respiratory depression, and septicemia. Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis, bronchospasm, infection, injury). Immediately report symptoms such as difficulty breathing, chest pain, fever, hyperpnea, hypertension, nausea, palpitations, pruritus, rash, tachycardia, urticaria, or vomiting to the appropriate HCP. Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation. Administer ordered antihistamines or prophylactic steroids if the patient has an allergic reaction. A rectal suppository containing an NSAID, such as indomethacin or diclofenac, may be administered to help prevent postprocedural pancreatitis in certain high-risk patients.

Treatment Considerations afer ERCP

➧ Do not allow the patient to eat or drink until the gag reflex returns due to aspiration risk.

➧ Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and as ordered. Take temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Protocols may vary among facilities.

➧ If nausea is present, administer ordered antiemetics while assessing the frequency and duration of nausea. Evaluate hydration status, monitor intake and output, and administer ordered parenteral fluids. Provide oral care and identify any factors that precipitate the experience of nausea.

➧ Manage pain by using a pain rating scale appropriate to the age, mental status, and language barrier. Administer ordered pain medications and identify alternative methods of pain management that work for the patient (imagery, diversion, etc.). Evaluate response to pain management and adjust as appropriate. Tell the patient to expect some throat soreness and possible hoarseness. Advise the patient to use warm gargles, lozenges, ice packs to the neck, or cool fluids to alleviate throat discomfort.

➧ Inform the patient that any belching, bloating, or flatulence is the result of air insufflation.