Diseases of the hepatobiliary system and
pancreas are often encountered in clinical practice. A thorough
examination of the biliary and pancreatic ducts is required for the
appropriate diagnosis and management of patients with diseases of the
pancreatic and hepatobiliary systems. These conditions include
gallstones, and their complications, pancreatic and biliary cancers,
pancreatitis and pancreaticobiliary pain. Technical advances of flexible
endoscopy have resulted in endoscopic retrograde
cholangiopancreatography (ERCP) being used as a primary method of
diagnosing and treating many of these conditions. ERCP uses a
combination of endoscopic and radiologic techniques to visualize the
biliary and pancreatic ducts. Therapeutic ERCP allows an alternative
approach to invasive surgery, thereby decreasing the patient’s
morbidity and recuperation time. Advances in technology, equipment, and
training of physicians as well as nurses has improved proficiency,
competence and confidence in the procedure.1
Since the development of newer diagnostic
modalities in the last 2 decades, ERCP has evolved from a diagnostic to
a therapeutic procedure in evaluating pancreaticobiliary disorders. Due
to advancements in magnetic resonance cholangiopancreatography (MRCP),
endoscopic ultrasound (EUS), and computed tomography (CT), there is
little need to do diagnostic ERCPs. These diagnostic tests have been
proven to be useful and safer in diagnosing and staging of pancreatic
and hepatobiliary diseases. The results of these tests allow the
physician to confirm the patient’s diagnosis, thus being readily
prepared to treat the disorder.
Conclusions from a 2002 NIH State of the Science
Statement on ERCP confirmed that ERCP is evolving into a predominately
therapeutic procedure. An understanding of patient/procedure related
risks are important in the decision-making of whether ERCP should be
performed. This statement concluded that "avoidance of unnecessary
ERCP is the best way to reduce the number of complications. ERCP should
be avoided if there is a low likelihood of biliary stone or stricture,
especially in women with recurrent pain, a normal bilirubin, and no
other sign of biliary disease."
With the new advances in treating
pancreaticobiliary disorders come new challenges for the assisting
nurses. Therapeutic ERCPs require great skill on the part of the
assisting nurses. Various techniques and accessories are needed in
performing this procedure and it is imperative that the assisting nurses
be knowledgeable, competent and proficient in all aspects of ERCP. The
gastrointestinal (GI) nurse must also be comfortable with preparing and
reassuring the patient undergoing an ERCP. Thorough patient teaching and
excellence in patient care delivery help us provide the best possible
outcomes for our patients. It is essential that the nurse have knowledge
of the indications, contraindications, and complications of the
procedure, as well as being proficient with all devices and accessories
used in ERCPs.
Indications for ERCP include: obstructive
jaundice, which is the most common indication; choledocholithiasis;
common bile duct (CBD) stricture; ampullary mass with bleeding and/or
obstruction; stent occlusion; acute cholangitis -- from stone or stent;
suspicion for pancreatic-biliary malignancy; for differentiation between
chronic pancreatitis and cancer.2
Common bile duct stones can be removed pre- or
post-laparoscopic cholecystectomy by ERCP. If diagnostic tests were
performed that indicate stones are present in the CBD prior to the
scheduled laparoscopic cholecystectomy, the physician may opt to remove
the stones by ERCP prior to the surgery. Frequently, residual stones may
drop into the CBD during a laparoscopic cholecystectomy, which would
necessitate having a post-operative ERCP to remove those stones. If
there is a low probability that common bile duct stones are present,
then ERCP should be avoided. For patients with suspected
choledocholithiasis, an operative cholangiogram at the time of
laparoscopic cholecystectomy should be performed to definitely
demonstrate the presence or absence of CBD stones.
In patients with pancreatic or biliary cancer,
the principal advantage of ERCP is palliation of biliary obstruction
with stent placement when surgery is not elected. ERCP tissue diagnosis
can provide the needed tissue to diagnose pancreatic cancer prior to
treatment with chemotherapy and/or radiation. Brush cytology and forceps
biopsy are commonly done followed by stent placement.
Contraindications
Contraindications include: recent acute
pancreatitis unrelated to gallstones (for acute pancreatitis, MRCP is
the preferred diagnostic test of choice, since MRCP can define the
pancreatic anatomy and the extent of the disease, can diagnose and
quantify necrosis and determine if pseudocysts are present); medically
unstable patients; patients with a recent MI or significant arrhythmia;
previous contrast reaction; severe coagulopathy.
However, there is no contraindication in the
elderly, alcoholics or the obese, except to properly titrate their
sedation. The elderly process sedation slower, thus needing less. The
alcoholic usually needs more sedation, and the obese patient usually
needs a larger dose as well. In most hospitals, sedation is administered
by the anesthesiologist. The most common drug used is Diprivan
(propofol). This drug is rapidly effective and short-acting. Patients
usually wake up immediately after ceasing the IV drip of Diprivan. One
of the benefits of this drug is that the patient not only wakes up right
away, but is not very lethargic post-procedure. They are usually alert
and oriented within a short time post-procedure.
History
It is important to obtain a complete medical
history from the patient prior to performing an ERCP. This history
should include:
- Previous history of contrast reaction (for
patients that have experienced previous reactions to radio-opaque
dye, a regimen of steroids and Benadryl can be administered
according to the physician's instructions prior to and after ERCP to
avoid any possible reactions)
- Possibility of pregnancy -- if there are any
doubts, obtain urine for a pregnancy test. ERCP can be performed on
a pregnant patient, but with much precaution. Special consideration
must be given to the anesthesia administered and the amount of
radiation to assure the safety of the fetus.
- Pacemaker or automatic implantable
cardioversion device (AICD). Patients with pacemakers have an
increased risk of pacemaker malfunction or damage when
electrosurgical units (ESU) are used.3
When performing a sphincterotomy in ERCP,
electrocautery is used that generates electrical current with high
frequency signals that may be misidentified as intrinsic heart activity
by internal cardiac defibrillation devices or pacemakers. ESUs can cause
rearranged programming, erratic output or inhibition, and burns at the
pacemaker lead interfaces. Pre-procedure planning is imperative. The
nursing staff must have knowledge of the type of device that is
implanted. The company who manufactured the device as well as the
cardiologist should be consulted for proper precautions to be taken.
In order to prevent possible interactions during
exposure to electrocautery, the device should be temporarily programmed
to an asynchronous (non-sensing) mode or a magnet should be placed over
the device to pace asynchronously at the magnet rate. 4 A
clear policy on dealing with these devices will prevent complications
and reduce liability.
Diabetics
If they are taking insulin -- hold the dose for
the morning of the procedure. If they are taking Glucophage, it should
not be administered on the day of the procedure. Glucophage should be
withheld for 48 hours post-procedure if radio-opaque dye was used during
the procedure. Renal function should be checked prior to restarting
Glucophage (consult your hospital pharmacy for the policy regarding the
administration of radio-opaque dye and Glucophage). A surgical history
should be obtained including any abdominal surgery that may have altered
the GI tract, (i.e., Bilroth I or II).
For patients with a latex allergy, retrieval
baskets should be used to retrieve common bile duct stones instead of
retrieval balloons, which are composed of latex.
Prior to the procedure, patient should have
pertinent, current lab data available on the chart. The results should
be reviewed by the anesthesiologist, the gastroenterologist performing
the procedure and the assisting nurses. Included should be: PT /PTT,
INR, EKG, and a chemistry panel. The PT/PTT, INR should be within
PT<15 sec, INR<1.4 range.
Patient preparation should include:
- Informed consent
- A check for allergies
- ASA and NSAIDS should be held for several
days prior to and after the procedure. Heparin should be held for
four hours prior to procedure
- Place the IV in the right arm if possible,
because the patient will be lying partially on his/her left side
during the procedure
- IV antibiotics if cholangitis, biliary
obstruction or pancreatic pseudocyst is suspected
- NPO for eight hours prior to procedure.
Complications of ERCP include pancreatitis (most
common complication), hemorrhage, perforation, cholangitis due to failed
or incomplete biliary drainage, cholecystitis and stent-related
complications. Cardiopulmonary complications, such as dysrhythmias,
hypotension and hypertension -- mostly related to sedation/anesthesia --
although rare, are the leading cause of death in ERCP.
ERCP requires specific preparatory equipment.
This can include:
- Therapeutic scope -- 4.2 mm inner channel
- Locking device
- Cannulas
- Guidewire
- Papillotome
- Cytology brush- fixative, wire cutter
- Dilating balloons
- Retrieval balloons
- Lithotripter
- Sclero -- needles,sclero–agent
(epinephrine)
- Thermocoagulation for papillotomy
- Stents -- pushers, stent placement set
Stents
Indications for stent placement include:
- Palliation of unresectable biliary,
pancreatic, or periampullary neoplasm
- Palliation of benign biliary strictures
- Dilation of strictures
- Treatment of post-laparoscopic
cholecystectomy bile duct leaks
- Provision of ductal drainage following
therapeutic ERCP
Two types of plastic biliary stents are the
straight and double pigtail stents. The outside diameter of biliary
stents range from 5FR to 12FR. The scope’s channel size must
accommodate stent diameter. An ERCP scope with a inner channel of 4.2mm
is recommended since it accepts the various size stents.
The length of the stent is determined by length
of obstruction/stricture. The larger the diameter of the stent, the
greater the drainage. When inserted, one end of the stent is seated
above the ductal stricture/obstruction, and the other end protrudes into
the duodenum. The configuration of the stent serves to secure it in
place
Types of Stents
Plastic Straight -- used for biliary strictures.
Length is measured between flaps
Double Pigtail -- used to facilitate drainage
when unremovable biliary stones are present. When stones are present in
the common bile duct, the duct is usually dilated, so straight stents
would have a tendency to fall out. Pigtail stents, because of their
shape, will remain in place, even with dilated ducts.
Pancreatic (5 Fr to 7 Fr) -- Insertion after
ERCP may reduce the risk of post-ERCP pancreatitis in high-risk
patients. When cannulation is difficult, patients have a higher risk of
developing pancreatitis. Clinical studies show that placement of a
pancreatic stent reduces the risk of post-ERCP pancreatitis by
preventing the obstruction of the ductal orifice due to edema or trauma
to the area.
Metal Stents -- used as a palliative measure
when an inoperable tumor is present. "Covered" metal stents
are used for intrinsic tumors to prevent tumor growth through the stent.
"Uncovered" metal stents are used for extrinsic tumors -- used
if a hilar tumor is present at bifurcation; it allows intrahepatic
drainage.
Post-Procedure
Patients should be give explicit verbal and
written information following ERCP. They should be informed to contact
the hospital if they develop a fever, abdominal pain or distention, or
rigor. A 24-hour contact number should be provided, and patients leaving
the hospital within a few hours post-ERCP should be accompanied by
another adult and advised not to drive, or operate machinery for 24
hours. Before discharge the findings of the procedure and the
implications should be explained to the patient.
There is usually no pain post-procedure (unless
there were complications for the patient -- perforation, pancreatitis).
If there is any discomfort, it is usually due to excessive air in the
stomach and intestines due to insufflation during the procedure. This
discomfort is usually relieved when the patient passes flatus and
belches.
Aspirin, Motrin, or ibuprofen, is not
recommended for five to seven days post-procedure because they can cause
bleeding from the sphincterotomy site. Patients usually can eat one to
two hours post-procedure, typically starting with liquids and proceeding
to a regular diet within the next few hours.
Patients are given instructions not to take
aspirin, etc., and to observe themselves for any signs of infections or
adverse reactions such as abdominal pain, fever, nausea, vomiting, and
to notify the physician if there are any. They are not to make any
important decisions for 12 hours post-procedure. They are not to take
sedatives, narcotics, antihistamines (unless prescribed by the
physician) or drink alcohol for 24 hours post-procedure.
ERCP is an excellent diagnostic and therapeutic
procedure, but as in all medical and surgical treatment interventions,
there are risks involved. A strong comprehensive knowledge base and
quality patient care delivery help us to provide positive outcomes for
our patients.
Works Cited
1. National Institute of Health, NIH State-of
-the –Science Statement on Endoscopic Retrograde Cholangiography
(ERCP) for Diagnosis and Therapy. NIH Consensus and State-of –the-Science
Statements. 2002:19(1):1-26.
2. VanDam J. & Wong R.C.K. 2004.
Gastrointestinal Endoscopy. Georgetown; Landes Bioscience.
3. Society of Gastroenterology Nurses and
Associates. (2004). Manual of Gastrointestinal Procedures. (5th ed).
Chicago: SGNA.
4. Guidant Corporation, "Electrocautery,
Guidant ICD/CRT-D/CRT-P/ Pacing Systems" written on 9/02/04.,
retrieved on 7/28/05. www.guidant.com
