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Introduction ⬇

An endoscopic retrograde cholangiopancreatography (ERCP) is an examination of the hepatobiliary system that is completed using contrast medium that is instilled via a side-viewing flexible fiberoptic endoscope into the duodenal papilla, or ampulla of Vater allowing for radiologic visualization of the biliary and pancreatic ducts. An ERCP is used to evaluate jaundice, pancreatitis, persistent abdominal pain, pancreatic tumors, common duct stones, extrahepatic and intrahepatic biliary tract disease, malformation, and strictures and as a follow-up study in confirmed or suspected cases of pancreatic disease.

ERCP manometry is an additional test that can be done to obtain pressure readings in the bile duct, pancreatic duct, and sphincter of Oddi at the papilla. A special catheter is inserted into the ­endoscope during the procedure and placed within the sphincter zone. Measurements are obtained after the ERCP when the patient is awake and able to cooperate with testing.

Procedure ⬆ ⬇

  1. This examination is usually performed in a hospital or outpatient setting where fluoroscopy and x-ray equipment are available.

  2. Have the patient gargle, or spray the throat with, a topical anesthetic.

  3. Start an IV line and use for administration of sedatives and analgesic agents. These medications are given to achieve a state of conscious sedation. In some situations, general anesthesia may be used. Resuscitation equipment must be available.

  4. Perform continuous monitoring of the patient’s vital signs, cardiac rhythm, and oxygen saturation (pulse oximetry).

  5. Remove partial dental plates or dentures. Insert a mouthpiece to prevent the patient from biting the endoscope and to prevent injury to the patient’s teeth, tongue, or other oral structures.

  6. Have the patient assume a left lateral position with the knees flexed. The endoscope is well lubricated and inserted via the mouthpiece, down the esophagus and stomach, and into the duodenum. At this point, have the patient assume a prone position.

  7. Instill simethicone to reduce bubbles from bile secretions. Give glucagon or anticholinergic agents intravenously to relax the duodenum so that the papilla can be cannulated. (Atropine increases the heart rate.)

  8. Pass a catheter into the ampulla of Vater and instill the contrast agent through the cannula to outline the pancreatic and common bile ducts. Perform fluoroscopy and x-rays at this time.

  9. Take biopsy specimens or cytology brushings before the endoscope is removed.

  10. Monitor for side effects and drug allergy reactions (e.g., diaphoresis, pallor, restlessness, hypotension).

  11. Follow guidelines in Chapter 1 for safe, effective, informed intratest care.

Clinical Implications ⬆ ⬇

Abnormal results reveal stones, stenosis, and other abnormalities that may indicative of the following conditions:

  1. Biliary cirrhosis

  2. Primary sclerosing cholangitis

  3. Cancer of bile ducts, gallstones

  4. Pancreatic cysts

  5. Pseudocysts

  6. Pancreatic tumors

  7. Cancer of the head of the pancreas

  8. Chronic pancreatitis

  9. Pancreatic fibrosis

  10. Cancer of duodenal papilla

  11. Papillary stenosis

  12. Peptic ulcer disease

Clinical Alert

Contraindications include:

  1. Acute pancreatitis, pancreatic pseudocysts, and cholangitis

  2. Obstructions or strictures within the esophagus or duodenum

  3. Acute infections

  4. Recent myocardial or severe pulmonary disease

  5. Coagulopathy

  6. Recent barium x-rays of the GI tract (barium obscures views during ERCP)

Interventions ⬆ ⬇

Pretest Patient Care

  1. Explain the purpose, procedure, benefits, and risks of the test. If done as an outpatient procedure, be sure that the patient has arranged for a ride home. Blood work, urinalysis, x-ray films, and scans should be reviewed and charted before the procedure. Record baseline vital signs and preprocedure signs and symptoms (e.g., jaundice, persistent abdominal pain, and signs of pancreatic cancer).

  2. Ensure that an informed consent is signed and witnessed an in the patient’s medical record.

  3. Confirm that the patient has fasted for 8–12 hours before the procedure.

  4. Inform the patient to expect the following:

    1. Becoming sleepy during ERCP and possibly not recalling much of the experience after the procedure is complete.

    2. Being asked to swallow and should not attempt to talk (to prevent damage to the oral pharynx).

    3. Experiencing a gagging or choking sensation that quickly subsides and that slow, deep breathing may help with this feeling. Having sensations of abdominal pressure or bloating is normal.

    4. Needing to lie still while x-rays are being taken.

  5. Refer to conscious sedation precautions in Chapter 1.

  6. Follow guidelines in Chapter 1 for safe, effective, informed pretest care.

Posttest Patient Care

  1. Withhold food or liquids until the patient’s gag reflex returns.

  2. Monitor the patient’s cardiac rhythm, blood pressure, pulse, respirations, oxygen saturation, and temperature according to institutional policy.

  3. Observe the patient for signs of complications such as infection, urinary retention, cholangitis, or pancreatitis. Check for temperature elevation, which may be the first sign of inflammation. Monitor the white blood cell count and assess for signs of sepsis.

  4. Monitor for respiratory and central nervous system depression from narcotic drugs (naloxone may be used to reverse narcotic effects, and flumazenil is used for reversing benzodiazepines).

  5. Explain that some abdominal discomfort may be experienced for several hours after the procedure.

  6. Advise patient that drowsiness may last up to 24 hours. During this time, the patient should not perform any tasks that require mental alertness, and legal documents should not be signed.

  7. Tell patient that a sore throat can be relieved by gargles, ice chips, fluids, or lozenges if permitted.

  8. Notify healthcare provider of any of the following signs or symptoms:

    1. Prolonged, sharp abdominal pain; abnormal weakness; faintness

    2. Fever

    3. Nausea or vomiting

  9. Review test results; report and record findings. Modify the nursing care plan as needed.

  10. Follow guidelines in Chapter 1 for safe, effective, informed posttest care. Provide written instructions to outpatients. Outpatients should be discharged to the care of a responsible adult.

Clinical Alert

Observe for possible complications:

  1. Pancreatitis (most common complication)

  2. Sepsis

  3. Hemorrhage

  4. Perforation

  5. Aspiration

  6. Respiratory depression or arrest

  7. Medication reaction

Reference Values ⬆

Normal