Synonym/Acronym
ERCP.
Rationale
To visualize and assess the pancreas and common bile ducts for occlusion or stricture.
Patient Preparation
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 American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. The Canadian Anesthesiologists’ Society has fasting guidelines for preprocedural fasting. Related information can be located at https://www.cas.ca/English/Page/Files/97_Appendix%206.pdf.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.
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 anticoagulant, 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. Protocols may vary among facilities.
Normal Findings
- Normal appearance of the duodenal papilla
- Patency of the pancreatic and common bile ducts.
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 labelled, 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 iodinated or noniodinated contrast material, with x-rays. It allows the health-care 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.
Contraindications
Pregnancy is a general contraindication to procedures involving radiation.
Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast 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.
Patients with bleeding disorders or receiving anticoagulant therapy, because the puncture site may not stop bleeding.
Patients with an acute infection of the biliary system (cholangitis, pancreatitis, or possible pseudocyst of the pancreas), pharyngeal or esophageal obstruction (e.g., Zenker’s diverticulum).
Factors That May Alter the Results of the 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
- Blood specimens for bilirubin, amylase, or lipase, if ordered, should be collected before the procedure; results will be elevated after the procedure.
Abnormal Findings Related to
Potential Nursing Problems: Assessment & Nursing Diagnosis
| Problems | Signs and Symptoms |
|---|
| Fluid volume (deficit—related to fluid loss secondary to vomiting, NG suction, diaphoresis, insensible loss) | Vomiting, dehydration, decreased urine output, increased urine concentration, poor skin turgor, dry mucous membranes, elevated heart rate, dry mucous membranes, weakness, weight loss | | Nausea (related to pain, inflammation, blockage) | Self-report of nausea, excess salivation, bad taste in the mouth, gagging, avoidance of food, inability to eat | | Pain (related to blockage, tumor, infection, inflammation; edema; peritoneal irritation) | Self-report of pain; facial grimace; crying; restlessness; diaphoresis; nausea; vomiting; guarding; social withdrawal; elevated blood pressure, heart rate, respiratory rate; pallor; agitated |
|
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist in assessing the bile ducts of the gallbladder and pancreas.
- Explain that the procedure takes 45 to 60 min and is performed in a GI lab or radiology department.
- Review the procedure with the patient.
- Explain that prior to the procedure, laboratory testing may be required to determine the possibility of bleeding risk (coagulation testing).
- Pregnancy testing may be required.
- Discuss how there may be moments of discomfort or pain when the IV line or catheter is inserted allowing for infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medications.
- Explain that a narcotic will be given prior to the procedure as well as a sedative to promote relaxation. There should be no pain but there may be moments of discomfort when the endoscope is inserted.
Procedural Information
- Note: Patients who have the procedure done in an outpatient setting must have arranged for someone to drive him or her home.
- Positioning is either in the left lateral position (Sims), on the stomach (prone), or on the back (supine).
- A protective guard is inserted into the mouth to cover the teeth.
- A bite block may also be inserted to maintain adequate opening of the mouth and to protect the teeth.
- Baseline vital signs will be recorded and monitored throughout the procedure.
- IV glucagon or anticholinergics may be administered to minimize duodenal spasm and to facilitate visualization of the ampulla of Vater.
- Contrast medium is injected, by catheter, at a separate site from the IV line.
- 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.
- 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 may be turned slightly to the right side to aid in 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.
- Once 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 are obtained as needed.
- Once the study is completed, the needle or catheter is removed, and a pressure dressing is applied over the puncture site.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
- Provide mouth care to reduce oral bacterial flora, as appropriate.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
- Note that a rare complication related to the cholangiography procedure is septicemia.
- Establishing an IV site and injection of contrast medium are invasive procedures that can cause rare complications. For additional information see Appendix A: Patient Preparation and Specimen Collection, subsection: Potential Contraindications and Complications Associated with Diagnostic Procedures.
- 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
- Follow post-procedure vital sign and assessment protocol.
- Do not allow the patient to eat or drink until the gag reflex returns due to aspiration risk.
- Inform the patient that any belching, bloating, or flatulence is the result of air insufflation.
Fluid Volume
- Facilitate management of fluid volume deficit.
- Weigh daily.
- Monitor and trend blood pressure and heart rate.
- Assess skin turgor to evaluate for dehydration.
- Document accurate intake and output including assessing urine color.
- Monitor laboratory values (BUN, K+, NA+, Hgb, Hct, urine specific gravity).
- Monitor for changes in mental status.
Nausea
- Administer ordered antiemetics while assessing the frequency and duration of the nausea.
- Provide oral care and identify any factors that precipitate the experience of nausea.
- Evaluate hydration status, monitor intake and output.
- Administer ordered parenteral fluids.
Pain
- Manage pain by using a pain rating scale appropriate to the age, culture, 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.
- Advise to expect some throat soreness and possible hoarseness.
- Explain that the use of warm gargles, lozenges, ice packs to the neck, or cool fluids is beneficial to alleviate throat discomfort.
Nutritional Considerations
- When safe, the patient is permitted to eat lightly for 12 to 24 hr and then to resume usual diet, fluids, medications, and activity as directed by the HCP.
Clinical Judgement
- Consider ways to address concerns over how a negative outcome will effect lifestyle choices and longevity.
Follow-Up and Desired Outcomes
- Understands that pain may be better managed by a combination of pharmacological and nonpharmacological treatment choices.
- Acknowledges which foods and odors to avoid to prevent nausea.
- Describes how antiemetics can assist to relieve nausea and improve oral intake.