Cholangiopancreatography, Endoscopic Retrograde


Cholangiopancreatography, Endoscopic Retrograde

Synonym/acronym: ERCP.

Common use

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

Area of application

Gallbladder, bile ducts, pancreatic ducts.

Contrast

Iodinated contrast medium.

Description

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 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.

This procedure is contraindicated for

  • high alertPatients 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.
  • high alertPatients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are still asked specifically if they have a known allergy to iodine or shellfish, it has been well established that the reaction is not to iodine, in fact an actual iodine allergy would be very 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 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.
  • high alertPatients with conditions associated with preexisting renal insufficiency (e.g., renal failure, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycocides and NSAIDs) because iodinated contrast is nephrotoxic
  • high alertElderly and compromised patients who are chronically dehydrated before the test, because of their risk of contrast-induced renal failure
  • high alertPatients with bleeding disorders or receiving anticoagulant therapy because the puncture site may not stop bleeding
  • high alertPatients with an acute infection of the biliary system, pharyngeal or esophageal obstruction (e.g., Zenker’s diverticulum), or possible pseudocyst of the pancreas

Indications

  • 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

Potential diagnosis

Normal findings

  • Normal appearance of the duodenal papilla
  • Patency of the pancreatic and common bile ducts

Abnormal findings related to

  • Duodenal papilla tumors
  • Pancreatic cancer
  • Pancreatic fibrosis
  • Pancreatitis
  • Sclerosing cholangitis

Critical findings

    N/A

Interfering factors

  • Factors that may impair clear imaging

    • Gas or feces in the gastrointestinal (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.
    • Incorrect positioning of the patient, which may produce poor visualization of the area to be examined.
    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status.

  • Other considerations

    • The procedure may be terminated if chest pain or severe cardiac arrhythmias occur.
    • A patient with unstable cardiopulmonary status, blood coagulation defects, or cholangitis (test may have to be rescheduled unless the patient received antibiotic therapy before the test).
    • Failure to follow dietary restrictions and other pretesting preparations may cause the procedure to be canceled or repeated.
    • Consultation with a health-care provider (HCP) should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactating. Pediatric & Geriatric Imaging Children and geriatric patients are at risk for receiving a higher radiation dose than necessary if settings are not adjusted for their small size. Pediatric Considerations Information on the Image Gently Campaign can be found at the Alliance for Radiation Safety in Pediatric Imaging (www.pedrad.org/associations/5364/ig/).
    • Risks associated with radiation overexposure can result from frequent x-ray procedures. Personnel in the examination room with the patient should wear a protective lead apron, stand behind a shield, or leave the area while the examination is being done. Personnel working in the examination area should wear badges to record their level of radiation exposure.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in assessing the bile ducts of the gallbladder and pancreas.
  • Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, contrast medium, or sedatives.
  • Obtain a history of the patient’s gastrointestinal and hepatobiliary systems, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Ensure that this procedure is performed before an upper GI study or barium swallow.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus). Note the last time and dose of medication taken.
  • If iodinated contrast medium is scheduled to be used in patients receiving metformin (Glucophage) for non–insulin-dependent (type 2) diabetes, the drug should be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Iodinated contrast can temporarily impair kidney function, and failure to withhold metformin may indirectly result in drug-induced lactic acidosis, a dangerous and sometimes fatal side effect of metformin related to renal impairment that does not support sufficient excretion of metformin.
  • Review the procedure with the patient. Address concerns about pain and explain that some pain may be experienced during the test, and there may be moments of discomfort. 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.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Explain that an IV line may be inserted to allow infusion of IV fluids such as normal saline, anesthetics, sedatives, or emergency medications. Explain that the contrast medium will be injected at a separate site from the IV line.
  • Instruct the patient to remove jewelry and other metallic objects from the area to be examined.
  • Instruct the patient to fast and restrict fluids for 8 hr prior to the procedure and to avoid taking anticoagulant medication or to reduce dosage as ordered prior to the procedure. Protocols may vary among facilities.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications:

  • Cholangiography is an invasive procedure and has potential risks that include allergic reaction related to contrast reaction, bleeding, septicemia, pancreatitis, and bowel perforation.

  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demographics, initials of the person collecting the specimen, date, and time of collection.
  • Ensure the patient has complied with dietary, fluid, and medication restrictions for 8 hr prior to the procedure.
  • Ensure the patient has removed all external metallic objects from the area to be examined.
  • Assess for completion of bowel preparation according to the institution’s procedure.
  • Administer ordered prophylactic steroids or antihistamines before the procedure if the patient has a history of allergic reactions to any relevant substance or drug. Use nonionic contrast medium for the procedure.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
  • Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results.
  • Record baseline vital signs, and continue to monitor throughout the procedure. Protocols may vary among facilities.
  • Establish an IV fluid line for the injection of saline, sedatives, or emergency medications.
  • Administer ordered sedation.
  • 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.
  • The patient is placed on an examination table in the left lateral position with the left arm behind the back and right hand at the side with the neck slightly flexed. 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.
  • The endoscope is passed through the mouth with a dental suction device in place to drain secretions. A side-viewing flexible fiberoptic endoscope is passed into the duodenum, and a small cannula is inserted into the duodenal papilla (ampulla of Vater).
  • The patient is placed in the prone position. The duodenal papilla is visualized and cannulated with a catheter. Occasionally the patient can be turned slightly to the right side to aid in visualization of the papilla.
  • IV glucagon or anticholinergics can be administered to minimize duodenal spasm and to facilitate visualization of the ampulla of Vater.
  • 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.
  • Place specimens in appropriate containers, label them properly, and promptly transport them to the laboratory.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Do not allow the patient to eat or drink until the gag reflex returns, after which the patient is permitted to eat lightly for 12 to 24 hr.
  • Instruct the patient to resume usual diet, fluids, medications, and activity after 24 hr, or as directed by the HCP. Renal function should be assessed before metformin is resumed, if contrast was used.
  • 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. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
  • Monitor for reaction to iodinated contrast medium, including rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
  • 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.
  • Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing, skin rash, itching, chest pain, persistent right shoulder pain, or abdominal pain. Immediately report symptoms to the appropriate HCP.
  • Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include amylase, CT abdomen, hepatobiliary scan, KUB studies, lipase, MRI abdomen, peritoneal fluid analysis, pleural fluid analysis, and US liver and biliary system.
  • Refer to the Gastrointestinal and Hepatobiliary systems tables at the end of the book for related tests by body system.