Question

2. What patient teaching would you do for a patient scheduled for ERCP?

3. What are the priority nursing interventions post procedure?

4. Your patient with advanced metastatic pancreatic cancer received conscious sedation with IV midazolam for an ERCP. Upon assessment 3 hours after the procedure, the patient is lethargic and slow to rouse, SBP is now 10 mm Hg below baseline. What classifications of medications would you check for on the MAR and why?

Answer 1

1)

ERCP is both a diagnostic and therapeutic procedure that uses a lighted flexible tube and x-ray to examine the bile and pancreatic ducts that drain the liver, pancreas and gallbladder into the small intestine.

During the ERCP procedure, your physician passes an endoscope, or narrow plastic tube, through your mouth, esophagus and stomach into the duodenum, or upper part of the small intestine. After slowly injecting a dye as contrast material, and with the aid of fluoroscopy (x-ray), a physician can study the biliary and pancreatic ducts for any stones, narrowing or other abnormalities.

Patient Teaching

1. Refer to Standard Considerations.

2. Explain specific positioning which will be required during the procedure: prone or left lateral position.

3. Explain symptoms of pancreatitis and sepsis (i.e. chills, low grade fever, pain, vomiting and tachycardia).

4. Explain that if pancreatitis occurs it usually occurs within 2-4 hours after the procedure.

Your physician may recommend an ERCP procedure if you are experiencing pain or have received abnormal lab (liver or pancreas blood tests) and/or imaging test (CT or MRI scans) results. The procedure is used to diagnose biliary or pancreatic disease, including benign and malignant origins of the disease, or etiologies. Patients who are jaundiced (a yellow discoloration of the skin and eyes) may also be advised to undergo the procedure. Additionally, an ERCP test is used to determine if surgery is necessary.

Advanced endoscopists can perform a variety of therapeutic techniques during an ERCP procedure to crush or remove stones in the bile ducts or to place stents to widen narrowed ducts. They also can take biopsies, or samples of tissue, from the ducts to diagnose certain medical conditions such as cancer.

• You may have diet and/or medication restrictions the week before the ERCP test. Please ask your physician for detailed instructions. Be sure to let your physician know if you take any type of blood thinning medication.
• You will not be allowed any heavy meal for at least 8 hours before the procedure, light meals or opaque liquids for 6 hours before, or clear liquids for at least 2 hours before.
• Plan to take the day off from work.
• Plan to have someone you know drive you home. Because the procedure is performed with general anesthesia, you will not be allowed to drive after the procedure or return to work until the next day.
• Let your physician know about any special needs, medical conditions, allergies (such as latex) and all current medications you are taking. In some cases, your doctor may prescribe an antibiotic before the procedure.
• The NorthShore GI Lab will try to contact you the evening before your procedure to answer any questions you may have.
• In some cases, when patients need certain therapeutic interventions during an ERCP procedure, they may be admitted to the hospital overnight for observation.

2)

The development of therapeutic endoscopic procedures over the past 20 years has been phenomenal. From the visualization of bile and pancreatic ducts years ago, technology has progressed to complex sphincterotomies, stenting and removal of common duct stones.

Nurses working with these patients after these procedures need physical assessment skills and a knowledge base of both the therapeutic endoscopic procedures and the complications associated with the procedures.

Post-Procedure Assessment/Care

1. Refer to Standard Considerations.

2. NPO status is usually maintained for 2-4 hours and then a clear liquid diet for the first 24 hours.

3. Observe for abdominal distention and signs of possible pancreatitis including chills, low grade fever, pain, nausea, vomiting, tachycardia. Especially for Children In premature and small infants, over inflation of the stomach can cause respiratory compromise. Assess for abdominal distention following the procedure.

4. Administer medications as ordered. Especially for Children Instruct parent or caregiver to monitor child’s head/neck position until fully awake to avoid airway obstruction post-procedure

3)

The patient is sedated and given potent pain relievers (opiate) after on overnight fast. A local anesthetic is sprayed to the back of the throat. Frequently, muscle relaxants are used to relax the duodenum and ampulla (an anticholinergic drug, or glucagon, nitroglycerin). During the test patients are monitored to ensure that they are not oversedated. The monitoring includes a pulse oximeter (a probe fastened to the patient's finger that measures blood oxygen concentration) and a heart rate monitor. During the ERCP, the degree of sedation is much greater than that used for an EGD, so often the patient is asleep.

Using a modified endoscope, the investigator visualizes the duodenum on a monitor and finds the small opening where the bile duct and pancreatic duct empty into the duodenum (the ampulla of Vater). A thin catheter is passed through an opening in the endoscope and through the ampulla. Once the catheter has been placed through the opening (cannulated), a dye is injected into the pancreatic and bile ducts. This enables images of these ducts to be obtained. X-rays are taken of the abdomen over the area of the pancreas and are examined by the attending physicians on screen.

Despite the medication, occasionally the patient may feel discomfort and may retch. If discomfort occurs additional pain relief is usually provided. Symptoms arising from complications may also rarely occur.

Accuracy:

• Will show the indirect effects of pancreatic cancer such as blockage or dilatation of the ducts and inflammation of the tissue. Similar symptoms can be caused by conditions such as chronic pancreatitis or stones in the pancreatic or bile ducts. By examining the pattern of these changes, it is possible to predict with a high degree of certainty if an abnormality is a cancer.
• An ERCP can detect an abnormality suspicious of cancer in about 9 out of 10 patients who are investigated for possible adenocarcinoma. Patients who have very small cancers, less than 2 cm, that currently do not alter the main ducts of the pancreas or the bile duct will not be visible.
• Occasionally, it can be very difficult to tell if an abnormality in the pancreatic duct is due to cancer or inflammation. Tissue biopsy provides confirmation of the presence of cancer (link to FNA and cytology). This test is not useful in detecting most endocrine types of pancreatic cancer.