ERCP investigation of the bile duct and pancreatic .small ducts then drain into larger bile ducts

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Transcript of ERCP investigation of the bile duct and pancreatic .small ducts then drain into larger bile ducts

  • I n f o r m a t i o n f o r p a t i e n t s

    ERCP investigation of the bile duct and pancreatic duct

  • ERCP invest igat ion of the b i le duct and pancreat ic duct2 3

    ERCP investigation of the bile duct and pancreatic duct

  • ERCP invest igat ion of the b i le duct and pancreat ic duct4 5

    You will soon be having an ERCP investigation to look at your bile ducts and pancreatic ducts. This will take place as part of an investigation which is known by the medical term: ERCP or endoscopic retrograde cholangiopancreatography.

    This brochure is provided for you and perhaps also your family to read so that you are better prepared for the investigation. After reading it you can, of course, still ask questions when you see the doctor who examined you in clinic or the doctor and nurse looking after you on the ward when you come in.You can also ask the doctor and nurse who will be carrying out the ERCP investigation. They will make every effort to ensure that you receive the best possible support during your investi-gation.

    The medical and nursing team in the biliary and pancreatic en-doscopy department

    INTRODUCTION 5

    NORMAL BILE DUCTS AND PANCREATIC DUCTS 6

    The bile ductThe pancreatic duct

    WHAT IS THE INVESTIGATION FOR? 9

    Jaundice with suspected narrowing of the bile ductPainful biliary colicOther conditions affecting the bile ductsConditions affecting the pancreas

    WHAT HAPPENS DURING THE INVESTIGATION? 11

    PREPARATION FOR THE INVESTIGATION 12

    WHAT WILL YOU FEEL DURING THE INVESTIGATION? 13

    AFTER-CARE 15

    Inpatient procedureOutpatient procedure

    THE PROCEDURE 16

    Inserting a tube into the bile duct Opening up a blocked tube Widening the papilla of Vater

    POSSIBLE COMPLICATIONS 18

    Bleeding Acute pancreatitis Perforation of the small intestine

    YOUR CO-OPERATION IS NEEDED 21

    INFORMED CONSENT FOR ERCP INVESTIGATION 23

    RECORD OF PATIENT SATISFACTION AFTER ERCP INVESTIGATION 25In

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  • ERCP invest igat ion of the b i le duct and pancreat ic duct6 7

    NORMAL BILE DUCTS AND PANCREATIC DUCTS

    The ERCP investigation looks at two types of ducts: the bile ducts and the pancreatic ducts.

    The bile ducTs

    One of the functions of the liver, which is located in the upper right side of the abdomen, is to produce bile. This bile carries a number of different substances from the liver to the intestines. Bile contains a yellow dye called bilirubin. This dye is excreted in your faeces, giving them their normal brown colour.

    Bile salts are also excreted in the bile. These fat-soluble substances travel to the intestines where they help to digest dietary fats.

    Bile is a fluid produced by the liver cells. Small bile ducts run between the liver cells, forming a complex network within the liver. These small ducts then drain into larger bile ducts which pass through the liver at first and then continue outside the liver, ultimately delivering the bile to the intestine.

    The large bile duct outside the liver is known as the common bile duct and drains into the small intestine. The outlet, known as the pa-pilla of Vater (see diagram) is surrounded by a small sphincter which is intended to regulate the flow of bile into the small intestine. This small sphincter is called the sphincter of Oddi. If we inject a contrast fluid into the bile ducts through the papilla of Vater, we can take x-rays of the main bile ducts. We can use these images to find out

    bile is produced by the liver

    right hepatic duct left hepatic duct

    common bile duct

    gallbladder

    duct of Wirsung

    intestinal wall

    papilla of Vater with its sphincter: the sphincter of Oddi

  • ERCP invest igat ion of the b i le duct and pancreat ic duct8 9

    whether there are abnormalities in the bile ducts and whether we can treat these abnormalities immediately.

    The pancreaTic ducT

    The pancreas is located in the upper abdomen just in front of the spine. The pancreas has two important functions.

    It produces insulin, a hormone that helps to keep your blood sugar level low so that you do not develop diabetes.

    It produces a number of digestive enzymes and secretes these into the intestines. These are chemical substances which are responsible for breaking down sugars, proteins and fats in the intestines.

    The digestive enzymes are channelled into the small intestine through a small duct. This small duct, which is called the duct of Wirsung (see diagram on p. 7) passes into the small intestine through the papilla of Vater together with the bile duct. Once again, a contrast fluid is in-jected through the papilla of Vater to obtain x-ray

    images of the pancreatic duct. Here you can see one of these x-ray images, showing both the bile duct (thin white arrow) and the pan-creatic duct (two thick white arrows).

    WHAT IS THE INVESTIGATION FOR?

    The ERCP investigation makes it possible to reach a correct diagno-sis. In many cases the condition can be treated immediately. There are a number of conditions that require an ERCP investigation. Here is a brief description of the four most important conditions.

    Jaundice wiTh suspecTed narrowing of The bile ducT

    When the bile duct is narrowed, the yellow dye found in bile (biliru-bin) can no longer flow easily from the liver into the small intestine. This causes yellowing of the skin and eyes, and often also results in a whitish discolouration of the faeces (putty-coloured stools) and darkened urine. The fat-soluble bile salts also cannot flow easily into the small intestine, which can cause itching.

  • ERCP invest igat ion of the b i le duct and pancreat ic duct10 11

    painful biliary colic

    You may have had severe pain in the upper abdomen recently and your doctor may suspect that this was biliary colic. Biliary colic is usually caused by stones in the common bile duct or a cramp-like contraction of the small sphincter in the bile duct called the sphinc-ter of Oddi. This may be associated with other complications such as jaundice and episodes of fever. Another possibility is that you may have acute inflammation of the pancreas (acute pancreatitis).

    oTher condiTions affecTing The bile ducTs As well as jaundice and biliary colic there are other reasons why the bile ducts may need investigation or treatment. You may have had a gall bladder operation or liver transplant and you may subsequently have a bile leak or a narrowing of the bile duct. Or perhaps your doc-tor may suspect that you have an inflammatory condition affecting the bile ducts. There are other reasons that are not listed here, but your doctor can give you the necessary information about these.

    condiTions affecTing The pancreas

    The pancreas may suffer from chronic inflammation; this is known as chronic pancreatitis. This can cause severe pain, the formation of cysts in or around the pancreas, stones in the pancreatic duct or narrowing of the pancreatic duct. In all these situations, the aim will be to provide immediate treatment during the ERCP investigation.

    WHAT HAPPENS DURING THE INVESTIGATION?

    In the endoscopy department you will lie down on an x-ray table. For your comfort, you will be wrapped in a blanket. The air will then be removed to ensure a snug fit, like a protective cocoon. Usually you will need to lie on your front with your head turned towards the doctor, as shown in the diagram below. You will always be accom-panied by a nurse during the investigation. The nurse stands beside your head.

    The doctor will insert a flexible tube or endoscope via your mouth. This tube is passed through the stomach until it reaches the papilla of Vater. A thin plastic tube is then inserted through the endoscope into the papilla of Vater. Using this fine catheter, an x-ray contrast fluid is in-jected into the bile duct and the pancreatic duct to obtain x-ray images of these ducts.

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    PREPARATION FOR THE INVESTIGATION

    Before the investigation we will insert an intravenous line or can-nula into a vein in your arm or hand. The purpose of the cannula is to allow us to give you medication easily into the vein during the investigation.

    To avoid damaging your teeth we will fit a small mouthpiece between your teeth. This also protects the endoscope from damage due to biting. If you have dentures, you must remove them before the in-vestigation.

    Since the endoscope has to pass through the stomach, you must not eat or drink. You can still have a light meal on the evening before the investigation.

    You will need to wear a surgical gown for the investigation. Women must also remove their bra.

    Since the investigation may take some time, you should empty your bladder immediately beforehand.

    The investigation is usually carried out under sedation and analgesia. This means that you will be given a calming medication into a vein (Valium or Dormicum) together with a painkiller (Dolantine).

    The investigation may also be carried out under a general anaesthe-tic. This can be done if you specifically request it or if the doctor carrying out the investigation considers that a general anaesthetic is necessary. In this case the anaesthetic doctor who gives you the anaesthetic will insert a tube into your windpipe to allow you to be ventilated during the investigation.

    In many cases treatment is provided during the investigation to remove stones from the bile duct. This involves widening the papilla of Vater or the sphincter of Oddi (papillotomy). Since the treatment involves the use of an electrical current, an earthing plate is p