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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


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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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


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.


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.


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 put on your leg beforehand. You will not normally feel the papilla or sphincter being widened.

WHAT WILL YOU FEEL DURING THE INVESTIGATION?

The investigation begins with an anaesthetic spray into your throat to make it easier to insert the endoscope. This spray does have an unpleasant taste and creates a sensation of swelling in the throat. The spray does not prevent you from breathing normally. We ask you not to swallow during the investigation and to let any saliva run out through your mouth. A towel is placed under your face for this reason.

At the beginning and during the investigation you will be given cal-ming medication and painkillers. The atmosphere during the investi-gation is therefore usually calm. After the investigation you may still


feel rather sleepy. It is quite possible that you will not remember anything about the procedure.

In order to obtain good views of the stomach, air is passed into the stomach through the endoscope during the investigation. This usually creates a bloated feeling in the stomach. This is normal and you should not be concerned if you need to pass wind during the investigation.

Saliva and mucus may build up in your throat during the investigation. This can make breathing difficult. The nurse can remove this fluid from your mouth using a thin suction tube.

In some cases you will need to lie on your back during and after the investigation to obtain better x-ray images. We will help you to find a good position.

AFTER-CARE

inpaTienT procedure

After the investigation you will go back to bed and you will be taken back to the ward where you can continue to rest.

During the first few hours after the investigation, the nurse on the ward will regularly check your pulse, blood pressure and tempera-ture. If you feel unwell, notice any unusual sensations or feel any pain, you must inform the nurse immediately.

A few hours after the ERCP investigation you can usually have a light liquid meal. If necessary the nurse will ask you not to eat or drink for the first few hours or days after the investigation. In this case you will be given plenty of fluid and nutrition through the intravenous catheter.

ouTpaTienT procedure

It is possible that your investigation may be carried out as an ‘outpa-tient’. This means that you will not be admitted to hospital and can return home the same day. You will be able to spend a few hours resting in a bed in the endoscopy department. The doctor and nurse who have carried out the investigation will monitor you during this time. If they do consider it best for you to be admitted after all, they will discuss this with you.

Patients staying in another hospital who are referred to UZ Leuven for this investigation will, in principle, be transferred back to the


referring hospital as soon as possible. If the doctor who has carried out the investigation considers that it is best for you to be admitted to UZ Leuven for further monitoring, this will be discussed with you and the doctor who referred you.

THE PROCEDURE

The ERCP investigation usually goes smoothly and only takes between ten and thirty minutes. In some patients it is difficult to find the papilla of Vater, inject the contrast dye into it or carry out the necessary procedures. In these cases the investi-gation may take up to one hour longer and it may also begin to feel uncomfortable. If necessary we can provide more sedative medication, or the investigation can be stopped and continued on a later date.

inserTing a Tube inTo The bile ducT

One first important procedure that can be carried out during the ERCP investigation involves inserting a tube into the bile duct. This is usually done for patients with a narrowing of the bile duct which is causing jaundice and itching. The tube is intended to allow bile to flow normally into the small intestine again, so that the jaundice and itching disappear.

On the x-ray image at the bottom right you can see a curve which is one of these tubes. This tube has been inserted in the bile duct for a patient with a narrowed bile duct (left, thick arrow).

opening up a blocked Tube

If the bile does not flow easily because the tube has quickly become blocked, fever may occur and the jaundice will not disappear or will quickly come back. In this case a new tube must be inserted as soon as possible to allow better drainage. You will also be given antibiotics to bring down the fever.

widening The papilla of VaTer

The most frequent treatment involves making a cut to widen the papilla of Vater. This technique is called a sphincterotomy or papil-lotomy. This treatment makes it possible to remove stones or gravel from the bile duct. This is the preferred technique to treat stones in the bile duct, particularly where there are also complications such as


jaundice, fever or acute pancreati-tis. It is mainly af-ter this treatment that complications can sometimes occur (see below).

POSSIBLE COMPLICATIONS

The overall risk of having a complication is estimated to be about five percent. It should therefore be clear that this in-vestigation or treatment is never carried out unless there is a good reason for it. You must also weigh up the risk of compli-cations against the risks that you will incur if you do not have the treatment. The condition (for example stones in the bile duct) may also cause complications and may also require sur-gery. Surgical intervention will require a longer stay in hospital, with more discomfort and a risk of further complications.

We now have a lot of experience with these investigations, so we are increasingly carrying out these procedures on an outpatient basis. This means that you can leave the hospital just a few hours after the investigation. In any case your doctor has already carefully conside-

red whether you need this investigation. You will also be treated by an expert team of doctors and nurses, which reduces the risk of complications to a minimum.

bleeding

If a blood vessel is touched while widening the papilla of Vater, blee-ding may occur and interfere with the procedure. Usually this is only light bleeding and stops spontaneously. If heavier bleeding occurs, a blood transfusion may have to be administered. In that case it will be necessary to review the cut endoscopically once again and stop the bleeding by giving a local injection.

It should be quite clear from this that a sphincterotomy can only be carried out if you do not have any blood clotting problems. This must be checked beforehand by means of an appropriate blood test. Taking medications that thin the blood such as Aspirin®, Ticlid®, Mar-coumar®, Sintrom®, Clexane®, Fraxiparine® and Fraxodi® does, of course, increase the risk of bleeding. You must always inform your doctor if you are taking these medications. You must stop taking these blood thinning medications before the investigation and you cannot start them again until several days after the treatment. You will be given the necessary instructions by your doctor.


acuTe pancreaTiTis

Since the pancreatic duct and the bile duct both flow through the same outlet, cutting the papilla of Vater can sometimes result in acu-te inflammation of the pancreas. This may cause severe abdominal pain during the first few hours after the investigation. If this happens you will of course need to stay longer in hospital and you will not be allowed to eat or drink until the pain has gone. If this happens you will be given painkillers and intravenous fluids. In rare cases, severe pancreatitis may require admission to an intensive care unit.

perforaTion of The small inTesTine

In rare cases a small perforation of the abdominal wall can occur, al-lowing air to escape from the intestine into the tissues around the bile duct and pancreas. This complication often causes pain but usually resolves by itself. The treatment for this is not eating or drinking for a few days. If this happens you will be given antibiotics and intravenous fluids.

YOUR CO-OPERATION IS NEEDED

There are two forms to tear out at the back of this brochure.

The first is an informed consent form. If you sign this form you are confirming that you have received all the information that you need to have the ERCP investigation, both in writing through this brochure and verbally by asking questions when you talk to the doctors and nurses.Please sign and date this form and hand it to the nurse in the endos-copy department. This form will be kept in your medical records.

A second document asks about your satisfaction with the investiga-tion. Please complete this form as fully as you can a few hours after the investigation or the following day. We will collect this form from you and it is intended to allow us to improve the care that we pro-vide in any way we can.

We are grateful for your cooperation. We will do everything we can to ensure that your ERCP investigation goes smoothly.

The medical and nursing team in the biliary and pancreatic endoscopy department.

Prof. dr. Werner Van Steenbergen Clinical Director, Hepatology Department, General Medicine Division

ERCP invest igat ion of the b i le duct and pancreat ic duct 2322

INFORMED CONSENT FOR ERCP INVESTIGATION

Dear Sir/Madam

You will soon be having an ERCP investigation or endoscopic retro-grade cholangiopancreaticography. The purpose of this investigation is to obtain more diagnostic information about your condition and above all to provide minimally invasive, non-surgical treatment.

By signing this form you confirm that you have been informed both in writing and verbally of the various aspects of this investigation and its possible complications.

In this way you are giving your consent for the investigation to be carried out after you have received this information.

Name of patient: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Signature of patient: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ERCP invest igat ion of the b i le duct and pancreat ic duct 2524

RECORD OF PATIENT SATISFACTION AFTER ERCP INVESTIGATION

Underline your preferred answer.

✗ Did you have to wait long for an appointment for this investiga-tion?

not long at all a long time much too long; distressing

✗ Did you have to wait long in the ERCP department before the investigation began?

not long at all a long time much too long; distressing

✗ Are you satisfied with the attitude of the doctor who carried out the investigation (courtesy, respect, friendliness etc.)?

very satisfied satisfied not satisfied

✗ Are you satisfied with the technical competence of the doctor who carried out the investigation (attentive care, competence etc.)?


✗ Are you satisfied with the attitude of the nurse who assisted with the investigation (courtesy, respect, friendliness etc.)?


✗ Are you satisfied with the verbal explanation about this investiga-tion that you received beforehand?


z.o.z.


✗ Are you satisfied with the brochure about this investigation that you received beforehand?


✗ How satisfied are you with this investigation overall? very satisfied satisfied not satisfied

✗ Would you have the investigation carried out again in this hospi-tal, with this team and by this doctor?

yes no

Comments:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Name of patient: Name of doctor:

Date of investigation: . . / . . / . . Name of nurse:

NOTES

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© april 2012 UZ Leuven

This text can only be reproduced with permission from the Communication De-

partment at UZ Leuven.

Design and production

This text was produced by the biliary and pancreatic endoscopy department in col-

laboration with the Communication Department.

If you have any comments or suggestions about this brochure please send these to

[email protected].

Published by:

UZ Leuven

Herestraat 49

3000 Leuven

tel. 016 34 49 00

www.uzleuven.be