Guest guest Posted December 13, 2003 Report Share Posted December 13, 2003 Hello Rick, I hope your ERCP will prove useful. Mark has posted all the details on the actual test itself. I found that post very enlightening. Thank you Mark! I only ever had one ERCP and that was in 1988! My understanding at the time was that it was exploratory ie. simply to find out if anything was wrong with the pancreas. The test itself was not at all unpleasant for me as they obviously put me out sufficiently for me to remember nothing about it. I wasn't in the least worried about it beforehand as I had never heard of it and there was no internet to chat to anyone about it! I'll just mention that I did have a nasty attack of pancreatic pain afterwards and it lasted a few days, being particularly severe the day after the procedure. I have found out since that this is quite common but hopefully it won't happen to you. Hope all goes well; I'm sure it will. Best wishes, Fliss Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 5, 2004 Report Share Posted January 5, 2004 Hi Cindy, I had an ERCP with stent placement on December 12, 2003. Mine was actually and ERCP with manometry. It so happened that I had Sphinctor of Oddi dysfunction and the doctor did a dual sphinctorotomy with stent placement. As you know when you have an ERCP one of the complications is an pancreatitis attack. I ended up in the hospital for 5 days. Not everyone that has this procedure will have an attack. The risk is there. I was readmitted 4days later with another acute attack and this time I was in the hospital 6days. I am still off work on Short term disability. I want to let you know that when I had my first ERCP I did not have any complications. As I said there is a risk. Hope this is helpful Patty Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 6, 2004 Report Share Posted January 6, 2004 What is ERCP? a.. What Can You Expect During an ERCP? b.. What are the Possible Complications from an ERCP? c.. What Can You Expect after Your ERCP? d.. HOW ERCP WORKS -------------------------------------------------------------------------- Your doctor has recommended that you have a medical procedure called an ERCP. This brochure will help you understand why ERCP is performed and what you can expect from the procedure. ERCP is short for. Endoscopic Retrograde Cholangio Pancreatography Endoscopic refers to the use of an instrument called an endoscope - a thin, flexible tube with a tiny video camera and light on the end. The endoscope is used by a highly trained subspecialist, the gastroenterologist, to diagnose and treat various problems of the GI tract. The GI tract includes the stomach, intestine, and other parts of the body that are connected to the intestine, such as the liver, pancreas, and gallbladder. Retrograde refers to the direction in which the endoscope is used to inject a liquid enabling X-rays to be taken of the parts of the GI tract called the bile duct system and pancreas. The process of taking these X-rays is known as cholangiopancreatography. Cholangio refers to the bile duct system, pancrea to the pancreas. ERCP may be useful in diagnosing and treating problems causing jaundice (a yellowing of the whites of the eyes) or pain in the abdomen. To understand how ERCP can help, it's important to know more about the pancreas and the bile duct system. Bile is a substance made by the liver that is important in the digestion and absorption of fats. Bile is carried from the liver by a system of tubes known as bile ducts. One of these, the cystic duct, connects the gallbladder to the main bile duct. The gallbladder stores the bile between meals and empties back into the bile duct when food is consumed. The common bile duct then empties into a part of the small intestine called the duodenum. The common bile duct enters the duodenum through a nipple-like structure called the papilla. Joining the common bile duct to pass through the papilla is the main duct from the pancreas. This pathway allows digestive juices from the pancreas to mix with food in the intestine. Problems that affect the pancreas and bile duct system can, in many cases, be diagnosed and corrected with ERCP. For example, ERCP can be helpful when there is a blockage of the bile ducts by gallstones, tumors, scarring or other conditions that cause obstruction or narrowing (stricture) of the ducts. Similarly, blockage of the pancreatic ducts from stones, tumors, or stricture can also be evaluated or treated by ERCP, which is useful in assessing causes of pancreatitis (inflammation of the pancreas). Problems with the bile ducts or pancreas may first show up as jaundice or pain in the abdomen, although not always. Also, there may be changes in blood tests that show abnormalities of the liver or pancreas. Other special exams that take pictures using X-rays or sound waves may provide important information for use along with that obtained from ERCP. How to Prepare for the Procedure Prior to having ERCP, there are a number of things you will need to remember: a.. First, don't eat or drink anything for at least six hours beforehand or after midnight if your ERCP is scheduled for first thing in the morning. a.. Be sure to tell your doctor all the medication you are taking, including aspirin, aspirin-containing drugs, or blood thinners. a.. Identify any allergies or any reactions you have had to drugs, particularly antibiotics or pain medications. a.. Follow all of your doctor's instructions regarding preparation for the procedure. ERCP can be done either as an outpatient procedure or may require hospitalization, depending on the individual case. Your doctor will explain the procedure and its benefits and risks, and you will be asked to sign an informed consent form. This form verifies that you agree to have the procedure and understand what's involved. What Can You Expect During an ERCP? Everything will be done to ensure your comfort. Your blood pressure, pulse, and the oxygen level in your blood will be carefully monitored. A sedative will be given through a vein in your arm. You will feel drowsy, but will remain awake and able to cooperate during the procedure. Although general anesthesia is usually not required, you may have the back of your throat sprayed with a local anesthetic to minimize discomfort as the endoscope is passed down your throat into your esophagus (the swallowing tube), and through the stomach into your duodenum. The doctor will use it to inspect the lining of your stomach and duodenum. You should not feel any pain, but you may have a sense of fullness, since air may be introduced to help advance the scope. In the duodenum, the instrument is positioned near the papilla, the point at which the main ducts empty into the intestine. A small tube known as a cannula is threaded down through the endoscope and can be directed into either the pancreatic or common bile duct. The cannula allows a special liquid contrast material, a dye, to be injected backwards - that is, retrograde - through the ducts. X-ray equipment is then used to examine and take pictures of the dye outlining the ducts. In this way, widening, narrowing, or blockage of the ducts can be pinpointed. Some of the problems that may be identified during ERCP can also be treated through the endoscope. For example, if a stone is blocking the pancreatic or common bile duct, it is usually possible to remove it. First, the opening in the papilla is cut open and enlarged. Then, a special device can be inserted to retrieve the stone. Narrowing or obstruction can also have other causes, such as scarring or tumors. In some cases, a plastic or metal tube (called a stent), can be inserted to provide an opening. If necessary, a tissue sample or biopsy can be obtained, or a narrow area dilated. What are the Possible Complications from an ERCP? Thanks to ERCP, these kinds of procedures may help you avoid surgery. Depending on the individual and the types of procedures performed, ERCP does have a five to ten percent risk of complications. In rare cases, severe complications may require prolonged hospitalization. Mild to severe inflammation of the pancreas is the most common complication and may require hospital care, even surgery. Bleeding can occur when the papilla has to be opened to remove stones or put in stents. This bleeding usually stops on its own, but occasionally, transfusion may be required or the bleeding may be directly controlled with endoscopic therapy. A puncture or perforation of the bowel wall or bile duct is a rare problem that can occur with therapeutic ERCP. Infection can also result, especially if the bile duct is blocked and bile cannot drain. Treatment for infection requires antibiotics and restoring drainage. Finally, reactions may occur to any of the medications used during ERCP, but fortunately these are usually minor. Be sure to discuss any specific concerns you may have about the procedure with your doctor. What Can You Expect after Your ERCP? When your ERCP is completed on an outpatient basis, you will need to remain under observation until your doctor or healthcare team has decided you can return home. Sometimes, admission to the hospital is necessary. When you do go home, be sure you have arranged for someone to drive you, since you're likely to be sleepy from the sedative you received. This means, too, that you should avoid operating machinery for a day, and not drink any alcohol. Your doctor will tell you when you can take fluids and meals. Usually, it is within a few hours after the procedure. Because of the air used during ERCP, you may continue to feel full and pass gas for awhile, and it is not unusual to have soft stool or other brief changes in bowel habits. However, if you notice bleeding from your rectum or black, tarry stools, call your doctor. You should also report vomiting, severe abdominal pain, weakness or dizziness, and fever over 100 degrees. Fortunately, these problems are not common. ERCP is an effective and useful procedure for evaluating or treating a number of different problems of the GI tract. HOW ERCP WORKS . Your doctor may determine that a stone is blocking a common duct. An endoscope will be lowered down your esophagus, through the stomach, and into the duodenum. A small tube will be threaded down into the duct. A dye will be injected backwards through the ducts, allowing X-rays to be taken. Your doctor will be able to remove the stone that is blocking the duct with the endoscope. . . . A Question on ERCP's I read a response from Henry regarding ERCP's that in my opinion explains the procedure to the letter. From the message board. Ann wrote I'm hoping to find some info on the ERCP experience from some folks who have actually been through it. I'm scheduled for an ERCP in two weeks (since I wasn't a heavy drinker and they couldn't find any stones with 2 CAT Scans, or an ultrasound. I'm a bit frightened of the ERCP but don't exactly see any other option. Is it painful? Does it take long to recover from it? Please share any ERCP experiences good or bad. I am a single mother of two. Yours truly, Ann (scaredy cat in Hawaii) Henry's reply: Dear Ann, Hi! I'm Henry from the group and welcome to this fine family of pancreas patients and their caregivers! Sorry you have pancreatitis, but you've come to a nice, friendly supportive group of folks who are happy to help. Some background to introduce my self, and my case may be helpful for you. My goodness, what a terrible thing to have happen on your birthday, and it has to be hard with your children. I'm 38- years-old and was diagnosed with chronic pancreatitis in early 1992 when I was 29. I had been having symptoms of pancreatitis for about eight months or so before the first major acute attack. I've had the Puestow surgery and the Whipple in 1998, and 2000, respectively and gal bladder removal in 1995. Since you've never had an ERCP before I thought you might want to know what the experience is like from a patient's standpoint. I will try my best to describe what the ERCP experience has been like for me to help give you an idea of what it's like if that is helpful for you. I have had over 20 ERCPs over eight years. One reason I had so many was that I was at a teaching hospital, The Medical University of South Carolina (MUSC), as part of a stent study they sere conducting so my treatments were free mostly. In my case they asked me to take nothing by mouth after midnight on the day of the procedure. (NPO) they call it. I came into the clinic in the morning and they took me into a cubicle with a cot in a large room and changed into a gown then they started an I.V. with saline. Then they wheeled me into a small surgical suite and had me lie on my left side and turned down the lights. They will put a nasal, oxygen tube under your nose. Then they began administering the anesthesia. In my case this was usually 100 milligrams of Demerol, or 20-30 milligrams of Morphine, and I forget how many milligrams of Verced (which induces relaxation and can produce an amnesia affect so that hopefully will help you not remember the procedure. They refer to this type of anesthesia as a " twilight sleep. " They want to be able to communicate with you if necessary, but for you to be as comfortable as is possible and relaxed. Since I have a high tolerance to anesthesia, this didn't usually work and I often was awake for the procedure, though somewhat groggy during and after. I worked out a system with the anesthesiologist where I would tap my fingers to signal him if I felt I needed more meds since you cannot speak with the tube down your throat during the ERCP. Next they numb your throat with an unpleasant tasting substance that comes out of a spray bottle. Then they put a mouthpiece in and began introducing the tube that goes into your mouth and down your esophagus into your stomach and past to the small bowel where the pancreatic ducts are located. They will slowly introduce the tube and ask you to begin swallowing the tube. The hardest part of this is getting it past the back of your throat and down into the esophagus. They had some difficulty with me at the ducts because I was born with pancreas divism (Latin for divided pancreas), and my ducts were small. They have a light and a camera on the end of the tube and can pass wires and cutting instruments and stents, (little plastic or rubber tubes that help the pancreas drain), through the tube. The tube is black and smaller in diameter than a garden hose, although I don't know the exact diameter. They do various things such as a cut on the duct to widen it and insert various size stents. I have had some pain with the cuts, (spinterotomies), but the Demerol, (or Morphine) helps some with this pain. They want you to lie very still so they don't risk puncturing bowel. In my case the procedure usually lasted about an hour or so depending on what they were doing on a given procedure. The longest ones were about two hours when they had to remove stones from my pancreas. When they are finished, they would rub my shoulder and say, " It's over Henry, we're finished! You did great! " or some such thing. Then they would help me off the operating table onto a stretcher and wheel me back to the recovery room where I would lie for about an hour. After this it would be time for me to go home unless I had to stay the night. I don't like ERCPs, but when I think about what people had to go through before they had the ERCP such as surgery to widen ducts, remove stones, then it seems like a good alternative. I hope that this helps some. If you have any other questions for me please feel free to e-mail me. There are a lot of good folks here who can answer your questions and know more about this than I do. I always enjoy receiving e-mail and it's great to meet all the new folks who have joined the " family. " I hope you are doing reasonably well and that I will hear from you again soon! There is another pancreas patient named Rich who lives in Hawaii here too. God Bless. Your New Pancreas Pal, Henry, from SC ERCP > I am scheduled for an ERCP with stent placement on Friday. Could > someone please give me an idea of what to expect? I'd appreciate any > info that I could get. Thanks. Cindy > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 6, 2004 Report Share Posted January 6, 2004 Several studies have shown that endoscopic sphincterotomy, stent placement, stricture dilation, and stone extraction are effective in short-term pain relief. The mechanism of this improvement is based on the theory that in a significant number of patients, pain is predicated on increased intraductal pressure. The goal of endoscopic therapy, like surgery, is decompression of the main pancreatic duct. There is a 75% success rate for endoscopic therapy. The advantage of endoscopic therapy is that it is a relatively noninvasive procedure. The endoscopic therapeutic approach should be regarded as a complement to surgery in an integrated management plan for the chronic pancreatitis patient and may predict candidates who will benefit from surgical intervention. Endoscopy is a well-established alternative for the management of a variety of biliary tract diseases and has proven to be useful in the treatment of strictures and other obstructions (stones and protein plugs) that affect patients with chronic pancreatitis. Matching the appropriate endoscopic treatment modality to the appropriate candidate is critical for optimal therapeutic results. Chronic pancreatitis is a new and exciting challenge for the potential of endoscopic therapy. Careful patient selection is crucial for optimal therapeutic results. Endoscopic management of the chronic pancreatitis patient should be considered one management option along with medical, surgical, and percutaneous treatment. Specific recommendations are difficult to make because of the scarcity of literature regarding controlled studies, long-term follow-up, cost efficacy studies, and results of surgical versus endoscopic treatment. Endoscopic pancreatic sphincterotomy has been used to reduce pancreatic duct pressure and to facilitate other procedures such as pancreatic stent placement, tissue sampling, dilation of strictures, or stone removal. The procedure is performed at the major papillain most chronic pancreatitis patients, but at the minor papilla in those patients with pancreas divisum. The papilla is divided maximally for stone extraction, whereas more modest splits suffice for drainage of pancreatic secretions. Two devices may be utilized to perform pancreatic sphincterotomy: a pull-type sphincterotome (with or without a guidewire) (Figure 26A) or a needle knife (Figure 26B). A pull-type sphincterotome (Figure 27) is inserted into the pancreatic duct and a 5-10-mm incision is made in the 1-2 o'clock orientation along the pancreatic duct axis. When the needle knife is employed to perform sphincterotomy, a pancreatic stent is placed first and remains in place following the procedure (Figure 28). Sphincterotomy of the minor papilla is similar to that of major papilla pancreatic sphincterotomy except the sphincterotome is inserted in the 10-12 o'clock orientation and the incision is 4-8 mm long. Sometimes endoscopic pancreatic sphincterotomy is the only technique necessary in patients in whom pancreatic stones are impacted at the papilla or in whom small stones or protein plugs in the main pancreatic duct can spontaneously pass to the duodenum. However, these cases are rare, and pancreatic sphincterotomy is frequently followed by stone removal or stent placement. It is difficult to determine the incidence of complications following endoscopic pancreatic sphincterotomy because the procedure is rarely performed in isolation. Furthermore, definitions of complications are not standardized. Potential complications of endoscopic pancreatic sphincterotomy include bleeding, perforation (cholangitis), stenosis, or restenosis of the sphincter. In addition, this procedure may exacerbate pancreatitis in a small group of patients. [top] Endoscopic treatment strategies are a less invasive alternative to surgical duct decompression procedures and are used to treat strictures resulting from chronic pancreatitis. Sphincterotomy, catheter or balloon dilation, and stent placement are included in these techniques. These techniques are often challenging because of the tortuosity and fibrotic nature of the ductal system. Endoscopic treatment may require multiple sessions to achieve or maintain a positive therapeutic result; therefore, patient compliance is critical. Careful selection of patients is essential for these procedures. Relief of symptomatic pain associated with chronic pancreatitis is the primary rationale for treatment of pancreatic duct strictures. The mechanism of pain in chronic pancreatitis may be multifocal, including elevated parenchymal interstitial pressure resulting from outflow obstruction, fibrosis and inflammation causing nerve entrapment, and pancreatic ischemia. Current studies on chronic pancreatitis report that decompression of the pancreatic duct may have a beneficial effect on preserving organ function. Ductal dilation alone is rarely successful in resolving strictures (Figure 29A) that arise from chronic pancreatitis and is, therefore, often accompanied by stenting. A guidewire is passed to the tail end of the pancreas and dilating bougies or balloon catheters are advanced over the wire to dilate the stricture (some patients may require sphincterotomy to facilitate endoprosthesis insertion). Passage of the deflated balloon through the stenosis (Figure 29B) may be difficult and require preliminary bougienage. After insertion the balloon is filled (Figure 29C) with contrast medium to a specified pressure utilizing an inflation device for a variable duration, enlarging lumen diameter (Figure 29D). Usually a stent is inserted extending beyond the previous stricture site to maintain patency (Figure 29E). Standard pancreatic stents are plastic tubes with holes along the sides at 1-cm intervals for better side branch pancreatic juice flow. The stent is anchored in place by pigtails or flaps. The diameter and length of the stent are subjective, depending upon the location and severity of the stricture as well as the duct size but generally stent diameter should not be greater than the size of the downstream duct. The stent is inserted coaxially over the guidewire after the dilation is completed and the dilating catheter removed. Frequently, shorter stents are used to decompress the duct (Figure 30) in the head of the pancreas. The stent is usually left in place for a short time. Prolonged stent usage may induce changes of chronic pancreatitis. The results of stent insertion for pancreatic ductal strictures in chronic pancreatitis patients have proven to be successful. Stent placement decompresses the ductal system and maintains the opening. Pain relief is reported to be in the 75-95% range for the short term. Beneficial results have persisted in many patients after removal of pancreatic stents. Improvement also correlated with a reduction in pancreatic ductal diameter and stricture resolution. [top] Duct stones, which may obstruct the flow of pancreatic juices, are a common finding in severe chronic pancreatitis. Endoscopic extraction, alone or combined with extracorpeal shock wave lithotripsy, has been useful in the treatment of ductal obstructions. Extracorpeal shock wave lithotripsy (ESWL) has been used to fragment calcified pancreatic stones before extraction. ESWL is not necessary with protein plugs (noncalcified stones), which are usually soft and pliable. During ESWL 100 shock waves per minute are delivered at an electric power of approximately 20 kV during a 30-minute session. A mean of 1,500 shock waves per stone is usually required. Fluoroscopic monitoring evaluates quality of stone fragmentation. A small Dormia Basket is used to remove stone fragments. The closed Dormia basket is introduced and extended beyond the calculi. It is opened and traps the stone (Figure 31). The basket is tightened, securing the stone, and withdrawn. A sphincterotomy may be required to facilitate passage through the papilla. Stone fragmentation by fluoroscopically guided ESWL can be achieved in most cases; however, complete ductal clearance is less effective. Main pancreatic ductal clearance was the single factor identifying pain relief in multivariate analysis. In the short term, most patients remained pain free. There are many patients with chronic pancreatitis who have pancreatic stones without pain. In this group of patients, no treatment is recommended. [top] I know the pictures wont come thru, so you can go to http://www.top5plus5.com/Pancreas/PROCEDURES/THERAPEUTIC%20ENDOSCOPY.htm to see the pics that belong with the text. I hope this finds you and yours well Mark ERCP > I am scheduled for an ERCP with stent placement on Friday. Could > someone please give me an idea of what to expect? I'd appreciate any > info that I could get. Thanks. Cindy > > > > > > > Quote Link to comment Share on other sites More sharing options...
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