SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 3 | 33 ERCP | A GUIDE FOR NURSES AND ASSISTANTS | Re-printed with permission WH E N I S AN E R C P N E C E S S A RY ? Essentially when the bile ducts are blocked, it may be that the best way to unblock them is by carrying out an ERCP. In addition, sometimes it is necessary to perform ERCP when there has been a bile leak following an operation to remove the gall bladder. As outlined in the previous chapter, bile will continue to be made and stored in the gall bladder as long as the sphincter at the bottom of the bile duct is shut. If the gallbladder has been removed, and the clips holding the cystic duct fall off, or cannot be placed for another reason, bile leaks out into the abdominal cavity. In this situation an ERCP is necessary to place a small tube into the CBD (a stent) to hold the sphincter open and allow the bile to flow into the bowel instead of up the cystic duct. This allows the leaking bile duct to heal up and the bile to stop leaking into the abdominal cavity. Bile ducts can be blocked by gallstones or tumours : Gallstones are usually formed in the gall bladder over time. It is thought that this is due to crystals of cholesterol or pigment in the bile forming a small amount of grit or sludge and this comes together over time to form a stone. They are very common, particularly in older women (about 1 in 5 women over 50 will have gallstones, although most don’t cause any trouble at all) but can occur at any age, and in men as well. When a gallstone is very small it can pass into the CBD and rest against the sphincter. It may pass through on its own (this is extremely painful), it may stay there causing a blockage, or (particularly in the elderly) stay in the CBD and grow over many years, sometimes to an enormous size, or form more stones around it. Very occasionally the gallstone stays in the gall bladder and becomes so large it presses on the CBD from the outside, blocking it off. This is called Mirizzi’s syndrome, and causes ERCPists and surgeons a lot of headaches! Tumours affecting the head of the pancreas or bile ducts themselves (cholangiocarcinoma) tend to be very aggressive and incurable. These patients often become jaundiced and their skin becomes terribly itchy as a result, so ERCP is used to insert stents to allow bile to flow normally past the stricture caused by the invading tumour. A small brush can also be passed up into the stricture to scrape off a few cells so that a diagnosis can be made. Rarely a tumour can form on the ampulla itself and cause jaundice but these are normally (but not always) benign and slow growing. 7