SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 3 | 46 ERCP | A GUIDE FOR NURSES AND ASSISTANTS | Re-printed with permission E R C P : T H E P RO C E DU R E I T S E L F PA R T 1 : I N T U B A T I ON It is at this point that the patient has just been sedated, and is calm and still. The operator inserts the endoscope into the mouth of the patient and the patient starts to cough and gag. As mentioned before, the patient is usually quite heavily sedated but may be slightly disinhibited and unable to process the sensation they are experiencing. It is likely that this is the only part of the procedure that they can feel as sensory nerves are most sensitive around the airway but once this area is passed the patients will often settle down. Gentle reassurance (not using the patients name, naturally) is all that is required. People learning ERCP often find this part of the procedure difficult as the patient is often face-down slightly, and the picture on the screen is confusing as the camera is positioned on the side of the scope rather than the end which is more familiar. Once in the oesophagus (which appears smooth on the screen) the scope is passed into the stomach, which appears as longitudinal folds, known as ‘rugae’. If a hiatus hernia is present this may cause the scope to curl up inside it which is dangerous as well as painful for the patient and requires a bit of manipulation to negotiate. The rugae all lead to the opening at the bottom of the stomach, the pylorus, and again the scope is negotiated down to this point and into the duodenum (which looks fluffy on the screen, and has transverse folds known as ‘haustra’). At this point the scope is given a final push, a twist to the right and the outer wheel is turned forward and locked into position to keep the endoscope from falling back into the stomach and gently withdrawn to approximately 60cm at the teeth, whereupon the ampulla will usually come into view. At this point Buscopan is administered to stop the duodenum from contracting and sometimes the duodenum needs to be washed with Infacol and water to clear any bubbles away. Generally this process should not take more than a minute or two, but is the main point of discomfort for the patient, particularly if there is prolonged pushing or manipulation required. There have been times when I have not been able to find my way out of a hiatal hernia, the stomach has been a strange shape or there is obstruction from ulceration or invading tumour into the duodenum. Even if the duodenum is reached there are times when the ampulla can not be found or is hidden under a haustral fold. 2 0