SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 3 | 57 ERCP | A GUIDE FOR NURSES AND ASSISTANTS | Re-printed with permission PA R T 5 : S T R I C T U R E S Strictures in the bile ducts can be malignant (cancerous) or benign. They can be caused by tumours pressing in from the outside of the duct, or growing within the duct. Benign strictures can be single or multiple. They can be caused by scar tissue in the head of the pancreas, a stone pressing in from the gall bladder, ischaemia ie reduction in the blood supply to the bile duct itself (seen after surgery for cholecystectomy or at the biliary anastomosis after a liver transplant) or due to inflammatory conditions (eg PSC or IgG4 disease). I’m not going to go through all the causes of biliary (or pancreatic) strictures here but the management of them at ERCP follows some basic principles. If the stricture is causing jaundice by blocking the bile duct then access should be gained by inserting a stent to allow bile to flow. The different types of stent, when to use them and how to deploy them is dealt with in the next chapter. The bile held back in the liver is usually sterile ie there are no bacteria in it. Once anything (contrast, guide wire, cannula) is passed into that bile there is the potential for infection to occur. There is a maxim in medicine I was taught which is: A duct can be blocked or infected, but never both. This applies to any duct in the body - ureter, fallopian tube, tear duct or bile duct. If there is infection in a closed duct, then the patient will quickly become unwell in a potentially life- threatening way. Cholangitis (infection of the bile ducts) in the presence of jaundice (so the duct is blocked) carries a mortality of up to 35% in the elderly, so this is one of the only times an ERCP is indicated out-of-hours. What it also means is that if ERCP is undertaken and a stricture is passed, then a stent has to be placed to prevent risk of life-threatening cholangitis, and antibiotics have to be given if drainage is not secured. Brushings are taken pretty much routinely whenever there is a stricture. The exceptions to this are when the nature of the stricture is already known. Traditionally it is thought that the yield of brushings is quite low (less than 40% pick up a cancer when there is one) and therefore a brush which does not show cancerous cells can’t be trusted, and it is true that a negative test is not useful. But a positive test can be helpful to guide chemotherapy when indicated. At RGH we did an audit some years ago which showed that 68% of our brushings showed cancerous cells when a cancer was present, so good brushing technique does make a difference. 31