SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 3 | 63 ERCP | A GUIDE FOR NURSES AND ASSISTANTS | Re-printed with permission PA R T 7 : MANAG EME N T O F C OMP L I C A T I ON S Failure to complete ERCP can occur for a number reasons as mentioned in the chapter on consent. The decision to halt ERCP can be difficult for a number of reasons, however the patient’s safety and what is right for them outweighs other factors such as waiting times, lunchbreaks, statistics, ego, training needs and so forth. It is easy to get caught up in the procedure itself and almost forget that there is a patient involved at all. The patient must be reassured that there is an advocate in the room looking after their interests whilst they are sedated and that can be anyone present. Other complications occur as a part of the nature of the procedure. Training in ERCP tries to prevent such complications, but if there’s one thing I have learned over the years carrying out ERCP and watching colleagues who are considered to be world leaders in ERCP, it’s that complications happen to everyone. Haemorrhage Bleeding is probably the commonest complication. This occurs usually at the time of sphincterotomy, either because the cut has been extended too far, or there is an unexpected blood vessel that starts to leak. Occasionally bleeding can occur during stone extraction, balloon dilatation of the ampulla, or at the time of needle knife fistulotomy. The quickest way to manage bleeding is to quickly change pedals and press the blue pedal on the floor to deliver a short one second burst of pure coag power to the area where the blood is seen to come from. If this doesn’t work the visibility may deteriorate quite rapidly, so the important thing is to ensure that the guide wire is in the CBD to guide other instruments. Then the following methods may be tried: • Washing with cold water - this is surprisingly effective for small bleeds. Filling the duodenum with 50-100ml of water and looking at the ampulla under water also helps to show if there is ongoing blood loss as it may be hard to see what is clot and what is washed off blood. Squirting water down a cannula directly onto the bleeding vessel can work as well. • Injecting with adrenaline - this can be done but small amounts (0.5ml) are used and it is difficult to extend the needle in a duodenoscope. Sometimes just squirting the adrenaline solution directly onto the bleeding surface works. • Balloon tamponade - if using a dilatation balloon, this can be inserted back into the bile duct and re-inflated to exert pressure onto the bleeding area. It is held for 60 seconds. If 37