SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 3 | 64 ERCP | A GUIDE FOR NURSES AND ASSISTANTS | Re-printed with permission an extraction balloon is used, it is inflated in the lumen to maximum diameter and pressed up against the ampulla for 60 seconds. You can actually see the bleeding point through the clear balloon sometimes. • Haemostatic agents - Haemospray used to be used (at the time of writing it was recalled due to a problem with the gas canister, but I’m sure it will be back). Other powders are available too. If successfully deployed it is very effective at stopping bleeding, but the duodenum looks like an explosion in a cake factory and the ERCP has to be halted. Purastat is a fabulously expensive clear gel which is spread on to the bleeding vessel and works very well also, but the visual field has to be relatively clean and dry for these agents to work. • Clips - can be used, but care has to be taken to avoid closing off the bile duct or pancreatic ducts. Leaving a clip in place near the bleeding point is a useful trick to guide interventional radiology (see below). • FCSEMS - this is a favoured method of mine if the bleeding looks like it is not stopping, or the visual field is obscured, or the patient is restless and it looks as if time is running out. A 6cm fully covered stent can be placed under Xray vision in a matter of minutes, and this will press up against the bleeding point and often staunches the blood loss. If there are stones in the bile duct, care must be taken not to trap stones between the stent and the duct wall, and a pigtail stent is left up inside the metal stent to prevent stones getting lodged. • Interventional radiology - these days surgeons rarely get involved to open patients up and sew up bleeding vessels. At RGH we are fortunate to have extremely skilled radiologists who can pass minuscule catheters into (or near) the very vessels that are bleeding via the femoral artery. Having a clip in place helps them see where to go. Glue or floppy wires are injected into the vessel to stop it bleeding. This is very much a last resort when all the above have failed. If the bleeding is thought to be significant careful observations of pulse and blood pressure must be kept. At the very least IV fluids should be started. The patient may need to be admitted overnight for observation. If the bleeding is thought to have been controlled and the patient is due to be discharged, they must be warned that bleeding may re-occur 7 days post ERCP and they should contact the unit or attend hospital if they pass melaena or feel unwell. Warfarin and other blood thinners are usually withheld for 48 hours if a minor bleed has occurred but this advice should be cleared with the operator. 3 8