Endoscopic Retrograde Cholangiopancreatography (ERCP): Indications, Patient Preparation and Complications

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic technique in which a specialised side-viewing upper endoscope is guided into the duodenum, allowing for instruments to be passed into the bile and pancreatic ducts. These are opacified by injection of a contrast medium, thereby permitting their radiologic visualization and allowing for a variety of therapeutic interventions. It is a relatively complex endoscopic procedure since it requires specialised equipment and has a long learning curve to develop proficiency. Its benefits in the minimally invasive management of biliary and pancreatic disorders are challenged by a higher potential for serious complications than any other standard endoscopic technique.¹Loperfido S, Costamagna G. Endoscopic retrograde cholangio pancreatography: Indications, patient preparation, and complications. Available from: http://www.uptodate.com/contents/endoscopicretrograde-cholangiopancreatography-indications-patient-preparationand-complications #H70259351 [Accessed on 6th July 2016].

INDICATION FOR ERCP

The American Society for Gastrointestinal Endoscopy (ASGE) has published guidelines regarding the role of ERCP in biliary tract and pancreatic diseases.

Indications for Biliary Disease Include the Following:

Assessment and treatment of biliary obstruction secondary to choledocholithiasis – Precholecystectomy. ERCP may be indicated when persistent or worsening jaundice, persistent or worsening pancreatitis, or ascending cholangitis is present.
Treatment of choledocholithiasis identified during cholecystectomy with intraoperative cholangiography or CBD exploration without stone extraction.
Assessment and treatment of bile duct strictures – Malignant strictures, benign strictures, congenital bile duct abnormalities, etc.
Postoperative complications.
Assessment and treatment of postoperative biliary leaks.
Assessment and treatment of selected patients with sphincter of Oddi dysfunction (SOD), with limited benefit in modified Milwaukee classification type III patients.

Indications for Pancreatic Disease Include the Following;

Assessment and possible treatment in patients with an unknown underlying cause of recurrent acute pancreatitis.
Assessment and treatment of symptomatic strictures associated with chronic pancreatitis.
Assessment and treatment of symptomatic pancreatic duct stones.
Treatment of symptomatic pancreatic pseudocysts or benign pancreatic fluid collections.

Indications for Diagnosis of Pancreatic Malignancies Include the Following:

Pancreatoscopy
Bile duct brushing and biopsy
Intraductal ultrasonography

Indications for Ampullary Disease Include the Following:

Assessment and treatment of ampullary adenomas
Assessment of ampullary malignancy

CONTRAINDICATIONS FOR ERCP

Like any invasive procedure, there are circumstances in which ERCP should not be performed.

Relative contraindications include:³Silviera ML, Seamon MJ, Porshinsky B, et al. Complications Related To Endoscopic Retrograde Cholangio-pancreatography: A Comprehensive Clinical Review. J Gastrointestin Liver Dis. 2009: 18(1): 73-82.

Portal hypertension with oesophageal and/or gastric varices.
Acute pancreatitis except gallstone pancreatitis (this may change).
Recent myocardial infarction and/or severe cardiopulmonary disease unless the procedure is life-saving (e.g., cholangitis).
Repeated failed attempts at ERCP therapy when alternatives are available. Patient cannot be adequately sedated.
Anaphylactic reaction to radiographic contrast although this usually refers to reactions after intravenous contrast and there is little to no evidence that ERCP carries the same risk.
ERCP with sphincterotomy or ampullectomy is relatively contraindicated in coagulopathic patients (international 2 normalised ratio [INR] >1.5 or platelet count < 50,000/μL).
Structural abnormalities of the oesophagus, stomach, or small intestine.²Malas A. Endoscopic Retrograde Cholangiopancreatography. Available rom:http://emedicine. medscape.com /article/1829797-overview [Accessed on 6th July 2016].

Absolute contraindications are the following:³Silviera ML, Seamon MJ, Porshinsky B, et al. Complications Related To Endoscopic Retrograde Cholangio-pancreatography: A Comprehensive Clinical Review. J Gastrointestin Liver Dis. 2009: 18(1): 73-82.

Patient refusal to undergo the procedure; unstable cardiopulmonary, neurologic or cardiovascular status and existing bowel perforation.
Pharyngeal or oesophageal obstruction (unless these can be treated simultaneously).
Severe uncorrected coagulopathy.
Inadequate indication, e.g., abdominal pain of unknown cause.
Known or suspected perforation.
Consent cannot be obtained, unless deemed an emergency.
The risks of the procedure outweigh the potential benefits.
Altered anatomy (Roux-en Y, Billroth II and pancreaticoduodenectomy) without the necessary skills and tools.

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PATIENT PREPARATION

¹Loperfido S, Costamagna G. Endoscopic retrograde cholangio pancreatography: Indications, patient preparation, and complications. Available from: http://www.uptodate.com/contents/endoscopicretrograde-cholangiopancreatography-indications-patient-preparationand-complications #H70259351 [Accessed on 6th July 2016].

Case History: Detail case history which includes; medical history and current medication. Investigation like blood tests, other laboratory tests etc. Patient should ask to fill the consent form.

Instruction to the Patient: A patient is asked not to eat or drink anything for six to eight hours before the test. It is important for the stomach to be empty to allow the endoscopist to visualize the entire area, and to decrease the chance of vomiting during the procedure. Patient needs a friend or family member to escort them to home after the examination. This is because the medications used for sedation can impair reflexes, judgment and ability to drive (similar to the effects of alcohol).

Medications: Patient is instructed to adjust the dose of medications or stop taking specific medications prior to the examination. Most drugs can be continued as usual, but some medications need to be discontinued for several days. All medications and dietary supplements should be discussed with the provider, since some are more important than others.

Pregnancy: In case of pregnancy, the ERCP should be postponed until after childbirth if possible, but if the procedure is urgent, it can be done safely during pregnancy.

Sedation: The most common sedation protocol includes the use of a nurse-administrated or physician-administered intravenous (IV) benzodiazepine (e.g., midazolam) along with an IV narcotic (e.g., meperidine). For patients in whom deep sedation is required, general anesthesia (e.g., propofol) should be considered.

Antibiotics: Antibiotics should be considered for patients who are at high-risk for developing infective endocarditis (i.e., those with prosthetic cardiac valves, previous bacterial endocarditis, surgically constructed systemic pulmonary shunts, complex cyanotic congenital heart disease) and for patients at risk for artificial prosthetic implant infections (i.e., synthetic vascular or joint prostheses placed within one year prior to ERCP). In addition, patients with primary sclerosing cholangitis predicted incomplete ductal drainage, biliary obstruction (i.e., hilar tumors) and pancreatic pseudocysts are at higher risk for infection and should receive prophylactic antibiotics before the ERCP. In cases where incomplete drainage is not predicted but does occur, antibiotics can be given right after the ERCP. Antibiotics should be continued for 48-72 hours in this high-risk patients.³Silviera ML, Seamon MJ, Porshinsky B, et al. Complications Related To Endoscopic Retrograde Cholangio-pancreatography: A Comprehensive Clinical Review. J Gastrointestin Liver Dis. 2009: 18(1): 73-82.

Antispasmodics: Antispasmodics are the drugs that relax the smooth muscle of the gut, used to treat indigestion not associated with peptic ulcers, irritable bowel syndrome and of diverticular disease. Broadly, the anti-cholinergics /antispasmodics are used to relieve cramps or spasms of the stomach, intestine and bladder.⁴Kulkarni K.S. Antispasmodics- New Perspectives. JAMA India 119-121. 2001. Drotaverine may reduce abdominal pain and spasm in patients with different gastrointestinal disorders. During ERCP procedure duodenal peristalsis can make cannulation of the papilla and the necessary therapeutic procedures difficult. Sometimes intravenous hyoscine-N-butylbromide is often used during ERCP to inhibit duodenal motility and enhance cannulation in some countries. However, the pharmaceutical agent is occasionally associated with serious complications such as cardiovascular events or anaphylactic shock. Drotaverine hydrochloride is an analogue of papaverine with smooth muscle relaxant properties. It is a non-anticholinergic antispasmodic, which selectively inhibits phosphodiesterase IV and is accompanied by a mild calcium channel-blocking effect. Adverse effects with Drotaverine hydrochloride, such as hypotension, vertigo, nausea, and palpitation, are generally not seen. Intravenous drotaverine hydrochloride might be a feasible antimotility alternative to intravenous hyoscine-N-butylbromide in ERCP. Drotaverine hydrochloride can help in successful cannulation of papilla during ERCP procedures. Hyoscine-Nbutylbromide being anticholinergic may affect the ocular, urinary and salivary systems.⁵Drotaverine Hydrochloride VersusHyoscine-N-butylbromide for Duodenal Antimotility During Endoscopic Retrograde Cholangiopancreatography (ERCP). Available from: www.clintrials.gov/ct2/show/NCT00731198 [Accessed on 6th July 2016].

To compare effect by Drotaverine hydrochloride before endoscopic retrograde cholangiopancreatography (ERCP) in suppression of duodenal motility, and to investigate effectiveness and safety of drug application before ERCP a study was performed. A total of 48 patients receiving ERCP were randomly divided into experimental group and control group, with 34 cases in each group. The control group received conventional therapy. The experimental group received additional 40 mg drotaverine hydrochloride in 30 min. Observation was made on duodenal motility score and intubation success rate. All patients received successful operation, and the difference of average duodenal motility score, average operation time and intubation time had statistical significance (p = 0.05). The study shows that oral administration of Drotaverine hydrochloride before ERCP shows good spasmolysis effect and reduces intubation and operation time. It can be taken as common drug before operation.⁶Hong-min X; Xin-kui Y; Jia-xuan L. Research of drotaverine applied before 48 ERCP case. China Practical Medicine. 2016: 11(14).

MONITORING DURING AND AFTER ERCP

Position of the Patient During ERCP: The prone position is standard for ERCP as it offers the best access for anteriorposterior fluoroscopic imaging. The supine position is indications for comorbid conditions, pregnancy and any factor that necessitates closer airway monitoring during the procedure.

Recovery after ERCP: The most common discomfort after the examination is a feeling of bloating as a result of the air introduced during the examination but this usually resolves quickly.

COMPLICATIONS

ERCP is a safe procedure and serious complications are uncommon. If complications do occur, they are usually mild and may include the following:

Specific Complications

Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis (PEP): Acute pancreatitis occurs in approx – imately 5% of diagnostic procedures and 10% of therapeutic procedures also called as Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis (PEP) which is mild abdominal pain for more than 24 hours after the procedure and levels of serum pancreatic enzymes three times above normal.⁷Pannu HK, Fishman EK. Complications of Endoscopic Retrograde Cholangiopancreatography: Spectrum of Abnormalities Demonstrated with CT. Radio Graphics 2001; 21:1441-1453. PEP is defined as new-onset or worsening abdominal pain with the elevation of serum amylase of 3 or more times the upper limit of normal at 24 hours postprocedure and the need for more than 2 days of pancreatitis-related hospitalization.8 Patient selection is a critical step in preventing PEP. Female sex, young age, clinical suspicion of SOD, a history of prior PEP, and the absence of chronic pancreatitis were noted to be risk factors in multivariate analyses.⁸Szary NM, Al-Kawas FH. Complications of Endoscopic Retrograde Cholangiopancreatography: How to Avoid and Manage Them. Gastroenterology & Hepatology. 2013: 9 (8). Post-ERCP pancreatitis usually evolves over 2–6 hours and manifests as epigastric or back pain and nausea.

Risk Factors: Risk factors for post- ERCP pancreatitis are sphincter of Oddi dysfunction and young age. A higher rate of pancreatitis is caused by increased manipulation around the papilla and multiple injections of the pancreatic duct. Pancreatitis is also more likely to develop in patients with contrast material visualized in the renal collecting system on a plain radiograph obtained at the conclusion of the procedure.⁷Pannu HK, Fishman EK. Complications of Endoscopic Retrograde Cholangiopancreatography: Spectrum of Abnormalities Demonstrated with CT. Radio Graphics 2001; 21:1441-1453.

Management: Management of post-ERCP pancreatitis is similar to management of pancreatitis due to other causes. General guidelines for performing CT include:⁷Pannu HK, Fishman EK. Complications of Endoscopic Retrograde Cholangiopancreatography: Spectrum of Abnormalities Demonstrated with CT. Radio Graphics 2001; 21:1441-1453.

Cases in which the clinical diagnosis is not definite.
Patients with hyperamylasemia, severe clinical pancreatitis, abdominal distention, tenderness, fever, or leukocytosis.
Patients whose condition does not improve within 72 hours of commencing conservative treatment.
Patients who develop an acute change after initial improvement in their condition.

The purpose of performing CT is to diagnose possible necrosis and fluid collections and to guide needle aspiration or 7 drainage. The use of prophylactic pancreatic duct stents is highly recommended in patients at predicted high risk for PEP.⁸Szary NM, Al-Kawas FH. Complications of Endoscopic Retrograde Cholangiopancreatography: How to Avoid and Manage Them. Gastroenterology & Hepatology. 2013: 9 (8).

Bleeding: Haemorrhage from ERCP usually occurs with sphincterotomy.⁷Pannu HK, Fishman EK. Complications of Endoscopic Retrograde Cholangiopancreatography: Spectrum of Abnormalities Demonstrated with CT. Radio Graphics 2001; 21:1441-1453. Postsphincterotomy bleeding has been reported in up to 2% of ERCP cases. The haemorrhage can be immediate but is delayed in most cases and is arterial or venous. Arterial bleeding can require surgery or embolization. Venous bleeding is treated during ERCP with local epinephrine, balloon occlusion or heat therapy. Patients are monitored for further bleeding with laboratory tests. Delayed bleeding occurs 24 or more hours after the procedure due to sloughing of the coagulum or restarting anticoagulation. Freeman et al., defined significant haemorrhage as clinical evidence of bleeding with melena or haematemesis with an associated decrease in haemoglobin concentration of at least 2 g/dL or need for a blood transfusion. Delayed haemorrhage is treated with repeat endoscopy and epinephrine injection, embolisation or surgery.⁸Szary NM, Al-Kawas FH. Complications of Endoscopic Retrograde Cholangiopancreatography: How to Avoid and Manage Them. Gastroenterology & Hepatology. 2013: 9 (8).

Although the assessment of bleeding after ERCP is most often based on its clinical manifestations, an objective classification has been defined as follows:

Mild bleeding – haemoglobin drop
Moderate bleeding transfusion requirements
Severe hemorrhage – transfusion requirements >4 units of PRBCs or intervention(Figure 2).³Silviera ML, Seamon MJ, Porshinsky B, et al. Complications Related To Endoscopic Retrograde Cholangio-pancreatography: A Comprehensive Clinical Review. J Gastrointestin Liver Dis. 2009: 18(1): 73-82.

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Risk Factors: Patients with coagulopathy and vascular anatomic variants are at increased risk.

Management: Treatment options for post-sphincterotomy bleeding include balloon tamponade, injection of dilute epinephrine solution through a sclerotherapy needle, heater probe or bipolar coagulation and/or the placement of endoscopic clips. First-line treatment of post-sphincterotomy bleeding is flushing the site with 1:100,000 epinephrine solution, followed by a direct injection of 1:10,000 epinephrine if bleeding continues. Injection of epinephrine solution around the bleeding site or at the apex of the sphincterotomy incision is the most common method of haemostasis and is quite effective. When injection fails to stop the bleeding, or when there are contraindications to its use, monopolar electrocautery can be applied to the bleeding site. The insertion of fully covered self expandable metal stents (SEMS) into the bile duct can also arrest bleeding. When endoscopic treatment fails and haemodynamically significant bleeding persists, the patient may need to undergo selective mesenteric angiography with embolization or even open surgery.⁸Szary NM, Al-Kawas FH. Complications of Endoscopic Retrograde Cholangiopancreatography: How to Avoid and Manage Them. Gastroenterology & Hepatology. 2013: 9 (8).

Infection: One of the most serious post-ERCP complications is cholangitis leading to subsequent septicaemia. Enteric bacteria enter the biliary tree by the haematogenous route or following endoscopic or radiologic manipulation. Improperly disinfected endoscopes and accessories may also introduce infection into the biliary tree. The most common organisms responsible for infection after ERCP are the Enterobacteriaceae (especially Escherichia coli and Klebsiella species), alpha haemolytic Streptococci, Pseudomonas aeruginosa, Enterococcus and Staphylococcus epidermidis. In most patients with acute cholangitis, a single organism is isolated from blood cultures.

Risk Factors: Risk factors for post-ERCP infection include the use of combined percutaneous and endoscopic procedures, stent placement in malignant strictures, low case volume incomplete or failed biliary drainage and presence of jaundice.⁸Szary NM, Al-Kawas FH. Complications of Endoscopic Retrograde Cholangiopancreatography: How to Avoid and Manage Them. Gastroenterology & Hepatology. 2013: 9 (8).

Management: Prevention and/or reduction of the risk of post-ERCP infectious complications can be achieved by judicious use of preprocedural antibiotics and intraprocedural steps, such as minimizing or avoiding contrast injection in patients with known biliary obstruction or cholangitis, endoscopic decompression, including the placement of a biliary stent or nasobiliary drain when complete drainage cannot be achieved, and prompt percutaneous drainage if endoscopic drainage is not possible or incomplete. Prophylactic preprocedural antibiotics should be given to patients with jaundice and suspected mechanical obstruction.⁸Szary NM, Al-Kawas FH. Complications of Endoscopic Retrograde Cholangiopancreatography: How to Avoid and Manage Them. Gastroenterology & Hepatology. 2013: 9 (8).

Perforation: Perforation of the bile duct, pancreatic duct, or duodenum is reported in less than 1% of patients undergoing ERCP. Mallery et al described three distinct types of ERCP-related perforations³Silviera ML, Seamon MJ, Porshinsky B, et al. Complications Related To Endoscopic Retrograde Cholangio-pancreatography: A Comprehensive Clinical Review. J Gastrointestin Liver Dis. 2009: 18(1): 73-82.

Guidewire-related perforations
Peri-ampullary perforations during sphincterotomy; and
Perforations that are remote from the papilla

Bile duct perforation can be a result of guidewire or sphincterotome manipulation and, if significant, leads to development of an encapsulated collection of bile (a biloma). Duodenal perforations during ERCP can be retroperitoneal (usually from sphincterotomy or guidewire manipulation) or free/intraperitoneal (typically resulting from endoscopic trauma or stent impaction).⁸Szary NM, Al-Kawas FH. Complications of Endoscopic Retrograde Cholangiopancreatography: How to Avoid and Manage Them. Gastroenterology & Hepatology. 2013: 9 (8).

Risk Factors: Risk factors for ERCP-related perforation include the performance of sphincterotomy, the presence of Billroth II anatomy, intramural injection of contrast, performance of biliary stricture dilatation, presence of sphincter of Oddi dysfunction, long duration of the procedure.³Silviera ML, Seamon MJ, Porshinsky B, et al. Complications Related To Endoscopic Retrograde Cholangio-pancreatography: A Comprehensive Clinical Review. J Gastrointestin Liver Dis. 2009: 18(1): 73-82.

Management: Management is usually guided by clinical symptoms and computed tomography (CT) findings. Suspected luminal perforation seen during the procedure should be immediately closed, if possible, using endoscopic clips (Figure 2), followed by a postprocedural CT scan with oral contrast to look for any evidence of leakage. Bile duct or pancreatic duct perforation/leaks are usually managed with stent placement and further observation. If a biloma develops, antibiotics and percutaneous drainage in addition to endobiliary stent placement is a key in management. Retroperitoneal perforations related to guidewire use or the performance of sphincterotomy may be initially treated with broad-spectrum antibiotics, biliary and duodenal decompression (i.e., via nasobiliary and nasogastric tubes). Clinical evaluation, abdominal CT scanning (with oral contrast to look for extravasation) and early surgical consultation are essential elements in the successful management of post- ERCP duodenal perforations.⁸Szary NM, Al-Kawas FH. Complications of Endoscopic Retrograde Cholangiopancreatography: How to Avoid and Manage Them. Gastroenterology & Hepatology. 2013: 9 (8).

NONSPECIFIC COMPLICATIONS

Conscious Sedation-Related Complications:⁹Amornyotin S. Sedation-related complications in gastrointestinal endoscopy. World J Gastrointest Endosc. 2013 Nov 16; 5(11): 527-533. Intravenous benzodiazepines along with an IV narcotic (e.g., midazolam, diazepamcan, meperidine, fentanyl, etc) occupy opioid receptor sites within the brain and cause respiratory depression. Drug induced hypoventilation may cause both hypoxemia and carbon dioxide retention.

Management of Over-Sedation: Stimulate the patient, both verbally and/or by light shaking, to wake up and take deep breaths. If the patient is not responding, then a benzodiazepine antagonist such as flumazenil and/or opioid antagonist such as naloxone may be required. The airway may need to be protected with chin lift, jaw thrust and, if necessary, airway or laryngeal mask.

Complication related to Propofol: The potential risk of propofol administration in patients with a known allergy against soy beans and egg should be stated. In addition, propofol usually produces a burning sensation at the injection site. Cardiovascular effects of propofol include decreases in cardiac output, systemic vascular resistance and arterial pressure. A fall in heart rate and/or cardiac stroke volume will also lower blood pressure.⁹Amornyotin S. Sedation-related complications in gastrointestinal endoscopy. World J Gastrointest Endosc. 2013 Nov 16; 5(11): 527-533.

Prevention of complication related to Propofol: The computer-assisted personalized sedation (CAPS) system designed for physicians to provide minimal to moderate sedation levels with propofol. The system continuously monitors and records patient parameters, including oxygen saturation, blood pressure, heart rate, respiratory rate, end tidal carbon dioxide and patient responsiveness.

CONTRAST ALLERGY

Cardiopulmonary complications:³Silviera ML, Seamon MJ, Porshinsky B, et al. Complications Related To Endoscopic Retrograde Cholangio-pancreatography: A Comprehensive Clinical Review. J Gastrointestin Liver Dis. 2009: 18(1): 73-82. Cardiopulmonary depression is the most common complication associated with endoscopy and is usually associated with the use of sedation. Hypotension, hypertension, cardiac arrhythmias, myocardial ischemia, respiratory depression, airway obstruction, hypoxia, pulmonary aspiration was associated with post- ERCP pancreatitis.

Carbon dioxide insufflation versus air insufflation:⁹Amornyotin S. Sedation-related complications in gastrointestinal endoscopy. World J Gastrointest Endosc. 2013 Nov 16; 5(11): 527-533. Patients under sedation must have physiological monitoring which includes heart rate, blood pressure, oxygen saturation and an expired concentration of carbon dioxide. Carbon dioxide insufflation during ERCP significantly reduces postprocedural abdominal pain and distension.

Post-sphincterotomy Strictures:³Silviera ML, Seamon MJ, Porshinsky B, et al. Complications Related To Endoscopic Retrograde Cholangio-pancreatography: A Comprehensive Clinical Review. J Gastrointestin Liver Dis. 2009: 18(1): 73-82. rotomy site causes mechanical obstruction to bile flow and patients can present with cholangitis and/or obstructive jaundice months to years after the index ERCP. Transjejunal and transgastric approaches to ERCP were utilised in the setting of suspected papillary stenosis. If stenosis is at right the duodenal wall (type 1 stenosis), then simply extending the prior sphincterotomy will relieve the narrowing. However, if the stenosis extends deep into the bile duct (type 2 stenosis), then sphincterotomy may not be definitive treatment and stricture dilation is needed. Patients with postsphincterotomy strictures were successfully treated with sphincterotome stricturoplasty in which electrocautery through the cutting wire of a sphincterotome (papillotome) was used to incise the biliary stricture. This technique differs from standard endoscopic sphincterotomy, during which one half to two thirds of the length of cutting wire remains outside the papilla.

Miscellaneous complications⁹Amornyotin S. Sedation-related complications in gastrointestinal endoscopy. World J Gastrointest Endosc. 2013 Nov 16; 5(11): 527-533.

Nausea and vomiting
Paradoxical reactions: Paradoxical reactions are characterized by combativeness, agitation, talkativeness, disorientation and tachycardia.

Late complications¹Loperfido S, Costamagna G. Endoscopic retrograde cholangio pancreatography: Indications, patient preparation, and complications. Available from: http://www.uptodate.com/contents/endoscopicretrograde-cholangiopancreatography-indications-patient-preparationand-complications #H70259351 [Accessed on 6th July 2016].

The following symptoms should be reported immediately:

Severe abdominal pain (not just gas cramps)
A firm, distended abdomen
Vomiting
Fever or chills
Difficulty in swallowing or a severe sore throat
A crunching feeling under the skin

OCCUPATIONAL RISKS IN ERCP

¹⁰Minami T, Sasaki T, Serikawa M, et al. Occupational Radiation Exposure during Endoscopic Retrograde Cholangiopancreatography and Usefulness of Radiation Protective Curtains. Gastroenterology Research and Practice.2014. http://dx.doi.org/10.1155/2014/926876

The 1990 Recommendations of the International Commission on Radiological Protection (ICRP) set safety standards for radiation exposure of 500 mSv / year for skin and 150 mSv / year for eyes. Use of radiation protective curtains mounted to the X-ray tube and radiation doses should be measured with electronic pocket dosimeters placed outside the protective apron.

CONCLUSION

ERCP will continue to play an important role in the management of patients with a variety of pancreatic and biliary disorders. Even when a skilled endoscopist is involved and all relevant guidelines are adhered to complications of ERCP can occur. Both medical and surgical practitioners should be well versed in indications, contraindications, potential complications, benefits, and alternatives to ERCP. Knowledge of ERCP-related complications and associated risk factors may allow the endoscopist to promptly recognize these risks and institute appropriate preventive measures. Operator experience, avoidance of unnecessary procedures, adequate pre-procedural preparation, and meticulous attention to detail during the procedure, all contribute to minimising the risk of ERCP-related complications. Endoscopy units should have quality assurance programme to track negative outcomes prospectively so that issues that need intervention can be identified. Sedation-related complications are relatively common. Appropriate pre-sedation assessment and proper patient selection, preparation and optimisation of patients, as well as the availability of skilled professionals for sedation administration are key components to provision of quality patient care. Drotaverine hydrochloride can be used to reduce duodenal motility during diagnostic and therapeutic ERCP. Periodical assessment of the level of sedation and continuous monitoring of cardiovascular and respiratory systems provides timely information. Pulse oximetry and oxygen supplementation are recommended for the reduction of hypoxaemia

REFERENCES

Loperfido S, Costamagna G. Endoscopic retrograde cholangio pancreatography: Indications, patient preparation, and complications. Available from: http://www.uptodate.com/contents/endoscopicretrograde-cholangiopancreatography-indications-patient-preparationand-complications #H70259351 [Accessed on 6th July 2016].
Malas A. Endoscopic Retrograde Cholangiopancreatography. Available rom:http://emedicine. medscape.com /article/1829797-overview [Accessed on 6th July 2016].
Silviera ML, Seamon MJ, Porshinsky B, et al. Complications Related To Endoscopic Retrograde Cholangio-pancreatography: A Comprehensive Clinical Review. J Gastrointestin Liver Dis. 2009: 18(1): 73-82.
Kulkarni K.S. Antispasmodics- New Perspectives. JAMA India 119-121. 2001.
Drotaverine Hydrochloride VersusHyoscine-N-butylbromide for Duodenal Antimotility During Endoscopic Retrograde Cholangiopancreatography (ERCP). Available from: www.clintrials.gov/ct2/show/NCT00731198 [Accessed on 6th July 2016].
Hong-min X; Xin-kui Y; Jia-xuan L. Research of drotaverine applied before 48 ERCP case. China Practical Medicine. 2016: 11(14).
Pannu HK, Fishman EK. Complications of Endoscopic Retrograde Cholangiopancreatography: Spectrum of Abnormalities Demonstrated with CT. Radio Graphics 2001; 21:1441-1453.
Szary NM, Al-Kawas FH. Complications of Endoscopic Retrograde Cholangiopancreatography: How to Avoid and Manage Them. Gastroenterology & Hepatology. 2013: 9 (8).
Amornyotin S. Sedation-related complications in gastrointestinal endoscopy. World J Gastrointest Endosc. 2013 Nov 16; 5(11): 527-533.
Minami T, Sasaki T, Serikawa M, et al. Occupational Radiation Exposure during Endoscopic Retrograde Cholangiopancreatography and Usefulness of Radiation Protective Curtains. Gastroenterology Research and Practice.2014. http://dx.doi.org/10.1155/2014/926876