Preparation of the Patient for ERCP

The planning required for successful endoscopic retrograde cholangiopancreatography (ERCP) is more complex than that for routine endoscopic procedures and requires the synthesis of multiple variables. Preparation for ERCP involves preparing not just the patient, but also the endoscopist, the endoscopy team, the anesthesia team, and the necessary equipment. The purpose of this chapter is to review the most important preprocedural decisions and planning steps when ERCP is being considered, with the intent of maximizing the chances of a successful procedure. Other chapters in the first section of this textbook discuss some preparatory issues in detail, including Chapter 3 concerning radiologic issues and Chapter 6 concerning sedation issues; thus, these particular issues will be only briefly addressed herein. The flow of this chapter will be in a rough chronologic order of factors to consider as the procedure draws nearer.

Should This Patient Undergo ERCP?

The refinement of alternative technologies, including magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS), which provide similar (or better) diagnostic information about the pancreas and biliary tree, has essentially restricted the role of ERCP to a therapeutic one. For this reason, critically questioning the strength of the indication for ERCP is the first step in planning. In answer to the question “Should this patient undergo ERCP?” the answer may range from “Yes” to “No” to “Not yet.” In some cases, ERCP is clearly not indicated (e.g., simply as a diagnostic test for abdominal pain), whereas other cases may be more nuanced, such as when a reasonably healthy patient has new painless jaundice and a small mass in the head of the pancreas that appears surgically resectable. Additionally, the efficacy and safety of ERCP may be enhanced in some patients by delaying the ERCP, for example, to allow for an MRCP to provide a road map in a patient with a suspected hilar malignancy, or to allow the correction of a coagulopathy before an elective ERCP.

When, Where, and With Whom?

Once the decision has been made that an ERCP is indicated, the next decision points relate to urgency, locale, and the potential need for other physician assistance. The vast majority of ERCPs do not need to be conducted on an urgent basis. Patients with severe acute cholangitis not responding to antibiotics and fluid resuscitation represent the lone group for whom a truly urgent procedure is indicated. However, there may be other instances in which a reasonably expedited ERCP is desirable, including patients with moderately severe acute cholangitis who are responding to conservative treatment.

Patients who are critically ill, such as those receiving mechanical ventilation and vasopressors, may not be appropriate for transfer to the gastrointestinal (GI) laboratory or radiology department for ERCP. In these instances, other options must often be explored, including performing the ERCP in a dedicated ICU procedure room or nearby operating room, in the patient's ICU room and bed with a portable C-arm fluoroscopy unit, or in the patient's room without fluoroscopy (i.e., using bile aspiration to confirm location). Many fluoroscopy tables have a weight limit of 350 lbs. (159 kg); some morbidly obese patients requiring ERCP may exceed these limits and must be cared for in an operating room with an appropriately rated table and portable fluoroscopy.

Additional scheduling coordination will be necessary in ERCPs requiring a second physician for completion. Most commonly this may occur with “rendezvous” procedures, in which an interventional radiologist performs a percutaneous transhepatic cholangiogram and passes a wire antegrade across the major papilla into the duodenum to facilitate endoscopic retrograde cannulation. Another instance of collaborative ERCP is laparoscopic-assisted ERCP for patients with prior Roux-en-Y gastric bypass, in which a laparoscopic gastrostomy is created into the excluded stomach and, during the same procedure, a duodenoscope is passed via the gastrostomy to perform ERCP (see Chapter 31 on surgically altered anatomy).

Evaluation of the Patient Before ERCP

History and Physical

Clearly a thorough history and physical examination should be completed on all patients before ERCP. Comorbid medical conditions may affect ERCP decision making in a number of ways, including need for preanesthesia testing, method of sedation chosen, management of antithrombotic agents, and need for postprocedure inpatient observation. However, in some systems of care, the endoscopist performing the ERCP may not meet the patient until shortly before the scheduled procedure. This may occur in the hospital setting when a GI trainee or surgical service has evaluated an inpatient, or in the outpatient setting when a patient is referred by another gastroenterologist for ERCP. In some instances there are nuances to the case that may not be apparent on initial review but affect the appropriateness of the procedure. One example would be a minimally symptomatic elderly patient with advanced pancreatic malignancy and very poor functional status for whom hospice care may be more appropriate than biliary decompression. In patients who have had prior surgery involving the foregut or biliary tree, it is critical to have the best possible understanding of their anatomy before embarking on ERCP ( Chapter 31 ). Many patients may be unable to provide a history more detailed than “stomach surgery,” and even referring physicians may not appreciate the implications of various reconstructions as they relate to ERCP. As such, when postsurgical anatomy is uncertain, obtaining the operative notes for review or speaking with the surgeon for clarification is recommended. The nature of the surgically altered anatomy and the skill set of the endoscopist will influence whether to perform or refer the procedure, and certainly will also influence endoscope and device selection if the ERCP is undertaken.

Laboratory Testing

The practice of routinely ordering laboratory tests before ERCP, irrespective of the specific clinical setting, is not recommended because of cost and low yield. However, there are instances in which some preprocedure testing may be appropriate, tailored to the patient's specific clinical scenario and comorbidities. In patients with a known bleeding disorder, liver disease, malnutrition, or prolonged biliary obstruction, or in those receiving warfarin treatment, testing of the prothrombin time (PT) and international normalized ratio (INR) may be considered. Routine measurement of the hematocrit and platelet count is not necessary, but may be appropriate in the setting of suspected anemia, perceived high risk for bleeding, myeloproliferative disorders, splenomegaly, or medications known to cause thrombocytopenia. All women of childbearing age should be asked about the possibility of pregnancy, and pregnancy testing before the procedure may be considered in this patient subset. A chemistry panel may be considered for patients with diabetes mellitus or chronic kidney disease, or in the setting of medications that may cause abnormalities of glucose, potassium, or renal function. Finally, electrocardiography and chest radiography may be considered in older patients with cardiopulmonary comorbidities, but are not routinely necessary before ERCP. A practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) covers the issue of laboratory testing before endoscopic procedures in more detail.

Review of Imaging Studies

Although each patient will present with imaging studies of varying nature and quality, it is always useful to personally review available prior radiographic studies before ERCP. Anecdotally, it is not uncommon to detect potentially relevant findings not described in the radiologist's report, such as pancreas divisum or a subtly dilated pancreatic duct, on a computed tomography (CT) scan. Even reported findings may not be described in adequate detail; for example, a CT or magnetic resonance imaging (MRI) report may describe a malignant-appearing hilar stricture with intrahepatic biliary dilation but omit key findings such as apparent Bismuth classification or lobar atrophy that will be relevant to the patient's management.

Preparing the Patient: Day(s) Before ERCP

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