Endoscopic Retrograde Cholangiopancreatography (ERCP) of the Gallbladder (Nursing)

00:01 Now the last test takes the most skill.

00:04 Ultrasound requires a skilled technician, an abdominal CAT scan requires a skilled technician, gallbladder radionucleotide scan involves a very skilled technician, however, an ERCP and endoscopic retrograde cholangiopancreatography requires a physician.

00:25 Now the picture I have for you there.

00:27 This is such a beautiful thing that they did.

00:30 Your going to feed a scope all the way down in your GI tract so we can push it all the way down gently so we can get a good view with a camera.

00:40 The ERCP is a much more involved process and it is clearly invasive and I'm going to explain to you why.

00:47 First of all this test takes longer than any of the others that we've discussed.

00:52 This can take anywhere from 30 to 90 minutes to complete.

00:56 Now the patient is going to have to be sedated at the very least maybe have general anesthesia.

01:02 That's a decision that will be made by the physician but during the procedure the patient is going to need to be monitored.

01:09 If the patients receiving general anesthesia, they will be as CRNA, a certified registered nurse anesthetist or an anesthesiologist right there monitoring the patient.

01:20 If they're under conscious sedation, you may as the nurse be the one who performs them patient monitoring, you're going to watch respiratory status, pulse ox, their oxygen saturation, their heart rate, and their blood pressure.

01:34 Now conscious sedation can only be monitored by a nurse who has been educated trained and certified on how to do this.

01:42 That's a program that will be offered by the hospital or the setting where you work.

01:46 So ERCP takes longer to do, takes a lot of skill to guide that scope through the patient's GI tract and it requires extra nursing skills to monitor that patient during conscious sedation.

02:01 The ERCP uses an endoscopic camera.

02:05 It's called a duodenoscope.

02:08 Now it's called the duodenum scope because the end goal is to visualize where the stomach meets the duodenum.

02:15 So this duodenoscope is a long flexible tube about the diameter of a pen.

02:21 So, you know, that doesn't seem that big unless they're inserting it into your GI tract then it seems really big.

02:29 But the end of this scope is a camera on the end.

02:32 Look at the picture I have for you there.

02:34 You're looking at the very end of that duodenum scope and it's got that little camera on the end.

02:40 Now the duodenum scope can be directed and moved around the many bends of the stomach and the duodenum to get it in just the right place.

02:49 Because a duodenal scope this little camera is inserted into the mouth and through the digestive tract till you arrived at the duodenum.

02:57 So think where this has to travel enters your mouth, down to your esophagus, into your stomach lining all the way around to you can get to where the duodenum can be visualized.

03:10 Now the camera transmits digital video images, got it.

03:15 Okay, so a scope in my mouth, all the way down to my duodenum, got this little camera, that's going to transmit digital video images to a TV screen right there in the room.

03:27 That way the physician can see problems in the bile and pancreatic duct.

03:32 Why? Because he's got a video crew at the end of this duodenoscope, there so you can actually visualize in real time.

03:40 Now this duodenoscope is a very thin fiber optic bundle.

03:44 It transmits light to the tip of the endoscope and then there's a thin wire with a chip that's also at the very tip of the endoscope and that's what transmit its back to that TV screen.

03:56 So just stop for a minute and think about how amazing this is.

04:00 This is something so tiny that brings back powerful images for the physician to assess and see what's going on in problems in the bile and pancreatic ducts.

04:13 You may be wondering why I have a slide here titled the ampulla, papilla and the santorini.

04:20 No, those are not names of 17th century sailing vessels.

04:24 I want to explain a little bit about the landmarks you'll be seeing if you ever get to see one of these ERCPs and isn't that one of the funnest parts of clinicals when you get to go off the floor and see if procedure actually done.

04:37 So the ampulla is specifically located at the major duodenal papilla.

04:43 So far I know you're not impressed, but stay with me, the ampulla of vater, underline that, ampulla of vater, you've seen that come up over and over again as we're talking about cholecystitis.

04:53 Because it's an important landmark halfway along the second part of the duodenum.

04:58 So we use that as landmark when the physician is performing the ERCP.

05:04 Now where does the santorini come in? Well much like the rest of history.

05:08 Vater is credited with the discovery, but it probably was santorini who was the first one to describe this ampulla.

05:17 So we call it the ampulla of vater but really it probably should be called the ampulla of santorini.

05:23 Sorry, dude.

05:24 Now the ampulla of Vater / Santorini marks where the celiac trunk stop supplying the gut and the superior mesenteric artery takes over.

05:35 Why do you care? And that's the major blood supply engaged in your intestines and bringing blood back up to your liver.

05:44 So that's critically important when the ampulla has identified this small plastic catheter, right? It's called a cannula is passed through an open channel of the endoscope.

05:55 Look at the picture that I have there for you so find the ampulla, the physician will pass say small plastic catheter or cannula through the open channel of the endoscope into the opening of the ampulla.

06:07 Now they're able to see the bile ducts and or the pancreatic ducts, whatever they need to visualize.

06:14 So we slow down here and took the time to show you.

06:18 This is an incredible feat to feed this little tiny camera all the way through the GI tract even advanced it through the ampulla.

06:28 It is a brilliant and it takes a very a skilled physician to perform this exam safely.

06:35 You think that's it, but it's not, that's not all.

06:39 They also have another open channel in the duodenum scope.

06:41 And here's what it lets the physician do.

06:44 One they can do biopsies.

06:46 Hey, that's really helpful.

06:48 When the patient were worried about pancreatic cancer or something that hepatobiliary duct.

06:52 We need biopsy so they can get a sample of the tissue and then examine it under a microscope.

06:59 Last, second, we can place a stent or a tube for obstruction.

07:04 So for looking for someone has scarring down there, maybe chronic inflammation.

07:09 We placed a stent here to allow for the bile to flow freely.

07:13 Just like we would in a coronary procedure or the blood flow to the heart is compromised.

07:18 We put a stent in to keep the vessel open, can also put a stent or a tube in here to keep bile flowing.

07:24 Remember they can do all this in about 30 to 90 minutes.

07:31 So the goal of this test is to take a very close look at the duodenum.

07:35 I mean an up-close-and-personal look at the duodenum or the small intestine.

07:41 So look at the picture I have for you there.

07:43 You've seen this before but I want you to think that through now look, you're threading that to widen the scope all the way through the stomach down to that spot right by the small intestine.

07:52 I are going to weave that through the sphincter of oddi and the ampulla of vater.