comprehensive patient report ercp

An endoscopic retrograde cholangiopancreatography (ERCP) procedure is not complete until it has been properly documented. A comprehensive report is crucial to ensure the appropriate output of the procedure. This chapter outlines the principles of structured reporting and highlights the recommended minimal requirements.

Full Answer

What happens if I have ERCP as an outpatient procedure?

If you have ERCP as an outpatient, you will be observed for complications until most of the effects of the medications have worn off before being sent home. You might experience bloating or pass gas because of the air introduced during the examination.

What is ERCP?

What is ERCP? Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that combines upper gastrointestinal (GI) endoscopy and x-rays to treat problems of the bile and pancreatic ducts. What are the bile and pancreatic ducts? Your bile ducts are tubes that carry bile from your liver to your gallbladder and duodenum.

What are the symptoms of ERCP?

If you have any of the following symptoms after ERCP, seek medical attention right away: 1 bloody or black, tar-colored stool 2 chest pain 3 fever 4 pain in your abdomen that gets worse 5 problems breathing 6 problems swallowing or throat pain that gets worse 7 vomiting—particularly if your vomit is bloody or looks like coffee grounds

What is an ERCP report?

Endoscopic retrograde cholangiopancreatography, or ERCP, is a procedure to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. It combines X-ray and the use of an endoscope—a long, flexible, lighted tube.

What should I look for after ERCP?

What should I expect after ERCP?You will most often stay at the hospital or outpatient center for 1 to 2 hours after the procedure so the sedation or anesthesia can wear off. ... You may have bloating or nausea for a short time after the procedure.You may have a sore throat for 1 to 2 days.More items...

What should you assess before ERCP?

Before the ERCP, you usually have a blood test to check how well your blood clots. Let the hospital department where you are having the test know if you're taking medicine that changes how your blood clots....Preparing for an ERCPaspirin.clopidogrel.arthritis medicines.warfarin or heparin.apixaban or rivaroxaban.

What is a clinical indication for an ERCP?

ERCP indications include obstructive jaundice, biliary or pancreatic ductal system disease treatment or tissue sampling, suspicion for pancreatic cancer, pancreatitis of unknown cause, manometry for sphincter of Oddi, nasobiliary drainage, biliary stenting for strictures and leakage, drainage of pancreatic pseudocysts, ...

What is the most common complication of ERCP?

Pancreatitis (inflammation of the pancreas) is the most frequent complication, occurring in about 3 to 5 percent of people undergoing ERCP. When it occurs, it is usually mild, causing abdominal pain and nausea, which resolve after a few days in the hospital.

Can ERCP remove gallstones?

ERCP can remove gallstones from the bile duct, but not from the gallbladder itself.

How do you prepare a patient for ERCP?

You may have diet and/or medication restrictions the week before the ERCP test. ... You will not be allowed any heavy meal for at least 8 hours before the procedure, light meals or opaque liquids for 6 hours before, or clear liquids for at least 2 hours before.Plan to take the day off from work.More items...

How is ERCP therapeutic?

ERCP is a procedure that doctors use to diagnose and sometimes treat a blockage or restriction of the pancreatic or bile ducts. During an ERCP, a tube is inserted into the patient's mouth, and then passed through the esophagus, stomach, and into the opening of the small intestine.

What are the side effects of a ERCP?

However, ERCP side effects pose a risk to the patient. ERCP side effects can be life-threatening, such as organ perforation or infection....ERCP Side EffectsSevere, worsening abdominal pain.A distended, firm abdomen.Fever or chills.Vomiting, especially vomiting blood.Difficulty swallowing or breathing.Severe sore throat.

When is ERCP indicated in pancreatitis?

ERCP should be performed after complete recovery from acute pancreatitis, usually 4 to 6 wk after presentation. If microlithiasis is detected, patients should be considered for cholecystectomy or biliary sphincterotomy depending on surgical risk.

What are the benefits of an ERCP?

ERCP offers the following advantages:Allows treatment of obstruction using sphincterotomy, stone extraction, stent placement, or balloon-dilation of strictures.Permits biopsies under direct visualization.Provides excellent visualization of the bile ducts.

Is ERCP a high risk procedure?

Because ERCP is a high-risk procedure, the indication for ERCP, especially in cases of asymptomatic CBDS, should be determined after careful consideration of the risks and benefits of the treatment.

What is ERCP?

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that combines upper gastrointestinal (GI) endoscopy and x-rays to treat problems of the bile and pancreatic ducts.

How do I prepare for ERCP?

To prepare for ERCP, talk with your doctor, arrange for a ride home, and follow your doctor’s instructions.

What should I expect after ERCP?

In some cases, you may need to stay overnight in the hospital after ERCP.

Why do doctors use ERCP?

Doctors use ERCP to treat problems of the bile and pancreatic ducts. Doctors also use ERCP to diagnose problems of the bile and pancreatic ducts if they expect to treat problems during the procedure. For diagnosis alone, doctors may use noninvasive tests—tests that do not physically enter the body—instead of ERCP.

What are the tubes that carry bile from the liver to the gallbladder?

Your bile ducts are tubes that carry bile from your liver to your gallbladder and duodenum. Your pancreatic ducts are tubes that carry pancreatic juice from your pancreas to your duodenum. Small pancreatic ducts empty into the main pancreatic duct. Your common bile duct and main pancreatic duct join before emptying into your duodenum.

What is the name of the tube that transports pancreatic juice?

Your pancreatic ducts are tubes that carry pancreatic juice from your pancreas to your duodenum. Small pancreatic ducts empty into the main pancreatic duct. Your common bile duct and main pancreatic duct join before emptying into your duodenum.

What is the camera on an endoscope?

A small camera mounted on the endoscope will send a video image to a monitor. The endoscope pumps air into your stomach and duodenum, making them easier to see. During ERCP, the doctor. locates the opening where the bile and pancreatic ducts empty into the duodenum.

What is ERCP?

Endoscopic retrograde cholangiopancreatography, or ERCP, is a specialized technique used to study the bile ducts, pancreatic duct and gallbladder. Ducts are drainage routes; the drainage channels from the liver are called bile or biliary ducts. The pancreatic duct is the drainage channel from the pancreas.

What are possible complications of ERCP?

Complications can include pancreatitis (inflammation of the pancreas), infections, bowel perforation and bleeding. Some patients can have an adverse reaction to the sedative used. Sometimes the procedure cannot be completed for technical reasons.

What is the tube that a doctor passes through the endoscope called?

After your doctor sees the common opening to the ducts from the liver and pancreas, called the major duodenal papilla, your doctor will pass a narrow plastic tube called a catheter through the endoscope and into the ducts.

Why do you have to accompany someone home from a sedative?

Someone must accompany you home from the procedure because of the sedatives used during the examination. Even if you feel alert after the procedure, the sedatives can affect your judgment and reflexes for the rest of the day. Because individual circumstances may vary, this brochure may not answer all of your questions.

Where is the endoscope in ERCP?

How is ERCP performed? During ERCP, your doctor will pass an endoscope through your mouth, esophagus and stomach into the duodenum (first part of the small intestine). An endoscope is a thin, flexible tube that lets your doctor see inside your bowels.

Can you pass gas during an ERCP?

You might experience bloating or pass gas because of the air introduced during the examination. You can resume your usual diet unless you are instructed otherwise.

Can sedatives cause adverse reactions?

Some patients can have an adverse reaction to the sedative used. Sometimes the procedure cannot be completed for technical reasons. Risks vary, depending on why the test is performed, what is found during the procedure, what therapeutic intervention is undertaken, and whether a patient has major medical problems.

ERCP Reporting and Documentation

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Summary

An endoscopic retrograde cholangiopancreatography (ERCP) procedure is not complete until it has been properly documented. A comprehensive report is crucial to ensure the appropriate output of the procedure. This chapter outlines the principles of structured reporting and highlights the recommended minimal requirements.

What is an ERCP?

ERCP stands for 'endoscopic retrograde cholangiopancreatography'. ERCP is a very useful procedure, as it can be used both to diagnose and to treat various conditions, such as:

What preparation do I need to do?

You should get instructions from the hospital department before an ERCP. The sort of instructions given include:

What can I expect after an ERCP?

If the procedure was done just to obtain X-ray pictures then most people are ready to go home after resting for a few hours. You should not drive, operate machinery or drink alcohol for 24 hours after having the sedative. If you go home on the same day as the procedure you will need somebody to accompany you home and to stay with you for 24 hours until the effects of the sedative have fully worn off.

What is cholangiopancreatography?

Cholangiopancreatography means X-ray pictures of your bile duct and pancreatic duct. These ducts do not show up very well on ordinary X-ray pictures. However, if a dye that blocks X-rays is injected into these ducts then X-ray pictures will show up these ducts clearly. Some dye is injected through an opening called 'the papilla' back up ...

What is ERCP in pancreatitis?

ERCP is a procedure that uses an endoscope and X-rays to look at your bile duct and your pancreatic duct. ERCP can also be used to remove gallstones or take small samples of tissue for analysis (a biopsy). Note: the information below is a general guide only.

What happens if you have an ERCP after 48 hours?

This may cause bleeding, infection and, rarely, perforation. If any of the following occur within 48 hours after an ERCP, consult a doctor immediately:

How does an endoscope work?

It is passed through your mouth, into your gullet (oesophagus) and down towards your stomach and the first part of your gut after your stomach (your duodenum). The endoscope contains fibre-optic channels which allow light to shine down so the doctor can see inside.

What is the CPT code for ERCP?

CPT® includes two codes to report ERCP with stenting procedures: 43268 Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct and 43269 Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde removal of foreign body and/or change of tube or stent.

What is ERCP in medical terms?

Get to Know ERCP. An ERCP is a study of the ducts that drain the liver and pancreas. Indications for this procedure include biliary obstruction due to choledocholithiasis or strictures, sphincter of Oddi dysfunction, acute and chronic pancreatitis, pancreatic pseudocysts, pancreatic necrosis, and pancreatic duct strictures.

How does an ERCP work?

In a diagnostic ERCP, the patient is typically sedated with intravenous sedation and analgesia. The doctor inserts the duodenoscope down the esophagus, through the stomach, and into the duodenum. Air is usually pumped through the endoscope to inflate the stomach and duodenum to make the examination easier.

Where does bile come from?

The bile is collected by a system of ducts that flow from the liver through the right and left hepatic ducts and drain into the common hepatic duct. The common hepatic duct joins with the cystic duct from the gallbladder to form the common bile duct (CBD). The CBD drains bile into the intestine through the ampulla of Vater.

What is the procedure performed by a duodenoscope?

Procedures performed through the duodenoscope include biopsy; sphincterotomy; destruction or removal of calculus; insertion, change, or removal of stents; dilation of the ducts; and ablation of lesions.

How many times can you report 43268?

Conversely, if multiple stents are placed in one duct (either side-by-side or overlapping), 43268 may be reported only once.

Which organs are involved in CPT?

To assign CPT® codes accurately, first be familiar with the anatomy involved, including that of the stomach, duodenum, liver, gallbladder, pancreas, biliary and pancreatic ducts, and the ampulla of Vater. The liver produces bile, which helps the small intestine digest food.