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Endoscopic Retrograde Cholangiopancreatography (ERCP)

ERCP stands for endoscopic retrograde cholangiopancreatography (ERCP). It is one of the methods which are used to visualize the pancreas and the pancreatic ducts. The advancement in the technology has allowed the physician to look at the internal ducts which were quite impossible in the past years. It is one of the most performed diagnostic tests to identify the pathologies in the pancreas. It is superior to the blood test or the ultrasound for identification of any pathology in the pancreases. It allows the physician to visualize the internal environment of the pancreas directly. ERCP is performed for many signs and symptoms. Some of the include jaundice, abdominal pain or weight loss. The other reasons to do ERCP includes an abnormal finding on the ultrasound or CT scan like mass or stones (Cotton, Garrow, Gallagher, & Romagnuolo, 2009).

In the study undertaken, the author will describe and evaluate routine clinical ERCP practices, evaluate the incidence of complications and mortality, identify possible risk factors for undesired outcomes after ERCP evaluate patient pain and satisfaction after ERCP, and investigate potential predictors of pain and dissatisfaction respectively (Glomsaker, 2013).

ERCP is one of the preferred choices of diagnostic and treatment modalities for many conditions. Although this procedure is associated with multiple side effects, some of the side effects include development of pancreatitis, infection of the gallbladder and the bile ducts, hemorrhage because of injury, altered response to sedatives which may lead to depression of the cardiac or respiratory system, perforation of the ducts, damage to the tissues because of the X-rays and even death (Wang et al., 2009).

One of the most common side effects of ERCP is the development of pancreatitis. The overall incidence of occurrence of pancreatitis is almost 2 to 10 % of the patients who undergo ERCP. The incidence of pancreatitis can increase to approximately 30% in association with certain risk factors. Pancreatitis after the ERCP is usually mild but in 10% of the cases it can be severe and can be life-threatening. The mortality associated with ERCP is almost 0.1 to 0.5%. Pancreatitis in the patients is usually identified with the aid of elevated serum amylase which is raised in 75% of the cases (Thaker, Mosko, & Berzin, 2014).

Multiple methods are under consideration for the prevention of the development of side effects of ERCP including pancreatitis. One of such method is the administration of indomethacin (Elmunzer et al., 2012).

PICO table

Example:
P (patient/problem) Patients undergoing ERCP

I – Administration of Indomethacin after the ERCP prevents pancreatitis

C- Administration of Indomethacin after the ERCP does not prevents pancreatitis

O- Pancreatitis

T- Post procedure

I (intervention/indicator) Administration of Indomethacin after the ERCP prevents pancreatitis
C (comparison) No Indomethacin after the ERCP
O (outcome) Decreased incidence of Pancreatitis by identifying the possible risk factors and investigate potential predictors of pain and dissatisfaction.

It also offers the clear framework for the planning, implementing and evaluating the health care practice (Horvath, 2016). In the study undertaken, the Patients undergoing ERCP will be the population of the study (P). Administration of Indomethacin after the ERCP prevents pancreatitis (I), the rate of readmission of the said population might be compared with those who will not participate in the educational program. The assumption (C) that the participating group will have No Indomethacin after the ERCP (O). The intervention will be a 30-days program.

C1: Search Strategy

Keywords: ERCP, acute pancreatitis, indomethacin, prevention of acute pancreatitis, acute pancreatitis and ERCP,

C2: The research articles were searched on multiple research databases notably Pub Med, CINAHL, and library one search. The research article was selected from 2010 to onwards. The only peer-reviewed articles were searched. The articles included randomized control trials, systemic reviews, observational studies and case-control studies. There were almost 100+ articles in each database.

There were many research articles which came up with different results. Some of the articles were for the use of indomethacin while others came up against its use.

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Research articles

The study by (Elmunzer et al., 2012) highlighted the use of indomethacin in the prevention of acute pancreatitis after ERCP. The study has done a randomized controlled trial and highlighted that acute pancreatitis could be prevented in patients after ERCP with the administration of indomethacin.

The study by (Yaghoobi et al., 2013) highlighted the effectiveness of the introduction of indomethacin just before ERCP in the prevention of acute pancreatitis in the patients.

Non-research articles

The study by (“Urgent-ERCP,” n.d.) has presented their research to prevent the development of acute pancreatitis after ERCP. They have focused their notion not only the pharmacological intervention including indomethacin for the prevention of acute pancreatitis after ERCP but also the use of interventions like pancreatic stents.

The study by (“Management of Acute Pancreatitis,” n.d.) is the study which has introduced the research for the management of a patient with acute pancreatitis after multiple tests including ERCP. This study has highlighted the use of indomethacin in the management of patients who undergo ERCP.

Evidence matrix

Article 1 Article 2 Article 3 Article 4 Article 5
Authors Elmunzer, B. J., Scheiman, J. M., Lehman, G. A., Chak, & Waljee, A. K Yaghoobi M

Rolland S

Waschke KA

McNabb-Baltar J

Martel M

Bijarchi R

Szego P

Barkun AN

Jianhua Wan

Yuping Ren

Zhenhua Zhu

Liang Xia

Nonghua Lu

Tenner, S., Baillie, J., DeWitt, J., & Vege, S. S. Levenick, J. M., Gordon, S. R., Fadden, L. L., Levy, L. C., Rocky, M. J., Hyder, S. M., … & Gardner, T. B.
Journal name The New England Journal of Medicine Alimentary pharmacology and therapeutics Biomedical Central Gastroenterology American Journal of Gastroenterology Gastroenterology
Year of publication 2012 2013 2017 2013 2016
Research design randomized, placebo-controlled, double-blind clinical trial, Meta-analysis of RCTs Meta-analysis of RCTs RCT RCT
Sample size Internal audit of high-risk ERCP decide sample size 1470 3013 300 944
Outcomes variable measured A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis Development of acute pancreatitis after Indomethacin in patients undergone ERCP Development of acute pancreatitis after Indomethacin in patients undergone ERCP American College of Gastroenterology guideline: management of acute pancreatitis Development of acute pancreatitis after Indomethacin in patients undergone ERCP
Level (I–III) II I I II II
Quality (A, B, C) B A A B B
Results/Author’s Suggested Conclusions The administration of indomethacin is associated with prevention of acute pancreatitis after ERCP This study concluded that providing indomethacin before ERCP reduces development of acute pancreatitis in patients undergoing ERCP The administration of indomethacin may not be suitable for the prevention of acute pancreatitis in the entire patient undergoing ERCP. However, it is suitable for the patients who are at high risk This study concluded that providing indomethacin before ERCP reduces development of acute pancreatitis in patients undergoing ERCP Administration of indomethacin before the procedure of ERCP is not effective in reducing the risk of acute pancreatitis

Recommended practice

One of the common complications of ERCP is the development of pancreatitis. It is necessary that interventions should be done to prevent this complication. One of the approaches for the prevention of acute pancreatitis after ERCP is the use of indomethacin.

The prevention of indomethacin requires not only indomethacin but also the use of nitrates. It also requires the use of certain techniques like the placement of a stent in the pancreatic duct before the performance of the procedure so it can be saved from damage and release of enzymes which can cause pancreatitis (Arain & Freeman, 2014).

The study of (Yaghoobi et al., 2013) administration of indomethacin just before the procedure of ERCP can reduce the risk of acute pancreatitis. It is effective in both the low-risk and high-risk patients.

The administration of indomethacin may not be suitable for the prevention of acute pancreatitis in the entire patient undergoing ERCP. However, it is suitable for the patients who are at high risk (Wang et al., 2009) Indomethacin, when combined with sublingual nitrates, is also effective in the prevention of acute pancreatitis after ERCP in those who have not used this combination (Wang et al., 2009).

The study by (Levenick et al., 2016) highlighted the fact that indomethacin is not effective in the prevention of acute pancreatitis after ERCP.

Implementation process

Change is never easy for any person to adopt. One of the problems which can be faced is the introduction of indomethacin to the nurses. Most of the nurse may find it difficult to perform as this process requires monitoring and great skill. Intangible understanding of the concept of nursing process, different views of the process, lack of knowledge and awareness among nurses related to the execution of process, supports of managing systems, and problems related to recording the nursing process were the main challenges that were extracted from review of literature (Zamanzadeh, Valizadeh, Tabrizi, Behshid, & Lotfi, 2015). To achieve the best strategy to minimize the challenge, in addition to preparing facilitators for implementation of the nursing process, intangible understanding of the concept of nursing process, different views of the process, and forming teams of experts in nursing education are recommended for internalizing the nursing process among nurses. These strategies result in internalizing and understanding the concept of the nursing process. Forming the team of experts in nursing education is recommended as the best way to minimize the current challenges (Zamanzadeh et al., 2015).

To implement this strategy, it is necessary that the staff should be trained properly. This requires proper classes or seminars so that the staff can be taught. It also requires the arrangement of several workshops where the staff can learn to perform this procedure with great ease and efficacy.

The staff also need to have the clear idea about the efficacy of this process. The introduction of the method may face some opposition as it is a difficult, time-consuming and requires skills. All of these issues can be treated with planning.

References

Arain, M. A., & Freeman, M. L. (2014). Pharmacologic prophylaxis alone is not adequate to prevent post-ERCP pancreatitis. The American Journal of Gastroenterology, 109(6), 910.

Elmunzer, B. J., Scheiman, J. M., Lehman, G. A., Chak, A., Mosler, P., Higgins, P. D., … Sherman, S. (2012). A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. New England Journal of Medicine, 366(15), 1414–1422.

Glomsaker, T. B. (2013). Endoscopic retrograde cholangiopancreatography (ERCP) in Norway: Patterns of activity and undesired events.

Horvath, C. (2016). Implementation of a new method to track propofol in an endoscopy unit. Georgetown University.

Levenick, J. M., Gordon, S. R., Fadden, L. L., Levy, L. C., Rocky, M. J., Hyder, S. M., … Gardner, T. B. (2016). Rectal indomethacin does not prevent post-ERCP pancreatitis in consecutive patients. Gastroenterology, 150(4), 911–917.

Management of Acute Pancreatitis. (n.d.). Retrieved July 14, 2017, from https://gi.org/guideline/acute-pancreatitis/

Thaker, A. M., Mosko, J. D., & Berzin, T. M. (2014). Post-endoscopic retrograde cholangiopancreatography pancreatitis. Gastroenterology Report, 3(1), 32–40.

Urgent-ERCP. (n.d.). Retrieved July 14, 2017, from https://www.researchgate.net/profile/Martin_Freeman2/publication/265607737_579_Urgent_ERCP_With_Pancreatic_Stent_Placement_or_Replacement_for_Salvage_of_Post-ERCP_Pancreatitis/links/54317cf80cf29bbc12789979/579-Urgent-ERCP-With-Pancreatic-Stent-Placement-or-Replacement-for-Salvage-of-Post-ERCP-Pancreatitis.pdf

Wang, P., Li, Z.-S., Liu, F., Ren, X., Lu, N.-H., Fan, Z.-N., Sun, W.-S. (2009). Risk factors for ERCP-related complications: a prospective multicenter study. The American Journal of Gastroenterology, 104(1), 31.

Yaghoobi, M., Rolland, S., Waschke, K. A., McNabb‐Baltar, J., Martel, M., Bijarchi, R., Barkun, A. N. (2013). Meta‐analysis: rectal indomethacin for the prevention of post‐ERCP pancreatitis. Alimentary Pharmacology & Therapeutics, 38(9), 995–1001.

Zamanzadeh, V., Valizadeh, L., Tabrizi, F. J., Behshid, M., & Lotfi, M. (2015). Challenges associated with the implementation of the nursing process: A systematic review. Iranian Journal of Nursing and Midwifery Research, 20(4), 411.

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