Las Vegas, Nevada
Advanced Endoscopic Procedures: A Comprehensive Nursing Guide
Pre-Procedure, Intra-Procedure, and Post-Procedure Management
Target Audience: GI/Endoscopy Nurses, Procedural Nurses, Advanced Practice Nurses
Level: Advanced
Release Date: February 2026 | Expiration Date: February 2029
Nevada State Board of Nursing Approved CE Provider
The author and planning committee have no relevant financial relationships to disclose.
• ASGE Standards of Practice Committee Guidelines • ASGE Quality Indicators for ERCP and EUS • SGNA Standards of Clinical Nursing Practice • ASA Practice Guidelines for Sedation and Analgesia
Upon completion, the participant will be able to:
Describe the anatomy and pathophysiology relevant to ERCP and EUS procedures
Identify indications, contraindications, and patient selection criteria for ERCP and EUS
Implement comprehensive pre-procedure assessment and preparation protocols
Demonstrate proficiency in assisting with ERCP/EUS equipment, accessories, and techniques
Apply ASGE quality indicators to monitor procedural outcomes and patient safety
Recognize and respond to complications including post-ERCP pancreatitis, bleeding, perforation, and cholangitis
Manage sedation and airway considerations specific to advanced endoscopic procedures
Understanding the anatomy of the biliary tree and pancreatic duct system is essential for ERCP nursing.
KEY ANATOMIC STRUCTURES: • DUODENUM: Second portion (descending) contains major and minor papillae • MAJOR PAPILLA (Ampulla of Vater): Opening where CBD and main pancreatic duct enter duodenum • MINOR PAPILLA: Opening of accessory pancreatic duct (Santorini) - present in ~70% of patients • SPHINCTER OF ODDI: Muscular valve controlling flow from CBD and pancreatic duct • COMMON BILE DUCT (CBD): Formed by junction of cystic duct and common hepatic duct; normal diameter <6mm (up to 8-10mm post-cholecystectomy) • MAIN PANCREATIC DUCT (Wirsung): Runs length of pancreas; joins CBD at ampulla • ACCESSORY PANCREATIC DUCT (Santorini): Drains via minor papilla; main drainage route in pancreas divisum
Endoscopic Retrograde Cholangiopancreatography (ERCP) is a specialized endoscopic procedure combining endoscopy with fluoroscopy to diagnose and treat disorders of the biliary and pancreatic ductal systems.
• Uses a side-viewing duodenoscope (different from standard forward-viewing endoscope) • Allows cannulation of the ampulla and injection of contrast into ducts • Primarily THERAPEUTIC (diagnostic ERCP largely replaced by MRCP) • Highest complication rate of any routine endoscopic procedure • Typically requires deep sedation or general anesthesia
Endoscopic Ultrasound (EUS) combines endoscopy with high-frequency ultrasound to obtain detailed images of the GI tract wall layers and adjacent structures (pancreas, bile duct, lymph nodes, vessels).
EUS MODALITIES: • RADIAL EUS: 360° view perpendicular to scope; excellent for staging, anatomy • LINEAR EUS: View parallel to scope shaft; allows needle passage for FNA/FNB • EUS-FNA: Fine Needle Aspiration - cytology samples • EUS-FNB: Fine Needle Biopsy - core tissue samples for histology • THERAPEUTIC EUS: Drainage procedures, celiac plexus neurolysis, fiducial placement
ABSOLUTE CONTRAINDICATIONS: • Known or suspected perforation • Hemodynamic instability/shock (unless emergent decompression needed) • Inability to obtain informed consent • Inadequate sedation/airway support RELATIVE CONTRAINDICATIONS: • Coagulopathy (INR >1.5, platelets <50,000 for therapeutic procedures) • Severe cardiopulmonary disease with high anesthesia risk • Altered surgical anatomy making access difficult (Roux-en-Y, Billroth II) • Recent MI (within 30 days) • Acute pancreatitis (unless for gallstone pancreatitis with cholangitis) For EUS-FNA specifically: • Cystic lesion with high likelihood of communication with pancreatic duct • Vascular lesion in needle path • Unable to identify safe needle trajectory
COMPREHENSIVE PRE-PROCEDURE CHECKLIST: □ HISTORY AND PHYSICAL review - indication confirmed, comorbidities noted □ ALLERGIES verified - especially iodine/contrast, antibiotics, latex, sedation medications □ NPO STATUS confirmed: • Solids: 6-8 hours • Clear liquids: 2 hours (ASA guidelines) • High aspiration risk may require longer □ INFORMED CONSENT obtained and documented - risks explained including: • Pancreatitis (3-5%) • Bleeding (1-2%) • Perforation (<1%) • Cholangitis (1-5%) • Sedation risks □ PREGNANCY TEST for women of childbearing age (radiation exposure) □ VITAL SIGNS baseline □ HEIGHT/WEIGHT for medication dosing □ IV ACCESS established (preferably 20g or larger in right arm for prone positioning) □ AIRWAY ASSESSMENT (Mallampati, neck mobility, dentition, sleep apnea history)
ASGE GUIDELINES - ERCP IS HIGH BLEEDING RISK: WARFARIN: • Hold 5 days prior to procedure • Check INR day of procedure (goal <1.5 for sphincterotomy) • Bridge with LMWH if high thromboembolic risk (mechanical valve, recent VTE) DOACs (Apixaban, Rivaroxaban, Dabigatran, Edoxaban): • Hold 48-72 hours depending on agent and renal function • No bridging needed • Resume 24-48 hours post-procedure if hemostasis achieved ASPIRIN: • Continue for diagnostic ERCP • Many continue for therapeutic ERCP (low incremental bleeding risk) • Decision individualized based on indication for aspirin P2Y12 INHIBITORS (Clopidogrel, Prasugrel, Ticagrelor): • Hold 5-7 days if possible • If on dual antiplatelet therapy post-stent, consult cardiology • May proceed with aspirin alone in most cases
Antibiotics are NOT routine for all ERCP but indicated in specific situations:
INDICATED: • Known or suspected cholangitis (therapeutic, not prophylactic) • Anticipated incomplete biliary drainage (hilar tumors, PSC, complex strictures) • Pancreatic pseudocyst or WON drainage • EUS-FNA of cystic lesions • Immunocompromised patients COMMON REGIMENS: • Ciprofloxacin 400mg IV + Metronidazole 500mg IV • Piperacillin-Tazobactam 4.5g IV • Ampicillin-Sulbactam 3g IV DURATION: Single dose pre-procedure if prophylactic; continue 3-5 days if cholangitis
DUODENOSCOPE (Side-Viewing Endoscope): • Optical system faces laterally (90° to shaft) - allows en-face view of ampulla • Elevator mechanism - directs accessories toward ampulla • Larger diameter than standard endoscopes (~11-13mm) • Working channel 3.7-4.2mm for accessories CRITICAL SAFETY NOTE: Duodenoscopes have been associated with transmission of multidrug-resistant organisms (CRE, MDRO) due to complex elevator mechanism that is difficult to clean. Enhanced reprocessing protocols are essential. Some centers use disposable-tip duodenoscopes.
• RADIAL ECHOENDOSCOPE: Provides 360° cross-sectional imaging; used for staging, anatomy • LINEAR ECHOENDOSCOPE: Provides sector imaging along scope axis; allows FNA/FNB • EUS NEEDLES: 19g (core biopsy/drainage), 22g (standard FNA/FNB), 25g (highly vascular lesions) • ULTRASOUND PROCESSOR: Generates and receives ultrasound signals; Doppler capability • FNA/FNB EQUIPMENT: Needles, cytology slides, cell block material, on-site cytopathologist (if available)
RADIATION PROTECTION IS ESSENTIAL: • Lead aprons (0.5mm Pb equivalent) for all personnel • Thyroid shields • Lead glasses for primary operators • Dosimeter badges (worn outside apron at collar level) • Minimize fluoroscopy time - use last-image-hold • Collimate to area of interest • Keep distance from source when possible • Pregnant staff should declare pregnancy and follow institutional policy DOCUMENT: • Total fluoroscopy time • Estimated radiation dose (if available) • Contrast volume used
ERCP AND EUS SEDATION REQUIREMENTS: ERCP typically requires DEEP SEDATION or GENERAL ANESTHESIA because: • Longer procedure time (30-90+ minutes) • Prone or left lateral position with head turned • Stimulating procedure (cannulation, sphincterotomy) • Need for patient immobility during fluoroscopy and therapeutic maneuvers SEDATION OPTIONS: • MAC (Monitored Anesthesia Care) with propofol - most common • General anesthesia with endotracheal intubation for: - Very high aspiration risk - Morbid obesity - Anticipated very long procedure - Difficult airway • Moderate sedation (nurse-administered) - rarely adequate for ERCP MONITORING (per ASA standards): • Continuous ECG, pulse oximetry • ETCO2 (capnography) - highly recommended for deep sedation • Blood pressure q3-5 minutes • Level of consciousness • Airway/ventilation assessment
• PRONE or SEMI-PRONE (left lateral with 30-45° tilt toward prone) • Head turned to right (toward endoscopist) • Left arm behind back or at side; right arm extended or at side • Padding under chest/pelvis for comfort • Bite block in place • IV access on right arm (left arm may be compressed) • All pressure points padded • Eyes protected and taped
• LEFT LATERAL DECUBITUS (similar to standard EGD) for upper EUS • Lithotomy or left lateral for rectal EUS • Bite block for upper procedures
INTRA-PROCEDURE NURSING RESPONSIBILITIES: • SEDATION MONITORING: Continuous assessment of airway, breathing, circulation; communicate with anesthesia team • ACCESSORY MANAGEMENT: - Prepare and pass accessories as requested - Prime balloons; test devices before insertion - Manage guidewires (keep tension, prevent looping, communicate wire position) - Document accessories used • ELECTROSURGERY: - Verify grounding pad placement and contact - Set and confirm electrosurgery settings per physician order - Have water available for irrigation during bleeding • SPECIMEN HANDLING: - Label all specimens immediately - Cytology slides for EUS-FNA - Stone/tissue specimens - Communicate with pathology if on-site review • DOCUMENTATION: - Procedure findings - Accessories used - Fluoroscopy time, contrast volume - Stent type/size if placed - Medications given - Complications noted • COMMUNICATION: - Time-out verification - Team communication for accessory needs - Alert to vital sign changes
Sphincterotomy is the cutting of the biliary or pancreatic sphincter to:
• Allow extraction of bile duct stones • Facilitate stent placement • Treat sphincter of Oddi dysfunction • Provide permanent biliary/pancreatic drainage
NURSING CONSIDERATIONS: • Verify electrosurgery settings (typically Blend 2 or Endocut) • Grounding pad properly placed on dry skin (thigh or flank) • Have hemostatic accessories available (epinephrine, clips, balloon tamponade) • COMPLICATION: Bleeding is most common immediate complication (1-2%); usually controlled endoscopically • POST-SPHINCTEROTOMY: Patients have permanently open sphincter - may have mild aerobilia on future imaging
After sphincterotomy, stones are removed using:
• EXTRACTION BALLOON: Inflated above stone(s), swept downward through sphincterotomy • RETRIEVAL BASKET: Captures stone, withdraws through sphincterotomy • MECHANICAL LITHOTRIPSY: For stones too large to extract intact; basket crushes stone • CHOLANGIOSCOPY with laser/EHL: For very large or impacted stones
NURSING TIP: If a basket becomes impacted around a large stone, emergency mechanical lithotripsy or surgery may be needed. Always have lithotripsy equipment available.
• PANCREATIC SPHINCTEROTOMY: For access to pancreatic duct; treatment of PD stones or strictures • PANCREATIC STENTING: For strictures, stones, or post-sphincterotomy prophylaxis (reduces pancreatitis) • PANCREATIC STONE EXTRACTION: Often combined with ESWL (extracorporeal shock wave lithotripsy) • PSEUDOCYST DRAINAGE: Transmural (through stomach or duodenum) with stent placement
ERCP HAS THE HIGHEST COMPLICATION RATE OF ANY ROUTINE ENDOSCOPIC PROCEDURE Overall adverse event rate: 5-10% Mortality rate: 0.1-0.5% Recognition and rapid response are critical nursing competencies.
MOST COMMON COMPLICATION (3-5%, up to 15% in high-risk patients) RISK FACTORS: • Patient-related: Female, younger age, normal bilirubin, prior PEP, sphincter of Oddi dysfunction, recurrent pancreatitis • Procedure-related: Difficult cannulation, pancreatic duct injection, pancreatic sphincterotomy, precut sphincterotomy, balloon dilation of intact sphincter PREVENTION (ASGE Guidelines): • Rectal indomethacin 100mg - give immediately before or after ERCP - REDUCES PEP BY 50% - Standard of care for all average/high-risk patients • Prophylactic pancreatic duct stent (5Fr) in high-risk cases • Aggressive IV hydration with lactated Ringer's • Guidewire-assisted cannulation • Avoid repeated PD cannulation/injection PRESENTATION: • New/worsening epigastric pain 2-24 hours post-procedure • Nausea/vomiting • Lipase ≥3x ULN with symptoms MANAGEMENT: • NPO, IV fluids, pain control • Admit for observation • Most cases are mild and resolve in 2-3 days
INCIDENCE: 1-2% (higher with sphincterotomy) TYPES: • IMMEDIATE: During sphincterotomy - usually controlled with balloon tamponade, epinephrine injection, clips, cautery • DELAYED: Hours to 2 weeks post-procedure; may present as melena, hematemesis, or hemobilia RISK FACTORS: • Coagulopathy, anticoagulation • Active cholangitis • Cirrhosis • Low-volume endoscopist MANAGEMENT: • Most stop spontaneously or with endoscopic therapy • Transfusion if hemodynamically significant • Rarely requires angiographic embolization or surgery
INCIDENCE: 0.3-1% - SERIOUS COMPLICATION TYPES: • Type I: Duodenal wall (endoscope trauma) - often requires surgery • Type II: Periampullary (sphincterotomy through wall) - often managed conservatively • Type III: Distal bile duct (guidewire/instrument) - usually managed conservatively • Type IV: Retroperitoneal air only - observe closely PRESENTATION: • Severe abdominal pain (often out of proportion) • Subcutaneous emphysema (crepitus) • Free air on imaging • Tachycardia, fever, sepsis DIAGNOSIS: CT abdomen with oral contrast (if any concern) MANAGEMENT: • Conservative (NPO, IV antibiotics, drainage) for contained perforations • Surgical repair for large or uncontained perforations • Early recognition and surgical consultation critical
INCIDENCE: 1-5% OCCURS WHEN: • Incomplete drainage after contrast injection into obstructed system • Bacteria introduced during instrumentation PRESENTATION: Fever, rigors, RUQ pain post-ERCP; can progress to sepsis rapidly PREVENTION: • Antibiotics for high-risk cases • Ensure complete drainage when possible • If drainage incomplete, leave stent or drain for decompression MANAGEMENT: • IV antibiotics (broad-spectrum) • May need repeat ERCP or PTC for drainage • ICU care if septic
POST-PROCEDURE MONITORING: • Vital signs every 15 min x 1 hour, then every 30 min until discharge criteria met • Monitor for complications: - Pain (especially epigastric - pancreatitis?) - Abdominal distension (perforation?) - Fever/rigors (cholangitis?) - Hematemesis/melena (bleeding?) - Respiratory status (sedation effects) • Assess sedation recovery using standardized tool (Aldrete or similar) • Document time to resumption of diet, ambulation, voiding DISCHARGE CRITERIA: • Vital signs stable and near baseline • Alert and oriented • Minimal nausea/vomiting • Tolerated clear liquids • Pain controlled with oral medications • Responsible adult escort • Understands discharge instructions
PATIENT/FAMILY EDUCATION: DIET: • Clear liquids immediately post-procedure • Advance to regular diet as tolerated (usually next day) • Avoid alcohol for 24 hours ACTIVITY: • No driving for 24 hours (sedation) • No operating heavy machinery for 24 hours • No important decisions for 24 hours • Resume normal activities next day if feeling well MEDICATIONS: • Resume home medications unless otherwise instructed • Anticoagulants: Restart per physician order (often 24-48 hours if no bleeding) • Pain medication as prescribed WARNING SIGNS - CALL IMMEDIATELY OR GO TO ER: • Severe abdominal pain • Fever >101°F (38.3°C) • Nausea/vomiting that doesn't stop • Black, tarry stools or vomiting blood • Chest pain or difficulty breathing • Any symptom that concerns you
• Complex or prolonged procedure • Difficult cannulation or multiple pancreatic duct injections • Precut sphincterotomy • Known cholangitis • Significant comorbidities • Lives far from medical care • Persistent pain or abnormal vital signs in recovery • High-risk features for post-ERCP pancreatitis • Incomplete drainage of obstructed system
ASGE has established quality indicators to measure competency and outcomes for ERCP and EUS. Nurses should be familiar with these metrics.
• Diagnostic adequacy rate for EUS-FNA of solid lesions: >85% • Complete staging exam for esophageal cancer: >98% • Complete staging exam for rectal cancer: >95% • Complication rate for EUS-FNA: <2% • Documentation of all required anatomic landmarks
PATIENT: Maria S., 68-year-old female INDICATION: Choledocholithiasis with jaundice (bilirubin 8.5) MEDICATIONS: Warfarin for atrial fibrillation, lisinopril, metformin ALLERGIES: Penicillin (rash) LABS: INR 2.4, Cr 1.1, platelets 185K
1. Can this patient proceed with ERCP today?
2. What antibiotic would you recommend given her allergy?
3. What prophylaxis should be given for post-ERCP pancreatitis?
ANSWERS: 1. NO - INR 2.4 is too high for sphincterotomy (goal <1.5). Options: • Hold warfarin 2-3 more days and recheck • Give vitamin K for faster reversal if urgent • If emergent cholangitis, could place stent without sphincterotomy, then return when INR corrected • DOAC bridging is generally not done for AF unless high-risk (mechanical valve, recent stroke) 2. Antibiotic alternative for penicillin allergy: • Ciprofloxacin 400mg IV + Metronidazole 500mg IV • Or if severe allergy and concern for cross-reactivity: Aztreonam + Metronidazole 3. Rectal indomethacin 100mg should be given immediately before or after the procedure to reduce PEP risk by ~50%.
PATIENT: James W., 52-year-old male, 4 hours post-ERCP for CBD stone PROCEDURE NOTES: Difficult cannulation requiring precut sphincterotomy, multiple attempts with PD injection, stone extracted successfully, rectal indomethacin given CURRENT: Severe epigastric pain, nausea, requesting pain medication VITALS: HR 98, BP 138/82, Temp 37.2°C, O2 sat 97%
1. What is the most likely complication?
2. What tests would confirm this?
3. What was his risk profile for this complication?
ANSWERS: 1. Post-ERCP pancreatitis (PEP) - classic presentation with epigastric pain and nausea within hours of procedure. 2. Check serum lipase (or amylase). PEP is defined as: • New/worsening abdominal pain • Lipase ≥3x upper limit of normal • Symptoms requiring hospitalization or prolonging planned admission 3. HIGH-RISK profile for PEP: • Difficult cannulation (risk factor) • Precut sphincterotomy (significant risk factor) • Pancreatic duct injection (significant risk factor) Good that indomethacin was given. He should also receive aggressive IV hydration with LR. Consider prophylactic PD stent if he had these risk factors (may have been placed). Admit for observation; most PEP is mild.
PATIENT: Robert L., 71-year-old male with pancreatic mass on CT INDICATION: EUS with FNA for tissue diagnosis before chemotherapy SETUP: Linear echoendoscope, 22g FNA needle, rapid on-site cytopathologist available
1. Why is EUS-FNA preferred over CT-guided biopsy for pancreatic masses?
2. What is the role of the cytopathologist on-site?
3. What are the main complications of EUS-FNA?
ANSWERS: 1. EUS-FNA advantages: • No peritoneal seeding risk (needle passes through stomach, not peritoneum) • Better access to pancreatic head/uncinate lesions • Can sample adjacent lymph nodes for staging • Can evaluate for vascular invasion • High diagnostic accuracy (>90%) 2. Rapid on-site evaluation (ROSE): • Cytopathologist immediately examines slides • Confirms adequate sample obtained • May allow fewer needle passes if diagnostic • Can provide preliminary diagnosis • Improves diagnostic yield 3. EUS-FNA complications: • Overall rate <2% • Bleeding (usually self-limited) • Infection (rare; antibiotics for cystic lesions) • Pancreatitis (if needle passes through pancreatic tissue) • Perforation (very rare)
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ASGE Standards of Practice Committee. Adverse Events Associated with ERCP. Gastrointest Endosc. 2023;97(1):1-14.
ASGE Quality Assurance Committee. Quality Indicators for ERCP. Gastrointest Endosc. 2023;97(6):989-1007.
ASGE Standards of Practice Committee. Role of Endoscopy in Biliary Tract Diseases. Gastrointest Endosc. 2022;96(4):531-554.
Elmunzer BJ, et al. Rectal Indomethacin for Post-ERCP Pancreatitis Prevention. N Engl J Med. 2012;366:1414-1422.
ASGE Technology Committee. Duodenoscope Reprocessing. Gastrointest Endosc. 2021;93(6):1222-1228.
ASGE Standards of Practice Committee. EUS-Guided Tissue Acquisition. Gastrointest Endosc. 2022;95(3):351-370.
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