Cooperation and Nursing of ERCP + ENBD Catheterization and Drainage in a Patient with Mirriz ‘s Syndrome Volume 58- Issue 2

Liu Shan and Qiu Guang Wei*

• Xuanwu Hospital Capital University. No. 45, Changchun street, Xicheng distract, Beijing, China

Received: August 15, 2024; Published: August 22, 2024

*Corresponding author: Qiu Guang Wei, Xuanwu Hospital Capital University. No. 45, Changchun street, Xicheng distract, Beijing, China

DOI: 10.26717/BJSTR.2024.58.009140

Abstract PDF

The experience of cooperation and nursing of ERCP + ENBD catheterization and drainage in Mirriz’s syndrome was summarized. Due to the severe stenosis and perforation of the common bile duct in patients with Mirriz’s syndrome, the key points of nursing include that any equipment through the common bile duct, rotating the bile duct slowly into the bile duct, a slight resistance, immediately stop, after adjusting the angle, and slowly tuming the device again until the hollow feeling appears. The exchange method of the guide wire and the ENBD tube Is different from the conventional method. After precise cooperation and careful nursing during the operation, the patient’s vital signs were stable, and the examination and treatment were successfully completed without complications.

Keywords: Mirriz’s Syndrome; ERCP; ENBD; Nursing

Abbreviations: ERCP: Endoscopic Retrograde Cholangiopancreatography; ENBD: Endoscopic Nasobiliary Drainage; NRS: Numeric Rating Scale

Mirriz's syndrome, also known as Exogenous Biliary Stricture Syndrome, is a rare complication of cholecystitis and a complication of chronic cholecystitis secondary to the infunnel-occlusive Harman's sac [1]. Mirriz's syndrome-associated cholelithiasis can cause bile duct, common bile duct stenosis, causing partial or complete total hepatic duct obstruction, and finally leads to liver dysfunction [2]. It has been reported that Mirriz's syndrome is very rare, with an Incidence of less than 1% per year In western developed countries and 4.7% -5.7% in developing countries [1]. This syndrome is a complication caused by long-term cholelithiasis, whose main symptoms are jaundice, upper abdominal pain, fever, nausea, vomiting, and anorexia, etc [3,4]. Although the principle of clinical management of Mirrizi's syndrome is surgical treatment, preoperative diagnosis by endoscopic retrograde cholangiopancreatography (ERCP), cleaning of bile duct stones and endoscopic nasobiliary drainage (ENBD) are currently common methods in the treatment of bile duct stones [5].Moreover, ERCP is the most accurate diagnostic method for Mirriz's syndrome at this stage [1]. Because most patients with Mirriz's syndrome have severe bile duct stenosis, after repeated stone removal, the bile duct wall is thin and easy to cause perforation [6]. Therefore, compared with the ERCP and endoscopic treatment of ordinary acute cholelithiasis patients, it increases the coordination and nursing difficulty of ERCP intraoperative treatment to nurses [7]. In the literature of ERCP + ENBD catheterization and drainage, the nursing of patients after the ERCP in the ward, with little detail about the care of patients during surgery. In January 2023, a case of ERCP + ENBD catheter placement and drainage with Mirriz's syndrome was implemented in our hospital. The operation process was smooth and the effect was good. The intraoperative nursing cooperation is introduced as follows.

Mrs.Li, female, 48 years old, was admitted to the hospital on January 12^th,2023 due to "intermittent right upper abdominal pain for more than 4 years, and recurrent jaundice for more than 8 months". In November 2018, the patient had no obvious cause of right upper abdominal colic, NRS(Numeric Rating Scale) 5 points, continuous unable to relieve, with fever, Tmax 38°C, with no other discomfort. Referring to the emergency department of our hospital, abdominal CT suggested multiple gallbladder stones and inflammatory changes of the gallbladder wall: gallbladder stones and cholecystitis were considered, and after symptomatic treatment, the symptoms were completely relieved. In May 2022, the patient experienced right upper abdominal pain, yellow sclera, itchy skin, and yellow urine irritation, nausea, vomiting, gastric content and no other discomfort. On May 20^th, she was admitted to the emergency department of our hospital. Abdominal CT indicated: multiple gallbladder stones and suspicious common bile duct stones. ERCP lithotomy was performed on May 25^th. During the operation, while the upstream bile duct lumen was slightly dilated and the middle and lower segments of the bile duct were narrow. Under ERCP to expand the nipple, a small amount of gravel can be removed, and local stenosis is still visible on contrast again.

Consider the high probability of Mirriz's syndrome. On May 26^th, a laparoscopic cholecystectomy was performed, and the postoperative pathology showed chronic active cholecystitis. The patient still had intermittent dull pain in the right upper quadrant after surgery. In July, the patient developed right upper abdominal pain again without obvious cause, NRS 7-8,2-3 times a day, each time for 40min, T37.4°C, clay discharges, yellow sclera, presented to our emergency department. MRCP suggested the upper segment of the common bile duct (lower common hepatic duct and common bile duct confluence, round short T2 signal), and the lower bile duct was not clear. Choledochal stenosis, Murriz's syndrome were considered. ERCP was performed on July 20^th, with purulent bile overflow and positive stone shadow was located beside the common bile duct; external pressure stenosis and bile duct stent was placed. Postoperatively, the patient had no complaints of discomfort, and the jaundice was significantly improved. Bile duct ultrasound suggested that a strong echo of 1.0cm with acoustic shadow was visible beside the common bile duct. More than 10 months, the basic surgery department of our hospital performed cystic duct incision and lithotomy. During the operation, the residual cystic duct was about 2cm long, and a hard stone of about 2cm was Visible in the cystic duct, which was squeezed out. There was no right upper abdominal pain, jaundice and other discomfort. The patient had intermittent fever after admission on 12^th January 2023, Tmax37.3°C, Other vital signs were stable, no abdominal pain, jaundice and other discomfort. Blood results are shown: PLT: 227 * 109/ L, TBil 10 μ mol/L, previously identified with Gitelman syndrome for 14 years. Considering that the patient had performed ERCP twice, the bile duct stenosis was serious, but the disease diagnosis was clear, the body temperature was increased and was in the acute stage of the disease. ERCP + ENBD was needed again to clear the bile duct stones, which met the indications of ERCP. After communication with the patient and his family, the patient agreed to perform ERCP + ENBD catheterization and drainage on January 13^th,2023.

Preoperative Care

Preoperative preparation: at least preoperative fasting, water for 6 h; check the basic information of patients;determine the communication with patients surgery risk and signed informed consent;tell the patient to take off all jewelry, watches, mobile phones, hairpin and other metal items;remove dentures or dentures, keep to family:change clothes for this operation;pay attention to protect the patient's privacy;evaluate patients if have a history of lung, brain disease; understand previous duodenoscopy, sector endoscopic related examination, determine the stone size, location, duodenal nipple opening, eliminate contraindications. Take lidocaine jelly 10ml; help the patient to lie flat on the examination bed; establish venous channel on the right forearm, has iodine allergy test (has been completed in the ward), do preoperative mission: the purpose of the operation and operation examination process; a gallbladder drainage tube will be through the nose after the operation; during the whole examination process, the patient is in anesthesia, will not feel any pain, to eliminate the patient tension, anxiety. The electrode piece was attached to the corresponding position of the patient's chest according to the lead requirements, and the finger oxygen monitor instrument was clamped on the patient's right index finger, and injected 654-!0mg intravenously as Instructed. The patient was placed In a prone position with the head tilted to the left, the right leg was bent, a soft pillow, the right arm was bent up, and the right front chest was placed with a thin soft pillow, a single pad under the patient's head, and a disposable double nasal oxygen tube and a disposable cuff plug were wor for the patient [8-10].

Item Preparation

Olympus 260 TJF duodenoscope * |, Elbo high frequency electric knife * 1, expanding ball clip * 1, zebra guide wire * |, nipple incision knife * |, Contrast tube * | root, | stone net basket * 1,1 stone net basket *, | stone breaker *, | stone balloon *. | foreign body pliers *, | trap * 1, Disposable syringe of 10m! * 10, 60% 40ml, Disposable paper cup * |, Disposable negative electrode plate * | out, Sterile gauze, * 10 pieces, 500ml sterilized water for injection (glass bottle) * 4 bottles, 0.09%500ml sodium chloride water for injection (glass bottle) * | bottle, Nasal bladder drain (ENBD tube) 8.5 Fr * 1 [1].

Intraoperative Coordination and Nursing Care

Remove the Indwelling Bile Duct Stent

The doctor will insert the duodenoscope into the descending part of the duodenum: insert it into the process, pay attention to fix the position of the patient's mouth plug, avoid prolapse, and clear the patient's oral and nasal secretions with disposable sterile gauze in time. Through the monitor, the patient's vital signs were stable, SpO296%, after finding the opening of the nipple under the lens, the plastic tail end of the bile duct could be seen at the nipple. The stent was partially removed, and the disposable snare was sent into the endoscope through the biopsy aperture. Because the patient had Mirriz's syndrome, there was a common bile duct stenosis, and the front end of the snare was seen under the lens, and the insertion was stopped. Open the snareunder the mirror, cooperate with the doctor, circle the plastic stent, slowly pull out the snare and the plastic stent with the endoscope. During the pulling process, gently shake the resistance with the frequency of the doctor, the mirror can smoothly pass through the resistance part and pull out the endoscope. Outside the patient, the snare was released, the plastic support was removed, and the snare was removed. The patient observed stable vital signs, SpO₂96%.

Balloon Stone Removal

Entry again into the duodenal drop, with the doctor insert nipple open knife, insertion process, occasional feeling slight resistance, about and around turn open knife, adjust position, when feel frustrated continue to insert open knife, under the mirror, stop insertion, and the doctor light adjust nipple open knife direction to 11 position, adjust, slowly inserted into the common bile duct. Under X-ray monitoring, 20ml of universal meglumine Injection was injected into the nipple incision uniformly, which indicated no obvious expansion of the common bile duct. The patient observed stable vital signs, SpO₂95%. The nipple incision knife was removed and the internal guide wire remained unchanged in situ. Continue under X-ray perspective, the stone balloon catheter along the wire into the common bile duct, assist the doctor to adjust to the position above the stone, with 1Oml syringe balloon, because the choledochal stenosis, so pump, slower than usual, a small number of many times, to the doctor slowly pull the balloon, and gradually exit the balloon, the nurse adjust the wire position, keep the original position, while according to the X-ray Imaging situation, into the right amount of contrast agent, observe with no residual stones, can pull out of the bile mud and bladder. After the complete extraction of the stone balloon, the X-ray indicated that the bile duct system was clear. The patient observed stable vital signs, SpO₂96%.

ENBD Catheterization and Drainage

The tip of the 8.5 Fr ENBD tube (rinsed with saline) was slowly inserted through the tail end of the guide wire, and the tail tip of the ENBD tube was inserted along the tail end until it was appropriate, and then exchanged with the ENBD tube: the nurse gently pulled out the guide wire (placed on the disposable treatment towel). The doctor slowly withdrew the endoscope to the oral cavity. With the assistance of the X-ray, the nurse withstood the ENBD tube and fixed it in the pre-indwelling position. The action was coordinated with the doctor until the remaining part of the ENBD tube was separated from the endoscope. The patient observed stable vital signs, SpO₂96%, In the left hand, the above guide wire on the treatment towel was folded into the shape of "&", inserted it into the posterior wall of the pharynx, and withstood the posterior wall of the pharynx. In the right hand, the guide tube from the right nostril of the patient to observe the patient's vital signs were stable, SpO₂95%, When the sensory drain enters the posterior wall of the pharynx, the left hand slowly pulls out the guide wire from the left hand so that it can take the guide tube out of the mouth. The ENBD tube was inserted into the side hole of the guide tube, and the guide tube was gently pulled out from the nostrils until all the parts connecting the ENBD tube and the guide tube entered the depth of the mouth, proving that the tube was straightened in the wall of the posterior pharynx, the joint was installed, the ENBD tube was temporarily fixed with a tape, and the patient's vital signs were stable, SpO296%, The ENBD tube was drawn back with a 10ml syringe, proving that the ENBD tube was in the common bile duct and connected to the drainage bag, without the liquid extraction, the ENBD tube was fixed with the tape (including the butterfly fixed on the face and the patient's right ear), and the label paper "ENBD tube 2023-0-1-13, exposed 157cm" was attached to the tube [8-10].

Postoperative Coordination and Nursing Care

Pull out the patient's mouth plug, clean up the mouth and nasal secretions, pull up to block, prevent the occurrence of falling into the bed, observe the patient's vital signs are stable, SpO₂97%, After the anesthesiologist confirmed that the patient was fully awake and his vital signs were stable, the patient was told that the examination had been completed successfully to eliminate the patient's tension and anxiety. The patient has no complaints of discomfort such as abdominal pain and nausea. Assist the patient to shift the bed to the examination bed. During the translation process, hold the patient ENBD tube by hand, protect the ENBD tube and prevent the prolapse, hang the ENBD tube drainage bag on the hook on the right side of the bed, and see the brown liquid out. The patient's vital signs were stable. After transport, the ECG lead on the patient was pulled out, the position of the electrode was kept unchanged, and the lead on the mobile ECG monitor was connected to the patient to continue to monitor the patient's vital signs. The patient's oxygen tube was connected to the oxygen cylinder connector on the transfer bed to adjust the oxygen flow for 3 L/min, and then the gas blowing out In the oxygen tube was confirmed with the patient. Cover the patient with the quilt to prevent the patient from catching cold during the transfer process, and then confirm that the patient's vital signs are stable again. The patient is accompanied by the anesthesiology nurse to leave the examination room [11].

ERCP + ENBD catheterization is currently the most reliable and effective method for the diagnosis and preoperative treatment of cholelithiasis [12]. However, patients with Mirriz's syndrome are often accompanied by stenosis of the common bile duct, which increases the difficulty of matching catheterization in endoscopy. This time

1. When nurses placed any tube equipment for patients with Mirriz's syndrome in ERCP, the movements were slower and softer than the conventional operation, and the movements were highly consistent.

2. Especially when passing through the narrow area, it is necessary to test the equipment under the auxiliary guidance of X-ray, and timely evaluate the vital signs after the operation, so as to ensure that the patient's bleeding tendency is found in the first time.

3. In the exchange of ENBD tube and guidewire, it is conventional to insert the ENBD tube at the side and exit the guidewire simultaneously.

In this cooperative operation, considering the particularity of the common bile duct stenosis, it is difficult to prevent the ENBD duct from passing through the stenosis site after the guide wire is completely pulled out [13-15]. This time, the ENBD tube is completely passed through the narrow site, and then withdraw from the guide wire, increasing the success rate of tube placement. The native patient had smooth postoperative drainage and no further abdominal pain, nausea and other discomfort. The ENBD tube was removed on 16 January 2023 and was discharged on the same day. This paper introduces the operation process of intraoperative nursing in detail, and also makes a detailed explanation of the postoperative nursing in the gastroscopy room, filling in the shortcomings in the literature.

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