HYANNIS – A number of years ago, I visited my mother in a rehabilitation hospital following her double knee replacement surgery. When I entered her room, I was alarmed to see her skin and the whites of her eyes were yellow. She was complaining of abdominal pain and generally feeling terrible.
The staff transferred her to an acute care hospital for tests, which showed she was having a gallbladder attack caused by gallstones blocking her bile duct. Since she was still recovering from the knee replacement surgery and could not have her gall bladder removed, they transferred her to a Boston hospital for an Endoscopic Retrograde Cholangiopancreatography (ERCP), a procedure to remove the stones and place a stent to keep her bile duct open.
The results were remarkable. Within a day or two, her skin color returned to normal, she felt much better and was able to continue her rehabilitation.
ERCP is now available at Cape Cod Hospital, and gastroenterologist Frederick Ruymann, MD, FACG, who arrived at the hospital earlier this year, specializes in the procedure.
“The symptoms of a gallbladder attack can make patients feel poorly,” he said. “Symptoms of a gallbladder attack may include: abdominal pain, fever, nausea/vomiting, itching of skin and jaundice.”
The condition is initiated by the migration of a gallstone which may block the passage of bile from the gallbladder or bile duct. In other words – gallstones aren’t usually a problem unless they move and, if they move, they can create challenges, he explained.
“If the stone makes its way through cystic duct from the gall bladder into the common bile duct, it can cause an obstruction. That’s when the liver enzymes elevate and you turn yellow.”
While the procedure can sound complicated, Dr. Ruymann uses the analogy of plumbing and clearing a blockage in a pipe. He draws a simple picture for his patients with the landmarks of the gall bladder, liver, pancreas, small intestine and bile ducts.
“When I can help them visualize the procedure, it demystifies what I am going to do,” he said.
The ERCP Procedure
ERCP is done using conscious sedation or occasionally, general anesthesia. Dr. Ruymann passes a scope with the approximate diameter of a pen down the patient’s esophagus and into the small intestine, where he visualizes the tiny pinpoint opening where the bile duct drains into the duodenum.
Dr. Ruymann then advances a catheter through the scope, inserts a wire into the bile duct and injects dye, which helps him visualize the anatomy. Following careful interpretation of the images, he may choose to enlarge the opening and, using a wire guided balloon, can extract gallstones from the bile duct – much like dredging and clearing a blocked pipe.
The procedure takes about 15 to 20 minutes.
Dr. Ruymann offers the following reassurances about the procedure:
Patients will be comfortable throughout the procedure.
Risks and benefits are discussed beforehand.
ERCP is often performed as an outpatient.
Patients can expect that all concerns are addressed prior to the procedure.
ERCP can be done prior to having your gall bladder removed or it can be done after gall bladder surgery, if stones are found later.
While gall stones are the cause of up 50 percent of ERCPs, Dr. Ruymann also does the procedure to relieve obstruction of the bile duct from tumors and inflammatory diseases.
“If someone has a growth in their pancreas that is impinging on the bile duct, I can biopsy the tumor through the scope, make a tissue diagnosis, and use a stent to help drain the blocked duct,” he said.
Patients are referred to Dr. Ruymann through the Cape Cod Hospital Emergency Department and inpatient consults. They are also referred by surgeons, gastroenterologists and primary care physicians.
Providing relief for patients through the ERCP procedure is rewarding, Dr. Ruymann said.
“What I found through the years is patient’s want timely answers to their problem, they want a ‘game plan’ and they want that person to work with them to solve the problem. The use of ERCP in diagnosing and solving problems can greatly influence the well-being of patients.”
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