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What Causes Chest Pain After ERCP?
Question: What causes chest pain after ERCP? I had spinchtrotomy with stent placemement. Ercp was recommended due to persistent jp drain leakage 100-150 Mls flowing penetrating wound to abdomen. Had emergency surgery to treat stab wound. General anesthesia was utilized for ERCP. 54 yr female. Good health prior to accident. Chest pain is sharp and worsens when taking deep breath. Belching relieves some of pain.
Brief Answer:
Some tests should be done.
Detailed Answer:
Hello!
Thank you for the query.
Is the chest pain on one side or both sides? Do you have any nausea, pale stool, dark urine? Do you have cough or shortness of breath?
Chest pain can be a sign of stent placement. Please note that bile ducts and liver pain very often radiates to the back and chest. Its because vagal and other nerves stimulation and diaphragm irritation.
It is possible that the stent is causing some pressure in the bile ducts (for sure it does) what causes chest pain. If so, the pain should get better after smooth muscles relaxation. Please try hot bath, Metamizole, Scopolamine or any other smooth muscles relaxing drug.
During the ERCP there is a small chance to cause esophagus perforation and pneumothorax (the air between the lung and chest wall). This can also cause chest pain. It usually can give shortness of breath as well.
If you feel also weak and kind of sick (like during flue), please consult your doctor. Abdominal ultrasound, blood work (including AST, ALT, GGTP, AP, bilirubin and amylase) and chest x-ray should be done.
Hope this will help. Feel free to ask further questions.
Regards.
Some tests should be done.
Detailed Answer:
Hello!
Thank you for the query.
Is the chest pain on one side or both sides? Do you have any nausea, pale stool, dark urine? Do you have cough or shortness of breath?
Chest pain can be a sign of stent placement. Please note that bile ducts and liver pain very often radiates to the back and chest. Its because vagal and other nerves stimulation and diaphragm irritation.
It is possible that the stent is causing some pressure in the bile ducts (for sure it does) what causes chest pain. If so, the pain should get better after smooth muscles relaxation. Please try hot bath, Metamizole, Scopolamine or any other smooth muscles relaxing drug.
During the ERCP there is a small chance to cause esophagus perforation and pneumothorax (the air between the lung and chest wall). This can also cause chest pain. It usually can give shortness of breath as well.
If you feel also weak and kind of sick (like during flue), please consult your doctor. Abdominal ultrasound, blood work (including AST, ALT, GGTP, AP, bilirubin and amylase) and chest x-ray should be done.
Hope this will help. Feel free to ask further questions.
Regards.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Pain is in middle only. Breast bone. Urine and stools are normal. I am not short of breath. It just hurts when I take a deep breath. I do not feel weak of flu like. Could pain simply be from gas/air introduced from procedure? Or from multiple tubes down my throat causing soreness? As far Stent you mention bile. I had a pancreatic stent. Would placement cause pain on in breastbone?
Brief Answer:
Stent is not the reason if the pain is in the middle.
Detailed Answer:
Yes it can be from gas indeed. However gas is evacuated from digestive tract quite quickly. So this explanation is valid only if the ERCP has been done yesterday or few days ago.
As the pain is in the middle only, stent is not causing it, no matter if it is in bile or pancreas duct (both location can give same symptoms).
Pneumothorax is also not that possible as you do not have breathing problems.
So the most probable reason seems to be esophagus irritation due to whole procedure and some acid reflux. Any endoscopy can leave such discomfort or pain as putting into esophagus tubes is not a natural thing.
I think that you may wait with it. It should go away by its own.
Stent is not the reason if the pain is in the middle.
Detailed Answer:
Yes it can be from gas indeed. However gas is evacuated from digestive tract quite quickly. So this explanation is valid only if the ERCP has been done yesterday or few days ago.
As the pain is in the middle only, stent is not causing it, no matter if it is in bile or pancreas duct (both location can give same symptoms).
Pneumothorax is also not that possible as you do not have breathing problems.
So the most probable reason seems to be esophagus irritation due to whole procedure and some acid reflux. Any endoscopy can leave such discomfort or pain as putting into esophagus tubes is not a natural thing.
I think that you may wait with it. It should go away by its own.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you Dr. G. A few final follow up questions. Yes the ERCP was two days ago. The chest pain is subsiding but I still feel sore. Last night I did have nausea (no vomiting) which kept me up. I could here the "grumbling" and acid like feeling in my stomach. Is the nausea also a side effect? Could the ERCP cause acid reflux? I do not have the nausea in the day. After my emergency laparotomy 3 months ago, I had quite a bit of acid and discomfort which abated after two months or so. Now it seems it has come back after all this disruption from the ERCP. I do feel like this is stomach upset but just am looking for reassurance as to when to worry and when not to.
On another front, the good news is that my pancreatic output has come down ... from 130 to 70 ml yesterday. How long does it typically take to resolve after stent placement? Also I am scheduled for another ERCP to have the stent removed when the drainage does reduce substantially. Can you please explain that how once the stent is removed how does the output remain low? It feels like there would be risk that leakage would return once the stent is removed. Finally, Please tell me that taking out the stent is easier than putting in? I would think that no contrast (assuming) and no sphincterotomy would be more straight forward and require less time?
On another front, the good news is that my pancreatic output has come down ... from 130 to 70 ml yesterday. How long does it typically take to resolve after stent placement? Also I am scheduled for another ERCP to have the stent removed when the drainage does reduce substantially. Can you please explain that how once the stent is removed how does the output remain low? It feels like there would be risk that leakage would return once the stent is removed. Finally, Please tell me that taking out the stent is easier than putting in? I would think that no contrast (assuming) and no sphincterotomy would be more straight forward and require less time?
Brief Answer:
Nausea is a very normal thing.
Detailed Answer:
Nausea is a very common sign of any pancreas or bile ducts manipulation. So no wonder you have it and no wonder you have an acid reflux. Moreover, ERCP is a kind of stress for your body. This greatly stimulates stomach acid secretion. It would be good to have some PPI (like Omeprasole or Esomeprasole) for a month or two.
I assume that the main problem is pancreas fistula. This is a very serious pancreas injury/surgery complication. Its serious as it can be active for a very long time and sometimes it is hard to stop the leakage. ERCP and stent placement is a good method especially if the pancreatic duct is tear.
However it is also good to keep the patient on parenteral nutrition so no food and liquids aren't given orally. And Somatostatine should be tried as well (its a medicine which can help with pancreas acid leakage).
All this things together can make the leakage inactive.
As I do not know what exactly has been injured and how effective is the stent, its hard to tell about the time the leakage will stop. If you have an ERCP result ( the image where the contrast flow is shown before and after stent placement) it would be much easier to give precise answer.
Removing stent is much easier if done in a proper time (3 months after the ERCP). If its done later, there might harder to remove it.
For sure no sphincterotomy is done during it as this can be done once in a life time. However contrast must be given to identify pancreas duct.
Nausea is a very normal thing.
Detailed Answer:
Nausea is a very common sign of any pancreas or bile ducts manipulation. So no wonder you have it and no wonder you have an acid reflux. Moreover, ERCP is a kind of stress for your body. This greatly stimulates stomach acid secretion. It would be good to have some PPI (like Omeprasole or Esomeprasole) for a month or two.
I assume that the main problem is pancreas fistula. This is a very serious pancreas injury/surgery complication. Its serious as it can be active for a very long time and sometimes it is hard to stop the leakage. ERCP and stent placement is a good method especially if the pancreatic duct is tear.
However it is also good to keep the patient on parenteral nutrition so no food and liquids aren't given orally. And Somatostatine should be tried as well (its a medicine which can help with pancreas acid leakage).
All this things together can make the leakage inactive.
As I do not know what exactly has been injured and how effective is the stent, its hard to tell about the time the leakage will stop. If you have an ERCP result ( the image where the contrast flow is shown before and after stent placement) it would be much easier to give precise answer.
Removing stent is much easier if done in a proper time (3 months after the ERCP). If its done later, there might harder to remove it.
For sure no sphincterotomy is done during it as this can be done once in a life time. However contrast must be given to identify pancreas duct.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
According to the report a side branch leak is suspected. There was no duct disruption or fluid collection of pancreatitis. I believe the leak was not seen on the ERCP. My pancreatic output from the jp drain has reduced from 130 to70 ml after stent and spinchtrotomy. It has been two full days since procedure. What do you think is sucess rate for side branch leak resolving with this treatment? How long does this type leak take to resolve? Does it typically go done gradually with this treatment or just close off? I have read that while spinchtrotomy and stent are effective for bilary duct to relieve pressure this treatment may not be enough for pancreatic leak. Trying to stay positive. Treatment was at teaching university and md a sub specialist in Ercp/pancreatic disease.
Brief Answer:
The stent might be not enough.
Detailed Answer:
If there is no leak from main pancreatic duct, the stent is only decreasing the pancreatic fluid pressure. This allows to decrease the amount of fluid, but most likely wont cause it complete stop. That is why it would be advisable to start peripheral nutrition along with Somatostatine. Otherwise the leak can be present for many months.
Pancreas acid leakage usually gradually decreases. It does not stop suddenly.
And you have heard right. Bile ducts narrowing can be treated with stents and it is much easier than any pancreas leakage. So like I have mentioned above, the stent might be not enough.
The stent might be not enough.
Detailed Answer:
If there is no leak from main pancreatic duct, the stent is only decreasing the pancreatic fluid pressure. This allows to decrease the amount of fluid, but most likely wont cause it complete stop. That is why it would be advisable to start peripheral nutrition along with Somatostatine. Otherwise the leak can be present for many months.
Pancreas acid leakage usually gradually decreases. It does not stop suddenly.
And you have heard right. Bile ducts narrowing can be treated with stents and it is much easier than any pancreas leakage. So like I have mentioned above, the stent might be not enough.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hello again. 3 was now after ERCP and down to low 70ml from 120ml. When you say otherwise without no oral nutrition it may take months to heal does that mean that these sort of side branch leaks do eventually heal over time? Months meaning 6 to 12? Does the pancreas leak have the ability to heal on its own with the help of the stent? My GI dr said feeding tube would not help speed profess. I have been eating since home from hospital since early XXXXXXX When I hospital I was in jg tube feed for 2 weeks but apparently did not impact fluid or lipase levels. Dr says waiting is only course of action now. What are your thoughts? How long should it take to heal up and it when should I seek another opinion. As I mentioned I went to well respected teaching univ in so california. Thank you.
Brief Answer:
The leakage should stop by its own.
Detailed Answer:
I was not thinking about feeding tube. I was rather thinking about complete parenteral nutrition. We do that to decrease the pancreatic juice production. And it is effective. But usually it is done right after the injury. So at this point, it is not necessary as you are in good general condition
Please see the article I have found for you (the case report) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC0000/. I know this is not exactly as yours case, but gives general image on how it should look like.
Generally the leakage should close by its own. But to obtain that, the pressure in the pancreatic duct must be low. The healing can take months what means 3-6 months or even longer. So you need to be patient. And waiting is the only option right now.
The leakage should stop by its own.
Detailed Answer:
I was not thinking about feeding tube. I was rather thinking about complete parenteral nutrition. We do that to decrease the pancreatic juice production. And it is effective. But usually it is done right after the injury. So at this point, it is not necessary as you are in good general condition
Please see the article I have found for you (the case report) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC0000/. I know this is not exactly as yours case, but gives general image on how it should look like.
Generally the leakage should close by its own. But to obtain that, the pressure in the pancreatic duct must be low. The healing can take months what means 3-6 months or even longer. So you need to be patient. And waiting is the only option right now.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you. Good news week 4 after stent and leakage down to 15 ml for last two days. How long should output be down before stent is pulled? How after stent pulled and output down should jp drain be pulled? Do the stents ever pass on own or is it necessary to take out. Mine is 5 cm pigtail stent I believe. On another note do you think having jg feeding tube pulled will help me not to feel so full so easily? I do not have nausea nor have I vomitted over last 4 months. Is is possible I could have mild gastoparesis? I also get a protrusion in my lower stomach after I eat but it is flat in the am. Thought at first it was incisional hernia but dr said probably tissue that got moved around from surgery. Is it possible this will go away over time or what are your thoughts?
Brief Answer:
Please see the answer below.
Detailed Answer:
Stent is usually removed 3 months after its placement if the leakage is 0. ERCP placed stent to pancreatic duct usually does not pass by its own. It has to be removed the same way it was placed (through ERCP). Feeding tube is not a good idea at this point. From your description you are getting better day by day so any intervention in digestive tract is not necessary at this point.
You may feel full after eating as there is inflammatory process very close to the stomach and duodenum. So both this organs can be narrow causing you the fullness. This is not a gastroparesis for sure.
If the protrusion is just diastasis recti (the abdominal muscle), it can go by its own if you start the exercises strengthening this muscle. If its hernia, wont go away by its own.
Please see the answer below.
Detailed Answer:
Stent is usually removed 3 months after its placement if the leakage is 0. ERCP placed stent to pancreatic duct usually does not pass by its own. It has to be removed the same way it was placed (through ERCP). Feeding tube is not a good idea at this point. From your description you are getting better day by day so any intervention in digestive tract is not necessary at this point.
You may feel full after eating as there is inflammatory process very close to the stomach and duodenum. So both this organs can be narrow causing you the fullness. This is not a gastroparesis for sure.
If the protrusion is just diastasis recti (the abdominal muscle), it can go by its own if you start the exercises strengthening this muscle. If its hernia, wont go away by its own.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you. Just to clarify I still have jg tube in however I am not using it. Question is do you think when they remove feeding tube that I will have some relief from feeling full ? Does inflammation you refer to ease over time? Regarding long term will I need to worry about scar tissue causing issues? As far as the protrusion it is horizontal and to left of my belly button. I don't seem to have any sort of gap in abdominal muscle. The protusion seems to be larger as day goes on and flat in am. Does not look like hernia pictures I have seen and it feels like fatty tissue vs intestine. Could this go away with time? Finally once jp drain is removed after stent is removed is there risk that leakage from side branch will return or is absence of leakage from drain indicate full healing and it is safe?
Brief Answer:
Please see the answers below.
Detailed Answer:
I have misunderstood the tube type you have been asking.
If its about G-J (gastrojejunostomy) tube, it can be removed at any time. The removal is very simple if the tube has been inserted during the surgery (not during the endoscopy). All you need to do is to pull it out (before that stitches or rubber which is attached to the skin needs to be released). You may find some relief when this tube is removed for sure. It takes some part of stomach and duodenum space.
If you do not use this tube, and the leakage is getting really low, they may to decide about the tube removal very soon. The time is of its removal is individual, but I am pretty sure it wont take longer than few weeks.
Yes, the inflammation caused by pancreas juice leakage can go away after some time. Usually it does. But for sure it will leave some adhesions. Luckily, adhesions in the stomach area (where the pancreas is located and where the incision is present) do not cause digestion problems or bowels obstruction. So it is very probable, you wont have any problems regarding that.
If its about the hernia (or hernia suspicion), its hard to tell not being able to examine your abdomen. Is there any chance you can attach a picture of your abdomen when standing, and when lying down with head elevated (in simple words, try to elevate look at your abdomen when lying down - I hope you get the point).
JP removal wont cause any leakage recurrence. Pig-tail drain removal from pancreatic duct also should not cause leakage recurrence. So we can say, once the leakage is stopped, should not come back.
Please see the answers below.
Detailed Answer:
I have misunderstood the tube type you have been asking.
If its about G-J (gastrojejunostomy) tube, it can be removed at any time. The removal is very simple if the tube has been inserted during the surgery (not during the endoscopy). All you need to do is to pull it out (before that stitches or rubber which is attached to the skin needs to be released). You may find some relief when this tube is removed for sure. It takes some part of stomach and duodenum space.
If you do not use this tube, and the leakage is getting really low, they may to decide about the tube removal very soon. The time is of its removal is individual, but I am pretty sure it wont take longer than few weeks.
Yes, the inflammation caused by pancreas juice leakage can go away after some time. Usually it does. But for sure it will leave some adhesions. Luckily, adhesions in the stomach area (where the pancreas is located and where the incision is present) do not cause digestion problems or bowels obstruction. So it is very probable, you wont have any problems regarding that.
If its about the hernia (or hernia suspicion), its hard to tell not being able to examine your abdomen. Is there any chance you can attach a picture of your abdomen when standing, and when lying down with head elevated (in simple words, try to elevate look at your abdomen when lying down - I hope you get the point).
JP removal wont cause any leakage recurrence. Pig-tail drain removal from pancreatic duct also should not cause leakage recurrence. So we can say, once the leakage is stopped, should not come back.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you. Having trouble attaching image. In meantime I have noticed as drainage had gone down to 3ml 24 hrs the color is no longer clear like saliva. Rather it is a dark yellow brownish color maybe a tinge of rust. Is this normal? I thought I recall my surgeon saying when color changes it means it is just abdominal fluid. What are your thoughts? I am waiting to see him. Also I get from time to time a popping sensation in my stomach like a little balloon popping. It moves around and is not painful just annoying. What could be causing this? Also is it normal to have a pulse on abdomen? I think I have always had it I an 5 ft 4. 115 lbs. of course if I read I worry about aaa. If I had hernia would I feel pain?
Brief Answer:
3ml means that the leakage is gone.
Detailed Answer:
3 ml/24 hours means that either the drain is obstructed or the pancreas leakage is gone. Yellow/brownish color (if does not smell bad) is just a fluid from the abdomen and from the tissues where the drain is. Such fluid appears as the drain irritates the tissues. But 3 ml is lie 0. So it might be the time to remove the drain. But first, CT should be repeated.
Popping sensation can be due to G-J tube or just a gas. It should not bother you as long as the drain stays there. This is a normal reaction.
Thin persons can easily palpate the hard pulse right in the front of the abdomen. This is an aorta. This is very normal as well. You might notice it especially if you have lost weight due to pancreas disease.
For sure you do not have any aneurysm there as it would be seen in every abdominal CT.
Hernia, if is large, can give no pain at all. Protruding lump especially when coughing is a characteristic symptoms of hernia.
3ml means that the leakage is gone.
Detailed Answer:
3 ml/24 hours means that either the drain is obstructed or the pancreas leakage is gone. Yellow/brownish color (if does not smell bad) is just a fluid from the abdomen and from the tissues where the drain is. Such fluid appears as the drain irritates the tissues. But 3 ml is lie 0. So it might be the time to remove the drain. But first, CT should be repeated.
Popping sensation can be due to G-J tube or just a gas. It should not bother you as long as the drain stays there. This is a normal reaction.
Thin persons can easily palpate the hard pulse right in the front of the abdomen. This is an aorta. This is very normal as well. You might notice it especially if you have lost weight due to pancreas disease.
For sure you do not have any aneurysm there as it would be seen in every abdominal CT.
Hernia, if is large, can give no pain at all. Protruding lump especially when coughing is a characteristic symptoms of hernia.
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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