Effects of Pre-procedure and Intra-procedure Simethicone and Dicyclomine Administration in Improving Quality of Endoscopic Reterograde Cholangipancreaticography (ERCP)

Study design: This is a randomized, double blind, controlled, trial which will be commenced after ethical approval by the institutional review board at Combined Military Hospital, Lahore. Written informed consent of all participants will be sought. Data will be prospectively collected over a period of 6 months.

Participants: Patients older than 18 years of age, presenting to the Gastroenterology department for an ERCP will be enrolled. Cases that are abandoned due to inability to access the ampulla will be excluded. Patients with grossly altered anatomy resulting in extended procedure time will also excluded.

Study Protocol: Patients will randomly assigned to one of three groups at presentation: The control group (Group 1), the pre-procedure treatment group (Group 2) and the intraprocedural treatment group (Group 3).

Patients will be randomized into three groups using block randomization. A 1:1:1 block randomization technique will be used with block sizes of 6. The random allocation sequence is generated using the randomization website https://www.sealedenvelope.com. A designated nurse shall allot the patients into the specific groups.

All procedures will be performed by two experienced endoscopists (MH and RD) using a side viewing duodenoscope. Each biliary cannulation will be attempted using a sphincterotome and 0.035" guidewire. Still images and high-quality videos will be recorded during the procedure and examined at the end of the procedure by a Hepatology fellow (MS) who is blinded to the treatment arm. The fellow shall grade the mucosal visibility and duodenal contractility using scales employed by previous studies

The four-point scale for mucosal visibility is as follows:

(0) No bubbles-the procedure could be easily performed.

• Very few bubbles-this did not interfere with the procedure.
• A slightly greater quantity of bubbles-the procedure could be performed with some difficulty.
• A large quantity of bubbles interfering with the procedure-accurate evaluation was impossible.

The duodenal motility was graded as follows:

(0) No contractions were observed.

• <5 contractions per minute were observed.
• 5 to 10 contractions per minute were observed.
• 11 to 15 contractions per minute were observed.
• Continuous contractions were observed. At the end of the procedure, the endoscopist satisfaction will be inquired and rated as good, moderate or poor. The total procedural time will also be recorded.

Inclusion criteria

• All patients presenting for ERCP older than 18years of age.
• Patients willing to participate in the study, meeting criteria No. 1

Exclusion criteria

• Cases that are abandoned due to inability to access the ampulla
• Patients with grossly altered anatomy resulting in extended procedure time