ERCP (1).pptx

Ercp

1. ERCP Endoscopic Retrograde Cholangiopancreatography Moderator-Dr Basavaraj Raikod Patil sir

2. Introduction ERCP is a combined endoscopic and fluoroscopic procedure in which an upper endoscope is lead into 2nd part of duodenum, making it possible for passage of other tools via major duodenal papilla into biliary and pancreatic ducts. Contrast material is injected into these ducts, allowing it as diagnostic and therapeutic tool when needed.

3. Anatomy

4. Indications Diagnostic Cholestatic jaundice Acute Cholangitis Choledocholithiasis Sphincter of Oddi manometry Suspected sclerosing cholangitis Recurrent acute pancreatitis Chronic pancreatitis Evaluation of pancreatic pseudocyst Pancreatic fistula, pancreatic ascites Brush cytology or biopsy for confirmation of diagnosis

5. Therapeutic Biliary drainage for cholangitis, pruritus, post-operative bile leak Extraction of stones, round worms or hydatid daughter cysts from bile duct Bile duct and pancreatic duct stricture dilatation Pancreatic duct and CBD stone extraction Pancreatic duct stenting in chronic pancreatitis, pancreatic ascites and fistula Sphincterotomy in case of sphincter of oddi dysfunction or stenosis Balloon dilation of the duodenal papilla and ductal strictures

6. Contraindications Unstable cardiopulmonary, neurology or cardiovascular status and existing bowel perforation. Structural abnormalities of esophagus, stomach and duodenum. Altered surgical anatomy. ERCP with sphincterotomy or ampullectomy is contraindicated in cogulopathic patients.

7. Contrast Media Non ionic tri-iodinated low osmolar contrast agent Iopamidol Iohexol Iopramide

8. Sedation Inj Diazepam [0.3mg/kg body weight] Inj Pethidine 75mg IM before 1 hour local anaesthetic agent like Xylocaine spray can be given.

9. Materials used Endoscope [side or forward viewing] Image processing equipment

10. Cannulation devices

11. Patient preparation NPO from midnight or atleast 6 hours prior to procedure. Information about any medications [anticoagulants, analgesics], major illness, pregnancy, allergy or previous other surgeries. Recent bood investigations, radiological reports to look for gall stones, pancreatic calcifications or any other diagnosis. May need IV antibiotics prior to ercp.

12. local anesthetic sprayed onto the tongue/throat before the procedure. known allergic to iodine contrast, pre treated with either 40mg prednisone 12 hours and 2 hours before or 40mg daily for 3 days before procedure. smooth muscle relaxant-Buscopan 20mg IM before 10 mins or atropine 0.6mg IM before 1 hour or 0.5-1ml glucagon Iv is given to reduce duodenal spasm and relax the sphincter of oddi for passage of endoscope and insertion of cannula.

13. PROCEDURE With the patient in the prone or semiprone position, the duodenoscope is passed through a mouth guard. Duodenoscope is then advanced through stomach pylorus into the duodenal bulb. The scope should be advanced to the second part of duodenum to visualise the major duodenal papilla, a protuberance at the junction of the horizontal and vertical duodenal folds. The recommended wire guided technique is done through a guide wire that passes under fluoroscopy into common bile duct or pancreatic duct before contrast injection.

14. On the other hand, the standard contrast-assisted method involves contrast material injection after introducing the cannulation device tip into the major duodenal papillary orifice to assure proper positioning. Difficult cannulation may be due to periampullary diverticulum, impacted biliary stone, bile duct stenosis, or tumor of the bile duct or pancreatic head. Infrequently, cannulation of the minor papilla with sphincterotomy may be done in cases of idiopathic recurrent acute pancreatitis or patients with pancreas divisum.

15. Therapeutic ERCP Brushing and biopsy Balloon dilation Stenting Sphincter of Oddi manometry Sphincterotomy Nasobiliary drainage

16. Brushing and biopsy Most of the strictures in the hepatobiliary ducts are caused by tumor compression the duct walls. Sample tissue is taken from stricture during ERCP procedure to confirm pathological diagnosis

17. Under fluoroscopic control, guide wire is introduced past through the stricture, then advance brush catheter upto the stricture. The brush is moved up and down several times to scrap and extract diseasesd tissues from stricture. The brush is removed from endoscope, cut off the wire placed in a formalin solution to be sent for pathological study.

18. Forceps Biopsy Small biopsy forcep is advanced over guide wire to stricture. Forceps are obtained touching the stricture walls, closed tightly to clamp tissues and pull back maintaing closed condition from endoscope. tissue sample is placed in formalin solution and sent to pathological study.

19. Balloon Dilation

20. Stenting

21. Types of stent

22. Sphincter of Oddi manometry

23. Sphincterotomy

24. Nasobiliary Drainage

25. After care NPO for 4 hours until anaesthetic effect return to normal. Avoid alcohol for atleast 24 hours Monitoring vitals hourly for 4-6 hours then 4 hourly for next 24 hours. Monitoring in the recovery room for 30-45 mins, until the effects of sedation remain.

26. Post procedure

27. Complications of ERCP Post ERCP pancreatitis - 1.New or worsened abdominal pain. 2.New or prolongation of hosptalisation for atleast 2 days. 3.Serum amylase levels obtained 2-6 hours post-ERCP are considered normal if less than 1.5 times the upper limit of normal. 4.Serum lipase levels obtained at same time are considered normal if less than 4 times the upper limit of normal.

28. Risk Factors for post-ERCP pancreatitis - 1.Balloon dilation of biliary sphincter 2.H/O post ERCP pancreatitis 3.Pancreatic duct injection 4.Pancreatic sphincterotomy 5.Precut sphincterotomy 6.Suspected sphincter of Oddi dysfunction 7.Increase cannulation attempts duration [more than 10 mins] 8.Young age

29. Methods of reducing post-ERCP pancreatitis Alternatives to ERCP like MRCP and EUS have similar sensitivity for detection of pancreatobiliary disorders without risk of pancreatitis. Pharmacological prophylaxis- significant reduction of PEP with indomethacin or diclofenac given rectally just before ERCP.

30. Modifications in techniques to avoid PEP Pancreatic duct stents - Temporary pancreatic duct stents show the benefits of lowering the risk and severity of PEP in high risk individuals. Wire guided cannulation -The use of wire guided cannulation beofre contrast injection has been shown resulting in greater success of biliary cannulation and lower risk of PEP by avoiding injection of contrast into pancreas

31. Hemorrhage Most ERCP-associated bleeding is intraluminal, intraductal bleeding and can also occur It is a complication related to sphincterotomy rather than diagnostic ERCP. It can be immediate or delayed, with recognition occuring upto 2 weeks after procedure. Risk of post -ERCP hemorrhage was associated with hemodialysis, visible bleeding during the procedure, higher bilirubin and use of pure-cut current for sphincterotomy Treatmen of bleeding includes injection therapy with epinephrine, with or without thermal therapy and endoscopic clips

32. Perforation Guidewire induced perforation Periampullary perforation during sphincterotomy Luminal perforation at a site remote from papilla RISK FACTORS- Sphincterotomy Billroth 2 anatomy Intramural injection of contrast Prolonged duration of procedure Biliary stricture dilation Sphincter of Oddi dysfunction

33. Infections Cholangitis- Seen in combined percutaneous-endoscopic procedures stent placement in malignant strictures incomplete or failed biliary drainage primary sclerosing cholangitis Cholecystitis - Seen in gall bladder stones and filling of gall bladder with contrast. Placement of self expandable metal stents particularly if stent is covered and cystic duct is obstructed.

34. Cardiopulmonary complications- Cardiac arrhythmia Hypoxemia Aspiration Other complications- Pneumothorax Hepatic abscess formation Antibiotic related diarrhea Perforation of colonic diverticula Duodenal hematoma

35. References Harrison’s Principles of Internal Medicine 21st edition. API Textbook of Medicine 12th edition. Sleisenger and Fordtran’s Gastrointestinal and liver disease 11th edition.

36. THANK YOU