(ERCP) Cholangiopancreatography Bile ducts procedure

Endoscopic Reterograde Cholangiopancreatography

Examination of the bile ducts by using endoscopy and injecting contrast media .

1. ERCP

2. Content Anatomy ERCP & PTBD Indication Contraindication Equipment Procedure Complication Aftercare Pathologies

3. Anatomy

4. Liver L iver  is largest abdominal organ major role in metabolism Glycogen storage Decomposition of red blood cells Plasma protein synthesis Hormone production Detoxification

5. Gross anatomy Liver is an irregular, wedge-shaped organ Lies below the diaphragm in the right upper hypo quadrant of the abdomen Closely related with the the gallbladder, diaphragm, stomach and covered by the costal cartilages.

6. Gross anatomy 2 surfaces: diaphragmatic surface visceral surface Craniocaudal length: 10-12.5 cm Transverse diameter: 20-23 cm

7. Pancreas • Pancreas is a retroperitoneal organ Has both endocrine and exocrine functions. • Production hormones(insulin, somatostatin) glucagon. • Digestion by its production and secretion of pancreatic juice Small intestine (duodenum) ality : Investigate

8. Endoscopic retrograde cholangio-Pancreatography ERCP is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat problems of the biliary or pancreatic ductal system.

9. Indication • Investigation of extrahepatic biliary obstruction • Post-cholecystectomy syndrome • Investigation of diffuse biliary disease • Sclerosing cholangitis • Pancreatic disease

10. Contraindication • Oesophageal obstruction • Pyloric stenosis • Previous gastric surgery • Acute pancreatitis • Pancreatic pseudocyst • Severe disease •Cardiorespiratory

11. Contrast Media Pancreas LOCM 240 Bile ducts LOCM 150; dilute contrast medium ensures that calculi will not be obscured.

12. Equipment Side-viewing endoscope Polythene catheters Fluoroscopic unit with spot film facilities

13. Fluoroscopic Unit

14. Self-Expanding Metal Stents Self-expanding metal stents.

15. Patient Preparation Nil orally for 4 h prior to procedure Patients may be asked to temporarily stop taking medications Patient may asked to stop smoking temporarily Diazepam 4 hour before procedure

16. Patient Preparation Sedation is given by using midazolam, meperidine or fentanlyl Explain patient about procedure Written consent Antibiotic cover

17. Preliminary film Prone AP and LAO of the upper abdomen, to check for opaque gallstones and pancreatic calcification/calculi Prone AP LAO

18. Procedure Pharynx is anaesthetized with 4% Xylocaine spray Patient is given diazepam 5 mg min -1 IV Patient then lies on left side and endoscope is introduced

19. Procedure Ampulla of Vater is located and patient is turned prone. Polythene catheter prefilled with contrast medium - inserted into ampulla, having ensured that all air bubbles are excluded.

20. Procedure Small test injection of contrast under fluoroscopic control is made to determine position of cannula If it is desirable to opacify both biliary tree and pancreatic duct, then latter should be cannulated first

21. Filming Pancreas Prone, LPO & RPO

22. Filming Bile ducts Early filling films to show calculi Prone - straight and posterior obliques Supine - straight, both obliques ; Trendelenburg to fill intrahepatic ducts semi-erect to fill lower end of common bile duct and gallbladder

23. Filming Films following removal of the endoscope, which may obscure the duct. Delayed films to assess the gallbladder and emptying of the common bile duct

24. After Care Nil orally until sensation has returned to the pharynx Pulse, temperature and blood pressure half-hourly for 6 h Maintain antibiotics if there is biliary or pancreatic obstruction Serum/urinary amylase if pancreatitis is suspected

25. Complication Due to contrast medium Allergic reactions - rare Acute pancreatitis - more likely with large volumes, high-pressure injections Due to the technique Local Damage by the endoscope, e.g. rupture of the oesophagus, damage to the ampulla, proximal pancreatic duct and distal common duct Distant Bacteraemia, septicaemia, aspiration pneumonitis, hyperamylasaemia (approx. 70%). Acute pancreatitis (0.7-7.4%)