Procedure of ercp and t tube cholangiography

ERCP PROCEDURE

1. Procedure of ERCP and T-Tube cholangiography Presenter:- Yashawant yadav B.Sc MIT 2 ND Year NAMS Bir-Hospital

2. Contents :- Introduction Anatomy of associated organs Indication And Contraindications Equipment’s Patients preparation Technique Filming

3. Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is a combined endoscopic and fluoroscopic procedure in which an upper endoscope is led into a second part of the duodenum, making it possible for passage of other tools via the major duodenal papilla into the biliary and pancreatic ducts. Contrast material may be injected in these ducts, allowing for radiologic visualization and therapeutic interventions when indicated.

4. Contd..

5. Anatomy The main pancreatic duct connects to the common bile duct and drains at the ampulla of Vater (hepato-pancreatic ampulla), controlled by the sphincter of Oddi. The major duodenal papilla is the opening of the ampulla of Vater into the second part of the duodenum. The common bile duct and the pancreatic duct may remain separate or merge at the end of the papilla, or they may form a common duct.

6. Indications:- Obstructive jaundice Chronic pancreatitis (controversial indication due to availability of safer diagnostic modalities) Gallstones with dilated bile ducts on ultrasonography Bile duct tumors and obstructions Suspected injury to bile ducts either as a result of trauma or iatrogenic Sphincter of Oddi dysfunction Choledocholithiasis ( calculus of CBD) Bile duct leak post cholecystectomy Patient with pancreatic or biliary cancer

7. Therapeutic purposes Tissue sampling in patient with pancreatic or biliary cancer Endoscopic sphincterotomy (both of the biliary and the pancreatic sphincters) Removal of stones Insertion of stent Dilation of strictures (e.g. primary sclerosing cholangitis, anastomotic strictures after liver transplantation)

8. Contraindications HIV positive patient Previous gastric surgery Oesophageal obstruction Acute pancreatitis Pancreatic pseudocyst When glucagon or buscopan contraindicated Severe cardio/respiratory disease Coagulation disorder

9. Contrast media Non ionic low osmolar contrast agent e.g. Omnipaque , ultravist ,optiray:200mgI/ml Dose :- 20 ml ANTIBIOTIC IN CM :-the addition of antibiotics to CM has been advocated by some center to decrease septic complication of ERCP.

10. Equipment's SIDE -VIEWING ENDOSCOPE

11. Contd.. FLUOROSCOPY WITH IITV SYTEM AND SPOT FILM DEVICE

12. Contd.. Catheter guide wires and cannula Guide wire ERCP CATHETER ERCP cannula

13. Contd.. Biliary cytology brush Biliary expandable stent CBD extraction balloon

14. Contd.. CBD stone retrieval basket Endoscopic lithotripter Pancreatic stent

15. Contd … sphincterotome

16. PATIENT PREPERATION NPO at least 6 hrs before the procedure Information about -any medication (warfarin or other anticoagulant), cardiac disease - barium x-ray or ct scan in the past 2-3 days -Any chance of pregnancy , major illness and recent surgery Stop taking aspirin or anti-inflammatory drugs 5 days prior to ERCP.

17. Contd.. Recent blood test report – PT, billirubin , albumin, LFT , Haemogram profile etc. Counseling , informed consent Remove radiopaque materials In case of obstructed duct may required to administer antibiotic I/V prior to ERCP and continue for 24 hrs if contrast has been instilled into an obstructed duct May require sedation – inj. Diazepam 10 mg I/v or inj. Pethidine 75 mg I/M

18. PREMEDICATION Known case of allergy to iodinated contrast medium is pre treated with either prednisone 40 mg 24 hrs and 2 hrs before or 40 mg daily for 3 days before the exam Smooth muscle relaxant - Buscopan 20 mg I/M before 10 min or 0.6 mg I/M atropine 1 hrs is given to reduce duodenal spasm and relax the sphincter of oddi

19. Pre-procedure investigations Liver tests Recent blood test– PT, bilirubin, albumin, LFT , Haemogram profile Platelet count and coagulation profile Imaging Ultrasound CT CT cholangiogram MRCP Endoscopic Ultrasound

20. Procedure To ease passage of endoscope, patients throat is sprayed with a local anesthetic(4%, 50-100 mg xylocaine) ,this causes temporary pharyngeal paresis Pt lies on the left side on fluoroscopy table a flexible camera (endoscope) is inserted through the mouth, down the esophagus, into the stomach, through the pylorus into the duodenum to the ampulla of Vater A polythene catheter or cannula with prefilled CM is inserted into the ampulla

21. Contd … A test dose of CM is injected under the fluoroscope to determine the position of cannula Then radio contrast is injected into the bile ducts and/or pancreatic duct If it is desirable to opacify both the biliary tree and pancreatic duct then the latter should be cannulated . A sample of bile should be sent for culture and sensitivity if there is evidence of biliary obstruction.

22. Contd … Fluoroscopy is used to look for blockages, or other lesions such as stones ,also spot images are taken as required when duct filling completes Oblique spot radiographs may be taken to prevent overlap of common bile duct and pancreatic duct

23. Filming's CM drains from normal ducts within approx 5min radiographs must be exposed immediately PANCREAS -prone , both oblique BILE DUCT 1. Early filling to show calculi A. prone - straight and post. Obliques B. supine - straight , both obliques , trendlengberg to fill intrahepatic duct , semi erect to fill lower end of common bile duct and GB

24. Contd.. 2. films after removal of endoscope which may obscure the duct 3. delayed films to assess the GB and emptying the common bile duct

25. ERCP in therapeutic uses When ERCPs are done to allow some sort of treatment ,they are referred to as therapeutic ERCP It includes A . Sphincterotomy B . Stone removal C . Stent placement D . Balloon dilatation E . Tissue sampling

26. Indication for therapeutic ERCP Bile duct stone Bile duct injury Bile duct stricture due to tumor or scarring Post cholecystectomy syndrome Some cases of pancreatitis Replacement of an obstructed ampullary stent

27. Sphincterotomy It is cutting the muscle that surrounds the opening of the ducts or papilla The cut is made while looking through the ERCP scope at the papilla A small wire on a sphincterotome uses electric current to cut the tissue The sphincterotome has a special cautery unit that seals the tissue after the cut and prevent bleeding

28. During papillotomy After papillotomy Before papillotomy

29. Stone remove Most common treatment through ERCP Stones may have formed in the GB and travelled into the bile duct or may form in the duct itself After sphincterotomy the opening of the bile duct is enlarged and stones can be pulled from the duct into the bowel A variety of balloon and baskets attached to specialized catheter can be passed through ERCP scope into the ducts allowing stone removal

30. EXTRACTION WITH DORMIA BASKET Dormia basket is useful device for stone extraction. It is made up of 4 parallel wires Stone can be trapped in-between and extracted with it’s content via papilla

31. Mechanical lithotripsy The basket for lithotripsy in the bile duct shows a very similar design to retrieval basket although tensile strength of the wire is much higher. A metal lithotripsy is pushed over the basket to stabilize the device to the high occurring forces. The forces are mechanically applied to the baskets wire to cut stone to pieces. The fragments are then extracted one by one from the bile duct

32. Stent placement INDICATION -To treat obstruction in the bile duct -To treat biliary leak Stents are placed into the bile or pancreatic duct to bypass stricture or narrow part of the duct Two types of stents plastic or metal are commonly used Plastic stent looks like a small straw

33. Contd … The plastic stent is pushed through ERCP scope into the blocked duct to allow normal drainage Plastic stent is placed temporarily and should be removed in follow up ERCP The metal stent is flexible and springs open to a larger diameter than plastic stent Metal stent are placed permanently

34. Balloon dilation ERCP catheter fitted with dilating balloon is placed across a narrow area or stricture Often performed when the case of narrowing is benign After balloon dilation a temporary stent is placed for few month to help drainage

35. Tissue sampling In ERCP tissue sampling is a technique to take samples of tissue from the papilla or from bile or pancreatic duct There are several diff. sampling technique although the most common is to brush the area with subsequent examination of the cells obtained Tissue samples can help to decide if a stricture or narrowing is due to cancer

36. Contd.. Cytology forceps Brush cytology

37. Advancement in ERCP INTRADUCTAL ENDOSCOPY Describe the use of an endoscope to evaluate the biliary and pancreatic duct. It allows direct visualization of the biliary and pancreatic duct. This technique is developing that promises greater opportunity to provide improved diagnosis and therapy regarding lesion in the biliary and pancreatic duct.

38. EUS (ENDOSCOPY ULTRASOUND) EUS employs a duodenoscope with distal ultrasound probe that can be used to image organs , blood vessels , lymph nodes and bile ducts The EUS scope is advanced within the gastrointestinal tract that allows visualization of the pancreas and adjacent structure Preferable in high risk pt in ERCP or potential complication to ERCP

39. PATHOLOGY DIAGNOSED IN ERCP CBD stone

40. DIVERTICULA

41. Biliary stone Gallstone

42. Biliary stenosis Biliary dilation

43. STENOSIS

44. Aftercare Nil orally (0.5-3hrs) until sensation has returned to the pharynx Vitals should be checked half-hourly for 6 hrs Maintain antibiotic in case of biliary or pancreatic obstruction Serum/urinary amylase if pancreatitis is suspected

45. Complication GENERAL- common to all endoscopic procedure - Medication reaction - Oxygen desaturation - Cardio pulmonary accident - Hemorrhage and perforation induce by instrument passage.

46. Radiation protection Decrease fluoroscopy time Use time alarm/reminder - Alarm rings after a predetermined duration of fluoroscopy time (5min) Use pulse fluoro mode (not continuous) Maintain appropriate distance Avoid magnification mode Use collimator.

47. T – Tube cholangiography A T-Tube cholangiogram is a procedure done after a patient’s gallbladder has been removed and a surgeon has placed a tube in the patient’s right side to drain the bile ducts. The bile ducts and first section of the small bowel (duodenum) will be imaged. This exam takes about 30 minutes.

48. Contd … Indications patient's with possibility of residual small gallstones post cholecystectomy obstructive jaundice bile duct stricture surgeon unable to explore bile duct during cholecystectomy surgery Contraindications contrast or iodine allergy pregnancy (? pregnancy test required) barium study within last 3 days

49. Prepare for a T-Tube Cholangiogram Do not eat or drink anything after 10:00 pm (22:00) the night before test. can still take your medications with a small amount of water. Notify the technologist if you have any allergies (especially to iodine or seafood).

50. What will happen during the T-Tube Cholangiogram contrast medium will be injected through the T-Tube while taking x-ray images. Pt. may be asked to hold your breath. While injecting the contrast media. This test takes about 15-30 minutes After the T-Tube Cholangiogram pt. will be able to resume normal activity.

51. Contd.. Technique Notes Contrast media should be diluted with saline so that small biliary stones are not obscured by an overly dense contrast media Preliminary/scout images are important. Failure to take a preliminary/scout image is one of the most frequently made errors by Radiology Registrars performing fluoroscopy procedures air-bubbles can often be distinguished from stones by their behaviour - air bubbles tend to float 'up hill' and can change shape and may separate into two smaller bubbles. If the examination is marred by air bubbles, the biliary system can be flushed with saline and the study repeated. If there is any question of distal obstruction, a delayed drainage image should be obtained

52. Contd … This is an AP/PA supine T-tube cholangiogram image. The biliary tree is outlined with contrast medium. There appears to be extravasation of contrast medium outside the biliary tree and minimal contrast in the duodenum.

53. References https://www.ncbi.nlm.nih.gov/books/NBK493160/ http://www.wikiradiography.net/page/T-tube+Cholangiogram Hand book of radiological procedure Various web

54. Questions What are the therapeutic technique of ERCP? Contrast media in ERCP? What are the filming of ERCP? Indications of ERCP and its possible complications ? Define T – Tube cholangiography