Endoscopic retrograde cholangiopancreatography - PowerPoint Presentation

Slide1

Endoscopic retrograde

cholangiopancreatography

(ERCP)

Slide2

Introduction

Endoscopic retrograde

cholangiopancreatography

(ERCP) is a technique that combines the use of

endoscopy

and

fluoroscopy

to diagnose and treat certain problems of :

the duodenum (the first portion of the small intestine),

the papilla of

Vater

(a small structure with openings leading to the bile ducts and the pancreatic duct),

the bile ducts, and

the gallbladder and the pancreatic duct.

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Uses

Diagnostic

Used when it is suspected a person’s bile or pancreatic ducts may be narrowed or blocked due to:

tumors

gallstones that form in the gallbladder and become stuck in the ducts

inflammation due to trauma or illness, such as pancreatitis

infection

Dysfunction of valves in the ducts, called sphincters,

scarring of the ducts (sclerosis),

Pseudo-cysts—accumulations of fluid and tissue debris

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Therapeutic

Sphincterotomy

Stone Removal

Stent Placement

Balloon Dilation

Tissue Sampling

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Preparation of Patient before ERCP

The upper GI tract must be empty. Generally, no eating or drinking is allowed 8 hours before ERCP.

Smoking and chewing gum are also prohibited during this time.

C

urrent medications may need to be adjusted or avoided. Most medications can be continued as usual.

Removal of any dentures, jewelry, or contact lenses before having an ERCP.

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Before ERCP, all of the patient’s previous abdominal imaging findings (from CT scans, magnetic resonance imaging [MRI], ultrasonography, and cholangiography or

pancreatography

) should be reviewed.

Deep sedation is desirable during ERCP because a stable endoscopic position in the duodenum is important for proper

cannulation

, therapeutic intervention, and avoidance of complications.

Slide8

Procedure

Patients receive a local anesthetic that is gargled or sprayed on the back of the throat & IV sedatives.

patients lie on their back or side on an x-ray table

Then a flexible camera (endoscope) is inserted through the mouth, down the esophagus, into the stomach, through the pylorus into the duodenum where the ampulla of

Vater

(the opening of the common bile duct and pancreatic duct) exists. The sphincter of

Oddi

is a muscular valve that controls the opening of the ampulla. The region can be directly visualized with the endoscopic camera while various procedures are performed.

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A plastic catheter or cannula is inserted through the ampulla, and

radiocontrast

is injected into the bile ducts and/or pancreatic duct. Fluoroscopy is used to look for blockages, or other lesions such as stones

.

When needed, the opening of the ampulla can be enlarged (

sphincterotomy

) with an electrified wire (

sphincterotome

) and access into the bile duct obtained so that gallstones may be removed or other therapy

performed.

Slide10

Fluoroscopic image showing dilatation of the pancreatic duct during ERCP investigation. Endoscope is visible.

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Fluoroscopic image of common bile duct stone seen at the time of ERCP. The stone is impacted in the distal common bile duct. A

nasobiliary

tube has been inserted.

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Other procedures associated with ERCP include the trawling of the common bile duct with a basket or balloon to remove gallstones and the insertion of a plastic stent to assist the drainage of bile. Also, the pancreatic duct can be

cannulated

and stents be inserted. The pancreatic duct requires visualization in cases of pancreatitis.

In specific cases, a second camera can be inserted through the channel of the first endoscope. This is termed

duodenoscope

-assisted

cholangiopancreatoscopy

(DACP) or mother-daughter ERCP. The daughter scope can be used to administer direct electrohydraulic lithotripsy to break up stones, or to help in diagnosis by directly visualizing the duct.

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After the Procedure

Patients are monitored in the endoscopy area for 1-2 hours until the effects of the sedatives have worn off & observed for complications.

E

ating or drinking is allowed if the throat is no longer numb and are able to swallow without choking.

If a gallstone was removed or placed a stent during the test, the patient is made to stay in the hospital overnight.

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An Example (Bile Duct Cancer (

Cholangiocarcinoma

)

Cholangiocarcinoma

is a cancer that arises from the cells within the bile ducts; both inside and outside the liver. tumors arise along the bile ducts that enter the liver, the tumors are smaller than those which arise from within.

Slide15

Comparison of radiographic images showing

cholangiocarcinoma

; A, computed tomography (CT) image; B,

cholangiogram

(ERCP) image. Arrows designate the tumor

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A, B, Position of the endoscope in the duodenum during ERCP

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A, technique of

transhepatic

percutaneous cholangiography; B, corresponding percutaneous

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Complications

ERCP is a highly specialized procedure which requires a lot of experience and skill.

The procedure is quite safe and is associated with a very low risk when it is performed by experienced physicians.

The success rate in performing this procedure varies from 70% to 95% depending on the experience of the physician.

Complications can occur in approximately one to five percent depending on the skill of the physician and the underlying disorder.

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Significant risks associated with ERCP include

Infection

Pancreatitis

Allergic reaction to sedatives

Excessive bleeding, called hemorrhage

Puncture of the GI tract or ducts

Tissue damage from radiation exposure

Death

,

in rare circumstances

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Duodenoscope

Reprocessing

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Duodenoscopes

and the “Superbug

”

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Current FDA Recommendations

Beyond strict adherence to the

manufacturer’s recommended

cleaning

protocol, facilities

should

conside

at

least one of the following

Microbiologic

culturing

Ethyelene

oxide sterilization

Use

of a liquid chemical

sterilant

processing

system; and/or

Repeat

high-level disinfection

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What to do in your practice?

While the risk of infection transmission cannot be

completely eliminated

, the benefits of these devices continue

to outweigh

the risks in appropriately selected

patients.

FDA

Communication, August 4, 2015

Reasonable

to advise patients on the low risk of

infection transmission

associated with ERCP

Advocate

for appropriate use ERCP

Work

with hospital infection

preventionists

on

optimizing endoscope

reprocessing to make infection transmission

a “never

” event

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Preventing Post-ERCP Pancreatitis

Stenting the Pancreas Duct

Pancreatitis may occur in up to 15% of patients

after ERCP

and may in part be due to

Papillary

swelling after ERCP (possibly as a

delayed result

of

sphincterotomy

)

Contrast

injection into pancreas duct

which independently

increases the risk of pancreatitis

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Multiple studies have shown that placement of a

small pancreatic

stent in at risk patients reduces the risk of

postERCP

pancreatitis

Preventing Post-ERCP Pancreatitis

Stenting the Pancreas Duct

Slide27

Rectal Indomethacin Reduces Risk of

Post-ERCP Pancreatitis

Elmunzer

BJ, NEJM, 2012

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Indomethacin protective across entire range of pancreatitis risk

Elmunzer

BJ, NEJM, 2012

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Aggressive IV hydration after ERCP

may reduce post-ERCP pancreatitis

60 patients randomized 2:1 to aggressive vs

standard hydration

.

Buxbaum

J et al, CGH, 2014

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Cannulation

Success Rates Vary Widely

Williams EJ, Gut, 2007

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As ERCP has become more complex,

are we still comfortable with it?

ERCP is becoming technically more complex and

training is

no longer typically obtained in a standard GI fellowship

Thus

, it is unclear whether these advances are

translated to

the general gastroenterologist or whether this

has resulted

in physicians performing procedures they do

not feel

comfortable with

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Contraindications

U

nstable cardiopulmonary, neurologic, or cardiovascular status; and existing bowel perforation.

Structural abnormalities of the esophagus, stomach, or small intestine may be relative contraindications for ERCP.

An altered surgical anatomy.

ERCP with

sphincterotomy

or

ampullectomy

is relatively contraindicated in

coagulopathic

patients.

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The Intersection of EUS and

ERCP

EUS has supplemented and supplanted ERCP

for many

indications including

Patients

with low-moderate risk of bile

duct stones

Exclusion

and evaluation of biliary strictures

Tissue

diagnosis

of pancreas

neoplasms

Evaluation

of

pancreas cystic

lesions

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ERCP

vs

EUS

vs

MRCP

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