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ERCP - PowerPoint PPT Presentation


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ERCP . Dr David Scott Gastroenterologist Tamworth Base Hospital. ERCP. What is it? When is it recommended? How is it performed? What are the complications? What’s new in ERCP?. What is ERCP?. Endoscopic Retrograde Cholangiopancreatogram Essentially it is a radiological procedure

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Presentation Transcript
slide1

ERCP

Dr David Scott

Gastroenterologist

Tamworth Base Hospital

slide2
ERCP

What is it?

When is it recommended?

How is it performed?

What are the complications?

What’s new in ERCP?

what is ercp
What is ERCP?

Endoscopic Retrograde Cholangiopancreatogram

Essentially it is a

radiological procedure

performed via an endoscope

to diagnose and treat

conditions of the bile and pancreatic ducts

when is it recommended
When is it recommended?

Gall stones in the bile duct

Malignant bile duct obstruction

Bile duct leak post cholecystectomy

Benign bile duct obstructions

Tissue sampling of bile duct lesion

Sphincter of Oddi Dysfunction (type 1)

Pancreatic duct stones and obstruction

Pancreatic pseudocysts

Others…

slide6

Complications Of Gall Stones

Biliary colic

(pain but

normal BR)

Cholecystitis

(pain and fever

but normal BR)

Biliary colic

(pain and

raised BR)

Cholangitis

(pain and fever

and raised BR)

Pancreatitis

(pain +/-

raised BR)

slide7

Malignant Bile Duct Obstruction

Bile

duct

cancer

Pancreatic

cancer

clinical presentations for ercp
Clinical Presentations for ERCP

Gall stones:

PAIN AND JAUNDICE

Malignant obstruction:

PAINLESS JAUNDICE

special situations
Special Situations
  • Gallstone Pancreatitis
    • <24 hours if persisting bile duct obstruction and severe pancreatitis
    • Otherwise avoid
  • Gall bladder in situ
    • Depends on the surgeon
pre procedure investigations
Pre-procedure investigations

Liver tests

Platelet count and coagulation profile

Imaging

Ultrasound

CT

CT cholangiogram

MRCP

Endoscopic Ultrasound

pre procedure imaging
Pre-procedure Imaging

Transabdominal Ultrasound

MRCP

Endoscopic Ultrasound

Sens 25-82%

Spec 50-85%

Sens 81-91%

Spec 100%

Sens 84-100%

Spec 87-100%

CT Cholangiogram

Pre-procedure imaging has revolutionised ERCP

how is it performed
How is it performed?

Similar to a Gastroscopy

NBM for 6 hours prior (no bowel prep)

IV sedation (not usually intubated)

Left lateral position (sometimes prone)

NOT sterile – just clean

Different to a Gastroscopy

Side viewing endoscope

Portable image intensifier used

Diagnostic and therapeutic equipment

About 30 minutes

major papilla anatomy

Common channel

Common bile duct

Pancreatic duct

Major Papilla Anatomy

Image property of Marco Bruno, AMC Amsterdam, From: Atlas of human anatomy. Gosling et al. Gower Medical Publishing Ltd. 1985

sphincterotomy31
Sphincterotomy

Biliary sphincter is like a valve

Needs to be cut to allow most interventions to relieve biliary obstruction

Highest risk part of standard ERCP

Perforation

Bleeding

Pancreatitis

stents
Stents
  • Plastic
    • Biliary
      • 7 or 10 FG
      • Need to be removed/replaced within 3 months
    • Pancreatic
      • 5 FG
      • Need to be removed within 2-4 weeks
  • Metal
    • 10mm
    • Not removable (usually)
cardiologists and ercp
Cardiologists and ERCP
  • Aspirin
    • OK
  • Clopidogrel / Warfarin / Enoxaparin
    • No sphincterotomy
    • Stent can solve acute problem and allow definitive treatment to be deferred
  • Implantable defibrillator
    • No sphincterotomy without local technician
    • Need to go to tertiary centre
complications of ercp
Complications of ERCP
  • Failure 5 - 10%
  • Pancreatitis 5% (severe in 0.5%)
  • Bleeding 1%
  • Perforation 0.1%
  • Anaesthetic complications
predicting post ercp pancreatitis
Predicting Post ERCP Pancreatitis
  • Doctor Factors
    • Low case volume, trainee
  • Procedure Factors
    • Difficult cannulation, pancreatic injection, precut
  • Patient Factors
    • Young, female, normal BR, previous pancreatitis
reducing the risks of ercp
Reducing the Risks of ERCP
  • Patient selection
  • Patient selection
  • Patient selection
  • Wire guided technique
  • Pancreatic stents
  • Don’t persist indefinitely
teamwork
Teamwork

Radiographer

Nursing

Assistant * VERY IMPORTANT ROLE *

2nd Assistant

Anaesthetics / Recovery

Medical

Endoscopist

Anaesthetist

ercp set up
ERCP Set up

Anaesthetic Nurse

Anaesthetist

‘Scout’ nurse

Anaesthetic Stuff

‘Scrub’ nurse

Equipment

Video

Assistant’s Table

XRay viewer

Processor

XRay Machine

Diathermy Machine

Radiographer

Endoscopist

summary
Summary

More like interventional radiology than endoscopy

Patient selection important

Needs Teamwork and Communication