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ERCP - PowerPoint PPT Presentation


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ERCP. Aswad H. Al.Obeidy FICMS, FICMS GE&Hep Kirkuk General Hospital. ERCP. ERCP was first described by McCune and coworkers in 1968. Patients receive sedation and analgesia (conscious sedation).

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slide1
ERCP

Aswad H. Al.Obeidy

FICMS, FICMS GE&Hep

Kirkuk General Hospital

slide2
ERCP
  • ERCP was first described by McCune and coworkers in 1968.
  • Patients receive sedation and analgesia (conscious sedation).
  • The side-viewing endoscope has a viewing field that is perpendicular to the long axis of the instrument to permit better visualization of the medial wall of the descending duodenum.
  • Various diagnostic and therapeutic duodenoscopes with channels of different sizes are available.
  • Mother-daughter” scopes (cholangioscopes that can be inserted through a 4.2-mm channel of a standard duodenoscope).
slide3
ERCP
  • The routine use of antibiotics prior to ERCP is controversial.
  • Oral antibiotic prophylaxis appears to be safe and cost-effective in patients undergoing therapeutic ERCP.
  • Adequate sedation is of the utmost importance.
  • If standard sedation and analgesia are not possible or are too dangerous, general anesthesia must be considered.
  • Midazolam (a benzodiazepine) and meperidine (a narcotic) are generally administered.
slide4
ERCP
  • In patients with a normal anatomy, cannulation of the papilla is usually successful.
  • to achieve better than a 95% success rate, a precut papillotomy may be needed.
  • Neither cholangitis nor pancreatitis is a contraindication to ERCP if a thera-peutic maneuver is being considered.
  • Competence in therapeutic ERCP requires specialized training and mentoring.
  • When an attempt at ERCP fails, the patient may need to be referred to a specialized center with a more experienced endoscopist trained in advanced techniques.
  • Success rates higher than 96% with an acceptable complication rate of 10% should be expected.
  • Storage of data and images is particularly important with therapeutic procedures; the precise anatomy must be delineated for surgical and radiologic colleagues
slide5
ERCP
  • Patients can often be discharged home after a therapeutic ERCP.
  • But those:
  • Who experience pain after the procedure.
  • Have had pancreatitis in the past.
  • Have suspected sphincter of Oddi dysfunction.
  • Have cirrhosis.
  • Have had a difficult cannulation or a precut papillotomy.
  • Are at higher risk of a complication and should be admitted to the hospital for observation.
complications
Complications
  • Infection
  • Bleeding
  • Pancreatitis
  • Retro duodenal perforation
  • Impaction of a stone or retrieval basket
  • Complications of varying severity occur in 5% to 10% of endoscopic biliary interventions.
post ercp pancreatitis
Post-ERCP pancreatitis
  • Women.
  • In patients with sphincter of Oddi dysfunction.
  • In those with previous ERCP-associated pancreatitis.
  • In patients in whom the pancreatic duct is filled excessively with contrast dye.
  • In those in whom a precut papillotomy is performed .
late complications
Late complications
  • Acute cholecystitis.
  • Stenosis of the papilla.
  • Cholangitis.
  • Retained or new CDB stones.
  • Inexperience of the biliary endoscopist (<200 cases per year).
  • Use of a precut papillotomy to gain access to the bile duct are independent risk factors for major complications.
ercp difficult or impossible
ERCP difficult or impossible
  • Previous surgery, such as a Billroth II gastrojejunostomy.
  • Roux-en-Y choledochojejunostomy.
  • Uncorrectable coagulopathy also is associated with increased risk and may represent a contraindication to ERCP