Transcript ERCP
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
performed via an endoscope
to diagnose and treat
conditions of the bile and pancreatic ducts
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…
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)
Malignant Bile Duct Obstruction
Bile
duct
cancer
Pancreatic
cancer
Clinical Presentations for ERCP
Gall stones:
PAIN AND JAUNDICE
Malignant obstruction:
PAINLESS JAUNDICE
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
Liver tests
Platelet count and coagulation profile
Imaging
Ultrasound
CT
CT cholangiogram
MRCP
Endoscopic Ultrasound
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?
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
Cannulation of the
Bile Duct
Major Papilla Anatomy
Common channel
Common bile duct
Pancreatic duct
Image property of Marco Bruno, AMC Amsterdam, From: Atlas of human anatomy. Gosling et al. Gower Medical Publishing Ltd. 1985
Sphincterotomy
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
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
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
Failure
5 - 10%
Pancreatitis
5% (severe in 0.5%)
Bleeding
1%
Perforation
0.1%
Anaesthetic complications
Predicting Post ERCP Pancreatitis
Doctor Factors
Procedure Factors
Low case volume, trainee
Difficult cannulation, pancreatic injection, precut
Patient Factors
Young, female, normal BR, previous pancreatitis
Reducing the Risks of ERCP
Patient selection
Patient selection
Patient selection
Wire guided technique
Pancreatic stents
Don’t persist indefinitely
Teamwork
Radiographer
Nursing
Assistant * VERY IMPORTANT ROLE *
2nd Assistant
Anaesthetics / Recovery
Medical
Endoscopist
Anaesthetist
Anaesthetic Nurse
Anaesthetist
Anaesthetic Stuff
‘Scout’ nurse
‘Scrub’ nurse
Equipment
Video
Assistant’s Table
XRay viewer
Processor
XRay Machine
Diathermy Machine
Radiographer
Endoscopist
ERCP Set up
What’s new in ERCP?
Summary
More like interventional radiology than
endoscopy
Patient selection important
Needs Teamwork and Communication