kuliah blok gi tract-ercp , agustus 2010

8/3/2019 Kuliah Blok GI Tract-ERCP , Agustus 2010

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Endoscopic, Retrograde CholangioPancreatography/ERCP

Dr. Yanto Budiman, Sp.Rad., M.Kes

Bagian Radiologi FK/RS Atma Jaya

Jakarta


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ERCPEndoscopic, Retrograde Cholangio Pancreatography Endoscopic :use of an instrument called an endoscope - a

thin, flexible tube with a tiny video camera and light on the

end. Retrograde :The direction in which the endoscope is usedto inject a liquid enabling X-rays to be taken of the parts ofthe GI tract called the bile duct system and pancreas.

The process of taking these X-rays is known as

cholangiopancreatography. Cholangiopancreaticography :Imaging the bile ductsystem, and pancreas.


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Indications for imaging

Gallstones, which are trapped in the main bile duct

Blockage of the bile duct

Jaundice Undiagnosed upper-abdominal pain

Cancer of the bile ducts or pancreas

Pancreatitis


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When pancreatitis is caused by gallstones, it isnecessary to remove the gallbladder.

At times, an ERCP (Endoscopic RetrogradeCholangioPancreatography) test is recommended.This involves passing a flexible tube through themouth and down to the small intestine. A smallcatheter is then inserted into the bile duct to see ifany stones are present. If so, they are thenremoved with the scope.


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Preparations Patients should ingest no solids for at least 6-7 hours and

no liquids for at least four hours prior to the procedure. For some procedures, topical pharyngeal anesthesia alone

is sufficient, especially when the endoscopy is performedwith a small diameter endoscope. For prolonged examinations, those in children, or in

patients with a high degree of anxiety, rapid onset sedativesand/or analgesics are often necessary.

Anticholinergics (e.g., atropine) have been given todecrease saliva, gastric secretions and motility, and reducethe likelihood of vasovagal reactions; For procedures in

which paresis of gastroduodenal motility is necessary,parenteral glucagon may be useful


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Basic Procedure

The throat is anesthetized with a spray or solution The endoscope is then gently inserted into the upper esophagus. The

patient breathes easily throughout the exam, with gagging rarelyoccurring.

A thin tube is inserted through the endoscope to the main bile duct

entering the duodenum. Contrast media is then injected into this bile duct and/or thepancreatic duct and x-ray films are taken.

The patient lies on his or her left side and then turns onto the stomachto allow complete visualization of the ducts.

If a gallstone is found, steps may be taken to remove it. If the duct has

become narrowed, an incision can be made using electrocautery(electrical heat) to relieve the blockage, it is possible to widennarrowed ducts and to place small tubing, called stents, The exam takesfrom 20 to 40


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Side Effects and Risks

A temporary, mild sore throat sometimes occurs after theexam. Serious risks with ERCP are uncommon. One suchrisk is excessive bleeding, especially when electrocautery isused to open a blocked duct.

In rare instances, a perforation or tear in the intestinal wallcan occur. Inflammation of the pancreas also can develop.

There is also a small risk of an allergic reaction to the dye,which contains iodine. Rarely, drugs used to relax theampulla of Vater can have side effects such as nausea, dry

mouth, flushing, urinary retention, rapid heart rate (sinusor supraventricular tachycardia), or a drop in bloodpressure

Due to the mild sedation, the patient should not drive oroperate machinery for six hours following the exam.


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Contrast Media 20 ml non-ionic/low-osmolality 200 mg/ml contrastmedia


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ERCP


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Magnetic resonance cholangiopancreatography

(MRCP)When compared to ERCP or PTC the accuracy is

very similar. MRCP has a sensitivity and specificityof 91% and 98% respectively for

choledocholithiasis . Its accuracy for benign and malignant obstruction

is 90%.

Does not carry the 5 - 30% failure rate associatedwith ERCP . It is also spares the morbidity (1-7%)and mortality (0.2-1%) of ERCP and is twice as costeffective .


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The disadvantage is that it is solely a diagnostictest.

It should not be used in choledocholithiasis whenthere is a high likelihood of a CBD stone. In thissituation ERCP would be indicated sinceendobiliary therapy can also be carried out. MRCP

is not the initial investigation of choice incholecystitis as ultrasound is just as accurate andmuch more cost effectiv


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THANK YOU

kuliah blok gi tract-ercp , agustus 2010

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