Endoscopic Reterograde Cholangiopancreatography Examination of the bile ducts by using endoscopy and injecting contrast media .

2. Anatomy
ERCP & PTBD
Indication
Contraindication
Equipment
Procedure
Complication
Aftercare
Pathologies

4. Liver is largest abdominal organ
major role in metabolism
Glycogen storage
Decomposition of red blood cells
Plasma protein synthesis
Hormone production
Detoxification

5. Liver is an irregular, wedge-
shaped organ Lies below the
diaphragm in the right upper
hypo quadrant of the abdomen
Closely related with the the
gallbladder, diaphragm,
stomach and covered by the
costal cartilages.

6. 2 surfaces:
diaphragmatic surface
visceral surface
Craniocaudal length: 10-12.5 cm
Transverse diameter: 20-23 cm

7. • Pancreas is a retroperitoneal
organ Has both endocrine and
exocrine functions.
• Production hormones(insulin,
somatostatin) glucagon.
• Digestion by its production
and secretion of pancreatic juice
Small intestine (duodenum)
ality: Investigate

8. ERCP is a technique that combines the use of
endoscopy and fluoroscopy to diagnose and
treat problems of the biliary or pancreatic
ductal system.

9. • Investigation of extrahepatic biliary obstruction
• Post-cholecystectomy syndrome
• Investigation of diffuse biliary disease
• Sclerosing cholangitis
• Pancreatic disease

10. • Oesophageal obstruction
• Pyloric stenosis
• Previous gastric surgery
• Acute pancreatitis
• Pancreatic pseudocyst
• Severe disease
•Cardiorespiratory

11. Pancreas
LOCM 240
Bile ducts
LOCM 150; dilute contrast medium
ensures that calculi will not be obscured.

12. Side-viewing endoscope
Polythene catheters
Fluoroscopic unit with spot
film facilities

14. Self-expanding metal stents.

15. Nil orally for 4 h prior to procedure
Patients may be asked to temporarily stop
taking medications
Patient may asked to stop smoking
temporarily
Diazepam 4 hour before procedure

16. Sedation is given by using
midazolam, meperidine or
fentanlyl
Explain patient about
procedure
Written consent
Antibiotic cover

17. Prone AP and LAO of the
upper abdomen, to check for
opaque gallstones and
pancreatic
calcification/calculi
Prone AP
LAO

18. Pharynx is anaesthetized with
4% Xylocaine spray
Patient is given diazepam 5 mg
min-1 IV
Patient then lies on left side
and endoscope is introduced

19. Ampulla of Vater is located and
patient is turned prone.
Polythene catheter prefilled with
contrast medium - inserted into
ampulla, having ensured that all air
bubbles are excluded.

20. Small test injection of contrast
under fluoroscopic control is made
to determine position of cannula
If it is desirable to opacify both
biliary tree and pancreatic duct,
then latter should be cannulated
first

21. Pancreas
Prone, LPO &
RPO

22. Bile ducts
Early filling films to show calculi
Prone - straight and posterior obliques
Supine - straight, both obliques;
Trendelenburg to fill intrahepatic
ducts
semi-erect to fill lower end of common
bile duct and gallbladder

23.  Films following removal of
the endoscope, which may
obscure the duct.
Delayed films to assess the
gallbladder and emptying of
the common bile duct

24. Nil orally until sensation has returned to the pharynx
Pulse, temperature and blood pressure half-hourly for 6
h
Maintain antibiotics if there is biliary or pancreatic
obstruction
Serum/urinary amylase if pancreatitis is suspected

25.  Due to contrast medium
 Allergic reactions - rare
 Acute pancreatitis - more likely with large volumes, high-pressure
injections
 Due to the technique
 Local
 Damage by the endoscope, e.g. rupture of the oesophagus, damage to
the ampulla, proximal pancreatic duct and distal common duct
 Distant
 Bacteraemia, septicaemia, aspiration pneumonitis, hyperamylasaemia
(approx. 70%). Acute pancreatitis (0.7-7.4%)