Retrograde Cholangiopancreatography (ERCP)

Retrograde cholangiopancreatography (ERCP) is the insertion of the endoscope into the descending segment of the duodenum. After the duodenal papilla is found, the endoscopic biopsy hole is inserted into the contrast tube to the nipple opening, and the contrast agent is injected to make the pancreatic duct X. Line angiography, bile bacteriology and cytology, biliary tract sphincter and nipple sphincter function tests, in addition, can be used for nipple sphincterotomy, biliary pancreatic duct lithotripsy, biliary pancreatic duct stent placement drainage, nasal bile duct drainage And biliary aphid removal and other treatments. Mainly in the lower common bile duct stones, pancreatic duct stones, biliary tract tumors, acute biliary pancreatitis and biliary ascariasis, compared with traditional surgery, it has the advantages of small trauma, quick recovery, low cost, etc. An important means of disease treatment. Basic Information Specialist classification: Digestive examination classification: X-ray Applicable gender: whether men and women apply fasting: fasting Tips: 4-6 hours before the angiography, fasting and water-free, the first few minutes of injection of sedatives and antispasmodic agents, including mucosal anesthetics. Extremely poor general condition can not tolerate the examination, contraindications for fiber and gastroduodenal examination, allergic to contrast agents, patients within 2 weeks of acute pancreatitis are not suitable for this examination. Normal value Show normal pancreatic duct. Clinical significance The diagnosis of bile duct disease can be checked by non-invasive means, which can save the patient from unnecessary pain, and can also improve the early diagnosis rate and greatly improve the surgical resection rate of certain diseases. Endoscopy is expensive, easy to wear, difficult to promote, and 2% to 3% of complications. Applicable to: 1. Obstructive jaundice. 2. Clinically suspected biliary tract disease, and oral or intravenous cholangiography failed to confirm. 3. Suspected of pancreatic tumor or chronic pancreatitis. 4. Post-cholecystectomy syndrome. 5. X-ray or endoscopy revealed signs of oppression outside the duodenum. Precautions Patient preparation (1) Informed consent form should be signed before surgery to explain to patients in detail the necessity of examination or surgery, complications that may occur during or after surgery, and the patient and family members can obtain the consent. (2) The patient should be explained to the patient before the operation to relieve the concern, strive for active cooperation, and do allergic tests on related drugs. (3) Fasting at least 8 hours before surgery. (4) The patient is required to wear X-ray film, do not wear too much, too thick, remove metal objects or other clothing fabrics that affect photography. (5) Throat anesthesia is the same as common upper gastrointestinal endoscopy. (6) The right hand forearm establishes a venous access. In order to effectively control gastrointestinal motility, it is advantageous to perform routine intravenous injection of exocridine (Xie Lingling) 20mg, diazepam (diazepam) 5-10mg and pethidine (degree cold) 25-50mg. In the case of a child, an anesthesiologist assists in ERCP under anesthesia. (7) Patients with critical illness or elderly patients, with important diseases such as heart and lung or brain, should be monitored for oxygen saturation, ECG and blood pressure, and oxygen if necessary. 2. Instrument preparation (1) Duodenal goggles, for general examination and treatment, the endoscopic biopsy aperture is 2.8 ~ 3.8mm; if placed ≥ 11F bile duct stent or mother and child microscopy, the biopsy channel is required to be more than 4.2mm; If the infant is undergoing ERCP, the pediatric duodenoscopy should be prepared; if the patient is undergoing ERCP after the patient's stomach, the anterior gastroscopy should be prepared. (2) Various types of contrast catheters, including common standard type, pointed, metal head, cone, etc. (3) Conventional contrast balloon catheter and guide wire. (4) Duodenal nipple pull and needle cutting knife. (5) Special high-frequency electric devices for endoscopes. (6) Vital signs monitoring equipment. (7) X-ray fluoroscopy and photographic device, X-ray machine for traditional gastrointestinal barium meal inspection can also be used for ERCP, but it is best to use fixed-point camera, digital X-ray equipment, and equipped with high-resolution monitor, check bed It can be moved in both directions and can raise or lower the bedside, necessary protective clothing, gloves and collar. (8) The contrast agent is a sterile water-soluble iodine solution, commonly used 60% diatrizoate, non-ionic contrast agent is more ideal. (9) All accessories should be strictly disinfected as required. Inspection process 1. The patient is placed on the X-ray examination table in the left lateral position. 2. Insert the fiber duodenoscope after the local anesthesia of the pharynx. After observing the entire stomach cavity, insert the mirror into the pyloric opening. 3. Through the pylorus, enter the duodenum, find the annular fold of the duodenal descending, the mirror is then reversed to the clock to reset, and then look for the nipple on the inner wall. 4. After finding the nipple, adjust its position in the middle of the field of view and the direction in which the catheter moves. The contrast agent is then filled into the catheter to remove the air and then intubated. In the common opening, if you want to perform pancreatic duct and cholangiography at the same time, the catheter should not be inserted more than 1cm. If you need to do selective pancreatic duct or cholangiography, the catheter can be inserted 3~4cm. Generally, the catheter is inserted into the pancreatic duct in a direction perpendicular to the nipple. 5. After successful intubation, first inject about 1ml of contrast agent under the observation of the fluorescent screen or TV screen to observe which tube is developed, so that the part to be inspected can be clearly displayed when the film is taken. Pancreatic ductography generally requires only about 5 ml of contrast agent, and total bile duct and intrahepatic cholangiography requires about 20 ml of contrast agent, but it takes 50 to 80 ml to fill the gallbladder. The lower head helps to make the intrahepatic bile duct develop more clearly. Fat meal can also be added. After 30 to 60 minutes, the film should be taken to observe the contractile function of the gallbladder. Not suitable for the crowd 1. Non-biliary acute pancreatitis. 2. Severe biliary infection and bile duct obstruction without drainage. 3. Patients with severe heart, lung, kidney, liver and mental illness. 4. Other upper digestive tract endoscopy contraindications. 5. Severe iodine allergy. Adverse reactions and risks (1) hyperamylasemia and pancreatitis: is one of the most common complications of ERCP. Hyperamylasemia can be manifested as elevated serum amylase, but no obvious clinical symptoms, the incidence rate is 20%~ 75%. If both upper abdominal pain and upper abdominal tenderness occur, it is pancreatitis after ERCP, the incidence rate is 1.9% to 5.2%, mostly mild pancreatitis, but severe pancreatitis can also occur. (2) biliary tract infection: the incidence rate is 0.33% to 1.5%, manifested as fever, abdominal pain, jaundice or jaundice deepening, tenderness in the right upper abdomen, and even toxic shock and sepsis. (3) Perforation: The incidence rate is 0.1%, which usually occurs when the endoscope passes through the duodenal ampulla and when the nipple is cut with a needle-shaped incision knife. If it occurs, surgical treatment should be taken. (4) bleeding: incidence rate <0.5%, the incidence of diagnostic ERCP is low, seen in patients with excessive gastrointestinal reactions, severe nausea, vomiting and tearing of the cardia mucosa, can also occur after nipple incision. After medical treatment or endoscopic treatment, it can be cured. (5) Others: drug reactions, cardiovascular and cerebrovascular accidents, heartbeat, respiratory arrest and other conventional endoscopy complications.