ERCP PROCEDURE

1. Procedure of ERCP and T-Tube cholangiography
Presenter:-
Yashawant yadav
B.Sc MIT 2ND Year
NAMS Bir-Hospital

2. Contents :-
• Introduction
• Anatomy of associated organs
• Indication And Contraindications
• Equipment’s
• Patients preparation
• Technique
• Filming

3. Introduction
• Endoscopic retrograde cholangiopancreatography (ERCP) is a
combined endoscopic and fluoroscopic procedure in which an upper
endoscope is led into a second part of the duodenum, making it possible
for passage of other tools via the major duodenal papilla into the biliary
and pancreatic ducts.
• Contrast material may be injected in these ducts, allowing for radiologic
visualization and therapeutic interventions when indicated.

4. Contd..

5. Anatomy
• The main pancreatic duct connects to the
common bile duct and drains at the ampulla
of Vater (hepato-pancreatic ampulla),
controlled by the sphincter of Oddi.
• The major duodenal papilla is the opening of
the ampulla of Vater into the second part of
the duodenum.
• The common bile duct and the pancreatic
duct may remain separate or merge at the end
of the papilla, or they may form a common
duct.

8. Indications:-
• Obstructive jaundice
• Chronic pancreatitis (controversial indication due to availability of safer
diagnostic modalities)
• Gallstones with dilated bile ducts on ultrasonography
• Bile duct tumors and obstructions
• Suspected injury to bile ducts either as a result of trauma or iatrogenic
• Sphincter of Oddi dysfunction
• Choledocholithiasis ( calculus of CBD)
• Bile duct leak post cholecystectomy
• Patient with pancreatic or biliary cancer

9. Therapeutic purposes
• Tissue sampling in patient with pancreatic or biliary cancer
• Endoscopic sphincterotomy (both of the biliary and the pancreatic
sphincters)
• Removal of stones
• Insertion of stent
• Dilation of strictures (e.g. primary sclerosing cholangitis, anastomotic
strictures after liver transplantation)

10. Contraindications
oHIV positive patient
oPrevious gastric surgery
oOesophageal obstruction
oAcute pancreatitis
oPancreatic pseudocyst
oWhen glucagon or buscopan contraindicated
oSevere cardio/respiratory disease
oCoagulation disorder

11. Contrast media
• Non ionic low osmolar contrast agent e.g. Omnipaque ,ultravist
,optiray:200mgI/ml
• Dose :- 20 ml
• ANTIBIOTIC IN CM :-the addition of antibiotics to CM has been
advocated by some center to decrease septic complication of ERCP.

12. Equipment's
• SIDE -VIEWING ENDOSCOPE

13. Contd..
• FLUOROSCOPY WITH IITV SYTEM AND SPOT FILM DEVICE

14. Contd..
• Catheter guide wires and cannula
Guide wire ERCP CATHETER
ERCP cannula

15. Contd..
Biliary cytology brush
Biliary expandable stent
CBD extraction balloon

16. Contd..
CBD stone retrieval basket
Endoscopic lithotripter
Pancreatic stent

17. Contd…
sphincterotome

18. PATIENT PREPERATION
oNPO at least 6 hrs before the procedure
oInformation about
-any medication (warfarin or other anticoagulant), cardiac disease
- barium x-ray or ct scan in the past 2-3 days
-Any chance of pregnancy , major illness and recent surgery
oStop taking aspirin or anti-inflammatory drugs 5 days prior to ERCP.

19. Contd..
oRecent blood test report – PT, billirubin, albumin, LFT ,Haemogram
profile etc.
oCounseling , informed consent
oRemove radiopaque materials
oIn case of obstructed duct may required to administer antibiotic I/V
prior to ERCP and continue for 24 hrs if contrast has been instilled into
an obstructed duct
oMay require sedation – inj. Diazepam 10 mg I/v or inj. Pethidine 75
mg I/M

20. PREMEDICATION
oKnown case of allergy to iodinated contrast medium is pre treated with
either prednisone 40 mg 24 hrs and 2 hrs before or 40 mg daily for 3
days before the exam
oSmooth muscle relaxant - Buscopan 20 mg I/M before 10 min or 0.6
mg I/M atropine 1 hrs is given to reduce duodenal spasm and relax the
sphincter of oddi

21. Pre-procedure investigations
•Liver tests
•Recent blood test– PT, bilirubin, albumin, LFT ,Haemogram
profile
•Platelet count and coagulation profile
•Imaging
• Ultrasound
• CT
• CT cholangiogram
• MRCP
• Endoscopic Ultrasound

22. Procedure
• To ease passage of endoscope, patients
throat is sprayed with a local
anesthetic(4%, 50-100 mg xylocaine) ,this
causes temporary pharyngeal paresis
• Pt lies on the left side on fluoroscopy table
• a flexible camera (endoscope) is inserted
through the mouth, down the esophagus,
into the stomach, through the pylorus into
the duodenum to the ampulla of Vater
• A polythene catheter or cannula with
prefilled CM is inserted into the ampulla

23. Contd…
• A test dose of CM is injected under the fluoroscope to determine the
position of cannula
• Then radio contrast is injected into the bile ducts and/or pancreatic duct
• If it is desirable to opacify both the biliary tree and pancreatic duct then
the latter should be cannulated .
• A sample of bile should be sent for culture and sensitivity if there is
evidence of biliary obstruction.

24. Contd…
• Fluoroscopy is used to look for blockages, or other lesions such as
stones ,also spot images are taken as required when duct filling
completes
• Oblique spot radiographs may be taken to prevent overlap of common
bile duct and pancreatic duct

25. Filming's
• CM drains from normal ducts within approx
5min radiographs must be exposed immediately
• PANCREAS
-prone , both oblique
oBILE DUCT
1. Early filling to show calculi
A. prone - straight and post. Obliques
B. supine - straight , both obliques ,
trendlengberg to fill intrahepatic duct , semi
erect to fill lower end of common bile duct
and GB

26. Contd..
2. films after removal of endoscope
which may obscure the duct
3. delayed films to assess the GB and
emptying the common bile duct

27. ERCP in therapeutic uses
oWhen ERCPs are done to allow some sort of treatment ,they are
referred to as therapeutic ERCP
oIt includes
A . Sphincterotomy
B . Stone removal
C . Stent placement
D . Balloon dilatation
E . Tissue sampling

28. Indication for therapeutic ERCP
oBile duct stone
oBile duct injury
oBile duct stricture due to tumor or scarring
oPost cholecystectomy syndrome
oSome cases of pancreatitis
oReplacement of an obstructed ampullary stent

29. Sphincterotomy
oIt is cutting the muscle that surrounds the opening of the ducts or
papilla
oThe cut is made while looking through the ERCP scope at the papilla
oA small wire on a sphincterotome uses electric current to cut the tissue
• The sphincterotome has a special cautery unit that seals the tissue after
the cut and prevent bleeding

30. During papillotomy
After papillotomy
Before papillotomy

31. Stone remove
oMost common treatment through
ERCP
oStones may have formed in the GB
and travelled into the bile duct or may
form in the duct itself
oAfter sphincterotomy the opening of
the bile duct is enlarged and stones
can be pulled from the duct into the
bowel
oA variety of balloon and baskets
attached to specialized catheter can be
passed through ERCP scope into the
ducts allowing stone removal

32. EXTRACTION WITH DORMIA BASKET
• Dormia basket is useful device
for stone extraction. It is made
up of 4 parallel wires
• Stone can be trapped in-
between and extracted with it’s
content via papilla

33. Mechanical lithotripsy
• The basket for lithotripsy in the bile duct
shows a very similar design to retrieval
basket although tensile strength of the
wire is much higher.
• A metal lithotripsy is pushed over the
basket to stabilize the device to the high
occurring forces.
• The forces are mechanically applied to
the baskets wire to cut stone to pieces.
• The fragments are then extracted one by
one from the bile duct

34. Stent placement
INDICATION
-To treat obstruction in the bile duct
-To treat biliary leak
oStents are placed into the bile or pancreatic duct to bypass stricture or
narrow part of the duct
oTwo types of stents plastic or metal are commonly used
oPlastic stent looks like a small straw

35. Contd…
oThe plastic stent is pushed through
ERCP scope into the blocked duct to
allow normal drainage
oPlastic stent is placed temporarily and
should be removed in follow up ERCP
oThe metal stent is flexible and springs
open to a larger diameter than plastic
stent
oMetal stent are placed permanently

37. Balloon dilation
oERCP catheter fitted with dilating
balloon is placed across a narrow area
or stricture
oOften performed when the case of
narrowing is benign
oAfter balloon dilation a temporary
stent is placed for few month to help
drainage

38. Tissue sampling
oIn ERCP tissue sampling is a technique to take samples of tissue from
the papilla or from bile or pancreatic duct
oThere are several diff. sampling technique although the most common
is to brush the area with subsequent examination of the cells obtained
oTissue samples can help to decide if a stricture or narrowing is due to
cancer

39. Contd..
Cytology forceps
Brush cytology

40. Advancement in ERCP
INTRADUCTAL ENDOSCOPY
• Describe the use of an endoscope to evaluate the biliary and pancreatic
duct.
• It allows direct visualization of the biliary and pancreatic duct.
• This technique is developing that promises greater opportunity to
provide improved diagnosis and therapy regarding lesion in the biliary
and pancreatic duct.

42. EUS (ENDOSCOPY ULTRASOUND)
oEUS employs a duodenoscope with distal ultrasound probe that can be
used to image organs , blood vessels , lymph nodes and bile ducts
oThe EUS scope is advanced within the gastrointestinal tract that allows
visualization of the pancreas and adjacent structure
oPreferable in high risk pt in ERCP or potential complication to ERCP

44. PATHOLOGY DIAGNOSED IN ERCP
• CBD stone

45. DIVERTICULA

46. Biliary stone Gallstone

47. Biliary stenosis
Biliary dilation

48. STENOSIS

49. Aftercare
oNil orally (0.5-3hrs) until sensation has returned to the pharynx
oVitals should be checked half-hourly for 6 hrs
oMaintain antibiotic in case of biliary or pancreatic obstruction
oSerum/urinary amylase if pancreatitis is suspected

50. Complication
oGENERAL- common to all endoscopic procedure
- Medication reaction
- Oxygen desaturation
- Cardio pulmonary accident
- Hemorrhage and perforation induce by instrument passage.

51. Radiation protection
oDecrease fluoroscopy time
oUse time alarm/reminder
- Alarm rings after a predetermined duration of fluoroscopy time
(5min)
oUse pulse fluoro mode (not continuous)
oMaintain appropriate distance
oAvoid magnification mode
oUse collimator.

52. T – Tube cholangiography
• A T-Tube cholangiogram is a procedure
done after a patient’s gallbladder has
been removed and a surgeon has placed
a tube in the patient’s right side to drain
the bile ducts.
• The bile ducts and first section of the
small bowel (duodenum) will be
imaged.
• This exam takes about 30 minutes.

53. Contd…
• Indications
patient's with possibility of residual small gallstones post cholecystectomy
• obstructive jaundice
• bile duct stricture
• surgeon unable to explore bile duct during cholecystectomy surgery
Contraindications
• contrast or iodine allergy
• pregnancy (? pregnancy test required)
• barium study within last 3 days

54. Prepare for a T-Tube Cholangiogram
• Do not eat or drink anything after 10:00 pm (22:00) the night before
test.
• can still take your medications with a small amount of water.
• Notify the technologist if you have any allergies (especially to iodine or
seafood).

55. What will happen during the T-Tube Cholangiogram
• contrast medium will be injected through the T-Tube while taking x-
ray images.
• Pt. may be asked to hold your breath. While injecting the contrast
media.
• This test takes about 15-30 minutes
• After the T-Tube Cholangiogram pt. will be able to resume normal
activity.

56. Contd..
Technique Notes
Contrast media should be diluted with saline so that small biliary stones are not
obscured by an overly dense contrast media
• Preliminary/scout images are important. Failure to take a preliminary/scout image
is one of the most frequently made errors by Radiology Registrars performing
fluoroscopy procedures
• air-bubbles can often be distinguished from stones by their behaviour- air bubbles
tend to float 'up hill' and can change shape and may separate into two smaller
bubbles.
• If the examination is marred by air bubbles, the biliary system can be flushed with
saline and the study repeated.
• If there is any question of distal obstruction, a delayed drainage image should be
obtained

57. Contd…
• This is an AP/PA supine T-tube
cholangiogram image.
• The biliary tree is outlined with
contrast medium.
• There appears to be extravasation of
contrast medium outside the biliary
tree and minimal contrast in the
duodenum.

59. References
• https://www.ncbi.nlm.nih.gov/books/NBK493160/
• http://www.wikiradiography.net/page/T-tube+Cholangiogram
• Hand book of radiological procedure
• Various web

60. Questions
• What are the therapeutic technique of ERCP?
• Contrast media in ERCP?
• What are the filming of ERCP?
• Indications of ERCP and its possible complications ?
• Define T – Tube cholangiography