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ERCP - Endoscopic Retrograde
Cholangiopancreatography
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The
biliary tree is that portion of the anatomy which drains the
gallbladder, liver and pancreas into the duodenum (most proximal
portion of the upper intestine). The liver produces bile which
drains into the common hepatic duct. The gallbladder stores bile
produced by the liver and which drains into the cystic duct. The
cystic and hepatic ducts join to form the common bile duct. The
pancreas produces pancreatic enzymes which drain into the
pancreatic duct. Most commonly the common bile duct and
pancreatic duct join to form the ampulla of Vater. This empties
into the duodenum through an opening called the papilla of Vater.
Problems
in the biliary tree (for example, the presence of gall stones)
may require a radiological examination of the biliary tree, an
ERCP. To do so, the endoscopist passes a special endoscope
called a cholangioscope into the stomach, out through the
pylorus and into the duodenum. He/she then locates the papilla
of Vater endoscopically. An ERCP cannula is advanced through the
endoscope and into the opening of the papilla. Sometimes a
guidewire is used to better position the ERCP catheter,
particularly if a specific duct is to be visualized only (for
example the common bile duct). Contrast media is then injected
into the biliary tree to enable X-ray visualization of the
biliary tree.
If the
presence of stones is confirmed, it is possible to remove them
endoscopically. Because stones are often too large to pass
through the papilla, a sphincterotomy may be Performed. To do
so, a papillotome (also called a sphincterotome) is positioned
(usually over a guidewire) so that its cutting wire is across
the papilla of Vater. Current is applied to the papillotome from a
generator cutting the sphincter muscle. The choice of papillotome design and dimension is determined by the nature of
the patient’s anatomy and by physician preference.
Stones may
then pass through the various ducts and out into the duodenum
now that the size of the opening of the papilla has been
increased. Stones that do not pass on their own are removed
using an occlusion balloon. The occlusion balloon is passed over
a guidewire so that the balloon portion is above the location of
the stones. The position of the balloon is determined under
fluoroscopy. Once positioned, the balloon is inflated and the
catheter pulled back. The inflated balloon sweeps stones down
the duct through the papilla and into the duodenum as the
catheter is pulled back. Stones that are difficult to remove
using an occlusion balloon can also be removed using a helical
wire basket.
Another
procedure that can be performed endoscopically is balloon
dilatation of the biliary tree. Strictures of the ducts can
occur as a result of scarring, inflammation or cancer. These
strictures prevent the normal passing of stones and bile.
Dilatation is performed to open strictures restoring the normal
lumen size on the duct.
If the
physician believes that the stricture will recur (most often in
cancer patients), he/she may position a stent in the location,
of the stricture to keep it permanently open. Stents are of
various shapes and materials.
Stents are
positioned in the following manner. A guidewire is passed
through the ERCP cannula which was used to visualize the biliary
tree and the location of the stricture. A guide catheter is
advanced over the guidewire so that its tip is well beyond the
stricture. The stent is placed over the guide catheter and a
pusher catheter behind the stent. The pusher catheter is then
used to advance the stent over the guide catheter until it is
properly positioned. The guidewire and guide catheter are
removed with the pusher catheter ensuring that the stent remains
properly positioned. Finally, the pusher catheter is removed.
Amsterdam
stents may become blocked over time. These blocked or occluded
stents must be removed and replaced. The Carr-Locke stent
remover is specifically designed for this purpose. The stent
remover catheter is advanced through the cholangioscope until it
exits the scope channel in the vicinity of the stent. The loop
is then place around the end of the stent to be removed. The
stent remover handle is then operated closing the loop around
the stent. The stent can then be removed.
*Disclaimer*
The content of this page is
intended for educational and informational purposes only. This
information is not for procedural application. Please consult
your physician or healthcare provider for professional
consultation in regards to these educational topics.
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