Technique for performing erCP. Endoscopic retrograde cholangiopancreatography

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ERCP currently plays one of the leading roles in the diagnosis of pancreatic diseases. In most modern scientific publications and guidelines, it is cited as the “gold standard” for diagnosing CP (see Fig. 2-9). ERCP can detect: stenosis of the main bile duct (with determination of the localization of obstruction), structural changes in small ducts, intraductal calcifications and protein plugs, pathology of the common bile duct (strictures, choledocholithiasis, etc.). ERCP is one of the most important research methods allowing for differential diagnosis of pancreatic cancer.

Rice. 2-9. Endoscopic retrograde cholangiopancreatography: a — a filling defect in the middle third of the common bile duct caused by a stone (choledocholithiasis) is clearly visualized; the main pancreatic duct is not contrasted; b - in the lower third of the common bile duct - several filling defects with unclear contours (calculi); the main pancreatic duct was contrasted, without pathological changes

Characteristic signs of dyskinesia: contrast enhancement of the intrahepatic ducts, lack of expansion of the common bile duct, evacuation of contrast from the intrahepatic ducts within 10-35 minutes, absence of free passage of the contrast agent in the duodenum at the beginning of the study.

Pancreatograms are assessed by the nature of the filling of the pancreatic ducts with contrast, the length and diameter of the pancreatic duct are measured (dilatation, narrowing, obstruction by stone or tumor), and the nature of the surface of the duct is specified (smooth, jagged, etc.). In addition, its location (displacement), the structure of the pancreas (homogeneity, the presence of cystic formations, the structure of the ductal “tree”) are assessed.

When analyzing pancreatograms, attention should be paid to the patient’s age, because the diameter of the pancreatogram increases markedly with age. Only 30% of elderly patients without pancreatic pathology have a “normal” GLP diameter.
In CP, uneven contours of the ducts and their tortuosity are noted; areas of stenosis and dilatation (“clear-shaped” duct), cystic dilation of the ducts (symptom of the “chain of lakes”); rigidity of the walls of the ducts, the presence of stones in them; expansion of lateral branches, their shortening and breaks; slowing down the release of contrast into the duodenum. Similar changes are observed on the part of the common bile duct (see Fig. 2-10). ERCP allows you to obtain pure pancreatic juice and perform an endoscopic biopsy of the pancreas.

Rice. 2-10. Endoscopic retrograde cholangiopancreatography for chronic pancreatitis: a — main pancreatic duct with unchanged contours without dilatation; local dilatation of the lateral branches in the area of ​​the head of the pancreas (marked by arrows in the diagram); b — signs of moderate pancreatitis; the main pancreatic duct is moderately dilated almost throughout its entire length; dilatation of the lateral ducts; c — calcifying chronic pancreatitis with the development of narrowing of the terminal part of the common bile duct and prestenotic dilatation

When performing endoscopic retrograde cholangiopancreatography (ERCP), the possibility of developing serious complications due to the fact that contrast is introduced into the GPP retrogradely and under pressure cannot be excluded. The most common complications: AP, cholangitis, sepsis, allergic reactions to iodine-containing contrast agent, perforation of the duodenum and common bile duct, bleeding, etc. Their incidence ranges from 0.8 to 36.0%, mortality - 0.15-1. 0% of cases.

It must be remembered that in some cases, after ERCP, laboratory signs of cholestasis and cytolysis of hepatocytes are detected. That is why, to achieve good results, it is extremely important to exclude patients with a high risk of complications from the study and conduct appropriate preoperative preparation of the patient (with the participation of a team of doctors consisting of a surgeon, radiologist and endoscopist). If acinarization (contrast of small lobar ducts) was recorded during ERCP, then the risk of developing post-manipulation AP is especially high (see Fig. 2-11).

Rice. 2-11. Endoscopic retrograde cholangiopancreatography. All parts of the unchanged main pancreatic duct are visualized. Arrows indicate the exit of contrast into the lobar ducts (acinarization)

Maev I.V., Kucheryavyi Yu.A.

Medical statistics indicate an annual increase in patients with chronic pancreatitis. This disease is based on a degenerative-inflammatory process occurring in the tissues of the pancreas. The main reason for its development is considered to be a motor disorder - a violation of the outflow of digestive enzymes into the duodenum (duodenum).

The main feature of the course of chronic pancreatitis is the combination of:

• with pathologies of the biliary tract and small intestine;
• disorder of protein, carbohydrate and water-salt metabolism;
• the entry into the circulating blood of plasma decapeptides, which promote vasodilation.

The most characteristic sign of pancreatitis is considered to be severe pain that occurs as a result of the Wirsung duct overflowing with pancreatic secretions and the involvement of nerve endings located in the glandular tissue in the inflammatory process. One of the most reliable methods for diagnosing a pathological condition that combines inflammation of the pancreas, duodenum and gallbladder is endoscopic retrograde cholangiopancreatography.

Using this method, practitioners can make a competent diagnosis and carry out a rational course of treatment and preventive measures, which will allow the patient to avoid surgical intervention. In our article, we want to provide detailed information about the principle of action and the main advantages of ERCP, indications and main contraindications for the use of this diagnostic technique, as well as features of preparation for it and possible complications.

The essence of endoscopic examination

The method of combined use of optical and x-ray equipment was first used in 1968. Since that time, the technique of endoscopic retrograde cholangiopancreatography has been significantly improved and is now widely used for the diagnosis and clinical delimitation of pathological processes that occur in the digestive tract.

To carry out ERCP, an endoscope is inserted into the duodenum and attached to the mouth of the papilla of Vater (the junction of the bile and pancreatic ducts), then a contrast agent is fed into the working channel of the device through a special probe, filling the ducts, and a series of X-ray photographs of the area under study are taken.

To examine internal organs, an endoscope with lateral placement of optical equipment is used. The cannula of the probe, which is inserted through the instrumental channel to fill the pancreatic and bile ducts, is made of dense plastic and can be rotated in different directions - this ensures complete filling of the ducts of the systems under study with X-ray contrast agent. The diagnostic procedure is carried out in a hospital setting.

In what cases is ERCP indicated for a patient, and in what cases is it contraindicated?

This examination method is considered invasive and is prescribed to the patient only in certain cases:

• Chronic diseases of the hepatopancreatoduodenal system.
• Detection on MRI of an increase in the size and heterogeneity of the structure of the pancreas.
• Suspicion of the presence of stones in the biliary and pancreatic tracts.
• Obstructive jaundice of unknown etiology.
• Suspicion of the formation of a tumor-like formation in the gallbladder and its ducts.
• The patient has biliary or pancreatic fistulas.
• Periodic exacerbations of chronic cholecysto-pancreatitis.
• Suspicion of a malignant tumor of pancreatic parenchyma cells.
• The need to carry out therapeutic measures: installation of a catheter to drain excess amounts of the product of hepatocyte activity - bile, removal of stones from the bile ducts, stenting of the bile ducts.

Endoscopic retrograde cholangiopancreatography is contraindicated:

• for acute pancreatitis;
• acute angiocholitis (inflammation of the biliary tract as a result of infection entering them from the gallbladder, intestines, blood and lymphatic vessels);
• pregnancy;
• acute viral hepatitis;
• stenosing duodenal papillitis (reduction in the diameter of the major duodenal papilla);
• stenosis of the esophagus or duodenum;
• severe pathological processes in the cardiovascular system and respiratory organs;
• insulin therapy;
• the use of antithrombotic drugs (substances that prevent the formation of blockages in the bloodstream);
• the patient has an allergic reaction to the X-ray contrast agent.

In some cases, endoscopic examination is forced to be canceled due to the patient's categorical refusal to undergo diagnostics.

Preparatory activities

After the examination is prescribed, the patient is hospitalized in a hospital, where general clinical and biochemical tests of urine and blood, fluorography, electrocardiogram, ultrasound sonography of the abdominal organs, and a test for tolerance of anesthetic drugs and contrast agent are performed. If necessary, magnetic resonance imaging may be performed.

The patient must inform the doctor about possible allergic reactions and all medications taken. In some cases, the use of certain medications should be discontinued or their dosage adjusted. On the eve of the study, the last meal should be no later than 18.30 and consist of easily digestible foods. Before going to bed, you need to do a cleansing enema and take a sedative.

A few days before ERCP, the patient can take mild sedatives - this will help calm the nervous system and minimize significant anxiety during the diagnostic procedure.

On the day of the diagnosis, it is prohibited to have breakfast or drink water! Half an hour before the procedure, the patient is given premedication - drugs are administered intramuscularly to reduce salivation, pain and contractility of the muscles of the gastrointestinal tract:

• Atropine;
• Metacin;
• Platifillin or No-shpu;
• Promedol;
• Diphenhydramine;
• Benzohexonium or Buscopan.

Procedure for performing the examination

To facilitate insertion of the endoscope, the oropharynx is treated with local anesthetics - Lidocaine or Dicaine. After a feeling of numbness appears, the patient is placed on his back, a mouthpiece is inserted into the oral cavity, the patient is asked to take a deep breath and an endoscopic probe is inserted into the esophagus. A qualified specialist advances the device to the duodenum and carefully examines its mucous membranes.

Then the endoscope is brought to the papilla of Vater, its ampulla is examined and the cannulation process is performed - the introduction of contrast into the biliary and pancreatic tract system through a special catheter. After filling the ducts with the substance, a series of X-rays are taken. If stenosis, stones or other pathological processes are detected, the patient undergoes appropriate surgical procedures:

• endoscopic papillosphincterotomy (EPST) is a minimally invasive operation to eliminate the pathology of the major duodenal papilla;
• biopsy of altered tissue areas.

After removing the endoscope, the patient is transported to the ward. The duration of the diagnosis is about 1 hour. With additional studies or therapeutic manipulations, the procedure can last about two hours - in this case, the patient is repeatedly administered sedatives and painkillers.

Actions after diagnosis

After the procedure, the patient should be under the supervision of medical staff of the gastroenterology department to exclude the occurrence of a possible complication - internal bleeding or perforation (through disruption of the integrity of the intestinal wall). Almost 5% of patients, after endoscopic examination of the pancreatic tissues, develop an inflammatory process.

This phenomenon is facilitated by:

• presence of acute pancreatitis in the patient's medical history;
• difficulties encountered with cannulation of the major duodenal papilla;
• the need to re-administer an X-ray detecting substance into the ducts.

Upon completion of ERCP, the diagnostician draws up a conclusion - describes in detail all the identified changes and the manipulations performed, the final data is transferred to the specialist who referred the patient for examination

About 1% of patients may encounter such an undesirable consequence of the diagnostic procedure as internal bleeding - most often it appears after surgical procedures. Blood coagulation disorders and the small size of the orifice of the papilla of Vater predispose to its occurrence. If, within 3 days after ERCP, the patient experiences abdominal pain, cough, chills, nausea (including vomiting), an ambulance should be urgently called; these manifestations are considered clinical signs of diagnostic complications.

For some time, after the end of diagnostic endoscopy, the patient may experience pain in the throat, heaviness and bloating in the abdomen; when a tumor-like formation is removed, the stool may have a dark tint. These symptoms are not considered manifestations of complications and go away on their own after a few days. Discomfort in the larynx can be relieved with lozenges for sore throat.

In conclusion of the above information, I would like to emphasize once again that a properly performed endoscopic examination of the hepatopancreatoduodenal system is not a life-threatening medical procedure for the patient. Qualified specialists argue that the occurrence of possible undesirable consequences of the diagnostic procedure can be minimized if the patient unquestioningly follows all the recommendations of doctors.

Endoscopic retrograde cholangiopancreatography is a combination of endoscopy (to detect and cannulate the ampulla of Vater) and x-ray examination after the injection of a contrast agent into the bile and pancreatic ducts. In addition to obtaining images of the bile duct and pancreas, endoscopic retrograde cholangiopancreatography (ERCP) can examine the upper gastrointestinal tract and periampullary region, as well as perform a biopsy or perform surgery (eg, sphincterotomy, gallstone removal, or placement of a bile duct stent).

To successfully perform endoscopic retrograde cholangiopancreatography and obtain high-quality radiographs, in addition to endoscopes and a set of catheters, an X-ray television installation and radiopaque agents are required. In most cases, ERCP is performed using side-mounted endoscopes. In patients who have undergone gastrectomy using the Billroth-II method, endoscopic retrograde cholangiopancreatography must be performed using endoscopes with end or oblique optics.

The requirements for X-ray equipment are quite high. It should provide visual monitoring of the progress of the study, obtaining high-quality cholangiopancreatograms at its various stages, and the permissible level of radiation exposure for the patient during the study. For endoscopic retrograde cholangiopancreatography, various water-soluble radiopaque agents are used: verografin, urografin, angiographin, triomblast, etc.

Indications for endoscopic retrograde cholangiopancreatography:

1. Chronic diseases of the bile and pancreatic ducts.
2. Suspicion of the presence of stones in the ducts.
3. Chronic pancreatitis.
4. Obstructive jaundice of unknown origin.
5. Suspicion of a tumor of the pancreaticoduodenal zone.

Preparing patients for endoscopic retrograde cholangiopancreatography.

Sedatives are prescribed the day before. In the morning the patient comes on an empty stomach. 30 minutes before the study, premedication is carried out: intramuscularly 0.5-1 ml of 0.1% solution of atropine sulfate, metacin or 0.2% solution of platyphylline, 1 ml of 2% solution of promedol, 2-3 ml of 1% solution of diphenhydramine. As a narcotic analgesic, the use of morphine-containing drugs (morphine, omnopon), which cause spasm of the sphincter of Oddi, is unacceptable. The key to a successful study is good relaxation of the duodenum. If it was not possible to achieve it and peristalsis persists, then cannulation of the major duodenal papilla (MDP) should not be started. In this case, it is necessary to additionally administer drugs that inhibit intestinal motor function (buscopan, benzohexonium).

Methodology for performing endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography includes the following steps:

1. Revision of the duodenum and major duodenal papilla.
2. Cannulation of the major duodenal papilla and trial administration of a radiocontrast agent.
3. Contrasting one or both duct systems.
4. Radiography.
5. Control of contrast agent evacuation.
6. Carrying out measures to prevent complications.

During an endoscopic examination of the duodenum, the papilla is found on the inner wall of the descending part of the intestine when viewed from above. Detailed inspection of the papilla is difficult with pronounced peristalsis and narrowing of this section caused by cancer of the head of the pancreas, primary duodenal cancer, and enlarged pancreas in chronic pancreatitis. Of great practical importance is the detection of two duodenal papillae - large and small. They can be differentiated by location, size and nature of the discharge. The major papilla is located distally, the height and diameter of its base range from 5 to 10 mm, and bile is secreted through an opening at the apex. The minor papilla is located approximately 2 cm more proximally and closer to the anterior, its dimensions do not exceed 5 mm, the opening is not contoured, and the discharge is not visible. Occasionally, both papillae are located nearby. Pancreatography in such cases is safer and more often successful, since if contrast through the major papilla fails, it can be performed through the minor.

At the beginning of the study, an inspection of the duodenum and major duodenal papilla is carried out with the patient positioned on the left side. However, in this position, the papilla is more often visible in the lateral projection and not only cannulation, but also a detailed examination of it is difficult, especially in patients who have undergone surgical interventions on the bile ducts. The frontal position of the major duodenal papilla, convenient for cannulation and radiography, can often be obtained only with patients lying on their stomach. In some cases (in the presence of a diverticulum, in patients after surgical interventions on the extrahepatic bile ducts), bringing the large duodenal papilla into a position convenient for cannulation is possible only in the position on the right side.

Cannulation of the major duodenal papilla and trial injection of contrast agent . The success of cannulation of the ampulla of the major duodenal papilla and selective contrasting of the corresponding ductal system depends on many factors: good relaxation of the duodenum, the experience of the researcher, the nature of the morphological changes in the papilla, etc. An important factor is the position of the major duodenal papilla. Cannulation can be performed only if it is located in the frontal plane and the end of the endoscope is placed below the papilla so that it is viewed from bottom to top and the opening of the ampulla is clearly visible. In this position, the direction of the common bile duct will be from bottom to top at an angle of 90°, and the direction of the pancreatic duct will be from bottom to top and forward at an angle of 45°. The actions of the researcher and the effectiveness of selective cannulation are determined by the nature of the fusion of the ductal systems and the depth of insertion of the cannula. The catheter is pre-filled with contrast agent to avoid diagnostic errors. It should be administered slowly, accurately identifying the opening of the ampoule by its characteristic appearance and the flow of bile. Hasty cannulation may be unsuccessful due to injury to the papilla and spasm of its sphincter.

When the openings of the biliary and pancreatic ductal systems are located separately on the papilla, to contrast the first of them, the catheter is inserted into the upper corner of the slit-like opening, and to fill the second - into the lower corner, giving the catheter the direction indicated above. With the ampullary version of the BDS, in order to reach the mouth of the bile duct, it is necessary to insert the catheter from the bottom up by bending the distal end of the endoscope and moving the elevator. It will slide along the inner surface of the “roof of the major duodenal papilla” and slightly lift it, which is clearly noticeable, especially when the bile duct and duodenum merge at an acute angle and there is a long intramural section of the common bile duct. To reach the mouth of the pancreatic duct, the catheter inserted into the opening of the ampoule is advanced forward, first introducing a contrast agent. Using these techniques, it is possible to either selectively or simultaneously contrast the bile and pancreatic ducts.

In patients who have undergone surgery (in particular, choledochoduodenostomy), it is often necessary to selectively contrast the ducts not only through the orifice of the major duodenal papilla, but also through the anastomotic opening. Only such a complex study allows us to identify the cause of painful conditions.

X-ray control over the position of the catheter is possible already with the introduction of 0.5-1 ml of contrast agent. If the cannulation depth is insufficient (less than 5 mm) and the ductal system is blocked low (close to the ampulla) by a stone or tumor, cholangiography may be unsuccessful. When the cannula is located in the ampulla of the major duodenal papilla, both ductal systems can be contrasted, and when it is inserted deeply (10-20 mm), only one can be contrasted.

If only the pancreatic duct is contrasted, then an attempt should be made to obtain an image of the bile ducts by injecting a contrast agent while removing the catheter and performing repeated shallow cannulation (3-5 mm) of the ampulla of the major duodenal papilla, directing the catheter up and to the left. If the cannula is inserted 10-20 mm, and the contrast agent is not visible in the ducts, this means that it rests against the wall of the duct.

The amount of contrast agent required to perform cholangiography varies and depends on the size of the bile ducts, the nature of the pathology, previous operations, etc. Usually it is enough to administer 20-40 ml of contrast agent. It is removed slowly, and this circumstance allows you to take radiographs in the most convenient projections, which the doctor selects visually. The concentration of the first portions of contrast agent administered during endoscopic retrograde cholangiopancreatography should not exceed 25-30%. This allows you to avoid mistakes when diagnosing choledocholithiasis as a result of “clogging” of stones with highly concentrated contrast agents.

Endoscopic retrograde cholangiopancreatography (ERCP) is an X-ray examination of the pancreatic ducts and biliary tract after the injection of a contrast agent through the Vater nipple. Indications for the study are suspected or confirmed diseases of the pancreas and obstructive jaundice of unknown etiology. Complications include cholangitis and pancreatitis.

Target

• Determine the cause of obstructive jaundice.
• Detect cancer of the Vater's nipple, pancreas or bile ducts.
• To clarify the localization of gallstones and stenotic areas in the pancreatic ducts and bile ducts.
• Identify ruptures in the duct wall caused by trauma or surgery.

Preparation

• It should be explained to the patient that the study allows radiographic assessment of the condition of the liver, gallbladder and pancreas after the administration of a contrast agent.
• The patient should refrain from eating after midnight before the test.
• The essence of the study should be explained to the patient and informed who and where it will be performed.
• The patient should be warned that in order to suppress the gag reflex, the oral mucosa will be irrigated with a local anesthetic solution, which has an unpleasant taste, causes a sensation of swelling of the tongue and larynx and makes swallowing difficult.
• The patient should be warned not to interfere with the free flow of saliva from the mouth, which can be evacuated by suction. The patient should be reassured that the mouthpiece used to protect the teeth and endoscope will not obstruct breathing.
• To help the patient relax before the study begins, he is given sedatives, which, however, do not impair consciousness.
• The patient is warned that after insertion of the endoscope, an anticholinergic drug or glucagon will be administered intravenously, which may cause side effects (eg, dry mouth, thirst, tachycardia, urinary retention, blurred vision after administration of the anticholinergic drug, nausea, vomiting, urticaria, facial flushing after administration of the endoscope). administration of glucagon).
• The patient is warned about the possibility of transient facial hyperemia after the administration of a contrast agent, as well as a sore throat for 3-4 days after the study.
• It is necessary to ensure that the patient or his relatives give written consent to the study.
• It is necessary to find out whether the patient has hypersensitivity to iodine, seafood, or radiocontrast agents. If any, you should notify your doctor.
• Before starting the study, initial physiological parameters are determined, the patient is asked to remove metal and other radiopaque objects, as well as items of clothing containing metal parts. It is necessary for the patient to empty the bladder to prevent discomfort associated with possible urinary retention when using anticholinergic drugs.

Procedure and aftercare

• 150 ml of 0.9% sodium chloride solution is injected intravenously, then a local anesthetic solution is applied to the pharyngeal mucosa, the effect of which usually occurs within 10 minutes.
• When using a spray, you must ask the patient to hold his breath while irrigating the mucous membrane.
• The patient is placed on his left side, the vomit tray is brought closer and a towel is prepared. Since local anesthesia causes the patient to partially lose the ability to swallow saliva, which increases the risk of aspiration, he is asked not to obstruct the flow of saliva from the oral cavity.
• A mouthpiece is inserted.
• With the patient in the left lateral position, diazepam or midazolam is administered intravenously at a dose of 5~20 mg, and, if necessary, a narcotic analgesic.
• After drowsiness or slurred speech appears, the patient's head is tilted forward and asked to open his mouth.
• The doctor inserts the endoscope along the index finger to the back wall of the pharynx, then bends the endoscope downwards with the same finger and continues to insert it. After the endoscope has passed along the back of the pharynx past the upper esophageal sphincter, the patient's neck is slowly straightened to facilitate advancement of the endoscope. The patient's chin should be in the midline. After passing the upper esophageal sphincter, further advancement of the endoscope is carried out under visual control. While moving along the esophagus, the chin is tilted towards the surface of the table to ensure the free flow of saliva. Then, under visual control, the endoscope is inserted into the stomach.
• Upon reaching the pyloric part of the stomach, a small amount of air is introduced through the endoscope, and then it is turned upward and passed through the duodenal ampulla.
• To pass into the descending part of the duodenum, the endoscope is turned clockwise, after which the patient is placed on his stomach.
• To completely relax the duodenal wall and sphincter ampoules, an anticholinergic drug or glucagon is administered intravenously.
• A small amount of air is injected, then the endoscope is positioned so that the optical part is opposite the nipple of Vater. A cannula with a contrast agent is inserted through the biopsy channel of the endoscope and passed through the nipple of Vater into the hepatic-pancreatic ampulla.
• Under fluoroscopic control, the pancreatic duct is visualized using a contrast agent.
• The cannula is then oriented towards the patient's head and a contrast agent is injected; As a result, the bile ducts are visualized.
• After each administration of a contrast agent, photographs are taken.
• The patient is asked to remain prone until all images have been taken and reviewed. If necessary, additional photographs are taken.
• After completion of the study, the cannula is removed. Before removing the endoscope, tissue or fluid samples may be taken for histological or cytological examination.
• It is necessary to carefully monitor the patient due to the possibility of developing complications - cholangitis and pancreatitis. The first signs of cholangitis are hyperbilirubinemia, increased body temperature and chills; later arterial hypertension may develop against the background of septicemia caused by gram-negative microflora. Pancreatitis is usually manifested by symptoms such as abdominal pain and tenderness in the epigastric region on the left, increased serum amylase levels, and transient hyperbilirubinemia. If necessary, amylase activity and bilirubin levels in the blood serum are determined, but it should be taken into account that after ERCP these indicators are usually increased.
• It is necessary to ensure that there are no signs of perforation (abdominal pain, fever) or bleeding.
• The patient should be warned about the possibility of feeling heaviness in the abdomen, cramping pain and flatulence for several hours after the study.
• You should ensure that there is no respiratory depression, apnea, arterial hypotension, sweating, bradycardia, or laryngospasm. During the first hour after the study, basic physiological indicators should be recorded every 15 minutes, over the next 2 hours - every 30 minutes, then every hour for 4 hours, and then every 4 hours for 48 hours.
• The patient should not eat or drink until the gag reflex is restored. After the sensitivity of the back of the pharynx returns (checked with a spatula), dietary restrictions are lifted.
• According to indications, infusion therapy is continued or stopped.
• It is necessary to exclude urinary retention; if the patient cannot urinate independently within 8 hours, the doctor should be notified.
• If a sore throat persists, it is advisable to use emollient lozenges and recommend rinsing with a warm isotonic sodium chloride solution.
• If during the study a biopsy was performed or a polyp was removed, then during the first bowel movement there may be a small amount of blood in the stool. In case of severe bleeding, you should immediately notify your doctor.
• When conducting research on an outpatient basis, it is necessary to ensure the transportability of patients. If anesthetics or sedatives are used, the patient should not drive a car for at least 12 hours. Alcohol should not be consumed for 24 hours after the test.

Precautionary measures

• ERCP is contraindicated during pregnancy, as it is associated with a high risk of teratogenic effect.
• Contraindications to the study are infectious diseases, pancreatic pseudocyst, stricture or obstruction of the esophagus or duodenum, as well as acute pancreatitis, cholangitis or diseases of the heart and lungs.
• Patients receiving anticoagulants have an increased risk of bleeding.
• During the study, it is necessary to monitor basic physiological indicators. The doctor must make sure that there is no respiratory depression, apnea, arterial hypotension, sweating, bradycardia, or laryngospasm. It is necessary to have a resuscitation kit and antagonist narcotic analgesics (for example, naloxone) ready.
• If there is concomitant heart disease, ECG monitoring is necessary. In patients with impaired respiratory system function, continuous pulse oximetry is advisable.

Normal picture

Vater's nipple resembles a red (sometimes pale pink) area of ​​erosion protruding into the lumen of the duodenum. The mucous membrane around the nipple opening is usually white. The nipple is located in the lower part of the longitudinal fold running along the medial wall of the descending intestine perpendicular to the deep folds. Usually the pancreatic duct and the common bile duct join at the hepatopancreatic ampulla and are connected to the duodenum through the papilla of Vater, but sometimes they open into the intestine through separate openings. The contrast agent evenly fills the pancreatic duct, bile ducts and gallbladder.

Deviation from the norm

Various changes in the pancreatic duct or bile ducts are accompanied by the development of obstructive jaundice. Examination of the bile duct may reveal stones, strictures, or excessive tortuosity, indicating cirrhosis, primary sclerosing cholangitis, or bile duct cancer. Examination of the pancreatic duct may also reveal stones, strictures, and excessive tortuosity caused by cysts, pseudocysts, or pancreatic tumors, chronic pancreatitis, pancreatic fibrosis, cancer, or stenosis of the papilla of Vater. Depending on the data obtained, clarifying the diagnosis may require additional research. In addition, sometimes there is a need for interventions such as drainage or papillotomy with dissection of scar strictures for unimpeded outflow of bile and passage of stones.

Factors influencing the result of the study

Barium residues after X-ray contrast examination of the gastrointestinal tract (poor image quality).

B.H. Titova

"Endoscopic retrograde cholangiopancreatography" and others

Endoscopic retrograde cholangiopancreatography is an imaging technique for diagnosing diseases of the pancreas, liver, gallbladder and bile ducts. Retrograde cholangiopancreatography combines endoscopy and x-ray images.

Purpose of endoscopic cholangiopancreatography

Endoscopic retrograde cholangiopancreatography is used in the treatment of diseases that affect the organs of the gastrointestinal tract, in particular the pancreas, liver, gallbladder and bile ducts. The pancreas is an organ that secretes pancreatic juice in the upper part of the intestine. Pancreatic juice is made up of specialized proteins that help digest fats, proteins and carbohydrates. Bile is a substance that helps digest fats; it is produced by the liver, secreted through the bile ducts and accumulates in the gallbladder. Bile is secreted in the small intestine after eating a meal containing fat.

The doctor may recommend retrograde cholangiopancreatography if the patient experiences abdominal pain of unknown origin, weight loss, or jaundice. These may be symptoms of bile duct disease. For example, gallstones that form in the gallbladder or bile ducts can become lodged there, causing cramping or dull pain in the upper right abdomen, fever and/or jaundice.

Endoscopic retrograde cholangiopancreatography can be used to diagnose a number of pancreatic diseases, such as pancreatitis caused by chronic alcohol abuse, trauma, pancreatic duct obstruction (eg, gallstones), or other factors. The disease can be acute or chronic. Symptoms of pancreatitis include abdominal pain, weight loss, nausea and vomiting.

Endoscopic cholangiopancreatography can be used to diagnose pancreatic cancer; pancreatic pseudocysts; or strictures of the pancreatic ducts. Some congenital disorders can also be identified using retrograde cholangiopancreatography, such as inherited problems with the pancreas.

Endoscopic retrograde cholangiopancreatography: description

Endoscopic cholangiopancreatography is performed either under sedation or general anesthesia. The doctor then treats the back of the patient's throat with a local anesthetic. An endoscope (a thin, hollow tube connected to a viewing screen) is inserted into the mouth. The tube passes through the esophagus and stomach to the duodenum (upper part of the small intestine). At this point, a contrast agent is injected through another small tube. The term "retrograde" in the name of the procedure refers to the reverse direction of the dye.

Next, a series of x-rays are taken. If x-rays show that a problem exists, cholangiopancreatography may be used as a therapeutic tool. Special instruments may be inserted into the endoscope to remove gallstones, take tissue samples for further study (for example, if cancer is suspected), or a special stent tube may be placed in the canal to reduce the obstruction.

Retrograde cholangiopancreatography: diagnosis and preparation

Endoscopic cholangiopancreatography is generally not performed unless other less invasive diagnostic tests have been used to determine the cause of the patient's symptoms. Such tests include: a complete medical history and physical examination, blood tests (some diseases can be diagnosed by abnormal levels of blood components), ultrasound (a procedure that uses high-frequency sound waves to visualize structures in the human body), computed tomography (CT) scan ) (an imaging device that uses x-rays to produce two-dimensional cross-sections on a screen).

Before the procedure, the patient is instructed to fast from eating or drinking for at least six hours to ensure that the stomach and upper intestines are empty. The doctor should also be provided with a complete list of all medications the patient is taking and any alternative medications or drugs. The patient should also notify the doctor if he is allergic to iodine.

Endoscopic cholangiopancreatography: care for a convalescent patient

After the procedure, the patient remains in the hospital or outpatient facility while sedation is in effect. A longer stay may be warranted if the patient experiences complications or other procedures have been performed.

Risks of retrograde cholangiopancreatography

Complications that have been reported from the procedure include pancreatitis, cholangitis (inflammation of the bile ducts), cholecystitis (inflammation of the gallbladder), duodenal injury, pain, bleeding, infection, and blood clots. Factors that increase the risk of complications include liver damage, bleeding disorders, and several other issues.

Normal results

After the procedure, the patient's pancreas and bile ducts should be free of stones and show no strictures or signs of infection or inflammation.

Morbidity and mortality

The overall complication rate associated with retrograde cholangiopancreatography is approximately 11%. Pancreatitis may occur in 7% of patients. Cholangitis and cholecystitis occur in less than 1% of patients. Infections, injuries, and blood clots occur in less than 1% of patients. The mortality rate of cholangiopancreatography is about 0.1%.

Endoscopic retrograde cholangiopancreatography: alternatives

Although less invasive methods (such as CT scans and ultrasound) are available to diagnose gastrointestinal diseases, these tests are often not accurate enough to provide a diagnosis of certain conditions. Endoscopic retrograde cholangiopancreatography is an alternative to endoscopic retrograde cholangiopancreatography; the former may be recommended if the latter procedure is not possible.

Magnetic resonance cholangiopancreatography is also a type of non-invasive examination of the bile ducts and pancreatic ducts. The disadvantage of this procedure, however, is that, unlike endoscopic retrograde cholangiopancreatography, it cannot be used for therapeutic procedures or imaging.

Denial of responsibility: The information presented in this article about endoscopic retrograde cholangiopancreatography is intended for the reader's information only. It is not intended to be a substitute for advice from a healthcare professional.