3. Biliary anatomy parallels the portal venous supply of the
liver.
The right hepatic duct drains the entire right lobe of the
liver. It is formed by the union of the anterior right hepatic
duct, which drains the anterior segments V and VIII, and
the posterior right hepatic duct, which drains the
posterior segments VI and VII.
The anterior right hepatic duct lies vertically, whereas the
posterior hepatic duct is more horizontal .
The left hepatic duct is formed by the union of ducts
draining segments II and III and one or more ducts from
segment IV .
Segment I normally drains to both the left and the right
hepatic ducts.
The bile ducts, together with branches of the hepatic
artery and portal vein, form the portal triad.
5. Endoscopic retrograde cholangiopancreatography
(ERCP) is a diagnostic and interventional procedure
technique using both endoscopy and fluoroscopy for
examination and intervention of biliary tree and
pancreatic ducts .
The standard technique for selective biliary
cannulation, which is the first part of performing an
ERCP, involves using a endoscope/duodenoscope and
advancing this to the second part of the duodenum
in a very similar manner to a conventional
gastroscopy procedure.
6. Patient preparation:
Control film (AP/LAO of upper abdomen)
Report of USG/CT/MRI/Cholangiogram if available :To
check opaque gall stones ,pancreatic
calcifications/calculi.
May need antibiotics prior to ERCP.
A local anesthetic sprayed onto tongue /throat just
before intubation.
May require sedation.
7. Known allergic to iodine contrast:Pretreated with
prednisone 40 mg for 3 days before exam.
Smooth muscle relaxant
:Buscopan/atropine/glucagon given to reduce
esophageal spasm and relax the sphincter of oddi for
passage of endoscope and insertion of cannula .
8. Contrast media :
Non ionic tri-iodinated contrast agent :
Iapamidol,iohexol,iopramide,ioversol
Pancreatic duct :Low osmolar (1.5 mg /ml)
Bile duct :Low osmolar (2.8 mg/ml)
9. Equipment :
A side viewing fibre-optic endoscope
Polythene catheters.
Over couch/under couch X-ray tubes with
tilting tables.
Fluoroscopic unit with spot film devices and
image intensifier television system.
11. Patient lies on left lateral /LAO position on the fluoroscopic table.
The initial process of ERCP involves esophageal intubation, navigation
through the esophagus and stomach and entering the duodenum via the
pylorus.
In the second part of the duodenum, the next step involves identifying the
major papilla in the duodenum in order to perform biliary cannulation.
The first step involves positioning the duodenoscope so that the lens and
working channel are located below the major papilla.
Once properly positioned, a sphincterotome or an alternative cannulation
catheter is engaged into the orifice of the major duodenal papilla, aiming
usually towards the 11 oclock position in order to achieve common bile
duct (CBD) cannulation.
Once suitably advanced, contrast injections can be given and this allows x-
ray images to be obtained which can serve as a diagnostic test to look for
pancreatobiliary pathology and also enable planning for any therapeutic
interventions.
13. Once the ampulla of vater is identified ,patient
is turned prone to assist in selective
cannulation of biliary duct .
It is easy to cannulate the pancreatic duct as it
is straight in the papilla and the CBD is slightly
angulated to the side.
14. A polythene catheter prefilled with contrast
media without any air bubble is introduced via
the endoscope through the ampulla into distal
end of CBD.
If failed try to introduce a guide wire into the
papillary opening .Catheter is directed up the
duct right over the guide wire.
Test injection of contrast under fluoroscopic
guidance is made to determine the position of
cannula .
Contrast is then injected to fill the biliary ducts
and gall stones.
16. Film sequences :
Early bile duct filling films to show any
calculi :Prone straight & prone oblique ,supine
straight ,both obliques
Intrahepatic ducts:Trendelenberg position .
Lower end of CBD and gallbladder :Semi erect .
17. Endoscope is removed to prevent obscuring the duct
visualization and further radiographs are taken.
Delayed films of CBD and gallbladder are taken to
evaluate emptying rate.
Usually four types of spot films are taken :
A)Initial scout
B)Initial cholangiogram.
C)Post procedure cholangiogram
D)Drainage film.
18. For therapeutic ERCP ,special instruments
are passed through the working channel of
the endoscope that are used for cutting
and opening into the bile duct ,stone
removal ,dilatation of stricture and
stent/drain placement .
19. Indications:
Biliary drainage.
Bile duct stones removal(choledocholithiasis).
Biliary stenting for strictures and leakage.
Biliary or pancreatic ductal system tissue sampling
Manometry for sphincter of oddi.
Balloon dilation of the duodenal papilla or ductal strictures.
Sphincterotomy ( sphincter of oddi dysfunction or stenosis).
Pre- or postoperative assessment of the biliary tree in patients
undergoing laparoscopic cholecystectomy .
20. Contraindications
Relative:
Altered anatomy in post-surgical states.
Structural abnormalities of esophagus,
stomach or duodenum.
Unstable patient (severe cardiac/respiratory
diseases).
Coagulopathy
36. Complications:
Pancreatitis (~5%)
Hemorrhage (2%)
Perforation leading to pneumoperitoneum and/or
pneumoretroperitoneum(<1%)
Infection (cholangitis)
Migration of a biliary or pancreatic duct stent
complications secondary to endoscopy
e.g. esophageal and gastric injury