HepatoBiliary system

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Hepato-Biliary system
RAD220
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topics

• ERCP

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ERCP

• Introduction
• ERCP
• Endoscopic Retrograde Cholangio Pancreatography
• Endoscope is a fibre optic instrument which is
  flexible and hand controlled.
• It has light and video capabilities.
• It is controlled by a specialist physician called
  a gastroenterologist and used to diagnose and
  treat a variety of pathologies within the
  gastrointestinal tract.
• Retrograde indicates the direction in which the
  endoscope enters the patient. As well the
  direction of contrast or fluid injected during
  the procedure.
• The technique used in imaging is termed
  cholangiopancreatography.
• Cholangio the bile ducts, and gall bladder.
• pancrea pertaining to the pancreas.
• Ography pertains to imaging.

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ERCP
Image sourced from internethttp//www.jcr.or.jp/t
rc/252/s6/ercp.jpg
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• Anatomy
• Hepatobiliary system

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• Stomach
• Gall bladder
• Pancreas
• Duodenum
• Hepatic duct
• Common hepatic
• Left hepatic
• Right hepatic
• Pancreatic duct
• Hepatopancreatic ampulla
• Cystic duct
• Greater duodenal papilla

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Image sourced from internethttp//www.lebertransp
lantation.de/bilder/ercp.gif
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http//images.webmd.com/images/hw/media69/medical/
hw/nr551717.jpg
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http//www.maerkische-kliniken.de/images/ERCP_1275
.jpg
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• Indications
• Gallstones.
• Blockage of the bile duct
• Jaundice.
• Upper abdominal pain
• Cancer of the bile ducts or pancreas
• Pancreatitis.
• Post radiographic findings

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• Contraindications
• Intestinal obstruction
• pseudocyst
• Insufficient endoscope skills
• patient refusal or poor cooperation
• recent attack of acute pancreatitis. inadequate
  surgical back-up
• Allergy to iodinated contrast
• overlying residual barium in the GI tract from
  recent abdominal CT scan, lower GI series, etc

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• Side Effects and Risks
• A temporary, mild sore throat sometimes occurs
  after the exam.
• excessive bleeding, especially when
  electrocautery is used to open a blocked duct.
• perforation or tear in the intestinal wall can
  occur.
• Inflammation of the pancreas also can develop.
• Rarely, drugs used to relax the ampulla of Vater
  can have side effects such as nausea, dry mouth,
  flushing, urinary retention, rapid heart rate
  (sinus or supraventricular tachycardia), or a
  drop in blood pressure
• Due to the mild sedation, the patient should not
  drive or operate machinery for six hours
  following the exam. For this reason, a driver
  should accompany the patient to the exam

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• Alternative Testing
• Computed tomography
• Ultrasonography
• to demonstrate the pancreas and bile ducts.

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Equipment required

• Aseptic conditions
• Endoscope
• Endoscopy (performed by gastroenterologist)
• All within theatre
• Contrast (non-ionic solution, 60-100ml contrast)
• Sterile local anaesthetic spray
• Drawing up cannula
• Syringe (10ml)
• Surgical equipment

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• http//gensurg.co.uk/images/ercp20endoscope.jpg

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• http//gensurg.co.uk/images/ercp20-endoscope.jpg

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http//www.liverme.org/arabic/procedures_a/images/
ercp.jpg
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http//www.yamanashi.ac.jp/education/medical/clini
cal/intern01/ERCP.jpg
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http//www.kemperhof.de/kliniken/bilder/msvc_inter
n/1485_13.jpg
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http//www.netdoktor.at/images/imagearchive/magen_
darm_und_leberkrankheiten/extended/ercpbild_large.
jpg
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• http//telesalud.ucaldas.edu.co/telesalud/endoscop
  iaterapeutica/cipw.jpg

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http//www.tmd.ac.jp/mdc/images/skills/kiki_1_img3
1.gif
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Patient preparation

• Patient changed into gown ensure all artefacts
  are removed.
• Procedure explained to patient (the
  gastroenterologist will do this)
• Patient pronated on fluoroscopy table
• Ready for endoscopy procedure.

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Introduction of contrast

• Contrast is hand injected through catheter via
  endoscope.
• This procedure is performed by either the
  Gastroenterologist or scrub nurse.
• This is only performed when the catheter is in
  the correct position.
• Contrast is injected until the hepatic and
  pancreatic ducts are filled or obstruction noted.

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Technique

• Patient
• Pronated on theatre (or fluoroscopy table)
• 20-40 degree oblique RAO/LAO
• Anaesthetised / sedated
• Comfortable
• Patient will have head turned to one side with
  mouth piece in.
• Image receptor
• Image intensifier (theatre)
• 30cm / 40cm film screen combination
• Ensure image is displayed correctly
• Central beam
• Perpendicular to image receptor
• Centred over relevant anatomy

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• Collimation
• To include lateral border of liver and tail of
  pancreas.
• Superiorly to include domes of diaphragm ,
  inferiorly to include iliac crests.
• Anatomy included
• Hepatic and pancreatic ducts in their entirety
• Gall bladder
• Liver
• Spleen
• Evaluation
• No motion
• Short scale of contrast to demonstrate contrast
  filled hepatobiliary ducts.

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http//www.rcsed.ac.uk/journal/svol1_1/10000025.gi
f
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http//www.sages.org/quiz/ta48.jpg
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http//www.hitachi-medical.com.cn/thesis/images/9/
image016.jpg
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http//www.med.unifi.it/didonline/Anno-IV/spec-med
chirII/oncologiamed/Ca_pancreas/ercp3.jpg
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http//www.spitalmaennedorf.ch/pi/leistungsangebot
/images/gatroenterologie_textbild.jpg
http//www.gezondheid.be/picts/galstenen-ercp.jpg
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http//www.terra.or.jp/sippitu/hyo-jun-tiryo-/2002
.2003/irasuto/ercp.jpg
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http//images.google.com.au/imgres?imgurlhttp//w
ww.imtc.gatech.edu/projects/archives/image_thumbs/
ercp.jpgimgrefurlhttp//www.imtc.gatech.edu/proj
ects/archives/ercp.htmlh75w100sz4hlenstar
t432tbnidXATi_bF1iaCFLMtbnh62tbnw82prev/
images3Fq3Dercp26start3D42026ndsp3D2026svnu
m3D1026hl3Den26lr3D26c2coff3D126sa3DN
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Pathologies

• Gall stones
• Acute cholecystitis
• Emphysematous cholecystitis
• Porcelain gall bladder

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http//www.merck.com/media/mmhe2/figures/fg140_1.g
if
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http//www.e-radiography.net/ibase5/Hepatic/slides
/Hepatic_cholelithiasis_muliple_gall_stones.jpg
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http//www.your-doctor.net/git/hepato_biliary/gall
stones/pics/ercp_cbd_stone.gif
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http//www.rad.msu.edu/Education/CourseInfo/CHM_do
main/digestive/Willekens/images/gallstone.png
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http//wings.buffalo.edu/smbs/pth600/IMC-Path/imag
es/Year1/gallstones-Mixed-Gross.jpg
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Acute Cholecystitis
http//www.emedicine.com/radio/images/8391839101.j
pg
http//coastalsurgery.com/images/c_c_c.gif
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http//www.eresidency.net/newsletter/images/000001
d9.jpg
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http//www.radiologychannel.net/Images/76_28_70022
_01.jpg
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Emphysematous cholecystitis
http//www.appliedradiology.com/Documents/Cases/im
ages/Mammen_figure02b.jpg
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http//www.emedicine.com/radio/images/1219Emphysem
a_chole_CT_composite.jpg
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http//www.meddean.luc.edu/lumen/MedEd/Radio/curri
culum/Harrisons/GI/Emph_cholecystitis4.jpg
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http//www.meddean.luc.edu/lumen/MedEd/Radio/curri
culum/Harrisons/GI/Cholecystitis5b.jpg
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Porcelain Gall bladder
http//www.uhrad.com/ctarc/ct186a1.jpg
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http//www.emedicine.com/radio/images/3806rad0569-
04.jpg
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http//www.e-radiography.net/radpath/p/porcellaing
allbladdder1.jpg