Endoscopic Retrograde Cholangiopancreatography Procedure Diagnoses Pathology Liver Pancreas Biology Essay

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Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that diagnoses the pathology of the liver, gall bladder, bile duct and the pancreas. Endoscopic retrograde cholangiopancreatography is usually performed by the physician or surgeon rather than radiologist and it is assist with the radiographer. Endoscopic and fluoroscopic is use in this technique to obtain images.

This procedure diagnose and treat the pathology of the bile system such as gall bladder stone, cancer in the liver, stricture in the biliary system, tumour, and ductal stone. The surgeon inserts a lighted scope with camera which is flexible into the mouth of the patient, and reaches the patient's stomach, and to the biliary tree. The surgeon will also inject contrast media in the biliary system so that the organ is visible in the x-ray image, to allow the surgeon to view the organ in details and analyze pathologies in the system. This procedure can also treat some disease, when the physician found some abnormal growth; a catheter is inserted in that particular region through the endoscope to collect some tissue for further diagnose.

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In endoscopic retrograde cholangiopancreatography can also treat certain disease on the spot such as gall stone, during this procedure, if the surgeon found stone in the gallbladder, he will remove the gallstone by inserting a device through the endoscopic. Furthermore, if a narrowed bile duct such as common bile duct is diagnose, then the surgeon will open the bile duct by inserting a plastic tube to enlarge the bile duct through the endoscopic.

Endoscopic retrograde cholangiopancreatography is performed in a x-ray department. It requires minimum preparation except fasting, and a sedative will be given to the patient and the procedure will begin. This ERCP has more advantages over percutaneous transhepatic cholangiography (PTC). Unlike ERCP, pancreatic duct cannot be visualize and access by percutaneous cholangiography, but in ERCP all the biliary system is visible. Besides, ERCP also has the ability to visualize ampullary lesion, and also obtain tissue (biopsy) for further diagnosis. ERCP has also greater therapeutic potential. Moreover, PTC cannot undergoes endoscopic sphincterotomy.

Indication

Endoscopic retrograde cholangiography (ERCP) is used to investigate biliary disease or pancreatic disease. There are many indication that require to undergoes ERCP such as sclerosing cholangitis, cholangitis, cholecystitis, cirrhosis, Sphincter of Oddi dysfunction, ascites, cholelith, cholelithiasis, choledocholithiasis, jaundice, bile duct tumour, bile duct obstruction, acute pancreatitis, hepatitis, and hepatoma.

Sclerosing cholangitis is a disease refers to the swelling of the bile duct inside or outside of the liver. In this case, the bile duct is scarred and narrowed. It is usually appear in patient with inflammation bowel disease such as crohn's disease and ulcerative colititis. Cholangitis is the inflammation of the bile duct, it is usually caused by infection from bacteria.

Cholecystitis is the inflammation of the gallbladder that is usually cause by the gall stone in the bladder. Cholecystitis trapped the bile in the gallbladder and causes the builup in the gallbladder and lead to inflammation. Cirrhosis is the scarring of liver tissue and poor liver function that may to chronic liver disease.

Sphincter of oddi dysfuntion is the failure of the sphincter muscular wall that controls the flows of the juices in the biliary system, it will cause the retention of the juice in the pancreatic duct and cannot be deliver. Ascites is the excessive accumulation of the fluid in the peritoneal cavity. Cholelithiasis refers to gallstone, it is a crystalline concrete that is form in the gallbladder, as the stone increase, it may obstruct the flow of the bile duct to other part of the biliary system.

Choledocholithiasis refers to the presence of the gallstone in the common bile duct, this may lead to the obstruction of the common bile duct. Jaundice is yellow fever, the skin of the patient appear to be yellowish. It is usually caused by hyperbilirubinemia.

Cathether is inserted from the mouth to the duodenum and reaches the pancreatic duct.

Endoscopic retrograde cholangiopancreatography (ERCP) Procedure

This procedure can diagnose the problem of the liver, pancreas, gallbladder and the biliary system

Care before, during and after the procedure

Before the procedure: Before the patient enters the room, the radiographers have to make sure the room is tidy, clean and is free of bacteria. The radiographers also have to check the x-ray machine to make sure there is no leakage in the x-ray tube and it is in a good condition. Besides, they are also in charge of setting the correct exposure, ready the cassette with film and the marker.Always ask patients for 10days rule and make sure patient is not pregnant. Radiographer also has to make sure that the correct amount and concentration of contrast media is administered to the patient. Furthermore, the radiographer must always inform consent and make sure the patient understands, and ask the patient to sign the consent form after he or she is fully understood. Make sure the parient is not allergy to seafood (patient who is allergy to seafood may also allergy to contrast media)

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During the procedure: make sure it is the correct patient by asking their name, identification number and registration number.Always assist patient during the procedure. Make sure patient is free from any electricity and mechanical source. Give radiation protection to the patient. Give comfort to the patient. Observe patient's condition during examination. Explain the procedure and make sure patient understand the procedure and always communicate with patient.

After the procedure: Assist patient to go out of the x-ray room. For outpatient, ask the date for the next appointment or arrange the next appointment. For inpatient, ask the nurse or staff in ward to come and take the patient. Nil orally until sensation has returned to the pharynx. Check the pulse, temperature and the blood pressure half-hourly for 6 hour. Maintain antibiotics if there is biliary or pancreatic obstruction. Serum/urinary amylase if pancreatitis is suspected.

Patient preparation: patients have to fast for about 4 hours prior the procedure, to keep the stomach and the duodenum empty for accurate image view and safer. The radiographer must make sure the patient is free from allergy of contrast media. Ask the patient to change into hospital gown, remove all the jewelries. A preliminary film is taken (prone AP and LAO of the upper abdomen, to check for opaque gallstone and pancreatic calcification/calculi). Patients are advise not to use any medication before the examination.

Positioning of patient and cassette: Patient lying supine, then he or she is given sedative to keep them asleep or relax. Then pharynx is anaesthetized with xylocaine spray. The patient is then moved to the left side and the endoscope is introduced. The ampulla of vater is located and the patient is turned prone. A polythene catheter prefilled with the contrast media is inserted into the ampulla, having ensured that all the air bubbles are excluded to prevent any complication. A small test injection of the contrast under fluoroscopic control is made to determine the position of the cannula. It is important to avoid over-filling of the pancreas. If it is desirable to opacify the biliary tree and pancreatic duct, then the latter should be cannulated first. A sample of the bile should be sent for culture and sensitivity if there is evidence of the biliary obstruction. If any gallstone happens to be in the gallbladder, the surgeon will immediately remove the gallstone. The plastic tube (stent) can also be inserted into the endoscopic if a narrow stricture is detected to enlarge it. Besides if a tumor is found, the tumour can be bypassed to prevent obstruction and also biopsy can be done to undergoes further diagnosis.

If gall stones is found in the biliary system, a special instrument in inserted via the endoscopic and remove the gallstone.

Endoscope that is used in the endoscopic retrograde cholangiopancreatography.

Complication,side effect and the risk of endoscopic retrograde cholangiopancreatography (ERCP)

ERCP requires lots of skill and technique which is very essential during this procedure. If the procedure is not done correctly certain complication may arise and may leads to life threathening.There are many complications in this procedure such as allergy reaction. Endoscopic retrograde cholangiopancreatography uses contrast media to make the soft tissue in the biliary system to be visible in the film, it act as a dye that is administered in the patient body by a catheters in the ampulla of vater. Contrast media allergy are basically very rare but it may also have possibility especially iodine contrast media. Contrast media will also cause flushing sensation and vomit.

Besides, it may also cause acute pancreatitis after this test, the gland of pancreas become inflamed, the digestive juices is then release to the surrounding tissue and causes pancreatitis. It is more likely after large volume and high pressure injections. It may also cause bleeding in the pancreas because of the insertion of the catheters, needles and tube. Furthermore, respiratory arrest may also occur if there is an overdose of the sedatives. If the sedative that is given to the patient is too heavy, the patient may feel too sleepy, and may lead to suppress of the lungs and causes respiratory arrest. After this procedure, patient will also feel discomfort because the surgeon inject dyes and blow air into the duodenum of the patient and the sedative use will make the patient feel lethargic.

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Other complication such as, the flexible thin scope can sometimes damage the internal organ of patient, by brushing the surface of the duodenum. The lining of the digestive system may occur and if serious it will causes a hole in the biliary system and will lead to internal bleeding. Patients are advice not to eat or drink 8 hours before the surgery; this is to avoid stomach choking after the insertion of the catheters.

Patient will also feel numb in the throat and bitter in the same time because of the anesthesia spray during the surgery. Patient will also feel bloated and nausea due to the technique (air is blown into the duodenum). Besides, patient will have abdominal cramping when the catheter is pulled out.

Patient must contact the doctor if symptoms like, vomiting blood, pain in the abdominal, fever or chill, dizzy or lethargic after few days of the procedure, and shortness of breath. Patient with history of heart disease will also experience cardiac arrest and irregular heartbeat. The contrast media being used in this procedure may promote blurred vision, hives (red sports on the surface of the skin, itchy), throat spasm, urine retention.

Results of endoscopic retrograde cholangiopancreatography (ERCP)

Normal results: the x-ray image will show normal structure of the biliary system. The bile duct, pancreas, gallbladder, and pancreatic duct appear to be in normal size. The digestive system such as, duodenum, eosophagus, stomach, pancreas looks normal with no stricture, abnormal growth, calcification or stones.

Abnormal results: the x-ray radiographer may show abnormal size of the gallbladder which may cause by crystalline of stone in the bladder, obstruction of the common bile duct, biliary stricture, cholangitis, cholelithiasis, chronic pancreatitis, cirrhosis, enlargement of the pancreas, pancreatitis, pancreatic divisum, narrowed of the common bile duct and pancreas carcinoma, tumor, cancer.

Endoscopic radiograph showing stone in the bile duct

ERCP showing dilated bile duct with stones

Normal ERCP image

Conclusion

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that diagnoses the pathology of the liver, gall bladder, bile duct and the pancreas. Endoscopic retrograde cholangiopancreatography is usually performed by the physician or surgeon rather than radiologist and it is assist with the radiographer. Endoscopic and fluoroscopic is use in this technique to obtain images. ERCP is performed using sedative without general anaesthetic. It is also a less invasive procedure and basically safe with very rare side effects. Besides, it is a very uncomfortable examination but it is not painful with very low risk.

This procedure diagnose and treat the pathology of the bile system such as gall bladder stone, cancer in the liver, stricture in the biliary system, tumour, and ductal stone, which cannot be obtain in other examination such as computed tomography scan (CT scans), magnetic resonance imaging (MRI), general x-rays, or ultrasound.The surgeon inserts a lighted scope with camera which is flexible into the mouth of the patient, and reaches the patient's stomach, and to the biliary tree. The surgeon will also inject contrast media in the biliary system so that the organ is visible in the x-ray image, to allow the surgeon to view the organ in details and analyze pathologies in the system. This procedure can also treat some disease, when the physician found some abnormal growth; a catheter is inserted in that particular region through the endoscope to collect some tissue for further diagnose.

In endoscopic retrograde cholangiopancreatography can also treat certain disease on the sport such as gall stone, during this procedure, if the surgeon found stone in the gallbladder, he will remove the gallstone by inserting a device through the endoscopic. Furthermore, if a narrowed bile duct such as common bile duct is diagnose, then the surgeon will open the bile duct by inserting a plastic tube to enlarge the bile duct through the endoscopic.

Endoscopic retrograde cholangiopancreatography is performed in a x-ray department. It requires minimum preparation except fasting, and a sedative will be given to the patient and the procedure will begin. This ERCP has more advantages over percutaneous transhepatic cholangiography (PTC). Unlike ERCP, pancreatic duct cannot be visualize and access by percutaneous cholangiography, but in ERCP all the biliary system is visible. Besides, ERCP also has the ability to visualize ampullary lesion, and also obtain tissue (biopsy) for further diagnosis. ERCP has also greater therapeutic potential. Moreover, PTC cannot undergoes endoscopic sphincterotomy.