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ERCP-endoscopic retrograde cholangiopancreatography, indications and reviews

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As mentioned earlier, this study can be used to identify the causes of violations of the outflow of bile, as well as to eliminate it.

For diagnostic purposes, cholangiopancreatography can be prescribed:

  • With obstructive jaundice. The cause of obstructive jaundice can be a tumor, squeezing, narrowing, or other mechanical damage to the bile ducts, through which bile normally passes from the liver to the intestines. In this case, the bilirubin pigment (which is formed in the liver and is part of bile) begins to enter the bloodstream and with it is delivered to various tissues of the body, including the skin, giving it a yellowish color. Therefore, an increase in the concentration of bilirubin in the blood and the inability to make a diagnosis using simpler studies is an indication for cholangiopancreatography. During the procedure, you can identify the level of obstruction (overlap of the lumen) biliary tract and suggest a diagnosis, as well as plan further treatment tactics or surgery (if necessary).
  • If stricture is suspected (narrowing) biliary tract. A stricture is a pathological narrowing of the lumen of the biliary tract, which can develop as a result of an acute or chronic inflammatory process in them (e.g. for injury, infection) In this case, the outflow of bile will gradually become more difficult, and in advanced cases it may completely stop, which will cause the appearance of obstructive jaundice. In this case, the implementation of cholangiopancreatography will determine the level of stricture, its severity (that is, whether the lumen of the bile ducts is completely blocked or whether bile can still pass through them) and plan further treatment.
  • If a bile duct tumor is suspected. A tumor can develop from the tissues of the biliary tract itself, growing inside their lumen and blocking it, thereby disrupting the outflow of bile. In other cases, the tumor may be located outside the biliary tract and squeeze them from the outside, which will also lead to a violation of the outflow of bile and to the development of jaundice. Cholangiopancreatography will help to identify the location of the pathological process, to determine the degree of blockage of the biliary tract (full or partial blockage) and plan further treatment.
  • With dysfunction of the sphincter of Oddi. With this pathology, the sphincter relaxation process is disrupted, as a result of which bile is not completely excreted from the bile ducts. Part of the bile stagnates in them, leading to their expansion, which can be detected by cholangiopancreatography. At the same time, other studies are required to make a diagnosis (in particular pressure measurement in the area of ​​the sphincter of Oddi and pressure in the biliary tract).
  • During preparation for surgery. If the patient has a tumor, stricture, developmental abnormality, or other pathology of the biliary tract or gallbladder requiring surgical intervention, diagnostic cholangiopancreatography can be performed before surgery. This study will allow the doctor to more accurately examine the anatomical location of the biliary tract and plan the details and scope of the operation.
  • If you suspect the presence of bile duct fistula.A fistula is a pathological hole in the wall of an organ, which normally should not be.Fistula in the bile ducts can form as a result of trauma or improperly treated inflammatory process in this area. Through the fistula, bile can be secreted into the surrounding space, leading to the development of complications. Using cholangiopancreatography, you can detect the presence of fistula (on an X-ray it will be seen that the contrast agent extends beyond the biliary tract), as well as plan her surgical treatment.
  • In chronic pancreatitis.Pancreatitis is a pancreatic disease in which the destruction of its cells occurs. Chronic pancreatitis is characterized by a paroxysmal course of the disease, during which bouts of calm (remission) are replaced by exacerbations. The cause of chronic pancreatitis can be stones, anomalies in the location or tumors of the bile duct, disrupting the outflow of pancreatic juice and, thereby, contributing to the progression of the disease and the development of exacerbations. To establish the cause of chronic pancreatitis, diagnostic cholangiopancreatography can be used.

Preparing for cholangiopancreatography

The first thing that awaits the patient before the procedure is a detailed survey during which the doctor will collect all the necessary information about the patient's condition. This will allow him to assess possible risks and take measures to prevent them.

During the interview, the doctor may ask:

  • How long has the patient started having bile secretion?
  • Has the patient previously had any gastrointestinal surgery? This is important, because after surgery in the gastrointestinal tract, adhesions or scars could form, which could complicate the procedure.
  • Does the patient have an iodine allergy? The fact is that during the study, a contrast is introduced into the bile ducts, which contains iodine. If the patient is allergic to this substance, its introduction into the body can provoke a severe allergic reaction (down to anaphylactic shock, which can kill a patient).
  • Did the patient take any medications? The doctor is interested in what kind of drugs the patient takes constantly (e.g. pressure medications, sedatives, and so on) The fact is that cholangiopancreatography is performed under general anesthesia. If the patient takes sedatives, the dose of anesthesia should be reduced.
  • Does the patient take blood thinners or clotting disorders? If the patient regularly takes such drugs (it can be aspirin, warfarin, cardiomagnyl and so on), before conducting the study, the blood coagulation system (in particular, to study the level of prothrombin, fibrinogen and platelet count) If expressed coagulation disorders are not detected, the procedure can be carried out. If any violations are detected, the intake of these drugs should be temporarily stopped (or reduce their dose), and after the study to resume.
  • Does the patient smoke?Smoking can create certain difficulties with anesthesia (pain relief) during the procedure.
Before cholangiopancreatography should be:
  • Do not eat or drink for at least 12 hours. During the procedure, an apparatus for examination will be introduced into the gastrointestinal tract of the patient. This will irritate the mucous membrane of the pharynx, which can provoke a cough or vomiting. If a patient has food or feces in the stomach or intestines, they can enter the throat during vomiting. If the patient is under the influence of anesthesia, the vomit can enter the vomit, as a result of which the patient may die.In addition, the presence of food or feces in the intestine will make it difficult to detect the duodenal papilla and conduct research. That is why before performing the procedure it is strictly forbidden to eat or drink anything.
  • Do not smoke during the day. Smoking stimulates the glands of the bronchopulmonary system, as a result of which more mucus is formed in the respiratory tract. During anesthesia, this can provoke respiratory failure or even bronchospasm (pronounced narrowing of the bronchi, disrupting the delivery of oxygen to the body), which can also lead to the death of the patient. That is why one day before the procedure, you should stop smoking or at least limit the number of cigarettes smoked.
  • Do not drink alcohol. Alcohol impairs the patient’s consciousness, which is unacceptable during the procedure. Moreover, drinking alcohol can disrupt the secretion of the pancreas and bile, which should also not be allowed before cholangiopancreatography.
  • Make a cleansing enema. During the study, the equipment is introduced into the upper intestine, where there is usually no feces. At the same time, if the patient has digestive disorders or other diseases of the gastrointestinal tract, the night before and the morning before the procedure, he should undergo an enema to clear the stool and lower intestines. This will prevent the development of complications during the study (e.g. involuntary bowel movements during anesthesia).

Types and methods of cholangiopancreatography

To date, two basic research methods have been described that differ from each other in terms of performance, information content and safety.

If necessary, the doctor may prescribe:

  • endoscopic retrograde cholangiopancreatography (ERCP),
  • magnetic resonance cholangiopancreatography.

Contraindications to cholangiopancreatography

This study is quite complex and involves certain risks, and therefore it can be prescribed not to all patients, but only to those who can withstand it without harm to health. It should be noted right away that there are much more contraindications for ERCP than for magnetic resonance cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography is contraindicated:

  • With increased sensitivity to iodine. As mentioned earlier, the contrast introduced into the biliary tract during the study contains iodine. If the patient is allergic to this substance, he is strictly forbidden to perform this procedure.
  • In acute pancreatitis (or with exacerbation of chronic pancreatitis). This pathology is characterized by the development of an acute pathological process in the pancreas, which is accompanied by the destruction of its tissue. Performing ERCP in such conditions can provoke increased progression of the pathological process and the development of complications.
  • In acute cholangitis. Acute cholangitis is an inflammation of the walls of the biliary tract. Conducting ERCP in the presence of an acute inflammatory process in the biliary tract can strengthen it, which will lead to more pronounced swelling of the tissues, impaired outflow of bile and the development of other complications.
  • With violations of the blood coagulation system. The fact is that during the procedure, the mucous membrane of the gastrointestinal tract can be injured (especially when removing stones from the biliary tract and with papillosphincterotomy) Under normal conditions, this is not dangerous, since a blood clot immediately forms in the area of ​​injury and the bleeding stops. At the same time, if the patient has bleeding disorders, even a slight injury to the mucous membrane can lead to heavy bleeding. That is why patients with such diseases should be prepared in advance in cholangiopancreatography.
  • With decompensated diseases of the cardiopulmonary system. Anesthesia and cholangiopancreatography is a certain stress for the body, accompanied by a load on the cardiovascular and pulmonary system. If the patient has severe diseases of these organs (for example, a recent heart attack, severe heart failure, or respiratory failure), he should not perform the procedure, as this may exacerbate the existing cardiopulmonary pathology, which can cause the development of serious complications (repeated heart attack, pulmonary edema, or even patient death).
  • In violation of patency of the upper gastrointestinal tract. As mentioned earlier, for the study, the doctor will have to enter the endoscope through the esophagus and stomach into the intestines of the patient. If in the area of ​​these organs there are any pathological narrowings (for example, congenital malformations, scars after illness, and so on), the endoscope will not be able to go through them, as a result of which it will be impossible to complete the procedure.
  • In acute viral hepatitis (in active phase). The essence of this pathology is that viral particles destroy liver cells. During the active phase, the processes of reproduction of viruses are most pronounced. If at the same time you try to perform ERCP, this can disrupt the outflow of bile and provoke liver damage, thereby complicating the course of hepatitis.
It is prohibited to carry out MR-cholangiopancreatography:

Is it possible to do cholangiopancreatography during pregnancy?

Endoscopic retrograde cholangiopancreatography during pregnancy is contraindicated, as this may pose a threat to the life of the mother or fetus.

The risks of ERCP during pregnancy are due to:

  • Anesthesia (anesthesia). If, under local anesthesia, the effect of the drugs used on the fetus is insignificant, sedation or general anesthesia is associated with the introduction of various medicinal substances into the woman’s body (including narcotic painkillers) These substances can penetrate the body of a developing fetus and cause various developmental abnormalities in it or even provoke its intrauterine death.
  • Introducing contrast. Although the contrast agent does not penetrate the fetus, it can cause allergic reactions of varying severity in the pregnant woman, which can also cause fetal death.
  • The volume of medical intervention. With therapeutic cholangiopancreatography, the doctor may need to perform stone removal, papillosphincterotomy, or another traumatic procedure. This will be a stressful reaction for the female body, which will lead to the activation of many compensatory and restorative systems. Under such conditions, the blood supply to the fetus may also be impaired, which will cause its damage.
  • X-ray exposure. As mentioned earlier, after the introduction of contrast into the bile ducts, a number of x-rays are taken, which gives the doctor the necessary information. For an adult, the radiation dose for an x-ray is negligible and does not harm him. At the same time, irradiation of the developing fetus (especially in the early stages of development) can cause many mutations and severe developmental abnormalities, often incompatible with life.

Side effects and complications of cholangiopancreatography

Various complications can occur both during the procedure and after it. Complications may be associated with an insufficiently complete examination of the patient, improper technique of the procedure, or with other factors.

Cholangiopancreatography may be complicated:

  • Bleeding. Clinically Significant (dangerous) bleeding may develop when performing therapeutic endoscopic retrograde cholangiopancreatography (for example, with papillosphincterotomy, removal of a large stone, and so on) In this case, a source of bleeding may be some artery of the intestinal wall, which the doctor injures during the procedure. If bleeding is detected immediately, the doctor may try to stop it right during the procedure (by introducing hemostatic agents through an endoscope onto the bleeding surface of the mucous membrane) If the bleeding cannot be stopped, surgery may be required (extremely rare) If the patient loses too much blood during the procedure, he may need a transfusion of donated blood or plasma. With MR-cholangiopancreatography, there is no risk of bleeding.
  • Damage (perforation) biliary tract or intestinal wall. The integrity of the wall of the biliary tract can be compromised as a result of damage to it by a stone that the doctor is trying to remove. Also, the cause of perforation may be careless manipulation of a doctor during papillosphincterotomy or another procedure. With a sufficiently large perforation of the biliary tract, bile will begin to flow into the surrounding space and may begin to accumulate there, which will lead to the development of complications. That is why when perforating the wall of the bile ducts, a surgical operation may be required, the purpose of which will be to restore integritysuturing) damaged tissue. Perforation of the intestinal wall is an absolute indication for surgery. With MR-cholangiopancreatography, there is no risk of perforation of the intestinal wall or biliary tract.
  • Allergic reactions. Allergic reactions can occur in response to the introduction of contrast into the body of a patient who has an increased sensitivity of the immune system to this substance. The patient may also be allergic to the local anesthetic used (local anesthetic - lidocaine, novocaine) In this case, the patient will begin to complain of a sharp deterioration, headaches and dizziness, shortness of breath (feeling of lack of air), palpitations, and so on. Clinically, there may be a pronounced and rapid drop in blood pressure, swelling of the mucous membranes and respiratory failure, which, without emergency assistance, can lead to the death of the patient. That is why when performing cholangiopancreatography, the office should always have a set of tools and drugs necessary for the provision of medical care.
  • Acute pancreatitis. This complication is manifested by the appearance or intensification of abdominal pain during the first day after the study. Pain syndrome should be combined with characteristic laboratory data (in particular, with an increase in the concentration of the enzyme A-amylase in the blood, which indicates damage to the pancreatic tissue) According to scientific studies, acute pancreatitis develops in more than 5% of patients undergoing ERCP. The treatment of this complication is carried out in a hospital, where the patient must remain for at least 2 days from the date of diagnosis. MR cholangiopancreatography does not increase the risk of acute pancreatitis.
  • Cholangitis. This term refers to an inflammatory lesion of the biliary tract that occurs within a few days after performing ERCP. The cause of the development of pathology can be traumatic damage to the mucous membrane during the procedure, as well as infection due to improper processing of the equipment or non-compliance with the rules of antimicrobial protection.
  • Infectious complications. Infectious agents can enter the mucous membrane of the gastrointestinal tract, biliary tract, pancreas, or even the liver.In this case, the patient will have symptoms of inflammatory lesions of a certain organ, accompanied by signs of general intoxication of the body (fever, weakness, headaches and so on) Treatment consists of the use of antibacterial drugs and can be performed on an outpatient basis (at home - in mild cases) or in a hospital (with the development of severe infectious complications) The risk of developing infectious complications with MR-cholangiopancreatography is minimal.

Sign up for cholangiopancreatography

To make an appointment with a doctor or diagnostics, you just need to call a single phone number
+7 495 488-20-52 in Moscow

+7 812 416-38-96 in St. Petersburg

The operator will listen to you and redirect the call to the desired clinic, or accept an order for recording to the specialist you need.

Preparation for the procedure

Before the procedure, you must refuse food and drink for 12 hours. This ensures that the stomach and upper intestines are empty. On the eve of the doctor provides a complete list of drugs that were used.

Inform in advance if there is an allergy to iodine, as well as the presence of chronic diseases of the gastrointestinal tract, heart and respiratory system.

The methodology of ERCP

One of the directions of the successful procedure is the relaxation of the duodenum. This is achieved through the introduction of drugs before the study or during the procedure. Perhaps the use of sedatives on the eve of the study.

To reduce pain, local anesthesia is also performed using an aerosol with lidocaine or the like.

At the very beginning of the study, the patient fits on his left side, placing his left hand behind his back. This allows you to start gastroscopy. After this, the endoscope advances to the duodenum. A person takes a position while lying on his stomach. Hands can be located along the body or behind the back.

An inspection of the intestine and a test introduction of a contrast medium is carried out. Then, the streaming systems are contrasted and radiographic images are made with the obligatory tracking of the evacuation of the contrast medium. As the endoscope advances, air is supplied to expand the intestines.

Contrast material is introduced through the endoscope at the exit site of bile and ducts. Contrast allows you to make the channels visible to x-rays.

If problems are found, the doctor can fix them right away. For example, with sphincterometry, the shape and plastic of the common duct are corrected. The method makes it possible to remove stones or install a stent. The latter refers to a special plastic element that acts as an expander for stenosis.

Complications after endoscopic retrograde cholangiopancreatography

The most dangerous complications are:

  • Pancreatitis This is the most popular complication. Characteristic for it is the appearance or intensification of pain in the abdomen, an increase in serum amylase by 3 or more times. In this case, observation is made in a hospital setting.
  • Bleeding. Usually appears while conducting medical manipulations. This can lead to a strong decrease in hemoglobin and the need for blood transfusion. The risk factors for the development of such a complication include the small size of the mouth of the BDS and problems with blood coagulation.
  • Perforation. Risk factors for breakthrough include preliminary dissection and instrumental introduction of contrast.
  • Purulent complications. They appear in the presence of obstruction of flow systems, for example, with cysts or stenosis.

After the procedure, less dangerous complications may occur that occur with other endoscopic research methods. These include: allergy, conjunctivitis, aspiration pneumonia.

Mortality after the study reaches 0.1-0.2%. On average, the frequency of complications occurs in 0.6-2.6% of cases.

Reviews

ERCP - the operation that is performed most often. Its success depends on two components: the qualifications of the doctor and equipment. Therefore, patients recommend that you carefully study them before the procedure.

This technique is invasive. If there are alternative ways to make a diagnosis, then preference is given to them.

According to patients' reviews, one can understand that many are recommended to rest throughout the day and it is forbidden to drink alcohol for another 24 hours. If there is a fever and chills, as well as the appearance of vomiting with blood, it is recommended to consult a doctor immediately.

The cost of the procedure depends on the qualifications of the doctor, the equipment used and the actions during the study.

The video shows the procedure for extracting stones with ERCP:

What is ERCP and what is the principle of action?

ERCP is a combined method for detecting disorders in the biliary tract and the Wirsung duct of the pancreas (pancreas). It consists of endoscopic and contrast x-ray studies, which are carried out sequentially and allow you to verify an unclear diagnosis. Refers to invasive procedures, leading to serious complications.

The principle of the study is based on the introduction of special contrast into the pancreatic ducts and bile ducts and at the same time performing x-ray images. Thus, stones, cysts, polyps and other formations that overlap the ducts, their exact location and size are detected.

In any place of the ducts, including the large duodenal papilla of the duodenum, calcine can form, blocking its lumen. This leads to severe damage to the pancreatic tissue or impaired outflow of bile and cholestasis.

The technique of ERCP is the introduction of an endoscopic apparatus with lateral optics into the lumen of the duodenum. A catheter with an existing channel is drawn through the tube of the device to deliver a contrast medium through the mouth of the Vater papilla. After contrast is entered into the ducts, X-ray equipment is taken; after studying them, an accurate diagnosis is established.

To diagnose changes in the ductal system, cholangiography, a type of MRI, is used. It is characterized by:

  • non-invasiveness
  • lack of radiation exposure to the body,
  • accuracy of images of all channels and the internal space of the gallbladder.

Special contrast agents are not introduced in this study, since you can focus on natural contrast - the bile of the patient himself, whose constant exit from the Vater papilla is visible during observation.

Indications for the appointment of a cholangiopancreatography procedure

The diagnostic procedure under consideration is technically complicated and unsafe, since its consequence may be laboratory signs of cholestasis and hepatocyte cytolysis. In this regard, antegrade cholangiopancreatography (cholecystocholangiography), in which contrast is injected directly into the bile duct, is used for strict indications, mainly for diagnosis, although in some cases it is used for treatment.

When performing ERCP, the following are detected:

  • obstruction of the Wirsung duct of the pancreas,
  • changes in small ducts,
  • stone or other formations that violate the patency of the duct,
  • pancreatic cancer.

Indications for the procedure are the clinical manifestations of the disease and the results of additional examinations of the patient, allowing to suspect the above pathology.

Statistical data indicate the following detected violations with ERCP:

  • calculi in the bile ducts (32%),
  • diverticulum of Vater papilla (15%),
  • strictures of the common bile duct (10%),
  • acute pancreatitis
  • cholecystolithiasis,
  • pancreatic cyst
  • crayfish.

In this regard, the indications of ERCP are:

  • Pancreatic diseases - benign and malignant neoplasms, cysts, stones, pancreatitis (chronic recurrent course with exacerbations more than 3 times a year), in the presence of fistulas, fistulas. In pancreatic cancer, the patient at risk is prescribed once every 2 years.
  • Pathology of the biliary tract - neoplasms of a different nature, calculi, cholangiectasias, strictures, diverticula, congenital cysts.
  • Diseases of the Vater papilla of the duodenum.
  • Obstructive jaundice with the aim of conducting a differential diagnosis, localization and nature of obstruction
  • PCES (postcholecitectomy syndrome).

    ERCP - a fairly informative method for the diagnosis of all of the above diseases. In connection with the x-ray exposure to which the patient is exposed, in the absence of contraindications MR cholangiopancreatography is used. In her case, the image is obtained using magnetic resonance imaging of the pancreas. Due to the high cost, the study is not widely used.

    The technique of conducting ERCP

    During the manipulation, the patient occupies a position lying on his left side. The jaw is fixed with a special ring - a transduodenal endoscope is inserted through it. The tube of the endoscope through the mouth, esophagus and stomach penetrates into the bulbous space. At this stage, the procedure is no different from EFGDS (esophagofibrogastroduodenoscopy - a manipulation that is performed daily in any clinic for examining the stomach and duodenum). Through a special teflon catheter through the papilla of the papilla (BDS), the antiseptic is pre-poured into the common course of the common bile duct and pancreatic duct in a solution of novocaine for anesthesia. This is necessary to carry out cannulation to a depth of approximately 1.5 cm. 30 ml of contrast is injected through the installed cannula. The whole process is controlled by the image on the screen: at the same time, X-rays of the duct system are taken, and its condition and patency are evaluated. After completion of the manipulation, solutions of antiseptics and protease inhibitors are poured into the channels.

    ERCP: what kind of study, indications and contraindications

    ERCP is a combined method for detecting disorders in the biliary tract and the Wirsung duct of the pancreas (pancreas). It consists of endoscopic and contrast x-ray studies, which are carried out sequentially and allow you to verify an unclear diagnosis. Refers to invasive procedures, leading to serious complications.

    The principle of the study is based on the introduction of special contrast into the pancreatic ducts and bile ducts and at the same time performing x-ray images. Thus, stones, cysts, polyps and other formations that overlap the ducts, their exact location and size are detected.

    In any place of the ducts, including the large duodenal papilla of the duodenum, calcine can form, blocking its lumen. This leads to severe damage to the pancreatic tissue or impaired outflow of bile and cholestasis.

    The technique of ERCP is the introduction of an endoscopic apparatus with lateral optics into the lumen of the duodenum. A catheter with an existing channel is drawn through the tube of the device to deliver a contrast medium through the mouth of the Vater papilla. After contrast is entered into the ducts, X-ray equipment is taken; after studying them, an accurate diagnosis is established.

    To diagnose changes in the ductal system, cholangiography, a type of MRI, is used. It is characterized by:

    • non-invasiveness
    • lack of radiation exposure to the body,
    • accuracy of images of all channels and the internal space of the gallbladder.

    Special contrast agents are not introduced in this study, since you can focus on natural contrast - the bile of the patient himself, whose constant exit from the Vater papilla is visible during observation.

    Do I have to go to hospital for the procedure?

    Due to the fact that the study is invasive, it can be complicated by severe pathology of the pancreas and biliary tract, the procedure for conducting ERCP is carried out in stationary conditions. The patient is hospitalized 2-3 days before the study. It's necessary:

    • for examination in order to exclude contraindications for conducting RCHP,
    • for allergy tests for tolerance of anesthetics and other drugs that are planned to be used when conducting x-ray studies.

    If the patient undergoes all the necessary preparatory examinations independently in another hospital, it is recommended not to refuse preliminary hospitalization.

    A special drug correction may be necessary a few days before the prescribed procedure. This is especially true for patients with high anxiety and labile psyche - 3-4 days before the study, they are prescribed tranquilizers, interviews and explanations about the upcoming procedure are held.

    Types of contrast

    When conducting pancreatocholangiography, iodine-containing contrast agents are used: Cholevid, Yopagnost, Telepak, Bilimin. Their introduction into the main duct of the pancreas can cause an allergic reaction of varying severity, as well as provoke the development of pancreatitis (similar complications are recorded in 1-5% of patients).

    In addition to ERCP, another method is used that has received positive feedback from many experts, which is an alternative to ERCP. This is a magnetic resonance cholangiopancreatography (MRCP).

    It is a special type of MRI, due to which a clear and detailed image of the pancreatic and hepatobiliary system is obtained, and has several advantages over computed tomography in the quality and safety of the examination.

    The technique was developed based on the use of a magnetic field; contact with harmful x-ray radiation is completely excluded. It differs in the contrast used: in tomography, gadolinium is used that does not contain iodine. This contrast does not cause allergic reactions.

    The disadvantage is the inability to detect calcifications (accumulations of calcium).

    Complications after the procedure

    When performing ERCP because of the retrograde method of introducing contrast, which comes under pressure, complications may develop. Their frequency is 0.8-36%, mortality after the manipulation - 0.15-1% of cases.

    More than half of patients after ERCP have the following complaints:

    • bloating and rumbling
    • feeling of fullness
    • heaviness in hypochondria,
    • pain.

    If this condition is accompanied by fever, vomiting, which does not bring relief, diarrhea, the cause may be the development of acute pancreatitis. Its frequency after ERCP is about 7.1%.

    Severe complications in the form of bleeding of varying severity and perforation of the duodenum are rare in diagnostic ERCP, but are characteristic for therapeutic ERCP.

    According to the statistics of multicenter studies, the most common complications after ERCP are:

    • acute pancreatitis
    • inflammation of the bile duct
    • sepsis,
    • allergic to iodine, which is part of the applied contrast,
    • perforation of duodenum and choledoch,
    • of varying severity of bleeding,
    • overdose of sedatives,
    • aspiration of the contents of the stomach.

    The frequency of complications increases significantly after treatment with ERCP, in comparison with the diagnostic procedure. Most often, acute pancreatitis and bleeding occur after endoscopic papillosphincterotomy (EPST).

    Internal bleeding

    Since the patient leaves the clinic after conducting the study after a few hours, then a black mushy stool may appear at home. This is a dangerous sign even in the absence of abdominal pain.

    This may cause internal bleeding. In this case, you must call an ambulance and take a horizontal position before the doctor arrives, eliminating any physical stress.

    Duodenal perforation

    Perforation of the duodenum occurs during papillotomy in 1% of patients. In these cases, urgent surgical intervention is not always performed - the treatment tactics are individual. According to the observations of specialists, perforation occurs when performing medical papillotomy, which is done to correct congenital anomalies of the structure.

    After detection of perforation, calculus extraction or further stenting procedures are often stopped.

    If timely adequate drainage of the bile ducts is carried out, the further spread of the infection into the retroperitoneal space is limited.

    For this purpose, nasobiliary drainage is carried out (small diameter drainages are installed - 6-8 mm) and a course of antibacterial therapy. The patient is urgently prepared for surgery to restore patency of the biliary ducts.

    Feeling unwell the day after the procedure

    During the procedure, discomfort in the throat appears. After the procedure, the throat will hurt for several days. Therefore, for a certain time it will be necessary to observe a diet - table No. 5 according to Pevzner.

    It restricts nutrition: spicy, fatty, fried, smoked is excluded, alcohol is categorically contraindicated. In addition, food should be gentle: a gruel-like consistency and a comfortable temperature for maximum sparing of the mucous membranes of the oral cavity and esophagus.

    The duration of the diet will be determined by the doctor.

    Contraindications for ERCP

    Conducting ERCP is contraindicated in the following diseases:

    • allergic to the contrast used or intolerance,
    • existing diseases of the pancreas, biliary tract or hepatitis in the active (acute) phase at the time of the planned examination,
    • esophageal stricture
    • duodenal bulb deformity,
    • diverticulum or stenosis of the large papilla of duodenum,
    • pancreatic cysts.

    In addition, the procedure is prohibited:

    • during pregnancy at any time,
    • with bronchial asthma and other severe respiratory diseases,
    • in diseases of the cardiovascular system (defects, decompensated heart failure, a history of myocardial infarction).

    It is not recommended to carry out the procedure against the background of insulin therapy or treatment with anticoagulants. ERCP is done after their cancellation, if possible, or dose adjustment of the prescribed drug.

    In the CIS countries

    In Kiev, the ERCP procedure is successfully carried out in several medical institutions, among them: the Main Military Medical Clinical Order of the Red Star Center “Main Military Clinical Hospital” (research cost - 730 hryvnias), Dobrobut “Medical and Diagnostic Center for Children and Adults”, regional clinical hospital, where they have been doing this research for many years. The average price in the capital of Ukraine is 1,500 hryvnia per service.

    In Kazakhstan, medical centers equipped with modern technology are located in Alma-Ata, among them the Medical Center “Private Clinic Almaty (Privat Clinic Almaty)”.

    How much does the procedure cost?

    The price largely depends on the clinic and the city, the qualifications of specialists, the available medical equipment and the amount of manipulations performed. The lowest is 2,900 rubles; when conducting treatment measures in parallel with the study, its cost can grow to 80,000 rubles or more.

    ERCP is one of the promising methods, thanks to which pathology can be diagnosed in one procedure and therapeutic measures can be taken to eliminate it. It is an alternative to many surgical procedures.

    Retrograde cholangiopancreatography (ERCP)

    Endoscopic retrograde cholangiopancreatography is a technique that is resorted to if necessary to confirm the disease in terms of destabilization of the bile ducts and pancreas - pancreas. Briefly, the technique is reduced to the abbreviation ERCP.

    Diagnosis is based on the involvement of radiological and endoscopic instruments. Their joint work guarantees the ability to accurately identify the current deviations in the work of these bodies.

    The method was first used back in 1968.

    Since then, technicians have significantly improved it in order to receive detailed information about possible pathologies of not only acquired, but also innate nature.

    Based on the information received, the doctor can not only confirm his guesses about the diagnosis, but also use the collected data as the basis for subsequent surgical intervention. It is not in vain that such an examination is often included in the program of compulsory preparatory measures before setting the date of the resection.

    Phased Diagnosis

    Despite the widespread use of this type of cholangiopancreatography, not all ordinary people understand what it is at least in general terms. The procedure involves the use of a special device - an endoscope. It is introduced into the duodenum, then to attach to the mouth of the large duodenal papilla.

    A probe is pulled through the endoscope channel along with a channel for transmitting a contrasting solution.

    After the substance enters the body, the expert captures the resulting visualization using X-ray equipment configured to the desired mode.

    Based on the images obtained, it is possible to figure out where the lesion is located, and also to understand how badly the neighboring tissues and organs were damaged.

    Schematically, the method is divided into several stages, allowing in the shortest possible time with minimal discomfort for the victim to control a number of digestive tract organs. Manipulation begins with monitoring of the duodenum and duodenal papilla.

    This is followed by cannulation of the papilla, along with the introduction of a contrast solution for subsequent radiography. Only after that the ducts of the studied systems are filled. Direct shooting takes place at this stage.

    The final stage involves the extraction of contrast medium from the duct, and then the prevention of possible side effects.

    The price of the procedure will fluctuate depending on the characteristics of the contrast medium, as well as the quality of the medical equipment used.

    Doctors advise you to go to clinics where there is a new generation of equipment.

    It implies devices with lateral placement of optics, which is the key to a neat and productive examination of internal organs. A convenient view facilitates the collection of information.

    Modern probes that pass through the endoscope have a special cannula, which is made of high-density material. It is easily rotated in the direction necessary for the laboratory assistant to maximize the filling of the ducts with an X-ray contrast solution. For convenience, the examination is almost always carried out in the usual radiography room in a hospital.

    Preparatory measures

    In order to obtain the most reliable result, preparation for ERCP should take place accordingly. Before sending a person to take an analysis, he is sometimes given a shot with a sedative injection if the victim is seriously worried.

    The procedure itself is quite complicated in terms of execution on the technical side, which leads to pain during its execution.Because of this, some experts insist that the intended patient be given a sedative injection on the eve of the day of admission.

    You should also make sure that the study is conducted only on an empty stomach. Because of this, most clinics prescribe such specific testing exclusively for the first half of the day. In addition to the ban on food intake, an identical restriction on drinking applies before the start of the inspection.

    About half an hour before the appointed time, some drugs are injected intramuscularly into the victim. They are designed to work as relaxing agents that will have a beneficial effect on the state of the duodenum. Without such a preliminary step, it is unlikely to be able to carry out the manipulation without hindrance.

    Only before introducing substances unfamiliar to the human body, it will be necessary to conduct a control test for a possible occurrence of an allergic reaction. Only a scrupulous approach to the implementation of all preparatory prescriptions will allow us to mitigate the risks of anaphylactic shock with possible individual intolerance to the drugs.

    Sometimes it happens that standard pharmacological agents do not work properly, and intestinal motility remains in its original form. Then you will have to postpone the date of manipulation, using the next time medications aimed at suppressing the motor function of the intestine.

    Main indications

    All thematic medical books present identical reasons for cholangiopancreatography, despite the fact that this is an invasive format for studying the health of certain organs. Due to the complexity of execution and pain in some cases, testing is prescribed only according to medical recommendations, but not as a preventive measure.

    The underlying symptomatology, contributing to the issuance of a referral to such an analysis, covers:

    • pain in the abdomen,
    • violation of patency of the bile ducts,
    • stones in the ducts
    • neoplasms of a malignant or benign nature.

    All of the above should be confirmed either by the corresponding complaints of the patient, or by the results of other laboratory, clinical trials.

    Against the background of the above, indications for invasive diagnostics are as follows:

    • obstructive jaundice
    • tumors
    • chronic course of pancreatitis with a regular transition to the stage of exacerbation,
    • pancreatic fistula
    • preparation for surgery.

    One of the most common primary sources of problems is the formation of stricture of the common bile duct, which involves the narrowing of the duodenal papilla, or choledocholithiasis.

    The latter option is typical of scenarios when gallstone disease develops rapidly and has a whole bunch of complications of varying severity.

    In some people, stones completely get stuck in the bile ducts, which provokes a complete or partial blockage of the outflow of bile.

    A similar anomaly is manifested by painful sensations in the right hypochondrium. Sometimes the pain gives even in:

    • right hand
    • lumbar area
    • scapular region
    • subscapular part.

    If computed tomography with a contrasting phase or ultrasound diagnostics could not provide detailed imaging in cases of suspected neoplasms, then ERCP cannot be dispensed with. The method is involved as a final argument.

    Absolute contraindications

    Due to the fact that the technique is ranked as invasive, by default it has a larger list of possible contraindications. Some of them are absolute. In practice, this means that the ban is considered complete.

    In this situation, experts recommend using other techniques for a thorough examination, which will be safer.

    Among them, ultrasound is distinguished, which is confirmed by numerous reviews of patients who have already passed the test.

    The most important absolute contraindication of a general type is the condition of the body when an endoscopic intervention cannot be performed on a person.

    This may be a serious condition of the victim due to polytrauma, or permanent injury.

    This also includes mental disorders that prompt a person to commit uncontrolled actions. Such a deviation almost always guarantees significant damage to the organs of the digestive tract.

    For an identical reason, people with uncontrolled convulsive syndrome, which is characteristic of epileptic seizures, are not allowed to receive.

    All of the above are prominent representatives of the absolute prohibitions, as well as intolerance to certain drugs.

    They are used at the preparation stage and are sometimes replaced by similar ones, but since the active substance still remains the same, this does not solve the root of the problem. This implies a logical rejection of the study.

    Separately considered are situations when the patient has already been diagnosed with:

    • acute pancreatitis,
    • chronic pancreatitis.

    The risks of accidentally damaging healthy tissue are too high to take such dangerous diagnostic measures.

    Another group of contraindications are relative prohibitions. They provide for the possibility of ignoring them if the benefits of the analysis exceed the potential harm. Each individual case here is examined by an individual attending physician, since the percentage of complications still remains high.

    Relative contraindications include the following conditions:

    • pregnancy and lactation,
    • diseases of the cardiovascular system,
    • diabetes mellitus with insulin,
    • the use of anticoagulants like the popular aspirin with its derivatives.

    The last two cases are quite easily correctable. The doctor will simply review the current approved treatment program for the ward. Reducing the usual dosage to the maximum permissible, you will get a pass to the procedure.

    In exceptional cases, anticoagulants are even canceled within a few days for the sake of a clean experiment. But to independently risk in this way without first consulting with a treating gastroenterologist is strictly prohibited.

    Serious and not very complications

    According to medical standards, endoscopic retrograde cholangiopancreatography is a non-hazardous type of medical examination, if you clearly follow the algorithm for its appointment. But even she carries with it some side effects.

    We have to prepare for the fact that after the completion of the manipulation, the patient may encounter an intestinal infection. The attending physician will help to cope with its manifestations by prescribing appropriate medications to endow well-being.

    No less often, victims face bowel perforation and bleeding. All this is not always the fault of the diagnostician, but the choice of an experienced specialist significantly reduces the likelihood of getting into the sad statistics of people with complications.

    Another option to avoid side effects is the correct behavior immediately after the examination. You should not go against the system, leaving home immediately after ERCP, even if everything seems to be fine. The next two to three hours should be spent under the strict supervision of medical personnel in a hospital unit.

    Often, victims additionally complain of discomfort in the throat after insertion of the probe. To reduce the negative effects, experienced people recommend purchasing a few softening throat lozenges at the pharmacy in advance.

    You should also carefully monitor the change in health over the next 24 hours. At the slightest deterioration, you must immediately let the doctor on duty know. Especially dangerous manifestations are called chills with cough. No less threatening signs of deviations are nausea, followed by vomiting, as well as severe pain in the sternum and abdomen.

    The aforementioned almost always indicates that during the diagnosis the laboratory technician admitted damage to adjacent tissues. Their healing will require a long and proper rehabilitation under the supervision of medical staff.

    In what cases is the procedure indicated

    Endoscopic retrograde pancreatocholangiography is prescribed by the attending physician if the patient has the following indications:

    1. Suspected duct obstruction. Causes of obstruction of the ducts can occur through obstruction of the canals or with the development of chronic gastrointestinal diseases.
    2. Chronic pancreatitis.
    3. Unclear causes of jaundice.
    4. The presence of a tumor or suspected neoplasm.
    5. Suspected duct damage after surgery.

    An endoscopic examination procedure is also prescribed to diagnose other types of diseases of the digestive system.

    Before the doctor prescribes the study, he will need to examine the patient, interview, check for the presence of relevant symptoms and get acquainted with the medical history.

    The procedure of ERCP is prescribed not only to identify diseases, but also in order to verify the effectiveness of the treatment and the absence of other pathologies in the digestive system.

    The essence of the method

    For the first time, ERCP for diagnosis was carried out in 1968. Since then, this technique has been greatly improved and, thanks to the introduction of many technical innovations in medicine, has become even more informative and safe.

    Now for its implementation and obtaining high-quality images are used:

    • various endoscopes,
    • a set of catheters, including a special cannula of dense material for introducing contrast,
    • X-ray television installation,
    • contrast drugs.

    Typically, endoscopic devices with a lateral optical system are used for ERCP, and equipment with beveled or end optics is used to examine patients after removal of the stomach.

    Modern x-ray equipment allows you to monitor the process of performing the study at all its stages, creates a minimum radiation load on the patient and makes it possible to obtain high-precision and high-quality cholangiopancreatograms. In addition, various radiopaque preparations can now be used to perform ERCP;

    • Urografin,
    • Verografin,
    • Triombrast
    • Angiographin and others.

    The study involves the introduction of an endoscope into the lumen of the duodenum. Subsequently, a catheter with a channel for supplying contrast to the bile duct and pancreatic ducts is passed through the tube of the device. After receiving these drugs, the doctor takes a series of shots.

    In conducting ERCP there are the following main stages:

    • examination of the duodenum and duodenal papilla,
    • insertion of the catheter cannula into the papilla and the entry of a contrast agent into it,
    • filling with contrast medium of the studied areas,
    • taking pictures
    • preventive measures to prevent complications.

    ERCP is performed in a specially equipped X-ray room in a hospital.

    Examination and psychological training

    When prescribing ERCP, the doctor explains to the patient the essence of the procedure and receives written informed consent from him to conduct the study. To exclude all possible contraindications, the patient is hospitalized and undergoes a comprehensive examination:

    If necessary, the doctor can expand the examination plan.

    Equally important for the proper preparation of the patient is his psychological readiness for the procedure. The doctor must explain to the patient the diagnostic value of this examination, familiarize him with the principles of the procedure and anesthetization of the procedure. In the presence of severe excitement, the patient is prescribed sedatives several days before the study.

    The patient must inform the doctor about all the medications he takes and allergic reactions to the drugs. If necessary, the doctor may recommend refusing to take certain medications or adjust their dose.

    On the day of the study

    1. On the morning of the day of ERCP, the patient should not drink water and eat food.
    2. The patient is administered a sedative intramuscularly.
    3. 30 minutes before the procedure, the patient is injected intramuscularly with the necessary drugs (premedication): Atropine, Metacin and No-spa (or Platifillin), Promedol, Diphenhydramine. They are used to reduce salivation, analgesia and relaxation of the duodenum. If these funds did not contribute to the cessation of intestinal motility, then the introduction of benzoghexonium or Buscopan.
    4. To prepare the oropharynx for the introduction of the endoscope, local anesthetics (Lidocaine, Dikain) are used in the form of an aerosol. A solution of these drugs can be taken in small sips inside.

    How is the study

    After the appearance of numbness in the oropharynx, the patient is taken to the office to perform ERCP. The procedure is carried out in the following sequence:

    1. The patient is laid on his back.
    2. A mouthpiece is inserted into the oral cavity.
    3. The patient is asked to inhale or perform a swallowing movement and an endoscope is inserted into the esophagus. The doctor carefully advances it to the duodenum and examines it.
    4. After that, the doctor brings the endoscope to the ampoule of the large duodenal papilla (or Vater papilla - the junction of the common bile duct and pancreatic duct) that opens into the lumen of the duodenum and examines it.
    5. To perform the cannulation of the Vater papilla, a special catheter is inserted into the endoscope, which will allow the introduction of an X-ray contrast medium into the system of bile and pancreatic ducts.
    6. After cannulation, which is performed under the control of an X-ray television screen, the doctor calculates the dose of the contrast agent needed for the examination and introduces it into the catheter.
    7. After some time, the bile ducts and pancreatic ducts are filled with contrast, and the specialist performs a series of x-rays.
    8. If stones or constrictions are detected, the doctor performs the necessary surgical procedures using the instruments introduced into the lumen of the endoscope. If necessary, a biopsy of suspicious tissue sites is performed.
    9. After completing the procedure, the patient is under the supervision of a specialist for some time to exclude possible complications of the procedure (perforations or bleeding).
    10. With the exception of complications, the endoscope is removed, and the patient is transported to the ward.

    After the completion of the ERCP procedure, the doctor of endoscopic diagnosis draws up a conclusion, which describes in detail all the identified changes and the performed medical manipulations. The results of the examination are sent to the attending physician.

    The duration of diagnostic ERCP can be about an hour. When supplementing the study with medical manipulations, the procedure, depending on the severity of the pathology, can take up to 2 hours and requires repeated administration of painkillers and sedatives.

    After the procedure

    In the first days after performing ERCP, the patient may have the following symptoms:

    • a sore throat,
    • heaviness in the stomach
    • flatulence,
    • dark feces (if neoplasm removal was performed).

    All these manifestations are not signs of complications and are eliminated on their own in a few days.

    The doctor should be informed about the appearance of the following dangerous symptoms:

    • stomach ache,
    • temperature rise,
    • nausea and vomiting,
    • dark color of feces.

    They can disturb the patient for 2-3 days and are signs of ERCP complications.

    Pancreatitis

    One of the most common complications of ERCP is pancreatitis. According to statistics, it develops in 1.3-5.4% of patients and can be triggered by a number of factors that accompany such a study.

    The presence of this disease in the patient’s history, prolonged and complex cannulation of the Vater papilla, sphincterotomy, the need for reintroduction of contrast into the ducts, etc. can contribute to the development of pancreatitis after ERCP.

    Bleeding

    In more rare cases, ERCP is complicated by clinically significant bleeding. The frequency of such an undesirable consequence of the study is 0.76-1.13%.

    Bleeding more often appears after completing additional surgical procedures. Predisposing factors for its occurrence may become pathologies of the blood coagulation system and the small size of the mouth of the large duodenal papilla.

    Features of preparation for the procedure

    As we have said above, an ERCP is only possible in a hospital setting. Before performing an endoscopic intervention, a sedative injection should be made, which will relieve the patient's tension and nervousness.

    Since the procedure is quite complex and sometimes painful, such an injection becomes a necessary requirement in preparation for ERCP.

    In some cases, the introduction of sedatives is possible not only on the day of the procedure, but also on the eve, if there is increased nervous irritability of the patient.

    Before the procedure, the patient should not eat food and drink water - ERCP is carried out exclusively on an empty stomach.

    Half an hour before the start of the retrograde cholangiopancreatography procedure, intramuscularly injected solutions of atropine sulfate, platifillin or metacin in combination with solutions of diphenhydramine and promedol.

    This will help to achieve maximum relaxation of the duodenum and allow unhindered ERCP procedure.

    However, at the same time, morphine and morphine-containing preparations are categorically not recommended as painkillers, since they can cause a reduction in the Oddi sphincter. If, despite the introduction of the aforementioned solutions, intestinal motility remains, then before retrograde cholangiopancreatographs, it is recommended to administer drugs that suppress the intestinal motor function. The most common of them are buscopan and benzohexonium.

    What is it and what is the principle of action?

    ERCP is a special examination technique that is used for diseases of the bile ducts and pancreas. It includes the use of X-ray and endoscopic instruments, a combination of which allows you to most accurately identify the current state of the examined organs. This survey method was first applied in 1968. To date, taking into account the development of medicine, it has been significantly improved. ERCP allows you to diagnose with high reliability, identify the picture of the disease and implement therapeutic measures.

    Endoscopic retrograde cholangiopancreatography is carried out by introducing an endoscope into the duodenum, where it is attached to the mouth of the large duodenal papilla, a probe with a special channel for supplying a contrast medium is drawn through the endoscope channel. After this substance enters the body through the channel, the specialist takes pictures of the studied area using x-ray equipment. Based on the obtained images, a particular disease is diagnosed. Conducting ERCP can be divided into the following stages:

    1. Checking the duodenum and duodenal papilla
    2. Cannulation of the papilla and the introduction of contrast medium for subsequent x-ray,
    3. Filling the ducts of the studied systems,
    4. X-ray imaging,
    5. Extraction of contrast medium from the ducts,
    6. Prevention of unwanted effects.

    To perform an ERCP, a device with lateral placement of optics is needed - this configuration allows the examination of internal organs in the most convenient perspective. The probe, which is passed through the endoscope, has a special cannula made of a dense substance, which rotates in a certain direction for the most complete filling of the ducts with an radiopaque substance. As a rule, endoscopic retrograde cholangiopancreatography is performed in an X-ray room in a hospital.

    The main contraindications and complications

    Since the ERCP method is associated primarily with invasive intervention, there are a number of limitations and features of its application. In this case, the main contraindication can be considered any state of the body in which endoscopic intervention is not allowed.

    In addition, if a patient has intolerance to drugs that are introduced into the body during the preparation and conduct of ERCP, then diagnosis by this method will be impossible.

    One of the contraindications is acute pancreatitis or exacerbation of chronic pancreatitis.

    If the above diseases can be attributed to strict contraindications, the following conditions of the body impose certain restrictions, but do not preclude the possibility of such a diagnosis:

    1. Pregnancy,
    2. Diseases of the cardiovascular system,
    3. Diabetes and insulin
    4. Reception of anticoagulants (the most common types include aspirin).

    In the last two conditions, doctors recommend adjusting the dose of the drug or changing it to similar medicinal substances that do not interfere with ERCP.

    In general, the ERCP procedure does not belong to life-threatening medical examinations, however, complications of various genesis may occur after it. The most common complications are intestinal infection, intestinal perforation, and bleeding.

    However, qualified medical professionals argue that it is likely to minimize possible complications if preventative measures are taken. First of all, after the diagnosis is completed, the patient should spend several hours in the hospital under the strict supervision of doctors. Unpleasant sensations in the larynx after insertion of the probe can be minimized thanks to lozenges for the throat. The patient's condition should remain stable for 24 hours after completion of the diagnosis. If symptoms such as chills, cough, nausea and vomiting, severe pain in the abdomen and chest are observed, then it is urgent to inform the doctor about them. The presence of such symptoms, as a rule, indicates errors made during the diagnosis.

    Thus, competent and skillful conduct of ERCP will allow you to obtain reliable information about the patient’s body condition without harm to health and other undesirable consequences.

    How to prepare for the study

    The pancreatocholangiography procedure is performed exclusively on an empty stomach. It is forbidden to eat 12 hours before the study. Food accumulates in the stomach, which leads to a deterioration of the study. In addition, if there is food in the stomach, then when the probe is swallowed, gag reflexes will develop, which will lead to the removal of product residues to the outside.

    On the eve of the study, it is forbidden to eat heavy food for 2-3 days, and go exclusively to light. It is necessary to give preference to liquid types of food: broths, kefir, yoghurts, milk porridges.

    It is not recommended to eat fresh fruits and vegetables, as they are enriched in fiber, which is digested for a long time. On the evening before the study, you can eat no later than 18.00 hours.

    The study of cholangiopancreatography is carried out directly in the hospital, for which an office with the necessary equipment should be specially equipped. If the patient comes to the procedure unprepared, then the doctor may cancel the study.

    It's important to know! It is quite dangerous to carry out an endoscopic procedure without preliminary preparation, as this can provoke damage to internal organs.

    On the eve of the study, the doctor warns the patient about possible complications and the dangers of the procedure. The patient is also required written consent to conduct this type of study.

    Before proceeding with the procedure, it is necessary to achieve relaxation of the duodenum.

    If intestinal motility will persist, then it will simply not be possible to penetrate the necessary area for the examination.

    It's important to know! To avoid unforeseen consequences during the study, the doctor may require the patient to take some tests.

    What is the research method using an endoscope and x-ray, we find out further.

    ERCP is a rather complex invasive procedure and is prescribed only for strictly defined indications.

    As a rule, such a study is carried out if there is a suspicion of impaired bile and pancreatic ducts due to blockage of their lumen by a stone or tumor formations.

    Indications for such a procedure are always determined by all the data of the clinical picture of the disease and by conducting an additional comprehensive examination of the patient.

    Erhpg (endoscopic retrograde cholangiopancreatography)

    Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most modern and effective methods of medical diagnosis, which allows you to make an accurate diagnosis and prescribe effective drug therapy and procedures for the patient. Below we will consider the main characteristics of this diagnostic method, indications for its implementation and other features faced by doctors and patients.

    Indications and contraindications for ERCP

    Conditions in which ERCP is necessary can be represented as follows:

    • suspected presence of stones in the bile ducts,
    • suspected stenosis or stricture of the biliary tract or duct of the pancreas,
    • congenital malformations of the ducts,
    • suspected neoplasm of the pancreas and bile ducts,
    • determination of the causes of postcholecystectomy syndrome (deviations that appeared after removal of stones from the biliary tract),
    • jaundice arising for unclear reasons.

    Despite the high information content, painlessness and minimally invasiveness of the method, ERCP should be replaced by alternative methods if the patient does not tolerate a contrast medium (usually containing iodine), if at the time of the study the patient has a clinic of acute pancreatitis or cholecystitis. Complications after ERCP are also possible, although they develop very rarely. This is anaphylactic shock (with iodine intolerance), sepsis, the development of acute cholecystitis or pancreatitis, bleeding, perforation of the walls of internal organs.

    Preparation and conduct of ERCP

    ERCP does not require the use of anesthesia. Before the study, the specialist treats the patient's throat with anesthetic gel. Promoting the endoscope through the esophagus, stomach and intestines, the doctor constantly maintains contact with the patient and asks about well-being.

    If ERCP is prescribed as a treatment method, then, depending on the established pathology, the following actions are performed:

    • sphincterotomy (correction of the shape, or plastic, of the common duct in order to improve its patency),
    • removal of stones from the biliary tract,
    • installation of a stent (a special plastic dilator of ducts with their stenosis or stricture).

    After ERCP, the patient is in the ward under the supervision of doctors for 1-2 hours, during this time the feeling of discomfort in the throat and esophagus should disappear.

    It is very advisable to get home not alone, but with an attendant. In addition, one of the closest people should look after the patient for the first day after ERCP.

    Also, in the first day you should not drive a car and work with any mechanisms.

    ERCP is a very effective and promising method that allows not only diagnosing a pathology in one procedure, but also taking measures to eliminate it. This is a worthy replacement for many methods of surgical intervention.

    ERCP: indications for the procedure, patient preparation, methodology, complications, price, reviews

    Endoscopic retrograde cholangiopancreatography is one of the most effective diagnostic methods, which is aimed at examining the bile ducts and pancreas. The technique combines the use of radiological and endoscopic instruments. The technique was first used in 1968.

    Today, thanks to the use of high-tech equipment, it is possible to make an accurate diagnosis with a high degree of reliability and prescribe treatment in a timely manner.

    With the passage of the endoscope through the esophagus, stomach and intestines, the technique makes it possible to additionally establish the presence of pathologies of these organs. Often the result is the identification of fistulas, neoplasms and ulcerative lesions.

    IN WHICH CASES A PROCEDURE IS SHOWN

    Endoscopic retrograde pancreatocholangiography is prescribed by the attending physician if the patient has the following indications:

    1. Suspected duct obstruction. Causes of obstruction of the ducts can occur through obstruction of the canals or with the development of chronic gastrointestinal diseases.
    2. Chronic pancreatitis.
    3. Unclear causes of jaundice.
    4. The presence of a tumor or suspected neoplasm.
    5. Suspected duct damage after surgery.

    An endoscopic examination procedure is also prescribed to diagnose other types of diseases of the digestive system. Before the doctor prescribes the study, he will need to examine the patient, interview, check for the presence of relevant symptoms and get acquainted with the medical history. The procedure of ERCP is prescribed not only to identify diseases, but also in order to verify the effectiveness of the treatment and the absence of other pathologies in the digestive system.

    HOW TO PREPARE FOR RESEARCH

    The pancreatocholangiography procedure is performed exclusively on an empty stomach. It is forbidden to eat 12 hours before the study. Food accumulates in the stomach, which leads to a deterioration of the study. In addition, if there is food in the stomach, then when the probe is swallowed, gag reflexes will develop, which will lead to the removal of product residues to the outside.

    On the eve of the study, it is forbidden to eat heavy food for 2-3 days, and go exclusively to light. It is necessary to give preference to liquid types of food: broths, kefir, yoghurts, milk porridges. It is not recommended to eat fresh fruits and vegetables, as they are enriched in fiber, which is digested for a long time. On the evening before the study, you can eat no later than 18.00 hours. Do not eat or drink in the morning.

    The study of cholangiopancreatography is carried out directly in the hospital, for which an office with the necessary equipment should be specially equipped. If the patient comes to the procedure unprepared, then the doctor may cancel the study.

    It's important to know! It is quite dangerous to carry out an endoscopic procedure without preliminary preparation, as this can provoke damage to internal organs.

    On the eve of the study, the doctor warns the patient about possible complications and the dangers of the procedure. The patient is also required written consent to conduct this type of study. Before proceeding with the procedure, it is necessary to achieve relaxation of the duodenum. If intestinal motility will persist, then it will simply not be possible to penetrate the necessary area for the examination.

    It's important to know! To avoid unforeseen consequences during the study, the doctor may require the patient to take some tests.

    What is the research method using an endoscope and x-ray, we find out further.

    ADVANTAGES AND DISADVANTAGES OF THE METHOD

    Retrograde pancreatocholangiography has one significant advantage - the ability to obtain the maximum amount of information about the condition of the ducts. Using this technique, you can diagnose the presence of diseases. Using this method, a specialist can determine the most difficult places, narrowings and stones in the ducts with maximum accuracy.

    Another advantage of the technique can be called the possibility of surgical intervention in the shortest possible time. Using special equipment, the doctor can carry out the procedure for removing stones, releasing the ducts from bile and even install stands in order to eliminate the cause of obstruction. After the procedure, the patient returns to a full life in the shortest possible time.

    This technique also has a significant drawback - the possible risks of complications after the study. If complications arise during the diagnosis or surgical intervention, this will lead to the need for a second intervention. To avoid the development of complications, the patient must be prepared for the study, and the procedure should be carried out exclusively by an experienced and qualified specialist.
    In conclusion, it is worth noting that the cost of this method is from 10,000 rubles. Patients who are shown this technique must definitely undergo a study to avoid the development of unforeseen complications.

    Complications of RCP

    This is the most common complication of HRPG - 1.3% −1.8% 8, 9 and up to 5.4% in the endoscopic PST group. The Pancreatitis Association developed by the American Association of Digestive Endoscopy Pancreatitis, which developed as a result of RCH, provides the following definition of “the appearance or intensification of abdominal pain and an increase in serum amylase 3 or more times higher than normal within 24 after performing RCP and requiring at least least 2-day hospitalization. ” A prospective multicenter study performed by Freeman et al. Showed that an independent risk factor for the development of this complication is a history of pancreatitis after RCP, balloon dilatation of the sphincter of Oddi, complex and prolonged cannulation, pancreatic sphincterotomy, more than a single administration of contrast in pancreatitis on dysfunction of the sphincter of Oddi, female gender, normal bilirubin level and the absence of chronic pancreatitis. Two other published studies offer a shorter list of risk factors for pancreatitis: age younger than 60 years, preliminary sphincterotomy and left bile duct stones and age younger than 70 years, the absence of dilatation of the biliary tract and the introduction of contrast into the pancreatic duct. Siegel, in turn, reports that preliminary sphincterotomy, on the contrary, is associated with a lower risk of developing pancreatitis than the standard method of PST. According to our data (by someone else), the risk factors for pancreatitis are female, young age, multiple cannulation (with or without contrast) of the pancreatic duct, and the absence of bile duct dilatation. As for the preliminary PST, we (who.) try not to perform it in people with the above risk factors and the absence of biliary hypertension.

    Preventive measures. Several methods have been proposed to reduce the incidence of pancreatitis after RCP. Technical tips: avoid repeated cannulation of the pancreatic duct with or without contrast, use a mixed current with a predominance of cutting when performing PST, when conducting a preliminary PST, dissect “through the roof” and not from the mouth of the BDS, use pharmacotherapy. A recently published study on the use of somatostatin in performing HRPG has demonstrated its effectiveness in reducing the likelihood of developing pancreatitis. In this work, somatostatin was used either as a continuous 12-hour infusion (3 mg of somatostatin per 500 ml of physiological saline), starting 30 minutes before RCP, or as a bolus intravenous injection at the time of BDS cannulation (3 mg per kilogram of weight). The percentage of development of pancreatitis in both groups was 1.7%, while in the placebo group it reached 9.8%. The work of Chinese scientists published in the Gut magazine on the use of somatostatin in therapeutic RCPH, showed a decrease in the risk of developing pancreatitis with its bolus administration (250 mg). Although another multicenter randomized trial did not show the advantage of somatostatin and gabexate (a proteolytic activity inhibitor) over placebo in the prevention of pancreatitis. In our practice, we administer somatostatin to prevent the development of pancreatitis (250 mg bolus intravenously) only in patients with risk factors for its development. The somatostatin analog octreotide causes a spasm of the sphincter of Oddi and should not be used.

    Bleeding Clinically significant bleeding develops, as a rule, after therapeutic manipulations on BDS, for example papillosphincterotomy. The total frequency of this complication varies from 1.13-0.76% 8, 9 reaching 2% in the PST group. Clinically significant may be considered bleeding with a drop in hemoglobin of at least 2 mg / deciliter or leading to the need for blood transfusion. The source of bleeding is most often a branch of the gastroduodenal artery. The risk factor for this complication is the small size of the mouth of the BDS and the violation of blood coagulation 3, 8. Bleeding at the beginning of the PST should not prevent its completion and extraction of calculi (if necessary), since tissue contraction in the incision area and edema resulting from manipulation of the nipple , lead to compression of the vessel and stop bleeding. If it continues, you can chop the source with a 1: 1000 adrenaline solution.

    Perforation The frequency of occurrence is 0.57-0.58% 8, 9 and 0.3% - 1.0% 3, 11 in the PST group and up to 4% during preliminary PST. Risk factors - preliminary dissection, intramural administration of contrast and the state after resection by Billroth-II. It is classified as perforation by a conductor, preampular perforation and duodenal (remote from the nipple) perforation. The first and sometimes the second type of perforation can be successfully treated by active aspiration in combination with broad-spectrum antibiotics, the third type is most often diagnosed late and requires surgical treatment. .

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