跳转到内容

内镜逆行胰胆管造影

维基百科,自由的百科全书
内镜逆行胰胆管造影
括约肌切开术后从胆总管中提取的两种色素结石的十二指肠镜图像
別稱ERCP
ICD-9-CM51.10
MeSHD002760
OPS-301英语OPS-3011-642

内窥镜逆行胰胆管造影英語:Endoscopic retrograde cholangiopancreatographyERCP)是一种结合使用内镜检查X线透视检查来诊断和治疗胆管胰管系统某些问题的技术。[1][2]主要由训练有素且受过专业培训的胃肠病学家执行。[2]通过内窥镜,医生可以看到十二指肠的内部,并将造影剂注入胆管和胰腺的导管,以便在X光片上显示。[2]

ERCP主要用于诊断和治疗胆管和主胰管的疾病,包括胆结石、炎症性狭窄(瘢痕)、渗漏(来自创伤和手术)和癌症。[3]ERCP 可以出于诊断和治疗的原因进行,尽管更安全和相对无创的检查(例如磁共振胰胆管成像(MRCP)和超音波内視镜)的发展意味着现在很少在没有治疗目的的情况下进行ERCP。[4]

医疗用途

诊断

ERCP时所见胆总管结石的透视图像。结石嵌在远端胆总管中。已插入鼻胆管。
透视图像显示ERCP检查期间胰管扩张。内窥镜可见。

以下是ERCP的适应症,特别是当侵入性较小的选择不充分或不明确时:

治疗

当需要以下任何一项时,可以在上述诊断场景中指示ERCP:

禁忌症

  • 急性胰腺炎(除胆红素持续升高或升高提示持续梗阻)[8]
  • 如果计划进行括约肌切开术,则会出现(不可逆的)凝血障碍
  • 近期心肌梗塞或肺栓塞
  • 严重心肺疾病或其他严重疾病

对碘对比剂过敏或碘对比染剂过敏史不是ERCP的禁忌症,但应与您的医疗保健提供者讨论,并应告知您对碘过敏,然后将另一种无碘对比材料(“染剂”)轻轻注入导管(胰腺或胆道)并拍摄X光片。[9]

程序

对病人进行镇静或麻醉。然后将内窥镜通过嘴插入食道,进入胃,通过幽门进入十二指肠,到达法特壶腹。Oddi括约肌是一个肌肉瓣膜,控制着壶腹的开口。该区域可以在执行各种程序时使用内窥镜相机直接可视化。通过壶腹插入塑料导管或套管,并将放射性造影剂注入胆管和胰管。透视检查用于寻找阻塞或其他病变,如结石。[10]

需要时,可用括约肌切刀切开来扩大壶腹和胆管的括约肌,以便去除胆结石或进行其他治疗。[11]

与ERCP相关的其他程序包括用篮或球囊拖曳胆总管以去除胆结石,以及插入塑料支架以帮助引流胆汁。[12]此外,还可以对胰管进行插管并插入支架。

在胰腺炎的情况下,胰管需要可视化。超声通常是入院时进行的第一项检查;虽然它对胰腺炎或其并发症的诊断价值不大。对比增强计算机断层扫描(MD-CECT)是最常用的成像技术。 然而,磁共振成像(MRI)提供类似于CT的诊断能力,并具有额外的内在优势,包括缺乏电离辐射和精细的软组织表征。[13]

在特定情况下,其他专用或辅助内窥镜可用于ERCP。 这些包括母婴和SpyGlass胆管镜(通过直接可视化导管而不是仅获得 X 射线图像来帮助诊断[14][15])以及球囊肠镜(例如,在以前接受过胰十二指肠切除术或鲁氏Y型吻合术解剖的消化系统手术的患者中)。

风险

经内镜逆行胰胆管造影术(ERCP)后最常见和最危险的并发症之一是ERCP术后胰腺炎(PEP)。在以前的研究中,PEP的发生率估计为3.5%至5%。[16][17]根据Cotton等人的说法,PEP被定义为“在需要入院或延长计划入院时间的手术后超过24小时,淀粉酶至少达到正常上限三倍的临床胰腺炎”。PEP严重程度的分级主要基于住院时间。[18]

发展PEP的风险因素包括与ERCP程序相关的技术问题和患者特定的技术问题。技术因素包括胰管的操作和造影剂注入、持续超过5分钟的插管尝试以及胆道球囊括约肌扩张;与患者相关的因素包括女性、年龄较小和Oddi括约肌功能障碍。[19]对临床试验的系统评价得出结论,既往有PEP或胰腺炎病史显着增加PEP的风险分别为17.8%和5.5%。[20][21]

肠穿孔是任何肠胃内窥镜手术的风险,如果进行括约肌切开术,则是额外的风险。由于十二指肠的第二部分在解剖学上位于腹膜后间隙(即在腹部的腹膜结构后面),因此括约肌切开术导致的穿孔位于腹膜后。括约肌切开术也与出血风险有关。[22][23]ERCP可能会导致易碎的肺门肿瘤创伤或导丝穿透胆管壁引起胆道出血,从而形成胆瘘。延迟出血是括约肌切开术的一种罕见但潜在的严重并发症,尤其是许多患者在ERCP后数小时内出院回家。

对于对含碘化合物过敏的患者,碘对比剂也存在相关风险,即使您在医院期间发生过敏反应,也可能非常严重。[24][25]

参见

参考文献

  1. ^ Ercp: what is it, symptoms and treatment. Top Doctors. [2022-07-02]. (原始内容存档于2022-07-09) (英国英语). 
  2. ^ 2.0 2.1 2.2 Endoscopic Retrograde Cholangio-Pancreatography (ERCP). inSite Digestive Health Care. [2022-07-02]. (原始内容存档于2022-07-02) (美国英语). 
  3. ^ Adler, Douglas G.; Baron, Todd H.; Davila, Raquel E.; Egan, James; Hirota, William K.; Leighton, Jonathan A.; Qureshi, Waqar; Rajan, Elizabeth; Zuckerman, Marc J.; Fanelli, Robert; Wheeler-Harbaugh, Jo. ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas. Gastrointestinal Endoscopy. 2005-07, 62 (1). ISSN 0016-5107. PMID 15990812. doi:10.1016/j.gie.2005.04.015. 
  4. ^ Tharian, Benjamin; George, Nayana Elizabeth; Tham, Tony Chiew Keong. What is the current role of endoscopy in primary sclerosing cholangitis?. World Journal of Gastrointestinal Endoscopy. 2015-08-10, 7 (10) [2022-07-02]. ISSN 1948-5190. PMC 4530326可免费查阅. PMID 26265986. doi:10.4253/wjge.v7.i10.920. (原始内容存档于2022-07-04). 
  5. ^ Tabibian, James H.; Visrodia, Kavel H.; Levy, Michael J.; Gostout, Christopher J. Advanced endoscopic imaging of indeterminate biliary strictures. World Journal of Gastrointestinal Endoscopy. 2015-12-10, 7 (18) [2022-07-02]. ISSN 1948-5190. PMC 4673389可免费查阅. PMID 26675379. doi:10.4253/wjge.v7.i18.1268. (原始内容存档于2022-07-16). 
  6. ^ Coucke, Ethan M.; Akbar, Hina; Kahloon, Arslan; Lopez, Peter P. Biliary Obstruction. StatPearls. Treasure Island (FL): StatPearls Publishing. 2022 [2022-07-02]. PMID 30969520. (原始内容存档于2022-07-06). 
  7. ^ Tabibian, James H.; Asham, Emad H.; Han, Steven; Saab, Sammy; Tong, Myron J.; Goldstein, Leonard; Busuttil, Ronald W.; Durazo, Francisco A. Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video). Gastrointestinal Endoscopy. 2010-03, 71 (3). ISSN 1097-6779. PMID 20189508. doi:10.1016/j.gie.2009.10.023. 
  8. ^ Scheurer, U. Acute pancreatitis--ERCP/endoscopic papillotomy (EPT) yes or no?. Swiss Surgery = Schweizer Chirurgie = Chirurgie Suisse = Chirurgia Svizzera. 2000, 6 (5) [2022-07-02]. ISSN 1023-9332. PMID 11077490. doi:10.1024/1023-9332.6.5.246. (原始内容存档于2022-07-09). 
  9. ^ ERCP (Endoscopic Retrograde Cholangiopancreatography). MNGI Digestive Health. [2022-07-02]. (原始内容存档于2022-07-06) (美国英语). 
  10. ^ Endoscopic Retrograde Cholangiopancreatography (ERCP). National Institute of Diabetes and Digestive and Kidney Diseases. [2022-07-03]. (原始内容存档于2022-07-13) (美国英语). 
  11. ^ Deng, Deng-Hao; Zuo, Hong-Mei; Wang, Jia-Feng; Gu, Zhi-E.; Chen, Hong; Luo, Yuan; Chen, Ming; Huang, Wen-Nuo; Wang, Lu; Lu, Wei. New precut sphincterotomy for endoscopic retrograde cholangiopancreatography in difficult biliary duct cannulation. World Journal of Gastroenterology. 2007-08-28, 13 (32) [2022-07-03]. ISSN 1007-9327. PMC 4250869可免费查阅. PMID 17708616. doi:10.3748/wjg.v13.i32.4385. (原始内容存档于2022-07-04). 
  12. ^ Kelly, Nicholas M.; Caddy, Grant R. Successful endoscopic management of fractured Dormia basket during endoscopic retrograde cholangiopancreatography for choledocholithiasis. The Ulster Medical Journal. 2008-01, 77 (1) [2022-07-03]. ISSN 0041-6193. PMC 2397011可免费查阅. PMID 18271088. (原始内容存档于2022-07-06). 
  13. ^ Busireddy, Kiran K.; AlObaidy, Mamdoh; Ramalho, Miguel; Kalubowila, Janaka; Baodong, Liu; Santagostino, Ilaria; Semelka, Richard C. Pancreatitis-imaging approach. World Journal of Gastrointestinal Pathophysiology. 2014-08-15, 5 (3) [2022-07-03]. ISSN 2150-5330. PMC 4133524可免费查阅. PMID 25133027. doi:10.4291/wjgp.v5.i3.252. (原始内容存档于2022-07-07). 
  14. ^ ASGE Technology Committee; Komanduri, Sri; Thosani, Nirav; Abu Dayyeh, Barham K.; Aslanian, Harry R.; Enestvedt, Brintha K.; Manfredi, Michael; Maple, John T.; Navaneethan, Udayakumar; Pannala, Rahul; Parsi, Mansour A. Cholangiopancreatoscopy. Gastrointestinal Endoscopy. 2016-08, 84 (2). ISSN 1097-6779. PMID 27236413. doi:10.1016/j.gie.2016.03.013. 
  15. ^ Farrell, J. J.; Bounds, B. C.; Al-Shalabi, S.; Jacobson, B. C.; Brugge, W. R.; Schapiro, R. H.; Kelsey, P. B. Single-operator duodenoscope-assisted cholangioscopy is an effective alternative in the management of choledocholithiasis not removed by conventional methods, including mechanical lithotripsy. Endoscopy. 2005-06, 37 (6) [2022-07-03]. ISSN 0013-726X. PMID 15933927. doi:10.1055/s-2005-861306. (原始内容存档于2022-08-12). 
  16. ^ Dumonceau, Jean-Marc; Andriulli, Angelo; Elmunzer, B. Joseph; Mariani, Alberto; Meister, Tobias; Deviere, Jacques; Marek, Tomasz; Baron, Todd H.; Hassan, Cesare; Testoni, Pier A.; Kapral, Christine. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - updated June 2014. Endoscopy. 2014-09, 46 (9) [2022-07-03]. ISSN 1438-8812. PMID 25148137. doi:10.1055/s-0034-1377875. (原始内容存档于2022-08-02). 
  17. ^ Årsrapporter 2016. GallRiks. Uppsala Clinical Research Center. 2017-08-19 [2022-07-03]. (原始内容存档于2022-07-06) (瑞典语). 
  18. ^ Cotton, P. B.; Lehman, G.; Vennes, J.; Geenen, J. E.; Russell, R. C.; Meyers, W. C.; Liguory, C.; Nickl, N. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointestinal Endoscopy. 1991-05, 37 (3). ISSN 0016-5107. PMID 2070995. doi:10.1016/s0016-5107(91)70740-2. 
  19. ^ Syrén, E.; Eriksson, S.; Enochsson, L.; Eklund, A.; Sandblom, G. Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography. BJS open. 2019-08, 3 (4) [2022-07-04]. ISSN 2474-9842. PMC 6681151可免费查阅. PMID 31406957. doi:10.1002/bjs5.50162. (原始内容存档于2022-07-04). 
  20. ^ Chen, Jian-Jun; Wang, Xi-Mo; Liu, Xing-Qiang; Li, Wen; Dong, Mo; Suo, Zong-Wu; Ding, Po; Li, Yue. Risk factors for post-ERCP pancreatitis: a systematic review of clinical trials with a large sample size in the past 10 years. European Journal of Medical Research. 2014-05-15, 19 (1). ISSN 2047-783X. PMC 4035895可免费查阅. PMID 24886445. doi:10.1186/2047-783X-19-26. 
  21. ^ Park, Namyoung; Lee, Sang Hyub; You, Min Su; Kim, Joo Seong; Huh, Gunn; Chun, Jung Won; Cho, In Rae; Paik, Woo Hyun; Ryu, Ji Kon; Kim, Yong-Tae. Optimal timing of endoscopic retrograde cholangiopancreatography for acute cholangitis associated with distal malignant biliary obstruction. BMC Gastroenterology. 2021-04-17, 21 (1). ISSN 1471-230X. PMC 8052855可免费查阅. PMID 33865307. doi:10.1186/s12876-021-01755-z. 
  22. ^ Andriulli, Angelo; Loperfido, Silvano; Napolitano, Grazia; Niro, Grazia; Valvano, Maria Rosa; Spirito, Fulvio; Pilotto, Alberto; Forlano, Rosario. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. The American Journal of Gastroenterology. 2007-08, 102 (8) [2022-07-04]. ISSN 0002-9270. PMID 17509029. doi:10.1111/j.1572-0241.2007.01279.x. (原始内容存档于2022-07-16). 
  23. ^ Canard, Jean Marc; Lennon, Anne Marie; Létard, Jean-Christophe; Etienne, Jacques; Okolo, Patrick. CHAPTER 10 - Endoscopic retrograde cholangiopancreatography. Canard, Jean Marc (编). Gastrointestinal Endoscopy in Practice. Edinburgh: Churchill Livingstone. 2011-01-01: 370–465 [2022-07-04]. ISBN 978-0-7020-3128-1. doi:10.1016/b978-0-7020-3128-1.00010-9. (原始内容存档于2022-07-06) (英语). 
  24. ^ Dewachter, Pascale; Mouton-Faivre, Claudie. [Allergy to iodinated drugs and to foods rich in iodine: Iodine is not the allergenic determinant]. Presse Medicale (Paris, France: 1983). 2015-11, 44 (11) [2022-07-04]. ISSN 2213-0276. PMID 26387623. doi:10.1016/j.lpm.2014.12.008. (原始内容存档于2022-07-09). 
  25. ^ Bottinor, Wendy; Polkampally, Pritam; Jovin, Ion. Adverse reactions to iodinated contrast media. The International Journal of Angiology: Official Publication of the International College of Angiology, Inc. 2013-09, 22 (3) [2022-07-04]. ISSN 1061-1711. PMC 3770975可免费查阅. PMID 24436602. doi:10.1055/s-0033-1348885. (原始内容存档于2022-08-04). 

外部链接