ERCP
Acute suppurative cholangitis caused by choledocolithiasis

Video Endoscopy Sequence 1 of 12.

Acute suppurative cholangitis caused by choledocolithiasis

96 year-old female, 20 years previously underwent a cholecystectomy, patient was hospitalized with abdominal pain in the right upper quadrant, tenderness and jaundice, elevated alkaline phosphatase more than 800 units, the total billirubins more than 18, direct billirubin: 16.9. Physical examination showed generalized jaundice.

Patient underwent an endoscopic Needle-knife precut sphincterotomy draining great amount of suppurative material successfully treated endoscopically and with course of two broad-spectrum antibiotics during four ten days..

CBD stones are either primary or secondary. Primary stones arise within the biliary duct system, while secondary stones develop in the gallbladder and migrate to the CBD.

Endoscopic biliary drainage is a safe and effective measure for the initial control of severe acute cholangitis due to choledocholithiasis and to reduce the mortality associated with the condition.

Older age has been considered a risk factor for increased morbidity and mortality rates in the treatment of acute cholangitis.

For more endoscopic details download the video clips by clicking on the endoscopic images, wait to be downloaded complete then press Alt and Enter; thus you can observe the video in full screen.

All endoscopic images shown in this Atlas contain
video clips.

 

 

 

 

Magnetic Cholangioresonance 3D reconstruction

Video Endoscopy Sequence 2 of 12.

Magnetic Cholangioresonance 3D reconstruction

Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive method for imaging the biliary and pancreatic ducts using magnetic resonance imaging. These techniques do not require intravenous contrast material and use specialized MRI sequences (i.e., heavily T2-weighted) to make the fluid in the ducts appear bright while the surrounding organs and tissues are suppressed and appear dark. Additional technical factors include fast imaging to reduce motion artifact and sufficient resolution to detect small ductal structures and pathology. When imaging pediatric subjects, a very small field of view and high pixel matrix provide better spatial resolution for small structures. Modifications of the MRCP protocol to include secretin infusion and functional evaluation have also been explored.

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ERCP

Video Endoscopy Sequence 3 of 12.

Needle-knife precut sphincterotomy Endoscopic biliary drainage for severe acute cholangitis.

The sphincterotomy is iniciates with pre-cut needle
emerging abundant purulent secretion (Colangitis).

Charcot triad of fever, RUQ pain, and jaundice is found in 50-70% of patients presenting with cholangitis.

Fever is present in approximately 90% of cases. Abdominal pain and jaundice is thought to occur in 70% and 60% of patients, respectively.

Patients present with altered mental status 10-20% of the time and hypotension approximately 30% of the time. These signs combined with Charcot triad constitute Reynolds pentad.

Most patients complain of RUQ pain; however, some patients (ie, elderly persons) are too ill to localize the source of infection.

Other symptoms include the following:

Jaundice.

Fever, chills, and rigors

Pruritus.

Acholic or hypocholic stool

The patient's past medical history may be helpful. For example, a history of the following increases the risk of cholangitis:

Gallstones, CBD stones

Recent cholecystectomy

Endoscopic manipulation or ERCP, cholangiogram

History of cholangitis

History of HIV or AIDS: AIDS-related cholangitis is characterized by extrahepatic biliary edema, ulceration, and obstruction. Etiology is uncertain but may be related to cytomegalovirus or cryptosporidium infections. Manage cholangitis as described below, although decompression usually is not necessary.

 

 

 

 

 

The Needle-knife precut extending the incision.

Video Endoscopy Sequence 4 of 12.

The Needle-knife precut extending the incision.

Cholangitis can be life-threatening, and is regarded as a medical emergency. Characteristic symptoms include jaundice, fever, abdominal pain, and in severe cases, low blood pressure and confusion. Initial treatment is with intravenous fluids and antibiotics, but there is often an underlying problem (such as gallstones or narrowing in the bile duct) for which further tests and treatments may be necessary, usually in the form of endoscopy to relieve obstruction of the bile duct.

Acute cholangitis is a bacterial infection superimposed on an obstruction of the biliary tree most commonly from a gallstone, but it may be associated with neoplasm or stricture.
Mortality of cholangitis is high due to the predisposition in people with underlying disease. Historically, mortality was 100%. Currently, mortality ranges from 7-40%.

 

 

 

 

MRI Portal System

Video Endoscopy Sequence 5 of 12.

MRI Portal System

As a imaging of a Magnetic Cholangioresonance Reconstruction the portal system is useful for adecuate diagnosis, in this image is observed the calculi, the choledoco, the aorta and the inferior cava vein.

MRCP has been proposed as a noninvasive alternative to more invasive imaging procedures such as endoscopic retrograde cholangiopancreatography (ERCP), percutaneous cholangiography, or intravenous cholangiography (IVC). ERCP is an invasive procedure using a long specialized endoscope that can cannulate the biliary tree. This procedure is associated with a risk of complications such as pancreatitis, bleeding, bowel perforation, infection, and rarely death, and it requires anesthesia, which is also associated with potential complications. Percutaneous transhepatic cholangiography (PTC) is also invasive and requires placement of a needle through the liver into an intrahepatic duct. ERCP and PTC obtain diagnostic images by direct ductal injection of radiographic contrast while IVC uses radiographic contrast that is injected into the bloodstream and later excreted into the bile ducts. ERCP or PTC may also be used to perform therapeutic interventions such as stent placement for obstruction, stone removal or sphincterotomy. In addition, ERCP may not be technically successful in approximately 3 to 10% of cases depending on operator skill and/or complex anatomy. Finally, MRCP is able to demonstrate the ducts beyond an obstructing lesion whereas this may be difficult with ERCP or PTC.

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Magnetic Cholangioresonance

Video Endoscopy Sequence 6 of 12.

Another projection of the Magnetic resonance cholangiopancreatography of the patient, It is observed the liver, choledoco which is dilated and distal the calculi.

This technique provides images derived from different magnetic properties of various tissues. Gadolinium is used as a contrast for this test.

It is a noninvasive tool with 97% accuracy, 92% sensitivity, and 100% specificity. It is improving with the advent of new sequences in imaging of the CBD.

Cost, inconvenience, and limitations (eg, obesity, presence of metal objects, eg, pacemakers) are some of its disadvantages.

It is a noninvasive tool with 97% accuracy, 92% sensitivit and 100% specificity. It is improving with the advent of new sequences in imaging of the CBD.

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Magnetic resonance cholangiopancreatography (MRCP)

Video Endoscopy Sequence 7 of 12.

Magnetic resonance cholangiopancreatography (MRCP)
depicting colelithiasis.

In Western countries CBDS typically originate in thegallbladder and migrate. Such secondary stones should bedifferentiated from primary CBDS that develop de novo inthe biliary system. Primary stones are more common insouth-east Asian populations, have a different compositionto secondary stones, and may be a consequence of biliaryinfection and stasis.

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ERCP

Video Endoscopy Sequence 8 of 12.

Emerging Purulent Secretion

In 1877, Charcot described cholangitis as a triad of findings of right upper quadrant (RUQ) pain, fever, and jaundice. The Reynolds pentad adds mental status changes and sepsis to the triad. A spectrum of cholangitis exists, ranging from mild symptoms to fulminant overwhelming sepsis. With septic shock, diagnosis can be missed in up to 25% of patients. Consider cholangitis in any patient who appears septic, especially with patients who are elderly, jaundiced, or who have abdominal pain. History of abdominal pain or past symptoms of gallbladder colic helps make the diagnosis.

 

 

 

 

ERCP

Video Endoscopy Sequence 9 of 12.

Dormia basket is used to removal the calculi

Emergency surgery for patients with severe acute cholangitis due to choledocholithiasis is associated with substantial morbidity and mortality. Emergency endoscopic drainage could improve the outcome of such patients.

Elderly patients with acute cholangitis have a high incidence of severe cholangitis, concomitant medical illnesses, hypotension, altered sensorium, peritonism, renal failure and higher mortality even after successful biliary drainage.

 

ERCP

Video Endoscopy Sequence 10 of 12.

Endoscopic retrograde cholangiopancreatography (ERCP) has become a widely available and routine procedure, whilst open cholecystectomy has largely been replaced by a laparoscopic approach, which may or may not include laparoscopic exploration of the common bile duct (LCBDE). In addition, new imaging techniques such as magnetic resonance cholangiography (MR) and endoscopic ultrasound (EUS) offer the opportunity to accurately visualise the biliary system without instrumentation of the ducts. As a consequence clinicians are now faced with a number of potentially valid options for managing patients with suspected CBDS.

 

 

Video Endoscopy Sequence 11 of 12.

Obstruction causes an increase in ductal pressure. The
bacteria proliferate and escape into the systemic
circulation via the hepatic sinusoids. The manifestations of
sepsis may overshadow those of hepato-biliary disease
causing acute suppurative cholangitis.

Without prompt diagnosis and treatment, acute cholangitis
can lead rapidly to septicaemia, shock and death.

 

Video Endoscopy Sequence 12 of 12.

The calculi responsible for the cholangitis is observed.

 

Larynx with ictericia (yellowish color).

Video Endoscopy Sequence 1 of 6.

Larynx with ictericia (yellowish color).

Patient with cholangitis and choledocholithiasis.

This 83-year-old male was admitted with abdominal pain
and increasing jaundice. Common bile duct stones were
diagnosed on abdominal ultrasound.

 

Video Endoscopy Sequence 2 of 6.

Hard Palate.

 

Video Endoscopy Sequence 3 of 6.

White bilis is emerging from the Vater papila (cholangitis).

This picture was taken through a forward-viewing
gastroscope.

 

Video Endoscopy Sequence 4 of 6.

Vater´s papilla is observed protrued

Acute cholangitis is a difficult diagnostic and therapeuticproblem. Classically, Charcot’s triad of jaundice, abdominalpain and fever have been the main basis of diagnosishowever 30%-45% of the patients with acute cholangitis donot satisfy the criteria of Charcot’s triad.

 

Video Endoscopy Sequence 5 of 6.

The principal indications for sphincterotomy include
removal of common bile duct stones, treatment of papillary
stenosis, and facilitation of endotherapy (ie, stent
placement, tissue sampling, and stricture dilation).

Altered sensorium, hypotension and renal failure can often
be seen in patients with suppurative cholangitis.

In many cases, bile duct infection is latent and does not
cause symptoms. Cholangitis varies in severity from a mild
form which responds to parenteral antibiotics alone to
severe or suppurative cholangitis which requires early
drainage of biliary system to reduce the incidence of
systemic complications.

 

Video Endoscopy Sequence 6 of 6.

ERCP.

Endoscopic Sphincterotomy and Stone Extraction.

Although most stones <1cm in diameter will pass
spontaneously in days or weeks following an adequate
sphinterectomy, most experts prefer to extract them
directly. This immediately clarifies the situation and
reduces the risk of impaction and cholangitis.

 

Video Endoscopy Sequence 1 of 10.

Adenocarcinoma of the head of the Pancreas that infiltrates
the wall of duodenum.

A 58 year-old male with heavy drinking habits, presented
with jaudince and weigh loss of 30 pounds, the ultrasound
examinations reveled dilatation of the biliary tree and
a mass of the pancreatic head.

 

Video Endoscopy Sequence 2 of 10.

The image and the video clip display an irregular and
nodular patterns of the periampullary region.

 

Video Endoscopy Sequence 3 of 10.

A biopsy was taken with an endoscopic snare excision.

 

Video Endoscopy Sequence 4 of 10.

The Vater papilla is observed.

 

Video Endoscopy Sequence 5 of 10.

An endoscopic sphincterotomy was attempted at standard
common bile duct cannulation and sphincterotomy were
unsuccessful, then precut sphincterotomy needle-nife
sphincterotomy was performed.

 

Video Endoscopy Sequence 6 of 10.

Precut sphincterotomy needle-nife sphincterotomy.

 

Video Endoscopy Sequence 7 of 10.

Video Endoscopy Sequence 8 of 10.

A guide-wire placement to deploy a self-expanding stent
used for drainage of malignant biliary stenosis.

Sphincterotomy is a technically complex procedure that is
performed under visual and fluoroscopic guidance. Deep
cannulation of the bile duct is followed by electrocautery to
incise the sphincter of Oddi.

 

Video Endoscopy Sequence 9 of 10.

A dilated biliar tree is observed with this ERCP image.

 

Video Endoscopy Sequence 10 of 10.

A dilated biliar tree is observed.

 

Video Endoscopy Sequence 1 of 7.

Adenocarcinoma of the Vater Papilla and stent migration.

A 62 year-old male with adenocarcinoma of Papilla of
Vater, a biliar stent was placed in another clinic, the stent
migrated one month after, patient presented anorexia,
nauseas and vomiting. The stent caused contralateral wall
ulceration with the danger of causing duodenal perforation.

Endoprostheses are commonly used in the treatment of
biliary and pancreatic disorders incidence rates of 4.% for
proximal biliary stent migration.

 

 

 

 

Video Endoscopy Sequence 2 of 7.

This image displays the adenocarcinoma of papilla of Vater.

Endoprosthesis which was inserted into malignant strictures
of the ampulla.

Because of its location with respect to the biliary system,
carcinoma of the ampulla of Vater is considered to manifest
earlier in its course of development than carcinoma of the
pancreas. The most common physical finding is jaundice,
which occurs in 93-100% of cases.

 

Video Endoscopy Sequence 3 of 7.

Periampullary Carcinoma.

Carcinoma of the ampulla of Vater is a malignant tumor
arising within 2 cm of the distal end of the common bile
duct, where it passes through the wall of the duodenum and
ampullary papilla. The common bile duct merges with the
pancreatic duct of Wirsung at this point and exits through
the ampulla into the duodenum. The most distal portion of
the common bile duct is dilated.

 

Video Endoscopy Sequence 4 of 7.

Ampullary cancer accounts for approximately 0.2% of all
gastrointestinal tract malignancies.

The Courvoisier sign, painless jaundice associated with a
palpable gallbladder, may be present. Unlike that due to a
neoplasm, obstructive jaundice due to a stone causes
scarring of the gallbladder, precluding its distension.

Although biopsy is not 100% accurate.

 

Video Endoscopy Sequence 5 of 7.

This image as well as the video clip display the tip of the
stent that ulcerated the contralateral wall of the duodenum.

 

Video Endoscopy Sequence 6 of 7.

This image Shows the tip of the stent causing a duodenal
wall ulceration with the danger of perforation.

 

Video Endoscopy Sequence 7 of 7.

More images and video clip of this case.

 

LARGE BULGING PAPILLA OF VATER.

Video Endoscopic Sequence 1 of 2.

LARGE BULGING PAPILLA OF VATER.

An 87 year-old male, with 10 months after cholecystectomy
due to gallstones, presented 20 days of fever, diarrhea,
jaundice and upper right quadrant pain. Abdominal
sonography demonstrated the intrahepatic ducts, comom
hepatic duct, and choledocho were dilated. Total Bilirrubine.
was of 3.0 mg/dl with a direct bilirrubine of 2.6 mg/dl and
Alkaline Fosfatase of 812. Duodenoscopic sphincterotomy
of the papilla of Vater was performed using a standard
side-viewing duodenoscope.

 

Video Endoscopic Sequence 2 of 2.

A point diathermy incision was made with a precut
papillotome (needle-knife). When the papillotome
advanced sufficiently, gush of bile and small gallstone were
observed. Slight bleeding was observed. 3 days later, the
patient reduced total bilirrubine to 1 mg/dl, abdominal
sonography was normal.

 

Stent Migration.

This 73 year-old male underwent placement of a biliary
stent due to Klatskin’s tumors in another clinic.

Endoscopic plastic biliary stenting is a common procedure
in the management of benign biliary pathology.
Complications from biliary stenting are rare, with stent
occlusion being the most common. Another late
complication of long-term biliary stenting is stent migration,
which occasionally can result in bowel perforation and
obstruction.

 

Magnetic Cholangio Resonance

Magnetic Cholangio Resonance

This 31 year-old lady, 8 years previously had an opencholecystectomy due to acute calculous cholecystitis anda biliodigestive surgery; Roux-en-Y, after that, has beensuffering of repeated episodes of cholangitis, the magneticcholangio resonance shows recurrent stones in the thebiliar tree with stenosis of the anastomosis of the asa withthe biliar tree, the patient underwent a new surgery.

Magnetic resonance Cholangiopancreatography (MRCP) is anon-invasive imaging technique able to provide projectionalimages of the bile ducts without any contrast.

Different sequences , using both breath-hold andnon-breath-hold acquisition techniques, have been employed inorder to obtain MRCP images.

The main indication for MRCP study is represented by theevaluation of common bile duct obstruction, with the aim ofassessing the presence of the obstruction (accuracy 85-100%)and, subsequently, its level (accuracy 91-100%) and its cause.The utility of associating conventional MR images to MRCP inmalignant strictures, in order to characterize and stage themalignant lesion, is also discussed. Finally, data are presentedregarding the indications and the utility of MR-pancreatographyin the evaluation of patients with pancreatic duct anomalies andchronic pancreatitis.

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