Endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography

• Endoscopic retrograde cholangiopancreatography (ERCP) is performed in patients with obstructive jaundice when a thera - peutic endoscopic procedure is indicated (see Chapter 9 ). It provides definitive views of Klatskin tumours (hilar cholangiocarcinoma) and facilitates staging by defining the extent of involvement of intrahepatic ducts. ERCP also provides clear images of the intrahepatic ducts in primary sclerosing cholangitis (PSC) and facilitates stenting and drain age of obstructed, infected segments. Endoscopic (peroral) cholangiography Cholangioscopy enables direct visualisation of the bile ducts, either operatively or endoscopically . The original ‘mother and baby’ ERCP cholangioscopy has been superseded by SpyGlass™ (Boston Scientific) cholangioscopy , which enables a single operator to examine the biliary mucosa. The inclusion of a working channel facilitates visualised biopsies and targeted therapy . Targeted biopsies improve diagnostic yields, with an overall accuracy of 85–95% in patients with indeterminate biliary strictures compared with 55–90% for brush cytology . Endoscopic ultrasonography Endoscopic ultrasonography (EUS) is predominantly used to evaluate the extrahepatic biliary tree and pancreas, but linear Summary box 69.7 Management of liver trauma /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF nodes and the caudate lobe and assessment of the liver paren - chyma ( Figure 69.7 ). Percutaneous transhepatic cholangiography Percutaneous transhepatic cholangiography (PTC) is indicated where endoscopic cholangiography has failed or is impossible because of anatomical constraints from previous surgery or malignant involvement of the duodenum. Tumour extent in patients with hilar tumours can be assessed and combined percutaneous/endoscopic or antegrade metal stent placement is facilitated. Laparoscopy and laparoscopic ultrasonography Laparoscopy is useful to stage primary hepatopancreatobiliary cancers. Unrecognised peritoneal metastases, superficial liver tumours and peritoneal disease can be identified and biopsied, avoiding an inappropriate laparotomy . Routine biopsy of resectable lesions is contraindicated to avoid tumour seeding. -

Figure 69.7 Endoscopic ultrasonography demonstrating liver paren chyma and a caudate lobe metastasis being biopsied. Remember associated injuries At-risk groups Stabbing or gunshot to lower chest or upper abdomen Crush injury with multiple rib fractures High-speed road traf /f_i c accident Resuscitate Airway Breathing Circulation Assessment of the injury CT chest and abdomen with contrast Laparotomy if haemodynamically unstable Treatment Correct coagulopathy Suture lacerations Resect if major vascular injury Packing if diffuse parenchymal injury