內鏡逆行胰膽管造影
內窺鏡逆行胰膽管造影(英語:Endoscopic retrograde cholangiopancreatography,ERCP)是一種結合使用內鏡檢查和X線透視檢查來診斷和治療膽管或胰管系統某些問題的技術。[1][2]主要由訓練有素且受過專業培訓的胃腸病學家執行。[2]通過內窺鏡,醫生可以看到胃和十二指腸的內部,並將造影劑注入膽管和胰腺的導管,以便在X光片上顯示。[2]
內鏡逆行胰膽管造影 | |
---|---|
別稱 | ERCP |
ICD-9-CM | 51.10 |
MeSH | D002760 |
OPS-301 | 1-642 |
ERCP主要用於診斷和治療膽管和主胰管的疾病,包括膽結石、炎症性狹窄(瘢痕)、滲漏(來自創傷和手術)和癌症。[3]ERCP 可以出於診斷和治療的原因進行,儘管更安全和相對無創的檢查(例如磁共振胰膽管成像(MRCP)和超音波內視鏡)的發展意味著現在很少在沒有治療目的的情況下進行ERCP。[4]
醫療用途
編輯診斷
編輯以下是ERCP的適應症,特別是當侵入性較小的選擇不充分或不明確時:
- 阻塞性黃疸 - 可能由於多種原因
- 慢性胰腺炎目前是一個有爭議的適應症,因為可以廣泛使用更安全的診斷方式,包括超音波內視鏡、CT和MRI/MRCP
- 胰腺腫瘤不再代表ERCP的有效診斷指征,除非它們引起膽管梗阻和黃疸。超音波內視鏡代表了一種更安全、更準確的診斷選擇
治療
編輯當需要以下任何一項時,可以在上述診斷場景中指示ERCP:
禁忌症
編輯對碘對比劑過敏或碘對比染劑過敏史不是ERCP的禁忌症,但應與您的醫療保健提供者討論,並應告知您對碘過敏,然後將另一種無碘對比材料(「染劑」)輕輕注入導管(胰腺或膽道)並拍攝X光片。[9]
程序
編輯對病人進行鎮靜或麻醉。然後將內窺鏡通過嘴插入食道,進入胃,通過幽門進入十二指腸,到達法特壺腹。Oddi括約肌是一個肌肉瓣膜,控制著壺腹的開口。該區域可以在執行各種程序時使用內窺鏡相機直接可視化。通過壺腹插入塑料導管或套管,並將放射性造影劑注入膽管和胰管。透視檢查用於尋找阻塞或其他病變,如結石。[10]
需要時,可用括約肌切刀切開來擴大壺腹和膽管的括約肌,以便去除膽結石或進行其他治療。[11]
與ERCP相關的其他程序包括用籃或球囊拖曳膽總管以去除膽結石,以及插入塑料支架以幫助引流膽汁。[12]此外,還可以對胰管進行插管並插入支架。
在胰腺炎的情況下,胰管需要可視化。超聲通常是入院時進行的第一項檢查;雖然它對胰腺炎或其併發症的診斷價值不大。對比增強計算機斷層掃描(MD-CECT)是最常用的成像技術。 然而,磁共振成像(MRI)提供類似於CT的診斷能力,並具有額外的內在優勢,包括缺乏電離輻射和精細的軟組織表徵。[13]
在特定情況下,其他專用或輔助內窺鏡可用於ERCP。 這些包括母嬰和SpyGlass膽管鏡(通過直接可視化導管而不是僅獲得 X 射線圖像來幫助診斷[14][15])以及球囊腸鏡(例如,在以前接受過胰十二指腸切除術或魯氏Y型吻合術解剖的消化系統手術的患者中)。
風險
編輯經內鏡逆行胰膽管造影術(ERCP)後最常見和最危險的併發症之一是ERCP術後胰腺炎(PEP)。在以前的研究中,PEP的發生率估計為3.5%至5%。[16][17]根據Cotton等人的說法,PEP被定義為「在需要入院或延長計劃入院時間的手術後超過24小時,澱粉酶至少達到正常上限三倍的臨床胰腺炎」。PEP嚴重程度的分級主要基於住院時間。[18]
發展PEP的風險因素包括與ERCP程序相關的技術問題和患者特定的技術問題。技術因素包括胰管的操作和造影劑注入、持續超過5分鐘的插管嘗試以及膽道球囊括約肌擴張;與患者相關的因素包括女性、年齡較小和Oddi括約肌功能障礙。[19]對臨床試驗的系統評價得出結論,既往有PEP或胰腺炎病史顯著增加PEP的風險分別為17.8%和5.5%。[20][21]
腸穿孔是任何腸胃內窺鏡手術的風險,如果進行括約肌切開術,則是額外的風險。由於十二指腸的第二部分在解剖學上位於腹膜後間隙(即在腹部的腹膜結構後面),因此括約肌切開術導致的穿孔位於腹膜後。括約肌切開術也與出血風險有關。[22][23]ERCP可能會導致易碎的肺門腫瘤創傷或導絲穿透膽管壁引起膽道出血,從而形成膽瘺。延遲出血是括約肌切開術的一種罕見但潛在的嚴重併發症,尤其是許多患者在ERCP後數小時內出院回家。
參見
編輯參考文獻
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