内窥镜逆行胰胆管造影(英語:Endoscopic retrograde cholangiopancreatography,ERCP)是一种结合使用内镜检查和X线透视检查来诊断和治疗胆管或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,医生可以看到胃和十二指肠的内部,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
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
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外部链接
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