Endoscopic retrograde cholangiopancreatography

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Endoscopic retrograde cholangiopancreatography
Pigment stone extraction.png
Duodenoscopic image of two black pigment stones extracted from common bile duct after sphincterotomy
ICD-9-CM 51.10
MeSH D002760
OPS-301 code 1-642

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. It is primarily performed by highly skilled and specialty trained gastroenterologists. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject a contrast medium into the ducts in the biliary tree and/or pancreas so they can be seen on radiographs.

Contents

ERCP is used primarily to diagnose and treat conditions of the bile ducts and main pancreatic duct, [1] including gallstones, inflammatory strictures (scars), leaks (from trauma and surgery), and cancer. ERCP can be performed for diagnostic and therapeutic reasons, although the development of safer and relatively non-invasive investigations such as magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound has meant that ERCP is now rarely performed without therapeutic intent. [2]

Medical uses

Diagnostic

The following represent indications for ERCP, particularly if or when less invasive options are not adequate or definitive:

Fluoroscopic image of common bile duct stone seen at the time of ERCP. The stone is impacted in the distal common bile duct. A nasobiliary tube has been inserted. ERCP stone.jpg
Fluoroscopic image of common bile duct stone seen at the time of ERCP. The stone is impacted in the distal common bile duct. A nasobiliary tube has been inserted.
Fluoroscopic image showing dilatation of the pancreatic duct during ERCP investigation. Endoscope is visible. ERCP dilatation.png
Fluoroscopic image showing dilatation of the pancreatic duct during ERCP investigation. Endoscope is visible.

Therapeutic

ERCP may be indicated in the above diagnostic scenarios when any of the following are needed:

Contraindications

Hypersensitivity to iodinated contrast medium or a history of iodinated contrast dye anaphylaxis is not a contraindication of ERCP, though it should be discussed with your health provider, and you should tell them you are allergic to iodine, as an alternative contrast iodine-free material ("dye") is then injected gently into the ducts (pancreatic or biliary) and x-rays are taken. [7]

Procedure

Diagram of an endoscopic retrograde cholangiopancreatography (ERCP) Detailed diagram of an endoscopic retrograde cholangio pancreatography (ERCP) CRUK 001.svg
Diagram of an endoscopic retrograde cholangiopancreatography (ERCP)

The patient is sedated or anaesthetized. Then a flexible camera (endoscope) is inserted through the mouth, down the esophagus, into the stomach, through the pylorus into the duodenum where the ampulla of Vater (the union of the common bile duct and pancreatic duct) exists. The sphincter of Oddi is a muscular valve that controls the opening to the ampulla. The region can be directly visualized with the endoscopic camera while various procedures are performed. A plastic catheter or cannula is inserted through the ampulla, and radiocontrast is injected into the bile ducts and/or pancreatic duct. Fluoroscopy is used to look for blockages, or other lesions such as stones. [8] [9]

When needed, the sphincters of the ampulla and bile ducts can be enlarged by a cut (sphincterotomy) with an electrified wire called a sphincterotome for access into either so that gallstones may be removed or other therapy performed. [10]

Other procedures associated with ERCP include the trawling of the common bile duct with a basket or balloon to remove gallstones and the insertion of a plastic stent to assist the drainage of bile. [11] Also, the pancreatic duct can be cannulated and stents be inserted.

The pancreatic duct requires visualisation in cases of pancreatitis. Ultrasound is frequently the first investigation performed on admission; although it has little value in the diagnosis of pancreatitis or its complications. contrast-enhanced computed tomography (MD-CECT) is the most used imaging technique. However, magnetic resonance imaging (MRI) offers diagnostic capabilities similar to those of CT, with additional intrinsic advantages including lack of ionizing radiation and exquisite soft tissue characterization. [12]

In specific cases, other specialized or ancillary endoscopes may be used for ERCP. These include mother-baby and SpyGlass cholangioscopes (to help in diagnosis by directly visualizing the duct as opposed to only obtaining X-ray images [13] [14] [15] ) as well as balloon enteroscopes (e.g. in patients that have previously undergone digestive system surgery with post-Whipple or Roux-en-Y surgical anatomy). [16]

Risks

One of the most frequent and feared complications after endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP). In previous studies, the incidence of PEP has been estimated at 3.5 to 5%. [17] [18] According to Cotton et al., PEP is defined as a "clinical pancreatitis with amylase at least three times the upper limit of normal at more than 24 hours after the procedure requiring hospital admission or prolongation of planned admission". Grading of severity of PEP is mainly based on the length of hospital stay. [19]

Risk factors for developing PEP include technical matters related to the ERCP procedure and patient-specific ones. The technical factors include manipulation of and injection of contrast into the pancreatic duct, cannulation attempts lasting more than five minutes, and biliary balloon sphincter dilation; among patient-related factors are female gender, younger age, and Sphincter of Oddi dysfunction.[ citation needed ] A systematic review of clinical trials concluded that a previous history of PEP or pancreatitis significantly increases the risk for PEP to 17.8% and to 5.5% respectively. [20] [21]

Intestinal perforation is a risk of any gastroenterologic endoscopic procedure, and is an additional risk if a sphincterotomy is performed. As the second part of the duodenum is anatomically in a retroperitoneal location (that is, behind the peritoneal structures of the abdomen), perforations due to sphincterotomies are retroperitoneal. Sphincterotomy is also associated with a risk of bleeding. [22] ERCP may provoke hemobilia from trauma to friable hilar tumors or a guide-wire penetrating the bile duct wall, creating a biliary fistula. Delayed bleeding is a rare but potentially serious complication of sphincterotomy, particularly as many patients are discharged home within hours of ERCP.

There is also a risk associated with the contrast dye in patients who are allergic to compounds containing iodine, which can be very severe, even if the anaphylactoid reactions occur while you are in a hospital. [23] [24]

Oversedation can result in dangerously low blood pressure, respiratory depression, nausea, and vomiting.[ citation needed ]

Other complications (less than 1%) may include heart and lung problems, infection in the bile duct called cholangitis, that can be life-threatening, and is regarded as a medical emergency. Using antibiotics before the procedure shows some benefits to prevent cholangitis and septicaemia. [25] In rare cases, ERCP can cause fatal complications. [26]

Cases of hospital-acquired (i.e., nosocomial) infections with carbapenem resistant enterobacteriaceae linked to incompletely disinfected duodenoscopes have occurred in the U.S. since at least 2009 per the Food and Drug Administration. [27] Outbreaks were reported from Virginia Mason Hospital in Seattle in 2013, UCLA Health System Los Angeles in 2015, Chicago and Pittsburgh. [28] The FDA issued a safety communication "Design of ERCP Duodenoscopes May Impede Effective Cleaning" in February 2015, [29] which was updated in December 2015, [30] and more recently in 2022 which recommended disposable components. [31]

Prevalence of vitamin K and vitamin D deficiency, [32] as bile is to assist in the breakdown and absorption of fat in the intestinal tract; a relative deficiency of bile can lead to fat malabsorption and deficiencies of fat-soluble vitamins.

See also

Related Research Articles

<span class="mw-page-title-main">Gastroenterology</span> Branch of medicine focused on the digestive system and its disorders

Gastroenterology is the branch of medicine focused on the digestive system and its disorders. The digestive system consists of the gastrointestinal tract, sometimes referred to as the GI tract, which includes the esophagus, stomach, small intestine and large intestine as well as the accessory organs of digestion which include the pancreas, gallbladder, and liver.

<span class="mw-page-title-main">Gallstone</span> Disease where stones form in the gallbladder

A gallstone is a stone formed within the gallbladder from precipitated bile components. The term cholelithiasis may refer to the presence of gallstones or to any disease caused by gallstones, and choledocholithiasis refers to the presence of migrated gallstones within bile ducts.

<span class="mw-page-title-main">Stent</span> Type of medical device

In medicine, a stent is a tube usually constructed of a metallic alloy or a polymer. It is inserted into the lumen of an anatomic vessel or duct to keep the passageway open.

<span class="mw-page-title-main">Cholecystectomy</span> Surgical removal of the gallbladder

Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. In 2011, cholecystectomy was the eighth most common operating room procedure performed in hospitals in the United States. Cholecystectomy can be performed either laparoscopically, or via an open surgical technique.

<span class="mw-page-title-main">Primary sclerosing cholangitis</span> Hardening of the bile ducts due to scarring and inflammation

Primary sclerosing cholangitis (PSC) is a long-term progressive disease of the liver and gallbladder characterized by inflammation and scarring of the bile ducts, which normally allow bile to drain from the gallbladder. Affected individuals may have no symptoms or may experience signs and symptoms of liver disease, such as yellow discoloration of the skin and eyes, itching, and abdominal pain.

<span class="mw-page-title-main">Acute pancreatitis</span> Medical condition

Acute pancreatitis (AP) is a sudden inflammation of the pancreas. Causes include a gallstone impacted in the common bile duct or the pancreatic duct, heavy alcohol use, systemic disease, trauma, elevated calcium levels, hypertriglyceridemia, certain medications, hereditary causes and, in children, mumps. Acute pancreatitis may be a single event, it may be recurrent, or it may progress to chronic pancreatitis and/or pancreatic failure.

<span class="mw-page-title-main">Common bile duct stone</span> Medical condition

Common bile duct stone, also known as choledocholithiasis, is the presence of gallstones in the common bile duct (CBD). This condition can cause jaundice and liver cell damage. Treatments include choledocholithotomy and endoscopic retrograde cholangiopancreatography (ERCP).

<span class="mw-page-title-main">Magnetic resonance cholangiopancreatography</span> Medical imaging technique

Magnetic resonance cholangiopancreatography (MRCP) is a medical imaging technique. It uses magnetic resonance imaging to visualize the biliary and pancreatic ducts non-invasively. This procedure can be used to determine whether gallstones are lodged in any of the ducts surrounding the gallbladder.

<span class="mw-page-title-main">Endoscopic ultrasound</span> Medical imaging procedure

Endoscopic ultrasound (EUS) or echo-endoscopy is a medical procedure in which endoscopy is combined with ultrasound to obtain images of the internal organs in the chest, abdomen and colon. It can be used to visualize the walls of these organs, or to look at adjacent structures. Combined with Doppler imaging, nearby blood vessels can also be evaluated.

<span class="mw-page-title-main">Ascending cholangitis</span> Medical condition

Ascending cholangitis, also known as acute cholangitis or simply cholangitis, is inflammation of the bile duct, usually caused by bacteria ascending from its junction with the duodenum. It tends to occur if the bile duct is already partially obstructed by gallstones.

<span class="mw-page-title-main">Hemosuccus pancreaticus</span> Medical condition

Hemosuccus pancreaticus is a rare cause of hemorrhage in the gastrointestinal tract. It is caused by a bleeding source in the pancreas, pancreatic duct, or structures adjacent to the pancreas, such as the splenic artery, that bleed into the pancreatic duct, which is connected with the bowel at the duodenum, the first part of the small intestine. Patients with hemosuccus may develop symptoms of gastrointestinal hemorrhage, such as blood in the stools, maroon stools, or melena, which is a dark, tarry stool caused by digestion of red blood cells. They may also develop abdominal pain. It is associated with pancreatitis, pancreatic cancer and aneurysms of the splenic artery. Hemosuccus may be identified with endoscopy (esophagogastroduodenoscopy), where fresh blood may be seen from the pancreatic duct. Alternatively, angiography may be used to inject the celiac axis to determine the blood vessel that is bleeding. This may also be used to treat hemosuccus, as embolization of the end vessel may terminate the hemorrhage. However, a distal pancreatectomy—surgery to remove of the tail of the pancreas—may be required to stop the hemorrhage.

<span class="mw-page-title-main">Percutaneous transhepatic cholangiography</span> Medical imaging of the biliary tract

Percutaneous transhepatic cholangiography, percutaneous hepatic cholangiogram (PTHC) is a radiological technique used to visualize the anatomy of the biliary tract. A contrast medium is injected into a bile duct in the liver, after which X-rays are taken. It allows access to the biliary tree in cases where endoscopic retrograde cholangiopancreatography has been unsuccessful. Initially reported in 1937, the procedure became popular in 1952.

<span class="mw-page-title-main">Pneumobilia</span> Medical condition

Pneumobilia is the presence of gas in the biliary system. It is typically detected by ultrasound or a radiographic imaging exam, such as CT, or MRI. It is a common finding in patients that have recently undergone biliary surgery or endoscopic biliary procedure. While the presence of air within biliary system is not harmful, this finding may alternatively suggest a pathological process, such as a biliary-enteric anastomosis, an infection of the biliary system, an incompetent sphincter of Oddi, or spontaneous biliary-enteric fistula.

<span class="mw-page-title-main">Sphincter of Oddi dysfunction</span> Medical condition

Sphincter of Oddi dysfunction refers to a group of functional disorders leading to abdominal pain due to dysfunction of the Sphincter of Oddi: functional biliary sphincter of Oddi and functional pancreatic sphincter of Oddi disorder. The sphincter of Oddi is a sphincter muscle, a circular band of muscle at the bottom of the biliary tree which controls the flow of pancreatic juices and bile into the second part of the duodenum. The pathogenesis of this condition is recognized to encompass stenosis or dyskinesia of the sphincter of Oddi ; consequently the terms biliary dyskinesia, papillary stenosis, and postcholecystectomy syndrome have all been used to describe this condition. Both stenosis and dyskinesia can obstruct flow through the sphincter of Oddi and can therefore cause retention of bile in the biliary tree and pancreatic juice in the pancreatic duct.

Endoscopic stenting is a medical procedure by which a stent, a hollow device designed to prevent constriction or collapse of a tubular organ, is inserted by endoscopy. They are usually inserted when a disease process has led to narrowing or obstruction of the organ in question, such as the esophagus or the colon.

Pancreaticobiliary maljunction(PBM) is a congenital malformation where the pancreatic and bile ducts meet outside of the duodenum. There are two varieties of PBM: one with biliary dilatation and the other without. When an abnormally long common channel is visible on direct cholangiography, such as endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography, PBM is diagnosed.

<span class="mw-page-title-main">Michel Kahaleh</span>

Michel Kahaleh is an American gastroenterologist and an expert in therapeutic endoscopy.

<span class="mw-page-title-main">Choledochoduodenostomy</span>

Choledochoduodenostomy (CDD) is a surgical procedure to create an anastomosis, a surgical connection, between the common bile duct (CBD) and an alternative portion of the duodenum. In healthy individuals, the CBD meets the pancreatic duct at the ampulla of Vater, which drains via the major duodenal papilla to the second part of duodenum. In cases of benign conditions such as narrowing of the distal CBD or recurrent CBD stones, performing a CDD provides the diseased patient with CBD drainage and decompression. A side-to-side anastomosis is usually performed.

<span class="mw-page-title-main">Nib Soehendra</span> German surgeon (born 1942)

Nib Soehendra is a German surgeon known for numerous contributions to the field of endoscopy and therapeutic endoscopy.

<span class="mw-page-title-main">Biliary endoscopic sphincterotomy</span> Use of endoscopy and fluoroscopy to treat and diagnose digestive issues.

Biliary endoscopic sphincterotomy is a procedure where the sphincter of Oddi and the segment of the common bile duct where it enters the duodenum are cannulated and then cut with a sphincterotome, a device that includes a wire which cuts with an electric current (electrocautery).

References

  1. ↑ 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; Faigel, Douglas O.; Standards of Practice Committee of American Society for Gastrointestinal, Endoscopy. (July 2005). "ASGE guideline: The role of ERCP in diseases of the biliary tract and the pancreas". Gastrointestinal Endoscopy. 62 (1): 1–8. doi:10.1016/j.gie.2005.04.015. PMID   15990812.
  2. ↑ Tharian, B.; George, N. E.; Tham, T. C. (2015). "What is the current role of endoscopy in primary sclerosing cholangitis?". World Journal of Gastrointestinal Endoscopy. 7 (10): 920–927. doi: 10.4253/wjge.v7.i10.920 . PMC   4530326 . PMID   26265986.
  3. ↑ Tabibian, James H (2015). "Advanced endoscopic imaging of indeterminate biliary strictures". World Journal of Gastrointestinal Endoscopy. 7 (18): 1268–1278. doi: 10.4253/wjge.v7.i18.1268 . PMC   4673389 . PMID   26675379.
  4. ↑ Coucke, E. M.; Akbar, H.; Kahloon, A.; Lopez, P. P. (2022). "Biliary Obstruction". StatPearls. StatPearls. PMID   30969520.
  5. ↑ Tabibian, James H.; Asham, Emad H.; Han, Steven; Saab, Sammy; Tong, Myron J.; Goldstein, Leonard; Busuttil, Ronald W.; Durazo, Francisco A. (March 2010). "Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video)". Gastrointestinal Endoscopy. 71 (3): 505–512. doi:10.1016/j.gie.2009.10.023. PMID   20189508.
  6. ↑ Scheurer, U (1 October 2000). "Acute Pancreatitis - ERCP / Endoscopic Papillotomy (EPT) Yes Or No?". Swiss Surgery. 6 (5): 246–248. doi:10.1024/1023-9332.6.5.246. PMID   11077490.
  7. ↑ "ERCP (Endoscopic Retrograde Cholangiopancreatography) | MNGI".
  8. ↑ "Endoscopic Retrograde Cholangiopancreatography (ERCP) | NIDDK".
  9. ↑ "Endoscopie bending rubber".
  10. ↑ Deng, D. H.; Zuo, H. M.; Wang, J. F.; Gu, Z. E.; Chen, H.; Luo, Y.; Chen, M.; Huang, W. N.; Wang, L.; Lu, W. (2007). "New precut sphincterotomy for endoscopic retrograde cholangiopancreatography in difficult biliary duct cannulation". World Journal of Gastroenterology. 13 (32): 4385–4390. doi: 10.3748/wjg.v13.i32.4385 . PMC   4250869 . PMID   17708616.
  11. ↑ Kelly, N. M.; Caddy, G. R. (2008). "Successful Endoscopic Management of Fractured Dormia Basket During Endoscopic Retrograde Cholangiopancreatography for Choledocholithiasis". The Ulster Medical Journal. 77 (1): 56–58. PMC   2397011 . PMID   18271088.
  12. ↑ Busireddy, K. K.; Alobaidy, M.; Ramalho, M.; Kalubowila, J.; Baodong, L.; Santagostino, I.; Semelka, R. C. (2014). "Pancreatitis-imaging approach". World Journal of Gastrointestinal Pathophysiology. 5 (3): 252–270. doi: 10.4291/wjgp.v5.i3.252 . PMC   4133524 . PMID   25133027.
  13. ↑ Cholangioscopy~technique at eMedicine
  14. ↑ 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.; Smith, Zachary L.; Sullivan, Shelby A.; Banerjee, Subhas; Banerjee, S. (2016). "Cholangiopancreatoscopy". Gastrointestinal Endoscopy. 84 (2): 209–221. doi: 10.1016/j.gie.2016.03.013 . PMID   27236413.
  15. ↑ Farrell JJ, Bounds BC, Al-Shalabi S, Jacobson BC, Brugge WR, Schapiro RH, Kelsey PB (2005). "Single-operator duodenoscope-assisted cholangioscopy is an effective alternative in the management of choledocholithiasis not removed by conventional methods, including mechanical lithotripsy". Endoscopy. 37 (6): 542–7. doi:10.1055/s-2005-861306. PMID   15933927. S2CID   260128740.
  16. ↑ Azeem, Nabeel; Tabibian, James H.; Baron, Todd H.; Orhurhu, Vwaire; Rosen, Charles B.; Petersen, Bret T.; Gostout, Christopher J.; Topazian, Mark D.; Levy, Michael J. (April 2013). "Use of a single-balloon enteroscope compared with variable-stiffness colonoscopes for endoscopic retrograde cholangiography in liver transplant patients with Roux-en-Y biliary anastomosis". Gastrointestinal Endoscopy. 77 (4): 568–577. doi:10.1016/j.gie.2012.11.031. PMID   23369652.
  17. ↑ Dumonceau, Jean-Marc; Andriulli, Angelo; Elmunzer, B.; Mariani, Alberto; Meister, Tobias; Deviere, Jacques; Marek, Tomasz; Baron, Todd; Hassan, Cesare; Testoni, Pier; Kapral, Christine (22 August 2014). "Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Updated June 2014". Endoscopy. 46 (9): 799–815. CiteSeerX   10.1.1.886.8874 . doi:10.1055/s-0034-1377875. PMID   25148137. S2CID   9899581.
  18. ↑ GallRiks. Annual report 2016. http://www.ucr.uu.se/gallriks/fou/arsrapporter [accessed 31 May 2018].
  19. ↑ Cotton, P.B.; Lehman, G.; Vennes, J.; Geenen, J.E.; Russell, R.C.G.; Meyers, W.C.; Liguory, C.; Nickl, N. (May 1991). "Endoscopic sphincterotomy complications and their management: an attempt at consensus". Gastrointestinal Endoscopy. 37 (3): 383–393. doi:10.1016/S0016-5107(91)70740-2. PMID   2070995.
  20. ↑ Chen, Jian-Jun; Wang, Xi-Mo; Liu, Xing-Qiang; Li, Wen; Dong, Mo; Suo, Zong-Wu; Ding, Po; Li, Yue (15 May 2014). "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. 19 (1): 26. CiteSeerX   10.1.1.981.3789 . doi: 10.1186/2047-783X-19-26 . PMC   4035895 . PMID   24886445. Gale   A541256167.
  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 (2021). "Optimal timing of endoscopic retrograde cholangiopancreatography for acute cholangitis associated with distal malignant biliary obstruction". BMC Gastroenterology. 21 (1): 175. doi: 10.1186/s12876-021-01755-z . PMC   8052855 . PMID   33865307.
  22. ↑ Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, Pilotto A, Forlano R (2007). "Incidence rates of post-ERCP complications: a systematic survey of prospective studies". Am. J. Gastroenterol. 102 (8): 1781–8. doi:10.1111/j.1572-0241.2007.01279.x. PMID   17509029. S2CID   38954883.
  23. ↑ Dewachter, Pascale; Mouton-Faivre, Claudie (1 November 2015). "Allergie aux médicaments et aliments iodés : la séquence allergénique n'est pas l'iode" [Allergy to iodinated drugs and to foods rich in iodine: Iodine is not the allergenic determinant]. La Presse Médicale (in French). 44 (11): 1136–1145. doi:10.1016/j.lpm.2014.12.008. PMID   26387623.
  24. ↑ Bottinor, W.; Polkampally, P.; Jovin, I. (2013). "Adverse Reactions to Iodinated Contrast Media". The International Journal of Angiology. 22 (3): 149–154. doi:10.1055/s-0033-1348885. PMC   3770975 . PMID   24436602.
  25. ↑ Brand, Martin; Bizos, Damon; O'Farrell, Peter JR (6 October 2010). "Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography". Cochrane Database of Systematic Reviews (10): CD007345. doi:10.1002/14651858.CD007345.pub2. PMID   20927758.
  26. ↑ Cotton, Peter B. (2013-05-31). "ERCP (Endoscopic Retrograde Cholangio-Pancreatography)". Medical University of South Carolina (MUSC) Digestive Disease Center. Archived from the original on 2018-03-21. Retrieved 2013-06-09.
  27. ↑ Sharon Begley; Toni Clarke (20 February 2015). "FDA knew devices spread fatal 'superbug' but does not order fix". Reuters. Retrieved 20 February 2015.
  28. ↑ "Deadly superbug infected patients at Seattle hospital". CBS. CBS Interactive Inc. January 22, 2015. Retrieved 21 February 2015.
  29. ↑ "Design of Endoscopic Retrograde Cholangiopancreatography (ERCP) Duodenoscopes May Impede Effective Cleaning: FDA Safety Communication". Medical Devices. US FDA. 19 February 2015. Retrieved 19 February 2015.
  30. ↑ Medwatch ED-530XT Duodenoscopes by FUJIFILM Medical Systems, U.S.A.: Safety Communication - FUJIFILM Medical Systems Validates Revised Reprocessing Instructions Safety alerts for Human Medical Products. U.S. FDA, 23 December 2015, retrieved 5 January 2016
  31. ↑ "The FDA is Recommending Transition to Duodenoscopes with Innovative Designs to Enhance Safety: FDA Safety Communication". FDA. 5 April 2022.
  32. ↑ Fisher, Leon; Byrnes, Elizabeth; Fisher, Alexander A. (1 September 2009). "Prevalence of vitamin K and vitamin D deficiency in patients with hepatobiliary and pancreatic disorders". Nutrition Research. 29 (9): 676–683. doi:10.1016/j.nutres.2009.09.001. hdl: 1885/32031 . PMID   19854384.
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