{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 28, Ep 2 of 7: Patient Selection and Complications","html":"","width":"100%","height":180,"duration":750,"description":"Episode two is about the decision that comes before cannulation and the restraint it takes to decline the procedure when objective evidence for benefit is absent. A landmark sham-controlled trial retired type three sphincter of Oddi dysfunction as a sphincterotomy indication, so pain with normal labs and a normal duct becomes a functional pain disorder, not an ERCP. Pregnancy raises the threshold highest because a second patient absorbs all the risk and none of the benefit. The back half turns on two failure mechanisms, the cut that bleeds and the elevator that harbors biofilm, and each names the patient to protect and the device choice that protects them.\n \nTopics covered\n\nSphincter of Oddi dysfunction types and the landmark trial\nPost-cholecystectomy duct dilation as physiologic compensation\nERCP in pregnancy and radiation minimization\nSedation and positioning in pregnancy\nPost-sphincterotomy bleeding risk factors\nBalloon dilation versus sphincterotomy in coagulopathy\nPerforation and the Stapfer classification\nDuodenoscope biofilm and single-use scopes\n \n \nKey decisions\n\nDo not offer sphincterotomy for type three sphincter of Oddi dysfunction (pain with normal enzymes and a non-dilated duct); a sham did at least as well, so manage it as a functional pain disorder with neuromodulators and behavioral therapy.\nTreat type one dysfunction (pain, elevated enzymes, dilated duct) with biliary sphincterotomy without manometry, and treat type two as shared decision-making with mandatory indomethacin, lactated Ringer, and a pancreatic duct stent since manometry is the highest-PEP procedure.\nRead a ten to twelve millimeter duct in a post-cholecystectomy patient with normal enzymes as physiologic compensation, not sphincter dysfunction, so it alone does not justify ERCP.\nIn pregnancy avoid diagnostic ERCP entirely: use non-contrast MRCP or EUS, shield the uterus, run pulsed fluoroscopy at four to eight pulses per second aiming under one minute, prefer the second trimester,...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}