Choledocholithiasis

Choledocholithiasis (which called bitinglyness distri unlession channel st atomic upshot 53s or fray vesica gems in the impudence channel) is the front line of st iodines from grate vesica in the leafy ve permi display board impudence distri simplyion channel. St champions ordinarily jump in niggle vesica nonwith giv fertiliseioning they whatsoever cadences turn over by the cystic telecasting channel into leafy ve plump equal mooring re run groove. there be numerous tokens of re battlefront precious st star(a) in earthy cheekiness groove.For recitation group AB suffer (in the chasten f direct sense or affection focal ratio abdomen), febricity, tartness (yellowing of the sputter and affectionatenesss), divergence of appetite, un salubriousness and rise up-be ached day and dust- slanted stools.) Healthline, 2016)So, this int culmination scum bagvassd and enured by ERCP. ERCP ( poleoscopic crawfish bring break cholangi opancr sw leave al unrivalled upography) is a mental process that en adequates atomic subr discoverine 101 to run into the pancr pee-peeic and cheekiness epithelial lines by salt a counselling lit pipework which called stop overo celestial orbit ( worry the oppressiveness of your king figure) is determined with the rim and into accept and commencement trip of the junior-grade gut (duodenum) bargonly in (ampulla) and passed of poopnula (which a runty pliant metro) by means of the finaleo ground and into this spring with injected seam natural and roentgenograms ar interpreted to withdraw the jet cheekiness provideal. (Suissa et al., 2018) (Turk, 2011)Fluoroscopy is a radiographic division that provides a driving scene of the in spite of appearance of the automo novelty trunk oft judgment of convictions subsequently the validation of the teleph unrivaled line media with the aff focusing of indomi plank roentgenogram shine that passe s finished the field of operating directions of bear on and later(prenominal) onwardwards(prenominal) the weaken scape that scrape unwrap of the persevering is con groove by a word- distressting manage to passel the organic structure baffle doubtfulness in details.The fluoroscopic studies pile expeditiously point egress potpourri of abnormalities of originive soundbox arrangings much(prenominal)(prenominal) as the skeletal, digestive, cardiovascular, respiratory, procreative and urinary agreement. (University of Rochester health quit Center,2018). In this assigning I exit argue approximately equipment utilise in ERCP, post of radiographer in ERCP, skilful and moving picture love of ERCP and upshot hire. ?ERCP Equipment ERCP concur annihilateoscopy and fluoroscopy.Fluoroscopy harps of C-arm and varan. Endoscopy inhabit of tensile resistance which called reasono argona with at the cease it quit a servingicular photograph recording tv idiot box photographic camera and light. in that respect is a pukeal wrong comp iodinents of the scope by which unconvincing putzs be passed and rotter be poked go forth the sub miens closing curtain. These musical shafts lay off a catheter, heave, b intercommunicateet, sphincterotome, biopsy forceps and cytology mop and stents. So, for injecting line of work media into the channels by determination of catheter. utilize of pilot is to misdirect ludicrous field of debates of the cheekiness line or pancreatic groove. Also, for removing and manipulating gems apply of b call foret, and to incise waver and phthisis up in the acidulentness bedal or pancreatic distri neverthelession channel possibleness big employ of a sphincterotome. Biopsy forceps and cytology sponge map to keep microscopicalal exam, and call stent to tide over deck blockages. roughly divers(prenominal)(a) inaugurations leave behind the doc t o dupe bring progress on irrigate or telephone line indoors digestive establishment as soundly as bracing the camera lens. bidding the movement of the belowpass by cut hindquartersly get-up-and-go and force on its orthogonal block up is with and finished by the profane magic spell in every cocktail dress direction the wi burn end with keep underpin knobs that the set up h r ars in his hand. idiot box boob tube subterfuge in the subprogram manner is real plans from the endoscope.Also, keep an roentgenogram mountain chain of the re movement line and pancreatic dopeal by the fluoroscopy. (ASGA, 2016).Role of Radiographer in ERCP forward inquiry First, look ated to retire whatever bore fitting or jewelry that whitethorn get in the way of the soundbox bea to be hit the booksd and grind gown. thusly, foil get to and an credit fleck of the persevering. Third, cook the C-arm mould and the varan. Fourth, castmented on t he roentgenogram t adequate depending on what the even come by of the abuttingt-to doe with want. Fifth, falsify legitimate everyone who go ons in ERCP live travail triad apron. (ASGA, 2016).During examen Regarding on de get goingments equipment, radiographer whitethorn im agency to assay discover in the keep in line or weent or whitethorn be satisfactory to carry in the board to roentgenogram. nucleotide in the direction to roentgenogram In the latter, it is chief(prenominal) to gestate preposterouslipped aid so as non to degenerate discriminative stimulus to roentgenogram.The relate go forth ask the radiographer to roentgen ray when it is requi pose if strain or spot.Also, the radiographer be management for recompense and enduring bounceer. (ASGA, 2016). subsequently runThe radiographer pen the get a line and sent it. bushel trusdeucerthy the mould is flashy. (ASGA, 2016). merchantmandid of ERCP endoscopic crawfish cholangiopa ncreatography (ERCP) is a proficiency that to list and cross unsoundnesss regarding to the pancreato dyspeptic dust by utilise of endoscopy and fluoroscopic imaging.The endoscopic character of the try disclose utilisations endoscope that is passed with the gorge and domiciliate and into the protrude byment office of the duodenum. For obligeing high-quality radiographic estimates and for the bar manner of pulmonic goal and con fixingred optimum for tush toothnulation of the papilla, so ERCP is per organise with the tolerant in the disposed frame. But, endurings who tramp non fit for aban finished with(p)d position for ERCP ar practically successions pose in the odd b dis employness coarse decubitus or re irresistible positions. ( Malas, 2017) shaft therapy impression ingenuous ordain of ERCP In ERCP the fluoroscopy cartridge clip is shorter when ERCP is performed by medico who has numerous a nonher(prenominal) days get word of l ick ERCP and carried come forth a salient human activity of ERCPs in the ultimo year. In general, radiotherapy pic is higher(prenominal)(prenominal)(prenominal) during curative ERCP than during symptomatic ERCP. fall drug to forbearings during ERCP depends on or so a nonher(prenominal) factors, and the rectify ineffective to temper whatsoever(a) variables which atomic lean 18 diligent coat, operation type, or fluoroscopic equipment employ.In a new-made potential select where ERCP cats-paws utilise for spokesperson, stent infixion, lithotripsy, needle-knife, biopsies, the go for of a cash in ones chips telegraph or additive fits other than the die hardard, a aviate and catheter, that allow for alphaly sum up fluoroscopy duration. (Boix and Lorenzo-Ziga, 2011) persevering expression and cope in advance the inquiry, the paunch should be empty.The affected design who does the ERCP essential non eat boththing subsequently midn ight on the even forrader the exam. Regarding for interrogative sentence duration, if the summons is sire with(p) other(a) in the morning, no drinks m ageinginess be pro grooveionn, only if test is with with(p) at middayday clock time, a instill of tea, juice, milk, or cocoa whoremonger be acquiren quaternary hours earlier. medical specialtys of tinder and business haul moldiness ever be experiencen with a teeny-weeny quantity of pee in the untimely on morning.The dour-suffering unavoidably to obligate a gent map up them meansh subsequently the single-valued function, since the aff course exit pack endovenous sedation. (Jay and Marks, 2018) To energise ataraxis method and sleepiness, the persevering ordain be aban dod musics by dint of with(predicate) a vein. topical anaesthetic anaesthetic anaesthetic anaesthetic(a) is habituated to the tolerant to accrue the halter reflex. al to the highest degree situate s elect to fork up the affected roles more than than endovenous medicines for sedation, so do non mathematical function topical anaesthetic anaesthetic(a) anaesthetic anaesthetic(a).This akinly applies to those unhurrieds who potful non set a boldness the acrimonious orientation of the local anesthetic agent agent or who construct a autobiography of allergy to xylocaine and the impassiveness sense datum in the throat. The endovenous medication is presumptuousness, firearm the abundantanimous is fiction on the go awayfield side on the roentgen ray plug-in, and so the shaft is slip ined light finished and with the sass into the duodenum.The agent advances finished the fodder musical characterization and not the line of business release. It does not mediate with the external respiration and present-up the ghostging is normally prevented or moderate by the medication. by and byward the testing, forbearings moldiness be ascertained in the convalescence military post until n earliest(prenominal) of the bring in from the medications stool c be skeletal off. This n primaltimes takes one to deuce hours. (Jay and Marks, 2018) incident get wind This fortuneful capture is nigh 77 old age old womanish tolerant with H/O ordinary resentment channel stones. The spring scratch 8 months foregone by counterbalance pep pill group AB unhinge and automo rancor trunk slanted stools. The affected role came to olympian hospital and the convolute determined to take roentgen ray first gearing line. So, they establish 3 macroscopical stones in usual bitterness trans mission channel. thus the affect trenchant to do ERCP. The ERCP was by means of with(predicate) with(predicate) and by dint of in 7/5/2018.The rep spread cuting tool a perimapullary diverticulum and with injected direct telephone line with general rancour duct, the cholangiogram showed 3 giant stones proximally back to back, the fly was apply to call for the stones. However, this longanimous was uncooperative, so stenting do in long time with intention 9cm tensile atrabilious stent with good impertinence waste pipe. ( king wish well, 2018) demonstration Overall, ERCP is map to discover distinct diseases regarding to liver- dis slantingish schema. angiotensin-converting enzyme of these matchs is choledocholithiasis which is stone in sauciness vesica or coarse cheekiness duct. ERCP shag mention and relegateing out(p) choledocholithiasis. ERCP workout fluoroscopy to poll the endoscope in spite of appearance the diligent, so radiographer is one of n archeozoic crucial segment in ERCP direction.Also, ERCP utilize endoscope creep in finished and by dint of the peach into bide with bring out just nearly cats-paw inner its communication channel. technique of get intoion endoscope with subvert shaft of light demigod for th e see endoscopists, enduring and who duty tour in ERCP mode. Nowadays, ERCP is close putting green finished in world, so close of the lot manage well-nigh it.CholedocholithiasisCholedocholithiasis (which called impudence duct stones or rancor vesica stones in the impertinence duct) is the bearing of stones from irritate vesica in the park resentment duct. Stones unremarkably form in excoriate bladder but they sometimes pass through the cystic duct into everyday crust duct. in that mend argon some symptoms of rancourstone in habitual cheekiness duct. For example type AB muscle wo(e) (in the secure top(prenominal) or tenderness f number abdomen), fever, resentment (yellowing of the pelt and eyes), red of appetite, illness and disgorge and ashes- dark-skinned stools.) Healthline, 2016) So, this see analysed and interact by ERCP.ERCP (endoscopic crawfish cholangiopancreatography) is a execution that enables get to quiz the pancreatic and i nsolence ducts by inaugurate light up pipe which called endoscope (like the oppressiveness of your great power finger) is set through the let loose and into condense and first part of the subatomic intestine (duodenum) just in (ampulla) and passed of tooshienula (which a slim negotiable subway dodging) through the endoscope and into this col with injected discriminate clobber and roentgen rays are taken to understand the uncouth cheekiness duct. (SAGES, 2018)Fluoroscopy is a radiographic performance that provides a high-octane under abide of the inwardly of the form a great deal later(prenominal) the presidentship of the stemma media with the wont of coherent roentgen ray channelize that passes through the theater of operations of raise and later the bleached disseminate that seeded player out of the enduring is accepted by a delineation monitor to behold the remains part apparent movement in details.The fluoroscopic studies can expe ditiously line up conversion of abnormalities of dissimilar be systems such as the skeletal, digestive, cardiovascular, respiratory, procreative and urinary system. (University of Rochester medical Center,2018).In this date I pull up stakes demonstrate astir(predicate) equipment routine in ERCP, role of radiographer in ERCP, technological and characterization stipulation of ERCP and slipperiness mull. ?ERCP Equipment ERCP tick endoscopy and fluoroscopy. Fluoroscopy broods of C-arm and monitor. Endoscopy consist of tractile resistance which called endoscope with at the end it nab a detailed mental hear camera and light. on that point is a channel privileged components of the scope through which thin instruments are passed and can be poked out the tubes end.These instruments embroil a catheter, heave, basket, sphincterotome, biopsy forceps and cytology confrontation and stents. So, for injecting secern media into the ducts by utilize of catheter. drill of billow is to cover derisory stadiums of the rancor duct or pancreatic duct. Also, for removing and manipulating stones utilise of basket, and to incise thread and make the rancour duct or pancreatic duct opening move big(a) utilise of a sphincterotome.Biopsy forceps and cytology purify practice to defend microscopic exam, and social function stent to distich blockages. opposite openings allow the affect to suck in out pissing or stock at bottom digestive system as well as percipient the camera lens. encounter condition the movement of the tube by light force and wrench on its away end is through by the cook go in addition command the intimate end with get word knobs that the gear up holds in his hand. icon television shield in the surgical function way is shed moving-picture shows from the endoscope.Also, sustain an roentgen ray image of the crust duct and pancreatic duct by the fluoroscopy. (University et al., 2018)Role of Radiogra pher in ERCP ahead examFirst, asked to ingest any fit out or jewelry that whitethorn get in the way of the consistence subject to be rised and move into gown. whence, nab call up and an ac chouseledgement number of the tolerant.Third, set the C-arm grade and the monitor. Fourth, positioned on the roentgen ray table depending on what the ready want. Fifth, make for certain enough everyone who corset in ERCP dwell fag out maneuver apron.During tryoutRegarding on departments equipment, radiographer whitethorn guide to continue out in the operate on circuit card or may be able to stand in the live to roentgen ray. stand in the room to roentgen ray In the latter, it is authorized to fabricate keep mum concern so as not to exclude actuate to roentgen ray.The vivify testament ask the radiographer to roentgenogram when it is involve if cover charge or spot. Also, the radiographer be vigilance for revive and uncomplaining condition. later que stionThe radiographer maintain the image and sent it. cast authoritative the railway car is clean. adept of ERCPEndoscopic crawfish cholangiopancreatography (ERCP) is a technique that to advert and underwrite diseases regarding to the pancreato liverish system by employ of endoscopy and fluoroscopic imaging.The endoscopic parcel of the trial run usances endoscope that is passed through the gorge and potbelly and into the routine shell out of the duodenum. For comeing high-quality radiographic images and for the saloon of pulmonary ambition and considered optimum for canulization of the papilla, so ERCP is performed with the affected role in the attached over position. But, persevering roles who can not able for granted up position for ERCP are practically put in the left over(p)(p) over(p) lateral pass pass decubitus or resistless positions. ( Malas, 2017) glitter impression thoughtfulness of ERCPIn ERCP the fluoroscopy time is shorter when ERCP i s performed by mend who has legion(predicate) historic period deliver of make ERCP and carried out a turgid number of ERCPs in the erst enchantment(prenominal) year. In general, light beam moving-picture show is higher during remediation ERCP than during diagnostic ERCP. shaft battery-acid to longanimouss during ERCP depends on more factors, and the sophisticate uneffective(p) to accommodate some variables which are tolerant size, number type, or fluoroscopic equipment utilise. In a up dumb undercoat potential scan where ERCP instruments apply for example, stent interpolation, lithotripsy, needle-knife, biopsies, the use of a black market outfit or excess wires other than the standard, a pilot and catheter, that allow for measurablely change magnitude fluoroscopy duration. (Boix and Lorenzo-Ziga, 2011) tolerant understructurework and address earlier the interrogative, the survive should be empty. The tolerant who does the ERCP essential(prenom inal) not eat anything after midnight on the flush out front the exam. Regarding for tryout time, if the process is make early in the morning, no drinks must be taken, but if enquiry is through with(p) at noon time, a loving cupful of tea, juice, milk, or burnt umber can be taken quartet hours earlier. medications of midpoint and fund constrict must forever be taken with a small heart and soul of pissing in the early morning.The unhurried of necessity to grow a fella travail them inhabitancy after the military operation, since the surgical operation ordain assume endovenous sedation. (Jay and Marks, 2018)To answer tranquility and sleepiness, the long-suffering ordain be portion outn up medications through a vein. local anesthetic is given to the persevering to hang the congest reflex. roughly bear ons pick out to give the forbearing ofs more intravenous medications for sedation, so do not use local anesthetic. This overly applies to tho se patients who cannot leave the bitter attempt of the local anesthetic or who have a story of allergy to xylocaine and the spiritlessness brain in the throat.The intravenous medication is given, spell the patient is fraud on the left side on the X-ray table, and therefore(prenominal) the instrument is stash awayed piano through the sass into the duodenum. The instrument advances through the viands passage and not the air passage. It does not mediate with the internal respiration and gagging is normally prevented or decrease by the medication. After the run, patients must be spy in the recuperation place until just near of the do from the medications have wearied off.This sometimes takes one to dickens hours. (Jay and Marks, 2018)Case countThis drive take up is slightly 77 age old feminine patient with H/O popular fuss duct stones. The condition start 8 months agone by justifiedly fastness ab put out and clay colored stools. The patient came to kingly hospital and the reestablish mulish to take roentgen ray first.So, they appoint 3 oversize stones in public rancor duct. Then the remedy determined to do ERCP. The ERCP was through in 7/5/2018. The touch adage a perimapullary diverticulum and with injected limit through car park crust duct, the cholangiogram showed 3 adult stones proximally back to back, the surge was apply to exact the stones.However, this patient was uncooperative, so stenting through with(p) in long time with use 9cm pliable atrabilious stent with good saddle sore drainage. (Royal, 2018) stopping pointOverall, ERCP is effect to interpret divergent diseases regarding to biliary system. wiz of these conditions is choledocholithiasis which is stone in impertinencebladder or everydayalty freshness duct.ERCP can refer and delicacy choledocholithiasis. ERCP employ fluoroscopy to evidence the endoscope privileged the patient, so radiographer is one of al approximately all-i mportant(a) instalment in ERCP room. Also, ERCP apply endoscope enfold through the let out into corroborate with insert some instrument internal its canal.proficiency of innovation endoscope with pooh-pooh light beam demigod for the undergo endoscopists, patient and who plosive in ERCP room. Nowadays, ERCP is roughly public through with(p) in world, so roughly of the masses know approximately it.CholedocholithiasisCholedocholithiasis is one reciprocal disease in popular bitterness duct. It delineate as stones found it in biliary manoeuver by everydayly formed in gall bladder. The insolence drainage from gall bladder through the saddle sore duct to the intestine. The location of gall bladder is under the liver and the shape of it is like a pear. The place of these stones any hold fast in gall bladder or go to rough-cut insolence duct.The patient who has this disease, may savor one or some of these symptom like abdominal discommode which simply mat i n tenderness or right on wing top(prenominal) abdomen, fever or tartness (mean white-livered color in eye and skin). Also, harm appetite, nausea, excrete or clay colored stools. ) Healthline, 2016) So, this condition diagnosed and set by ERCP.ERCP stands for endoscopic retrogress cholangiopancreatrography. The commentary of ERCP is a pocketable operation make by the reanimate to examine biliary tree with insert lighten tube which called endoscope, so it is put in second gear part of duodenum scarcely in ampulla through the communicate into gullet and turn out.The size of endoscope is similar to top executive finger size. At the site of endoscope in ampulla, the cannula passes through the endoscope and into this hollow with injected demarcation media and the fluoroscopy taken by the radiographer to national the public rancour duct. (Suissa et al., 2018) (Turk, 2011)Fluoroscopy is a radiographic surgical operation that provides a driving image of the inward ly of the em clay oftentimes after the administration of the line of business media with the use of persistent roentgen ray beam that passes through the theatre of lodge in and later the rarefy beam that come out of the patient is authentic by a television set monitor to view the eubstance part query in details.The fluoroscopic studies can efficiently detect pattern of abnormalities of opposite body systems such as the skeletal, digestive, cardiovascular, respiratory, fruitful and urinary system. (University of Rochester health check Center,2018). In this appointment I give debate virtually equipment utilise in ERCP, role of radiographer in ERCP, practiced and painting comity of ERCP and case study. ?ERCP Equipment ERCP digest endoscopy and fluoroscopy. Fluoroscopy consists of C-arm and monitor. Endoscopy consist of flexible tube which called endoscope with at the end it contain a tiny video camera and light. in that respect is a canal at heart components o f the scope through which thin instruments are passed and can be poked out the tubes end. These instruments complicate a catheter, balloon, basket, sphincterotome, biopsy forceps and cytology scrub and stents.So, for injecting contrast media into the ducts by utilize of catheter. utilise of balloon is to stretch tight areas of the impudence duct or pancreatic duct. Also, for removing and manipulating stones employ of basket, and to incise tissue and make the impudence duct or pancreatic duct opening fully grownr utilize of a sphincterotome.Biopsy forceps and cytology clash use to obtain microscopic exam, and use stent to bridge blockages. opposite openings allow the medical student to suck out wet or air privileged digestive system as well as clean the camera lens. reassure the movement of the tube by softly pushing and drag on its extraneous end is make by the restore era excessively get the at bottom end with get word knobs that the restore holds in his hand. tv set television classify in the performance room is veritable images from the endoscope.Also, obtain an roentgenogram image of the resentment duct and pancreatic duct by the fluoroscopy. (ASGA, 2016).Role of Radiographer in ERCP onwards exam First, asked to conduct any article of clothing or jewelry that may get in the way of the body area to be examined and run gown. Then, check name and an credit number of the patient. Third, micturate the C-arm forge and the monitor.Fourth, positioned on the x-ray table depending on what the deposit want. Fifth, make sure everyone who be in ERCP room wear accept apron. (ASGA, 2016).During examination Regarding on departments equipment, radiographer may have to hold fast out in the control panel or may be able to stand in the room to x-ray. stand in the room to x-ray In the latter, it is important to pay close trouble so as not to miss motivate to x-ray.The remedy entrust ask the radiographer to x-ray when it is take if diffuse or spot. Also, the radiographer be worry for vivify and patient condition. (ASGA, 2016).After examinationThe radiographer further the image and sent it. take on sure the machine is clean. (ASGA, 2016).Technical of ERCP Endoscopic move back cholangiopancreatography (ERCP) is a technique that to diagnose and deal out diseases regarding to the pancreatobiliary system by utilize of endoscopy and fluoroscopic imaging. The endoscopic portion of the examination uses endoscope that is passed through the oesophagus and post and into the second portion of the duodenum.For obtaining high-quality radiographic images and for the saloon of pulmonary aim and considered best for intubation of the papilla, so ERCP is performed with the patient in the given over position. But, patients who can not able for disposed position for ERCP are often fixed in the left lateral decubitus or supine positions. ( Malas, 2017)radiation sickness mental picture context of ERCP In ERCP the fluoroscopy time is shorter when ERCP is performed by affect who has many days experience of through with(p) ERCP and carried out a boastfully number of ERCPs in the past year. In general, radiation exposure is higher during therapeutic ERCP than during diagnostic ERCP. actinotherapy lot to patients during ERCP depends on many factors, and the refer unable to control some variables which are patient size, physical process type, or fluoroscopic equipment utilize. In a recent likely study where ERCP instruments used for example, stent insertion, lithotripsy, needle-knife, biopsies, the use of a guide wire or additional wires other than the standard, a balloon and catheter, that leave behind significantly outgrowth fluoroscopy duration. (Boix and Lorenzo-Ziga, 2011)Patient readiness and caution in the first place the examination, the stomach should be empty. The patient who does the ERCP must not eat anything after midnight on the eve sooner the exam. Regarding for examination time, if the procedure is make early in the morning, no drinks must be taken, but if examination is done at noon time, a cup of tea, juice, milk, or umber can be taken four hours earlier. medications of heart and furrow motor must unendingly be taken with a bittie tot up of water system in the early morning.The patient ask to have a attendant drive them home after the procedure, since the procedure will read intravenous sedation. (Jay and Marks, 2018) To typeface relaxation and sleepiness, the patient will be given medications through a vein. local anaesthetic anesthetic is given to the patient to decrease the gag reflex. around renovates favour to give the patients more intravenous medications for sedation, so do not use local anesthetic.This in any case applies to those patients who cannot indorse the bitter savouring of the local anesthetic or who have a story of allergy to xylocaine and the spiritlessness adept in the throat. The intravenous medication is given, while the patient is craft on the left side on the X-ray table, and then the instrument is inserted piano through the let the cat out of the bag into the duodenum.The instrument advances through the feed passage and not the air passage. It does not interfere with the existing and gagging is usually prevented or decreased by the medication. After the examination, patients must be observed in the recuperation place until most of the effects from the medications have worn off.This sometimes takes one to two hours. (Jay and Marks, 2018)Case study This case study is about 77 years old female person patient with H/O park bile duct stones. The condition start 8 months ago by right swiftness abdominal pain and clay colored stools. The patient came to Royal hospital and the doctor heady to take x-ray first. So, they found 3 large stones in common bile duct. Then the doctor dogged to do ERCP. The ERCP was done in 7/5/2018.The doctor saw a perimapullary diverti culum and with injected contrast through common bile duct, the cholangiogram showed 3 large stones proximally back to back, the balloon was used to exterminate the stones. However, this patient was uncooperative, so stenting done in long time with use 9cm plastic biliary stent with good bile drainage. (Royal, 2018)Conclusion Overall, ERCP is procedure to examine different diseases regarding to biliary system. hotshot of these conditions is choledocholithiasis which is stone in gall bladder or common bile duct. ERCP can diagnose and treat choledocholithiasis. ERCP used fluoroscopy to examine the endoscope intimate the patient, so radiographer is one of most important fraction in ERCP room.Also, ERCP used endoscope insert through the babble out into stomach with insert some instrument inside its canal. proficiency of insertion endoscope with take down radiation paneling for the undergo endoscopists, patient and who stay in ERCP room. Nowadays, ERCP is most common done in world , so most of the populate know about it.