From the Guidelines
ERCP, or Endoscopic Retrograde Cholangiopancreatography, is a medical procedure used to diagnose and treat problems in the bile ducts, gallbladder, and pancreas, with a primary therapeutic role due to advances in cross-sectional imaging, particularly MRCP 1.
Procedure Overview
ERCP is an invasive procedure that is typically performed by gastroenterologists or general surgeons in an interventional suite or operating room under general anesthesia, requiring the advancement of an endoscope into the duodenum, with cannulation of the ampulla and injection of contrast into the CBD with fluoroscopic images obtained to image the biliary tree 1.
Indications and Diagnostic Yield
The main indication for ERCP remains the management of CBD stones, which can be cleared in 80% to 95% of cases via balloon sweep of the duct 1. ERCP is very sensitive for detecting biliary ductal calculi 1, and it has a high success rate for stent placement in cases of obstructive jaundice, with more than 90% success in distal CBD strictures 1.
Risks and Complications
However, as an interventional procedure, ERCP has a risk of between 4% and 5.2% for major complications, including pancreatitis, cholangitis, hemorrhage, and perforation, with a 0.4% mortality risk 1. These factors need to be weighed against the potential benefits of ERCP, considering the patient's specific condition and the availability of alternative diagnostic and therapeutic options.
Therapeutic Applications
ERCP is not just diagnostic but also therapeutic, allowing for the removal of gallstones, placement of stents to open narrowed ducts, taking tissue samples for biopsy, or draining blocked ducts during the same procedure 1. The procedure usually takes 30-90 minutes, and most patients go home the same day, though some may need to stay overnight for observation.
Key Considerations
In the setting of suspected biliary obstruction, particularly if there is high concern for CBD stones or malignant obstruction, ERCP may be performed as the initial diagnostic and therapeutic imaging modality 1. However, ERCP is not useful in the setting of jaundice caused by suspected hepatitis/sepsis, alcoholic liver disease, or in the case of medical drug toxicity 1.
From the Research
Definition and Purpose of ERCP
- Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure with both diagnostic and therapeutic utilities in managing pancreaticobiliary conditions 2.
- ERCP has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease 3.
- The procedure is used to relieve biliary or pancreatic duct obstruction, and is mainly used as a therapeutic approach 4.
Indications for ERCP
- ERCP is indicated for gallstone-induced acute cholangitis and pancreatitis 5.
- The procedure is also used for choledocholithiasis with or without cholangitis, pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks 3.
- ERCP can be used for patients with surgically altered anatomy, and selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or EUS-directed transgastric ERCP 3.
Technique and Timing of ERCP
- The technique and optimal timing of ERCP depend on the disease state, its severity, anatomy, patient background, and the institutional situation 5.
- Endoscopic transpapillary biliary drainage within 24 hours is recommended for moderate to severe acute cholangitis 5.
- Early ERCP/EST are recommended in cases with impacted gallstones in the papilla 5.
Complications and Risks of ERCP
- Post-ERCP complications include pancreatitis, infection, hemorrhage, and perforation 2.
- The risks of these complications vary depending on several factors, such as patient selection, endoscopist's skills, and the difficulties involved during the procedure 2.
- The postprocedure 30-day mortality rate ranged between 1 and 5% and was strongly correlated with older age, male sex, emergency admission, and noncancer comorbidities 4.