When is Endoscopic Retrograde Cholangiopancreatography (ERCP) indicated?

From the Guidelines

ERCP is indicated for therapeutic purposes, such as removing common bile duct stones, placing stents in biliary strictures or obstructions, and managing sphincter of Oddi dysfunction, and should be used primarily when less invasive methods are inconclusive or have failed, as stated in the 2019 study by the American College of Radiology 1. The main indications for ERCP include:

• Removing common bile duct stones, which can be cleared in 80% to 95% of cases 1
• Placing stents in biliary strictures or obstructions, with a success rate of more than 90% for distal CBD strictures 1
• Managing sphincter of Oddi dysfunction
• Draining pseudocysts that communicate with the pancreatic duct
• Tissue sampling of suspected malignancies in the biliary or pancreatic ducts when less invasive methods are inconclusive Before proceeding with ERCP, less invasive imaging such as ultrasound, CT, MRI, or MRCP should be performed first due to ERCP's associated risks, including pancreatitis (5-10% of cases), bleeding, perforation, and infection, as highlighted in the 2019 study by the American College of Radiology 1. Patients should receive appropriate prophylaxis, including rectal NSAIDs (100mg indomethacin or diclofenac) before the procedure to reduce post-ERCP pancreatitis risk, as recommended by the 2017 guidelines for management of intra-abdominal infections 1. The procedure requires conscious sedation or general anesthesia and should be performed by experienced endoscopists at centers with surgical backup available, as emphasized in the 2017 guidelines for management of intra-abdominal infections 1. In cases of acute cholangitis, ERCP plays a central role in the management of biliary obstruction, and endoscopic biliary decompression by nasobiliary catheter or indwelling stent is equally effective for patients with acute suppurative cholangitis caused by bile duct stones, as demonstrated in a prospective randomized trial published in 2002, cited in the 2017 guidelines for management of intra-abdominal infections 1.

From the Research

Indications for Endoscopic Retrograde Cholangiopancreatography (ERCP)

• ERCP is indicated for the treatment of conditions such as acute gallstone pancreatitis, particularly when there is cholangitis or ongoing bile duct blockage 2
• It is used to manage pancreas divisum (PD), sphincter of Oddi dysfunction (SOD), and chronic pancreatitis (CP) 2
• ERCP plays a role in the removal of bile duct stones, especially in post-cholecystectomy patients and those with intact gallbladders 3
• It is used to treat bile duct lesions post bile duct surgery, including benign biliary strictures, biliary leakages, and retained stones 4
• ERCP is the procedure of choice to remove sludge/stones from the common bile duct (CBD), and its outcome can be improved with pre-procedural imaging and timely performance 5

Specific Conditions

• Acute gallstone pancreatitis: ERCP is indicated when there is cholangitis or ongoing bile duct blockage 2
• Sphincter of Oddi dysfunction (SOD): combined pancreaticobiliary sphincter therapy may be safer than biliary sphincterotomy alone 6
• Chronic pancreatitis (CP): ERCP helps to manage duct stones and strictures in suitable patients 2
• Bile duct stones: ERCP is the therapy of choice for removal, especially in post-cholecystectomy patients and those with intact gallbladders 3
• Bile duct lesions post bile duct surgery: ERCP is a useful adjunct in the management of these patients 4

Timing and Imaging

• Pre-procedural imaging, such as endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP), can reduce unnecessary ERCPs 5
• The time interval between EUS or MRCP and ERCP should be less than 2 days to increase the yield of ERCP for suspected CBD stones 5