Indications for Endoscopic Retrograde Cholangiopancreatography (ERCP)
ERCP is primarily indicated for therapeutic interventions rather than diagnostic purposes, with the main indication being management of common bile duct (CBD) stones, which can be cleared in 80-95% of cases with balloon sweep techniques. 1
Primary Therapeutic Indications
- Management of CBD stones, which remains the most common indication for ERCP 1, 2
- Stent placement for obstructive jaundice, with success rates >90% for distal CBD strictures 1
- Acute gallstone pancreatitis with cholangitis, which significantly reduces mortality and complications 3
- Gallstone pancreatitis with common bile duct obstruction 3
- Severe gallstone pancreatitis without clinical improvement within 48 hours 3
- Biliary drainage in cases of persistent biliary obstruction 2
- Management of biliary and pancreatic disorders in patients who are not surgical candidates 2
Specific Clinical Scenarios Warranting ERCP
- High suspicion of CBD stones based on clinical presentation, laboratory findings, or imaging studies 2
- Jaundice with elevated bilirubin levels suggesting biliary obstruction 2
- Visible stones in the common bile duct on imaging 2
- Cholangitis or infection of the bile ducts 2
- Increasingly deranged liver function tests with signs of cholangitis 3
Diagnostic Role of ERCP
- ERCP currently has an almost exclusively therapeutic role due to advances in non-invasive imaging such as MRCP 1
- ERCP is not useful in jaundice caused by hepatitis/sepsis, alcoholic liver disease, or drug toxicity 1
- For tissue diagnosis, ERCP-guided brushing or FNA can be performed with sensitivity between 57.1-82.4% for pancreatic neoplasms 1
Risks and Considerations
- Major complications occur in 4-5.2% of cases, including pancreatitis, cholangitis, hemorrhage, and perforation 1
- Mortality risk is approximately 0.4% 1
- Risk of iatrogenic pancreatitis is up to 10% following sphincterotomy 1, 2
- ERCP should be performed under antibiotic cover to reduce infection risk 3
- Technical difficulties may arise in patients with previous gastroenteric anastomoses 1
Special Considerations
- In patients with suspected sclerosing cholangitis or biliary stricture, ERCP should be performed with caution due to risk of suppurative cholangitis 1
- For stones >15 mm in size, ERCP alone is often not successful, requiring advanced endoscopic techniques 1
- In pediatric patients with choledocholithiasis, a surgery-first approach may be preferable as 69% of cases have findings amenable to surgical management without preoperative ERCP 4
- Prophylactic pancreatic duct stenting has significantly reduced the risk of severe post-ERCP pancreatitis 5