What is the purpose of Endoscopic Retrograde Cholangiopancreatography (ERCP)?

Purpose of ERCP (Endoscopic Retrograde Cholangiopancreatography)

ERCP is now primarily a therapeutic procedure for treating biliary and pancreatic duct obstruction, having evolved from its original diagnostic role due to advances in non-invasive imaging like MRCP. 1

Primary Therapeutic Indications

Common Bile Duct Stone Management

• The main indication for ERCP is management of CBD stones, which can be cleared in 80-95% of cases via balloon sweep of the duct. 1, 2, 3
• ERCP with sphincterotomy can remove CBD stones and may be curative when performed prior to cholecystectomy, though up to 5% of patients may develop recurrent primary CBD stone formation. 1
• Therapeutic endoscopic intervention has associated morbidity of up to 10% due to the risk of iatrogenic pancreatitis. 1

Biliary Obstruction Relief

• ERCP serves as the gold standard for visualizing the biliary tract and treating extrahepatic biliary obstruction caused by stones, tumors, cysts, or strictures. 1
• Stent placement via ERCP for distal CBD strictures is successful in more than 90% of cases. 1
• ERCP allows for biliary drainage in cases of cholangitis or persistent biliary obstruction. 3

Emergency Indications

• In gallstone pancreatitis with concomitant cholangitis, ERCP should be performed within 24 hours. 2
• For high suspicion of persistent common bile duct stone in gallstone pancreatitis, ERCP should be performed within 72 hours. 2
• ERCP may be performed as the initial diagnostic and therapeutic modality when there is high concern for CBD stones or malignant obstruction. 1

Diagnostic Capabilities (Limited Role)

• ERCP has largely been replaced by MRCP for diagnostic purposes due to significant advances in cross-sectional imaging. 1, 4
• ERCP-guided fine needle aspiration of solid pancreatic neoplasms demonstrates sensitivity between 57.1% (for pancreatic body/tail) and 82.4% (for pancreatic head). 1
• Tissue diagnosis can be obtained through endoscopically directed brushing or guided ultrasound with FNA, though brush cytology results for biliary strictures from pancreatic malignancies are inferior. 1
• ERCP has equivalent or greater sensitivity for tumor detection when the tumor is in the pancreatic head/duodenum or CBD, with superior sensitivity particularly for ampullary carcinoma, but does not provide staging information for operability. 1

Procedural Details

• ERCP involves advancing an endoscope into the duodenum, cannulating the ampulla, and injecting contrast into the CBD with fluoroscopic imaging. 1, 2
• The procedure is typically performed by gastroenterologists or general surgeons in an interventional suite or operating room under general anesthesia. 1, 2
• ERCP may include concomitant sphincterotomy, biopsy, or stent deployment (CBD or pancreatic). 1, 2

Critical Risk Profile

• Major complications occur in 4-5.2% of cases, including pancreatitis, cholangitis, hemorrhage, and perforation. 1, 2, 3
• Mortality risk is 0.4%. 1, 3
• When combined with sphincterotomy, bleeding occurs in 2% and cholangitis in 1% of cases. 1
• These risks must be weighed against potential benefits before proceeding with ERCP. 1

When ERCP Should Be Avoided

• ERCP is not useful for jaundice caused by suspected hepatitis/sepsis, alcoholic liver disease, or medical drug toxicity. 1
• When extrahepatic obstruction is considered but the need for endoscopic intervention is unclear, MRCP or EUS should be performed first to avoid unnecessary ERCP. 1
• In patients with suspected sclerosing cholangitis or biliary stricture, ERCP should be performed with caution as suppurative cholangitis may be induced by endoscopic catheter manipulation of an obstructed biliary system. 1
• ERCP is technically difficult in patients with previous gastroenteric anastomoses, as advancing the endoscope into the biliopancreatic limb is challenging. 1