ERCP (Endoscopic Retrograde Cholangiopancreatography) in Acute Pancreatitis
ERCP is the type of cholangiogram performed in acute pancreatitis, specifically indicated for severe gallstone pancreatitis with cholangitis or persistent biliary obstruction, not for routine diagnostic purposes. 1, 2
Specific Indications for ERCP
Urgent ERCP (Within 24 Hours)
- Perform immediately in patients with gallstone pancreatitis who develop cholangitis (fever, rigors, positive blood cultures, increasingly deranged liver function tests). 1, 2
- This represents the clearest Grade A recommendation where ERCP can reduce mortality and morbidity. 1
Early ERCP (Within 48-72 Hours)
- Indicated in severe gallstone pancreatitis when the patient fails to improve within 48 hours despite intensive resuscitation. 1, 2
- High suspicion of persistent common bile duct stones (jaundice, elevated bilirubin >4 mg/dL, dilated CBD >6mm on ultrasound) warrants early ERCP even without cholangitis. 2
- Available evidence suggests this intervention may reduce overall morbidity from severe attacks. 1, 3
ERCP Should NOT Be Performed
- Avoid routine ERCP in mild gallstone pancreatitis without jaundice, cholangitis, or bile duct dilation. 1, 4
- Do not use ERCP as a first-line diagnostic tool for idiopathic pancreatitis—EUS is preferred. 1, 4
- ERCP carries significant risks: post-procedure pancreatitis (3-5%), bleeding with sphincterotomy (2%), cholangitis (1%), and mortality (0.4%). 2
Important Technical Considerations
Antibiotic Coverage
- Always perform ERCP under antibiotic prophylaxis. 1
Therapeutic Intervention
- When ERCP identifies common bile duct stones, perform immediate sphincterotomy with stone extraction or stent placement. 1
- ERCP should be therapeutic, not merely diagnostic—facilities must have expertise available 24/7 for sphincterotomy and stone extraction. 1
Alternative Imaging Modalities
When NOT to Use ERCP
- For diagnostic evaluation of idiopathic or recurrent pancreatitis, use EUS as the preferred initial test, not ERCP. 1, 4
- MRCP is complementary to EUS for detecting ductal anomalies (pancreas divisum) and duct stones without the procedural risks of ERCP. 1
- Repeat ultrasound examination remains the most sensitive test for detecting missed gallstones after one negative study. 1
Common Pitfalls to Avoid
- Do not delay ERCP beyond 24 hours when cholangitis is present—this is the scenario with strongest mortality benefit. 1, 2
- Do not perform ERCP in mild pancreatitis with normal liver function tests and no CBD dilation—the procedural risks outweigh benefits. 1, 4
- Timing should be guided by clinical presentation (severity, cholangitis, biliary obstruction) rather than arbitrary time cutoffs. 2
- In patients unfit for surgery, ERCP with sphincterotomy alone can serve as definitive management of cholelithiasis. 1, 2