When is Endoscopic Retrograde Cholangiopancreatography (ERCP) indicated?

When is ERCP Indicated?

ERCP is primarily indicated for therapeutic management of common bile duct stones (clearable in 80-95% of cases), biliary stent placement for obstructive jaundice, and urgent intervention in acute gallstone pancreatitis with cholangitis or persistent biliary obstruction. 1, 2, 3

Primary Therapeutic Indications

Common Bile Duct Stones

• ERCP with sphincterotomy remains the gold standard for CBD stone management, achieving clearance via balloon sweep in 80-95% of cases 1, 2, 3
• Can be performed as initial diagnostic and therapeutic modality when there is high suspicion for CBD stones 1
• May be curative when performed prior to cholecystectomy, though 5% of patients develop recurrent primary CBD stones 1

Acute Gallstone Pancreatitis

• ERCP with sphincterotomy is strongly indicated (Grade 1B) for acute gallstone pancreatitis with concomitant cholangitis—perform within 24 hours 3
• Indicated for gallstone pancreatitis with persistent CBD obstruction—perform within 72 hours (Grade 2B evidence) 3
• Consider urgent ERCP in severe gallstone pancreatitis without clinical improvement within 48 hours to reduce overall morbidity 3
• Increasingly deranged liver function tests with signs of cholangitis require immediate therapeutic ERCP 3

Biliary Obstruction and Stenting

• ERCP is the standard procedure for stent placement in obstructive jaundice, successful in >90% of cases for distal CBD strictures 1
• Appropriate for patients who are not surgical candidates or when there is delay to definitive surgical resection 1
• Standard ERCP is sufficient for biliary decompression in 90-95% of patients requiring drainage 1

Secondary Indications

Malignant Obstruction

• Indicated in suspected malignant biliary obstruction with negative or equivocal CT/MRI, particularly when combined with EUS for tissue diagnosis 1
• Superior sensitivity for ampullary carcinoma detection, though does not provide staging information 1
• Brush cytology sensitivity is 68% for biliary malignancies but only 46% for pancreatic malignancies 1

Biliary Strictures and Leaks

• Used for management of benign strictures, though perform with caution in suspected sclerosing cholangitis as suppurative cholangitis may be induced by catheter manipulation 1
• Indicated for biliary leaks after laparoscopic cholecystectomy 2

Pancreatic Applications

• ERCP-guided FNA for solid pancreatic neoplasms shows sensitivity of 82.4% for pancreatic head lesions but only 57.1% for body/tail lesions 1
• Management of pancreatic duct stones in select cases 4

Critical Risk-Benefit Considerations

Complication Profile

• Major complication risk: 4-5.2% (pancreatitis, cholangitis, hemorrhage, perforation) 1, 3
• Mortality risk: 0.4% 1, 3
• Iatrogenic pancreatitis risk up to 10% with sphincterotomy 1, 3
• Always perform under antibiotic cover to reduce infection risk 3

When ERCP Should NOT Be First-Line

• ERCP has evolved to an almost exclusively therapeutic role due to advances in non-invasive imaging (MRCP) 1, 2
• For diagnostic purposes alone, MRCP should be performed first in most cases to avoid unnecessary procedural risk 1, 5
• MRCP-first strategy can avoid ERCP in approximately 50% of patients with suspected biliary obstruction 5

Technical Limitations

• Limited utility in patients with previous gastroenteric anastomoses due to difficulty advancing the endoscope 1
• Factors contributing to ERCP failure include gastric outlet obstruction, duodenal obstruction from tumor, or altered anatomy from prior surgery 1
• Alternative approaches (percutaneous transhepatic cholangiography, EUS-guided biliary drainage) are effective when standard ERCP fails 1

Common Pitfalls to Avoid

• Do not perform ERCP purely for diagnosis when non-invasive imaging (MRCP) can provide equivalent information without procedural risk 1, 2
• Exercise extreme caution in sclerosing cholangitis or biliary stricture cases due to risk of inducing suppurative cholangitis 1
• Ensure appropriate patient selection by weighing the 4-5% major complication risk against therapeutic benefit 1
• Do not delay ERCP beyond 24 hours in gallstone pancreatitis with cholangitis, as this significantly reduces mortality 3