What are the guidelines for performing Endoscopic Retrograde Cholangiopancreatography (ERCP)?

ERCP Guidelines and Clinical Recommendations

Primary Indication and Role

ERCP should be reserved exclusively for therapeutic intervention when biliary or pancreatic ductal pathology requires endoscopic treatment—diagnostic ERCP is no longer appropriate given safer non-invasive alternatives. 1, 2

The procedure has evolved from a diagnostic to a primarily therapeutic modality, with MRCP and EUS now serving as first-line diagnostic tools. 1

Pre-Procedure Diagnostic Algorithm

Initial Evaluation

• Ultrasound is the mandatory first imaging study for suspected biliary obstruction—it is sensitive, specific, non-invasive, and cost-effective. 1
• If bile duct abnormalities are detected on ultrasound, proceed to MRCP or EUS before considering ERCP to determine if therapeutic intervention is actually needed. 1

When to Avoid ERCP

• MRCP or EUS must be performed first when the need for endoscopic intervention is unclear, as ERCP carries significant complication rates (pancreatitis 3-5%, bleeding 2%, cholangitis 1%, perforation risk, mortality 0.4%). 1, 2
• MRCP accuracy for detecting biliary obstruction approaches that of ERCP in experienced centers with modern technology. 1
• EUS is equivalent to MRCP for detecting bile duct stones and extrahepatic obstruction and may be preferred in experienced endoscopy units. 1

Indications for Therapeutic ERCP

ERCP is indicated only when therapeutic intervention is anticipated simultaneously, including: 1, 2

• Stone extraction from common bile duct
• Biliary or pancreatic stent placement
• Sphincterotomy
• Stricture dilation
• Tissue acquisition when combined with intervention

Specific Clinical Scenarios

• Moderate to severe acute cholangitis: ERCP is the treatment of choice for biliary decompression. 1
• Common bile duct stones: ERCP with sphincterotomy and stone extraction is the gold standard when stones cannot be managed surgically. 1
• Acute pancreatitis with biliary obstruction: ERCP facilities must be available on an emergency basis. 1
• Suspected pancreatic duct or biliary tree injury in trauma: ERCP can be used for both diagnosis and treatment in hemodynamically stable patients. 1

Procedural Requirements and Standards

Facility and Personnel Standards

• Every hospital receiving acute admissions must have a single nominated clinical team to coordinate ERCP services. 1
• ERCP should be concentrated among endoscopists performing high volumes, as success rates are higher and complication rates lower with adequate experience. 3, 4
• Specialist units must include multidisciplinary support: experienced endoscopists, interventional radiologists, surgeons, anesthesiologists, and critical care facilities. 1

Sedation and Anesthesia

• Enhanced sedation with propofol or general anesthesia should be strongly considered over conscious sedation alone, particularly for complex cases. 1
• Conscious sedation (benzodiazepine and opiate) is poorly tolerated in 14% of cases and is an important cause of procedure failure. 1
• Complex cases (cholangioscopy-assisted lithotripsy, intrahepatic stones) specifically require propofol-assisted or general anesthesia for optimal success rates. 1

Antibiotic Prophylaxis

• Prophylactic antibiotics covering biliary flora (enteric gram-negatives and enterococci) are mandatory before EUS-guided biliary drainage and recommended for ERCP in obstructed systems. 1
• Use second-generation cephalosporin or quinolone. 1
• Without specific risk factors (sclerosing cholangitis, communicating pancreatic cysts, hilar strictures, failed drainage), prophylactic antibiotics may be safely avoided. 1

Technical Specifications

Equipment Standards

• 19-gauge FNA needle allows passage of 0.035 or 0.025 inch guidewire for EUS-guided procedures, enabling efficient wire manipulation. 1
• 0.035 or 0.025 inch guidewire with floppy tip should be used to negotiate the bile duct. 1
• Metal stents are recommended over plastic stents for EUS-guided biliary drainage to reduce bile leak risk. 1

Pre-Procedure Imaging

• MRCP should be obtained prior to intervention in patients with hilar obstruction to create a roadmap and avoid draining non-dilated or non-drainable segments that could cause cholangitis. 1

High-Risk Situations and Contraindications

Patient-Related Risk Factors

The following patient factors significantly increase complication risk: 3, 4

• History of acute pancreatitis (strongest predictor)
• Suspected sphincter of Oddi dysfunction
• Female sex
• Young age (<40 years)
• Normal serum bilirubin
• Previous post-ERCP pancreatitis

Procedure-Related Risk Factors

These technical factors independently increase complication risk: 4

• Difficult cannulation
• Needle-knife papillotomy
• Transpancreatic sphincterotomy
• Pancreatic duct opacification (especially acinarization)
• Balloon sphincter dilation
• Precut sphincterotomy by less experienced endoscopists

When to Refer to Specialist Centers

• Patients with >30% pancreatic necrosis or complications requiring ITU care, interventional radiology, or complex endoscopic/surgical procedures must be managed in or referred to specialist units. 1
• Patients at high risk for complications should be referred to advanced centers with experienced, high-volume endoscopists. 3

Alternative Approaches

When ERCP Fails or is Contraindicated

• Percutaneous transhepatic biliary drainage (PTBD) should be reserved for patients in whom ERCP fails. 1
• Open surgical drainage only when endoscopic or percutaneous approaches are contraindicated or unsuccessful. 1
• EUS-guided biliary drainage is an alternative in patients with altered anatomy, though it requires highly specialized expertise. 1

Altered Anatomy Considerations

• Device-assisted ERCP is the procedure of choice for short-limb reconstruction, but success rates decrease significantly in long-limb reconstruction. 5
• Laparoscopic-assisted ERCP has nearly 100% success rate in long-limb reconstruction using conventional duodenoscopes. 5

Training Requirements

Training in therapeutic ERCP should only occur at expert centers with facilities and expertise in EUS, ERCP, and PTBD. 1

• Trainees must first be experienced in EUS-FNA, wire manipulation techniques, and biliary stent placement before commencing advanced biliary drainage training. 1
• Pig or ex vivo models should be incorporated into training programs. 1

Documentation and Consent

Written informed consent must be obtained with sufficient time for patient questions, documenting explanation of the procedure, therapeutic interventions, complication risks (including specific rates for pancreatitis, bleeding, perforation, and mortality), and alternative options. 6

The most common legal consequence of ERCP complications is civil negligence claims, emphasizing the importance of appropriate indications, trained endoscopists, standard techniques, and thorough documentation. 6