What are the indications and guidelines for Endoscopic Retrograde Cholangiopancreatography (ERCP) in adult patients?

ERCP Indications and Guidelines in Adult Patients

ERCP should be reserved exclusively for therapeutic interventions in adult patients, not for diagnostic purposes, as non-invasive imaging (MRCP, EUS) has replaced its diagnostic role. 1

Primary Therapeutic Indications

Biliary Obstruction and Choledocholithiasis

• Common bile duct stones are the most frequent indication, with ERCP achieving 80-95% clearance success rates 2
• Pre-procedural imaging with EUS or MRCP is mandatory before ERCP to confirm stone presence and reduce unnecessary procedures—22% of ERCPs performed for suspected stones are negative 3
• Timing is critical: EUS or MRCP should be performed within 2 days before ERCP to maximize stone detection (odds ratio 2.35 for positive findings) 3

Acute Gallstone Pancreatitis

• ERCP with sphincterotomy within 24 hours is strongly indicated for acute gallstone pancreatitis with cholangitis, as it significantly reduces mortality and complications 2
• For acute gallstone pancreatitis with common bile duct obstruction, ERCP reduces local complications 2
• In severe gallstone pancreatitis without clinical improvement within 48 hours, urgent ERCP may reduce overall morbidity 2
• Increasingly deranged liver function tests with cholangitis signs require immediate therapeutic ERCP 2

Primary Sclerosing Cholangitis (PSC)

• ERCP should NOT be performed until expert multidisciplinary assessment justifies endoscopic intervention 1
• Specific indications in PSC include:
  • New or worsening jaundice, fever/chills suggesting cholangitis, or worsening pruritus 1
  • Rapid increase in serum bilirubin or cholestatic enzymes (ALP, GGT) 1
  • New dominant strictures or progression on MRCP with appropriate clinical findings 1
• Pathological sampling (brush cytology, forceps biopsy) is mandatory during ERCP for dominant strictures to exclude cholangiocarcinoma 1
• Biliary balloon dilation is preferred over stent insertion for dominant strictures (7% vs 45% complication rates) 1

Cholangiocarcinoma Evaluation

• ERCP with brush cytology and forceps biopsy (minimum 5 passes for brushings, 3 samples for biopsies) provides near 100% specificity when positive, though sensitivity is only 60% 1
• Transpapillary sampling should be performed during ERCP when biliary drainage is indicated 1

Post-Surgical Complications

• Biliary leaks after laparoscopic cholecystectomy (cystic duct stump leaks, ducts of Luschka) are successfully treated with temporary stenting or 3-7 days nasobiliary drainage 4
• ERCP can be performed safely within 24 hours of laparoscopic cholecystectomy when complications are suspected 4

Contraindications to ERCP

• Hemodynamically unstable patients should not undergo ERCP 1
• Purely diagnostic purposes when non-invasive imaging is available 1, 5
• Patients without expert multidisciplinary assessment in PSC cases 1

Pre-Procedural Requirements

Antibiotic Prophylaxis

• Prophylactic antibiotics are mandatory for PSC patients undergoing ERCP 1
• Active cholangitis requires antibiotic treatment before ERCP 5
• All ERCPs should be performed under antibiotic cover to reduce infection risk 2

Pancreatitis Prevention

• Rectal administration of 100mg diclofenac or indomethacin immediately before or after ERCP is recommended for all patients without contraindication 1
• In high-risk patients, placement of a 5-Fr prophylactic pancreatic stent should be considered in addition to NSAIDs 1

Operator Experience

• ERCP should be performed by experienced pancreaticobiliary endoscopists, particularly in PSC where complication rates are higher 1
• Primary cannulation success rates are approximately 88% in experienced hands 1

Complication Rates and Risks

• Overall complication rate: 4-5.2% in general population 2, 5
• Post-ERCP pancreatitis: 3-10% depending on technique and patient factors 2, 6
• Cholangitis, hemorrhage, and perforation are additional major complications 6
• Mortality risk: 0.4% in general population, substantially higher in decompensated cirrhosis 2, 5
• PSC patients have increased complication risk (1.8-18.4% in various studies) compared to other indications 1

Critical Pitfalls to Avoid

• Do not delay ERCP for common bile duct stones, as this may lead to complications including pancreatitis 4
• Never perform ERCP without pre-procedural MRCP in established PSC to confirm indication and provide imaging guidance 1
• Avoid stent insertion in PSC dominant strictures unless balloon dilation fails—stents have 45% complication rates vs 7% for balloon dilation 1
• Do not use ERCP as first-line diagnostic tool—reserve for therapeutic intervention only 1, 5