What is the guideline for ERCP (Endoscopic Retrograde Cholangiopancreatography) with stone extraction in a patient with a confirmed bile duct stone?

ERCP with Stone Extraction for Common Bile Duct Stones

All patients with confirmed common bile duct stones (CBDS) should be offered stone extraction via ERCP with biliary sphincterotomy, as this prevents serious complications including pancreatitis, cholangitis, and biliary obstruction in approximately 75% of patients who would otherwise experience unfavorable outcomes. 1

Core Recommendation

• Stone extraction is strongly recommended for all patients with confirmed CBDS who are fit enough to tolerate the procedure, with the greatest evidence of benefit in symptomatic patients 1, 2
• The British Society of Gastroenterology (BSG) emphasizes that leaving stones in situ results in a 25.3% rate of unfavorable outcomes (pancreatitis, cholangitis, obstruction) compared to only 12.7% when extraction is attempted 1
• This recommendation applies even to small stones (<4 mm), where conservative management still carries a 15.9% complication rate versus 8.9% with planned extraction 1

Pre-Procedure Requirements

Laboratory Testing:

• Full blood count (FBC) and INR/PT must be obtained before biliary sphincterotomy 1
• If coagulopathy or thrombocytopenia is identified, correct according to local protocols before proceeding 1
• Patients on warfarin, antiplatelet agents, or direct oral anticoagulants (DOACs) should be managed per combined BSG/ESGE endoscopy guidelines 1

Anesthesia Support:

• Hospitals managing CBDS patients must have ready access to propofol sedation or general anesthesia-supported ERCP, either on-site or through a clinical network 1
• This improves tolerability and therapeutic success rates in selected patients 1

Standard ERCP Technique

Primary Approach:

• Biliary sphincterotomy followed by balloon or basket extraction is the first-line treatment for post-cholecystectomy CBDS 1
• Standard techniques successfully remove stones in 85-90% of cases 3, 4

For Large or Difficult Stones:

• Limited sphincterotomy combined with endoscopic papillary large-balloon dilation (EPBD) is recommended as first-line for difficult stones 1, 2
• This combination has high-quality evidence supporting its use 1
• Mechanical lithotripsy should be available in all ERCP units as a readily accessible adjunct 4

Management of Difficult Stones

When standard extraction fails (10-15% of cases) 3, 4:

• Cholangioscopy-guided lithotripsy (electrohydraulic or laser) is strongly recommended when other endoscopic options fail 1, 2
• Success rates for cholangioscopy-guided lithotripsy range from 73-97% 1
• If immediate extraction fails, place two or more temporary biliary plastic stents for duct decompression 2, 4
• Consider adding ursodiol to aid stone fragmentation and dissolution 4
• Attempt repeat ERCP after stent placement and medical therapy 4

Alternative EPBD Strategy:

• EPBD without prior sphincterotomy may be considered in patients with uncorrected coagulopathy or difficult biliary access due to altered anatomy 1
• However, this approach carries increased risk of post-ERCP pancreatitis (PEP) 1
• If performed without sphincterotomy, use an 8 mm diameter balloon 1

Post-ERCP Pancreatitis Prevention

• Administer rectal NSAIDs to all patients undergoing ERCP 1
• In patients at high risk for PEP from repeated pancreatic duct cannulation, insert a pancreatic stent in addition to rectal NSAIDs 1

Clinical Context-Specific Timing

Acute Cholangitis:

• Patients failing antibiotic therapy or with septic shock require urgent biliary decompression via ERCP with stone extraction and/or stenting 1
• Severe cholangitis with septic shock: within 12 hours 2
• Moderate cholangitis: within 48-72 hours 2
• Mild cholangitis: elective timing 2

Gallstone Pancreatitis:

• Patients with cholangitis or persistent biliary obstruction require biliary sphincterotomy and stone extraction within 72 hours of presentation 1
• This recommendation has high-quality evidence 1
• Patients not requiring urgent ERCP should be considered for elective ERCP if imaging shows retained CBDS or if they are unsuitable for cholecystectomy 1

Surgical Alternatives

• Laparoscopic bile duct exploration (LBDE) via transcystic or transductal approach is equally valid to perioperative ERCP 1
• LBDE shows no difference in efficacy, mortality, or morbidity compared to ERCP, though it is associated with shorter hospital stays 1
• Both approaches should be considered equally valid treatment options 1

Altered Anatomy Considerations

• ERCP can be successfully performed in Billroth II anatomy; use forward-viewing endoscope if duodenoscope access is difficult 1
• Patients with Roux-en-Y gastric bypass (RYGB) and CBDS should be referred to centers offering advanced endoscopic and surgical options 1

Critical Pitfalls to Avoid

• Do not assume normal ultrasound and liver function tests exclude CBDS if clinical suspicion remains high 1
• Do not leave confirmed CBDS untreated based on small size alone—even stones <4 mm warrant extraction 1
• Ensure competency in access papillotomy for all endoscopists performing ERCP 1
• Do not attempt ERCP for difficult stones without access to mechanical lithotripsy and cholangioscopy capabilities, or establish referral pathways to tertiary centers 1, 4

Post-Extraction Management

• Perform laparoscopic cholecystectomy within 2 weeks of ERCP to reduce conversion rates and prevent recurrent biliary events 2
• For mild gallstone pancreatitis specifically, cholecystectomy should be performed within 2 weeks and preferably during the same admission 1