ERCP in Acute Biliary Pancreatitis
Direct Recommendation
Perform urgent ERCP within 24 hours only in patients with acute biliary pancreatitis who have concurrent cholangitis (fever, rigors, positive blood cultures, deranged liver function tests); for all other patients with predicted or actual severe pancreatitis, jaundice, or dilated common bile duct, perform early ERCP within 72 hours of symptom onset. 1, 2
Clinical Algorithm for ERCP Timing
Urgent ERCP (Within 24 Hours)
Perform immediately if any of the following are present:
- Acute cholangitis (fever, rigors, positive blood cultures, increasingly deranged liver function tests) 1, 2
- This is the only absolute indication for urgent intervention, as delay increases morbidity and mortality 2, 3
Early ERCP (Within 72 Hours)
Perform if any of the following are present WITHOUT cholangitis:
- Predicted or actual severe pancreatitis (Glasgow score ≥3, APACHE II score indicating severity, persistent organ failure >48 hours, obesity, CRP >150 mg/L at 48 hours) 1, 2
- Persistent jaundice or worsening liver biochemistry 1, 2
- Dilated common bile duct on imaging 1, 2
- Failure to improve within 48 hours despite intensive resuscitation 1, 2
No Urgent/Early ERCP Required
For mild biliary pancreatitis without the above features:
- Conservative management with elective ERCP if needed 4
- Most bile duct stones pass spontaneously into the duodenum 4
Technical Requirements
All ERCPs must be performed under antibiotic cover to prevent infectious complications 1, 2
Endoscopic sphincterotomy is mandatory in all patients undergoing early ERCP for severe gallstone pancreatitis, whether or not stones are found in the bile duct 1, 2
For patients with cholangitis, sphincterotomy or duct drainage by stenting is required to ensure relief of biliary obstruction 1, 2
Evidence Quality and Nuances
The recommendation for urgent ERCP in cholangitis is universally supported across all guidelines 1, 2, 3. However, the benefit of early ERCP (within 72 hours) for severe pancreatitis without cholangitis shows conflicting evidence:
Supporting early ERCP: One study showed emergency ERCP within 24 hours for predicted severe attacks resulted in only 1% mortality with successful stone clearance in all patients 5. Another study demonstrated better outcomes with ERCP within 24 hours compared to 72 hours (4% vs 6% mortality) 6
Against routine early ERCP: A multicenter randomized trial found early ERCP within 72 hours was not superior to conventional treatment in patients without biliary sepsis or obstructive jaundice, with potentially elevated mortality from emergency ERCP 4. A 2018 study found no difference in outcomes between urgent (<24h) and early (24-72h) ERCP in patients with biliary obstruction without cholangitis 7
The consensus from the highest quality guidelines (UK BSG 2005, Praxis summaries of AGA/ACG/ASGE) supports early ERCP within 72 hours for severe pancreatitis with the specific features listed above, but NOT routine urgent ERCP for all biliary pancreatitis. 1, 2, 3
Post-ERCP Management
Definitive cholecystectomy must be performed during the same hospital admission, or no later than 2-4 weeks after discharge to prevent potentially fatal recurrent pancreatitis 8, 2, 3. This is critical—delaying beyond 2-4 weeks significantly increases recurrent biliary events 8, 3
For mild gallstone pancreatitis, perform laparoscopic cholecystectomy as soon as the patient has recovered, preferably during the same admission 1, 8, 3
For severe pancreatitis, defer cholecystectomy until the inflammatory process has subsided and the procedure is technically safer 1, 8
Common Pitfalls to Avoid
Never delay ERCP in patients with cholangitis—this is the one scenario where immediate intervention (within 24 hours) is mandatory and delay increases mortality 2, 3
Do not perform routine urgent ERCP in all biliary pancreatitis patients—the evidence shows this may increase rather than decrease mortality in patients without cholangitis or severe disease 3, 4
Never delay cholecystectomy beyond 2-4 weeks in patients fit for surgery, as this dramatically increases the risk of recurrent pancreatitis 8, 2, 3
Always perform ERCP under antibiotic prophylaxis to reduce infectious complications 1, 2
Success Rates and Complications
ERCP is successful in 89-95% of cases, with CBD stone detection in 43-69% of patients 5, 6, 9
Stone clearance is successful in 80-95% of cases 2
Procedure-related complications occur in 3-5%, including post-ERCP pancreatitis (3-5%), bleeding with sphincterotomy (2%), cholangitis (1%), and mortality (0.4%) 2