What are the indications, contraindications, preparation, prophylaxis, technique, complications, and post‑procedure care for ERCP (Endoscopic Retrograde Cholangiopancreatography)?

ERCP: Comprehensive Clinical Overview

Indications

ERCP is primarily indicated for therapeutic intervention in biliary and pancreatic duct obstruction, not as a first-line diagnostic tool. 1

Biliary Indications

• Acute gallstone pancreatitis with cholangitis – This is the strongest indication, with Grade 1B evidence showing significant mortality reduction and decreased local/systemic complications 2
• Common bile duct stones – Achieves 80-95% clearance rate with balloon sweep 1, 2
• Severe gallstone pancreatitis without clinical improvement within 48 hours – Urgent ERCP with sphincterotomy may reduce overall morbidity 1, 2
• Biliary obstruction from malignancy – For stent placement when extrahepatic obstruction is confirmed 1
• Preoperative CBD evaluation – Only when high suspicion exists (jaundice, deranged LFTs, dilated CBD on ultrasound); otherwise perform intraoperative cholangiogram 1
• Definitive management in medically unfit patients – Endoscopic sphincterotomy can serve as primary treatment when surgery is contraindicated 1, 2

Pancreatic Indications

• Pancreatic duct stones ≤5 mm – Conventional ERCP with sphincterotomy, dilation, and balloon/basket retrieval 1
• Pancreatic duct stones >5 mm – Requires ESWL for fragmentation or pancreatoscopy-directed lithotripsy when ESWL unavailable 1
• Symptomatic pancreatic duct obstruction in chronic pancreatitis – Though surgery shows superior outcomes in randomized trials, ERCP remains first-line due to less invasive nature 1

Diagnostic Indications (Limited)

• Brush cytology/forceps biopsy during therapeutic ERCP – Particularly for perihilar cholangiocarcinoma when biliary drainage needed, achieving specificity near 100% with combined techniques 1
• Anatomical variants and tumors – Only when therapeutic intervention is anticipated 1

Contraindications

Absolute Contraindications

• Suspected duodenal perforation – ERCP is not recommended in this setting 1
• Hemodynamically unstable patients – Stabilization required first 1

Relative Contraindications for EPBD (without sphincterotomy)

• Biliary strictures, ampullary/pancreatic/biliary malignancies 3
• Prior biliary surgery (except cholecystectomy) 3
• Acute pancreatitis 3
• Large common bile duct stones 3
• Prior precut sphincterotomy 3

Clinical Scenarios Where ERCP Should Be Avoided

• Jaundice from hepatitis/sepsis, alcoholic liver disease, or drug toxicity – No role for ERCP 1
• When MRCP or EUS can provide equivalent diagnostic information without therapeutic need – Avoid unnecessary procedural risk 1

Preparation

Pre-Procedure Imaging

• MRCP or EUS should precede ERCP when extrahepatic obstruction is suspected but therapeutic need is unclear, to avoid unnecessary ERCP 1
• MRCP before biliary stent placement provides precise ductal extent information and facilitates liver metastasis identification 1
• Perform MRCP in specialized centers for optimal accuracy approaching that of ERCP 1

Patient Optimization

• Renal function considerations: In patients with eGFR <30 mL/min/1.73 m², minimize iodinated contrast during fluoroscopy and consider CO2 cholangiography 4
• Recent contrast exposure: Consider alternative imaging if contrast-enhanced CT performed <72 hours prior and creatinine >1.5 mg/dL 4
• Coagulopathy: Consider EPBD without sphincterotomy as primary alternative to reduce hemorrhage risk 3

Anesthesia

• General anesthesia or propofol sedation is standard, performed in interventional suite or operating room 1, 5

Prophylaxis

Antibiotic Coverage

• Always perform ERCP under antibiotic cover to reduce infection risk, particularly in immunocompromised patients 2, 4
• Cefuroxime is currently recommended for prophylactic antibiotics in severe acute pancreatitis, though duration remains unclear 1

Post-ERCP Pancreatitis Prevention

• For EPBD without prior sphincterotomy: Use 8 mm diameter balloon with inflation ≥1 minute following waist disappearance to reduce pancreatitis risk to levels similar to sphincterotomy 3

Technique

Standard Approach

• Advance endoscope into duodenum with cannulation of ampulla of Vater 1
• Inject iodinated contrast into CBD with fluoroscopic imaging of biliary tree 6
• Concomitant procedures: Sphincterotomy, biopsy, or stent deployment (CBD or pancreatic) as indicated 1

Sampling Techniques

• Brush cytology: Minimum five passes for optimal sensitivity 1
• Forceps biopsy: Three samples ideally during ERCP, six during cholangioscopy 1
• Combined techniques: Achieves sensitivity up to 60% with specificity near 100% 1

Stone Management

• Stones ≤5 mm: Standard extraction with sphincterotomy, dilation, balloon/basket retrieval 1
• Stones >5 mm: ESWL achieves >90% fragmentation with subsequent ERCP clearance in two-thirds of patients 1
• Stones >15 mm: ERCP alone often unsuccessful; advanced endoscopic techniques required 1

Alternative Access Routes

• EUS-directed transgastric ERCP for surgically altered anatomy 5
• Overtube-assisted enteroscopy for selective cannulation in altered anatomy 5
• Laparoscopic surgery assistance when endoscopic access fails 5

Complications

Major Complications (4-5.2% overall rate) 1, 2, 3

Post-ERCP pancreatitis (3-10%)

• Most common complication, occurring in 3-5% of cases 1
• Risk increases to 10% with sphincterotomy 2, 3
• EPBD without sphincterotomy carries higher pancreatitis risk than sphincterotomy alone 3

Hemorrhage (0.1-2%)

• Occurs in 2% when combined with sphincterotomy 1
• Clinically significant hemorrhage in 0.1-2% of sphincterotomies 3
• EPBD demonstrates significantly lower hemorrhage rates versus sphincterotomy 3
• Coagulopathy is major risk factor 3

Cholangitis (1%)

• Risk of suppurative cholangitis from catheter manipulation of obstructed biliary system 1
• Occurs in <1% with modern technique 1

Perforation

• Included in major complication rate 1, 7
• Duodenal perforation can occur, may be managed conservatively with antibiotics and parenteral fluids 8

Mortality (0.4%)

• Procedure-related mortality consistently reported at 0.4% 1, 2

Technical Failures

• Failed cannulation: 9-14% of patients, influenced by duodenal edema/hematomas and anatomical changes 1
• Inadequate pancreatography: Can occur in up to 14% 1

Post-Procedure Care

Monitoring

• Close clinical observation in high-dependency environment with hemodynamic monitoring 1
• Serial clinical examination and laboratory assays to detect complications early 1
• Immediate access to diagnostics, interventional radiology, endoscopy, and surgery must be available 1

Follow-Up Imaging

• CT scanning indications: Clinical deterioration suggesting complications, guidance for interventional procedures, monitoring established complications 1
• Dynamic CT timing: Perform within 3-10 days in severe cases for optimal necrosis assessment 1

Specific Scenarios

• Renal failure patients: Do not delay urgent ERCP for cholangitis due to renal concerns, as mortality benefit of drainage outweighs contrast-induced nephropathy risk 4
• Stone clearance verification: May require repeat ERCP if initial clearance incomplete 1

Common Pitfalls to Avoid

• Performing purely diagnostic ERCP when non-invasive imaging (MRCP, EUS) would suffice 4
• Delaying ERCP in cholangitis due to concerns about comorbidities – mortality benefit outweighs procedural risk 2, 4
• Inadequate sampling: Ensure minimum five brush cytology passes and three forceps biopsies when malignancy suspected 1
• Premature CT scanning: Wait 3-10 days for optimal necrosis demarcation in severe pancreatitis 1