ERCP for Bile Diversion in Perforated Cholecystitis
ERCP is contraindicated in acute cholecystitis with gallbladder perforation and biliary peritonitis, and immediate surgical intervention is the treatment of choice for this life-threatening condition. 1
Why ERCP is Contraindicated
Suspected or confirmed gallbladder perforation with biliary peritonitis is an absolute contraindication for ERCP. 1 This is a critical safety consideration that supersedes any potential benefit of endoscopic bile diversion.
The presence of free bile in the peritoneal cavity from perforation creates a surgical emergency requiring source control, not endoscopic manipulation. 2
Appropriate Management Algorithm
Immediate Surgical Intervention
Early diagnosis of gallbladder perforation and immediate surgical intervention substantially decreases morbidity and mortality rates. 2 Delays in surgical management directly correlate with worse outcomes.
Surgery should address both the perforated gallbladder (source control) and the peritoneal contamination through cholecystectomy and peritoneal lavage. 2
When ERCP Is Indicated in Cholecystitis
ERCP has a role in cholecystitis only under specific circumstances that do not include perforation:
ERCP is the treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis complicating cholecystitis. 2 This applies when there is ascending infection in the bile duct system, not gallbladder perforation.
For bile leaks occurring after cholecystectomy (postoperative leaks from cystic duct stump or ducts of Luschka), ERCP with stenting is highly effective with success rates of 87-100%. 2, 3 However, this is a completely different clinical scenario from acute perforation.
Role of ERCP in Postoperative Bile Leaks (Not Acute Perforation)
To clarify the distinction: if a patient develops a bile leak after cholecystectomy has been performed for the perforated gallbladder, then ERCP becomes appropriate:
ERCP is the first-line therapy for postoperative biliary leaks, with success rates ranging between 87.1% and 100%. 2 The goal is reducing transpapillary pressure gradient through stent placement with or without sphincterotomy.
Biliary stenting achieves faster fistula closure (mean 4.5 days) compared to sphincterotomy alone (6.5 days), particularly in patients with non-dilated common bile ducts. 3
Endoscopic treatment involves placing plastic stents for 4-8 weeks, with removal after cholangiography confirms leak resolution. 2
Common Pitfalls to Avoid
Never attempt ERCP in the setting of suspected or confirmed gallbladder perforation with peritonitis. 1 This delays necessary surgical intervention and exposes the patient to procedural risks without addressing the source of contamination.
Do not confuse acute cholecystitis with perforation (requiring surgery) with acute cholangitis (where ERCP is first-line). 2, 4 These are distinct entities with different management algorithms.
Failing to recognize that bile diversion through ERCP cannot substitute for surgical source control when there is free perforation and peritoneal soilage. 2
In critically ill patients with acute cholecystitis who are unfit for surgery, cholecystostomy (percutaneous drainage of the gallbladder) is appropriate—but this is different from ERCP and applies to non-perforated cases. 2
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