From the Guidelines
ERCP is indicated for therapeutic purposes in conditions affecting the biliary and pancreatic ducts, including removal of bile duct stones, management of biliary obstruction due to malignancy, and treatment of biliary leaks, with a risk of major complications ranging from 4% to 5.2%. The primary indications for ERCP include:
- Removal of bile duct stones, which can be cleared in 80% to 95% of cases 1
- Management of biliary obstruction due to malignancy, with ERCP being the standard procedure for stent placement in cases of obstructive jaundice 1
- Treatment of biliary leaks, evaluation and treatment of chronic pancreatitis, assessment of unexplained abnormal liver function tests, and diagnosis of primary sclerosing cholangitis 1 ERCP is particularly valuable for treating jaundice caused by common bile duct obstruction, placing stents to relieve strictures, and extracting stones using techniques such as sphincterotomy and balloon extraction 1. However, ERCP should be used judiciously due to potential complications including pancreatitis, bleeding, perforation, and infection 1. Less invasive alternatives like magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) are preferred for purely diagnostic purposes, with ERCP reserved for cases where therapeutic intervention is likely needed 1. Proper patient selection and preparation, including antibiotic prophylaxis for high-risk patients and management of anticoagulation, are essential for optimal outcomes 1.
From the Research
ERCP Indications
- ERCP is commonly performed for choledocholithiasis with or without cholangitis 2
- It is also used for the management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks 2
- ERCP is a minimally invasive treatment option for choledocholithiasis, with a primary treatment goal of removing bile duct stones 3
- The procedure is also used for the evaluation and treatment of other hepatobiliary and pancreatic diseases, including gallstone pancreatitis and Mirizzi syndrome 3, 4
Patient Selection
- Patients with suspected choledocholithiasis are stratified into low, intermediate, or high risk for choledocholithiasis based on the presence of predictors such as clinical ascending cholangitis, common bile duct stones on ultrasonography, and total bilirubin levels 4
- High-risk patients have a higher likelihood of confirmed choledocholithiasis on ERCP, with a sensitivity of 86% and positive predictive value of 79.8% 4
- ERCP can be considered as a definitive management option for treating common bile duct stones in the elderly, particularly in the comorbid population 5
Procedure Outcomes
- ERCP has a high success rate for stone removal, with a reported success rate of 90% in one study 5
- Factors associated with unsuccessful stone extraction include previous surgical sphincteroplasty, stone size, and Billroth I anastomosis 6
- The overall ERCP complication rate is reported to be around 7%, with no cases of post-ERCP pancreatitis or death in one study 5
- Recurrent lithiasis is diagnosed in around 4.3% of patients, with factors associated with recurrence including stone size, dilation of infundibulum, and the presence of periampullary diverticula 6