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Endoscopic retrograde cholangiopancreatography

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of endoscopic retrograde cholangiopancreatography are prepared by our editorial team based on guidelines from the American College of Gastroenterology (ACG 2024,2015), the American Society for Gastrointestinal Endoscopy (ASGE 2023,2021,2019,2017,2016,2015), the American Association for the Study of Liver Diseases (AASLD 2022), the European Society of Gastrointestinal Endoscopy (ESGE 2020,2019,2016), the World Society ...
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Classification and risk stratification

Risk factors for complications: as per ESGE 2020 guidelines, consider regarding patients as being at high risk for post-ERCP pancreatitis in the presence of at least one definite or two likely patient-related or procedure-related risk factors:
Situation
Guidance
Patient-related definite risk factors
Female gender, previous pancreatitis, previous post-ERCP pancreatitis, suspected sphincter of Oddi dysfunction
Procedure-related definite risk factors
Difficult cannulation
Pancreatic guidewire passages > 1
Pancreatic injection
Patient-related likely risk factors
Younger age
Nondilated extrahepatic bile duct
Absence of chronic pancreatitis
Normal serum bilirubin
ESRD
Procedure-related likely risk factors
Precut sphincterotomy
Pancreatic sphincterotomy
Biliary balloon sphincter dilation
Failure to clear bile duct stones
Intraductal ultrasound
C
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Diagnostic investigations

Coagulation studies: as per ESGE 2020 guidelines, avoid obtaining coagulation tests routinely before ERCP in patients not on anticoagulants and without jaundice.
D
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Diagnostic procedures

Diagnostic indications, pancreatobiliary pain: as per ASGE 2015 guidelines, do not perform diagnostic ERCP for the evaluation of pancreaticobiliary-type pain in the absence of objective abnormalities on other pancreaticobiliary imaging or laboratory studies.
D
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  • Diagnostic indications, acute pancreatitis

  • Diagnostic indications, choledocholithiasis

  • Diagnostic indications, PSC

  • Diagnostic indications, biliary strictures

  • Diagnostic indications, pancreatobiliary trauma

  • Diagnostic indications, pancreatic tumors (cystic lesions)

  • Diagnostic indications, pancreatic tumors (solid lesions)

  • Diagnostic indications, before laparoscopic cholecystectomy

Medical management

Management of bleeding
As per ESGE 2020 guidelines:
Consider administering local injection of epinephrine (1:10, 000), possibly combined with thermal or mechanical therapy when injection alone fails, for the management of persistent or delayed post-sphincterotomy bleeding.
C
Consider performing temporary placement of a biliary fully covered self-expandable metal stent for post-sphincterotomy bleeding refractory to standard hemostatic modalities.
C
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  • Management of perforation

  • Management of cholangitis

  • Management of pancreatitis

Therapeutic procedures

Therapeutic indications, acute cholangitis
As per ASGE 2021 guidelines:
Consider performing ERCP over percutaneous transhepatic biliary drainage in patients with cholangitis.
C
Consider performing ERCP within ≤ 48 hours after admission.
C
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  • Therapeutic indications, choledocholithiasis (general indications)

  • Therapeutic indications, choledocholithiasis (technical considerations)

  • Therapeutic indications, choledocholithiasis (cholangioscopic interventions)

  • Therapeutic indications, choledocholithiasis (post-ERCP cholecystectomy)

  • Therapeutic indications, acute pancreatitis

  • Therapeutic indications, sphincter of Oddi dysfunction

  • Therapeutic indications, PSC

  • Therapeutic indications, postoperative biliary leaks

Specific circumstances

Pediatric patients: as per NASPGHAN 2018 guidelines, perform ERCP for the management of acute pancreatitis related to choledocholithiasis causing biliary pancreatitis, and for pancreatic duct pathologies, such as ductal stones or ductal leaks.
E
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  • Pregnant patients (general principles)

  • Pregnant patients (prevention of post-ERCP pancreatitis)

  • Patients with altered anatomy

Patient education

Informed consent: as per ESGE 2020 guidelines, obtain both oral and written informed consent before ERCP, taking into account individual and procedure-related risks, correct indication, and urgency of ERCP, as well as national practice.
B
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Preventative measures

Prevention of pancreatitis, proceduralist expertise: as per ASGE 2017 guidelines, ensure that clinicians performing ERCP are facile with procedural techniques reducing the risk of pancreatitis (wire-guided cannulation, prophylactic pancreatic duct stenting).
A
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  • Prevention of pancreatitis (rectal NSAIDs)

  • Prevention of pancreatitis (IV fluids)

  • Prevention of pancreatitis (sublingual nitrates)

  • Prevention of pancreatitis (epinephrine)

  • Prevention of pancreatitis (protease inhibitors)

  • Prevention of pancreatitis (pancreatic stenting)

  • Prevention of pancreatitis (primary biliary cannulation)

  • Prevention of pancreatitis (difficult biliary cannulation, definition)

  • Prevention of pancreatitis (difficult biliary cannulation, contrast- or guidewire-assisted cannulation)

  • Prevention of pancreatitis (difficult biliary cannulation, pancreatic guidewire-assisted cannulation)

  • Prevention of pancreatitis (difficult biliary cannulation, precut sphincterotomy)

  • Prevention of pancreatitis (difficult biliary cannulation, transpancreatic biliary sphincterotomy)

  • Prevention of pancreatitis (difficult biliary cannulation, periampullary diverticulum)

  • Prevention of pancreatitis (difficult biliary cannulation, cannulation, and sphincterotomy of the minor papilla)

  • Prevention of pancreatitis (endoscopic papillary balloon dilation)

  • Prevention of pancreatitis (rendezvous ERCP)

  • Prevention of bleeding (sphincterotomy)

  • Prevention of bleeding (electrosurgical current mode)

  • Prevention of infection (antibiotic prophylaxis)

  • Prevention of infection (duodenoscope reprocessing)

  • Prevention of contrast allergy

Quality improvement

Quality indicators, preprocedural: as per ASGE 2015 guidelines, record and document the frequencies of the following as preprocedural quality indicators for ERCP:
endoscopy is performed for an indication included in a published standard list of appropriate indications
B
informed consent is obtained
B
preprocedure history is elicited and directed physical examination is performed
B
risk for adverse events is assessed before sedation
B
prophylactic antibiotics are administered only in selected settings where indicated
B
a sedation plan is documented
B
management of antithrombotic therapy is formulated in print before the procedure
B
a team pause is conducted
B
endoscopy is performed by a specialist fully trained and credentialed to perform that particular procedure.
B
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  • Quality indicators (intraprocedural)

  • Quality indicators (postprocedural)