ERCP Imaging and Intervention

Technical Aspects of ERCP

The American College of Radiology recommends ERCP for visualizing the biliary and pancreatic ductal systems by injecting contrast through an endoscope, creating cholangiograms and pancreatograms that show the anatomy and pathology of these ductal structures 1, 2
ERCP is performed by advancing an endoscope into the duodenum, cannulating the ampulla of Vater, and injecting contrast into the common bile duct (CBD) while obtaining fluoroscopic images to visualize the biliary tree 1, 2
The procedure captures real-time fluoroscopic images during contrast injection, creating a "roadmap" of the bile ducts and pancreatic ducts 2
Images demonstrate the intrahepatic bile ducts, extrahepatic bile ducts, common hepatic duct, CBD, cystic duct, and pancreatic duct system 1

In Primary Sclerosing Cholangitis (PSC), ERCP shows multifocal intrahepatic and extrahepatic bile duct strictures creating a characteristic "beaded" appearance, slight biliary dilatation with diverticular outpouchings, and a "pruned tree" appearance in chronic stages 3, 4
In Biliary Obstruction, ERCP reveals filling defects representing stones within the ductal system, strictures with upstream ductal dilatation, and abrupt cutoffs suggesting malignant obstruction 1, 2
In Periampullary Perforation (Type 2), ERCP demonstrates contrast extravasation beyond the normal ductal boundaries and visualization of retroperitoneal air on fluoroscopy 5

The American College of Radiology suggests that ERCP has shifted to a primarily therapeutic role due to advances in cross-sectional imaging, and should be reserved for cases requiring tissue acquisition or therapeutic intervention 1, 2, 6
ERCP is indicated when therapeutic intervention is anticipated simultaneously, such as stone extraction, stent placement, or sphincterotomy 1, 6
The procedure carries a 4-5.2% risk of major complications, including pancreatitis, cholangitis, hemorrhage, and perforation, and a 0.4% mortality risk 1, 2
Perforation risk is particularly elevated with sphincterotomy and in patients with altered anatomy 5