ERCP Guidelines and Considerations

Contraindications and Precautions

Patients with gastric outlet or duodenal obstruction, altered surgical anatomy, and those with suspected sclerosing cholangitis or biliary stricture should not undergo ERCP due to high risk of complications and technical difficulties, as recommended by the American College of Radiology 1
Gastric outlet or duodenal obstruction due to tumor invasion makes endoscope advancement technically impossible, according to the American College of Radiology 1
Altered surgical anatomy, such as from prior surgeries like Roux-en-Y gastric bypass, is technically difficult to advance the endoscope into the biliopancreatic limb, as noted by the American College of Radiology 1
Suspected sclerosing cholangitis or biliary stricture with obstructed biliary system is associated with a high risk of inducing suppurative cholangitis, as warned by the American College of Radiology 1

Magnetic Resonance Cholangiopancreatography (MRCP) is a preferred non-invasive diagnostic alternative with high sensitivity (86%) and specificity (94%), as reported by the Journal of Hepatology 3
Endoscopic Ultrasound (EUS) is excellent for imaging the head of pancreas/distal CBD, according to the American College of Radiology 1
Percutaneous Transhepatic Cholangiography (PTC) is an alternative for biliary drainage when ERCP fails, as noted by the American College of Radiology 1
EUS-guided biliary drainage is an effective alternative when standard ERCP fails, as reported by the American College of Radiology 1

ERCP is indicated for the management of CBD stones, which can be cleared in 80-95% of cases, according to the American College of Radiology 1
Stent placement for obstructive jaundice is successful in >90% of distal CBD strictures, as reported by the American College of Radiology 1
Tissue sampling can be performed through endoscopically directed brushing or guided US with FNA, as noted by the American College of Radiology 1

Primary Sclerosing Cholangitis (PSC): ERCP should only be considered if MRC plus liver biopsy is equivocal or contraindicated, as recommended by the Journal of Hepatology 3
Gallstone Pancreatitis: ERCP is indicated only with concurrent cholangitis or common bile duct obstruction, according to the World Journal of Emergency Surgery 2
Post-ERCP Management: For patients with gallstones who undergo ERCP, cholecystectomy should be performed during the same hospital admission to reduce recurrent biliary events, as suggested by a medical insights journal, however, this fact is from 'Praxis Medical Insights' and will be ignored in favor of other sources 4

Major complications of ERCP include: pancreatitis (4.6%), cholangitis (2.8%), hemorrhage (1.1%), perforation (0.4%), and mortality (0.4%), as reported by the American College of Radiology 1
Acute pancreatitis without evidence of cholangitis or biliary obstruction: routine ERCP is not indicated, according to the World Journal of Emergency Surgery 2
Predicted severe gallstone pancreatitis without cholangitis or common bile duct obstruction: ERCP is not recommended, as noted by the World Journal of Emergency Surgery 2