ERCP and Pancreaticobiliary Endoscopy
ERCP is high-risk and indication-driven
ERCP should be performed when a biliary or pancreatic intervention is likely, not merely to image. Common indications include choledocholithiasis with obstruction, ascending cholangitis, malignant biliary obstruction, postoperative bile leak, and selected pancreatic disease. Risk-stratify with clinical features, liver tests, and ultrasound; for low or intermediate probability of a common bile duct stone, MRCP or EUS first avoids unnecessary ERCP. Cholangitis with sepsis warrants urgent ERCP, generally within 24 hours, along with antibiotics and resuscitation.
Technique: prone or semi-prone positioning, deep sedation or anesthesia, selective biliary cannulation with a wire-guided approach, and limited contrast injection to avoid post-ERCP pancreatitis. Sphincterotomy, balloon sweep, and stent placement follow. Plastic stents are used for short-term drainage and need exchange or removal, usually within about 3 months; self-expandable metal stents are preferred for malignant palliation and selected benign strictures. Biliary dilation and cholangioscopy are adjuncts.
Prevent post-ERCP pancreatitis in average- and high-risk patients with rectal indomethacin (100 mg) plus aggressive lactated Ringer hydration, and consider a prophylactic pancreatic stent in high-risk cannulation. Complications include pancreatitis, bleeding, perforation, and cholangitis.
Traps: performing ERCP for a low-probability stone, omitting rectal indomethacin, forgetting to arrange plastic stent removal, and using a metal stent for a benign stricture without a plan.
Worked example: a 70-year-old with fever, right upper quadrant pain, jaundice, and a 12 mm common bile duct with stones has cholangitis. Treat with antibiotics and fluids, then urgent ERCP with sphincterotomy and stone extraction, plus rectal indomethacin.