ERCP in Acute Pancreatitis

Perform urgent therapeutic ERCP in acute biliary pancreatitis with acute cholangitis. Cholangitis is bacterial infection superimposed on biliary obstruction, most commonly from common bile duct stones; initial management requires antibiotics followed by adequate biliary drainage, preferably by ERCP. Untreated mortality has been reported as high as 50%, whereas mortality below 2% is achievable with adequate treatment. WileyWileyPerformance of diagnostic tools for acute cholangitis in patients with suspected biliary obstruction - Sperna Weiland - 2022 - Journal of Hepato-Biliary-Pancreatic Sciences - Wiley Online Library

Treat severe gallstone pancreatitis with progressively deranged liver tests plus cholangitis features—fever, rigors, or positive blood cultures—as an immediate ERCP indication. At ERCP, perform common bile duct evaluation and achieve drainage with sphincterotomy, stone extraction, or biliary stenting as anatomically required. BMJBMJUnited Kingdom guidelines for the management of acute pancreatitis | Gut

In acute biliary pancreatitis with biliary obstruction but no cholangitis, select ERCP for a persistent obstruction phenotype rather than automatically performing it at presentation. A study comparing timing strategies found urgent ERCP was not superior to early ERCP in biliary obstruction without cholangitis; timing should be individualized to illness severity, obstruction suspicion, and response to initial conservative management. Wolters Kluwer+1Wolters KluwerEmergency Endoscopic Retrograde Cholangiopancreatography Did ...ScienceDirectAcute biliary conditions

Avoid routine early ERCP in unselected acute gallstone pancreatitis. In a Cochrane review, early routine ERCP versus early conservative management did not produce statistically significant differences in mortality (risk ratio 0.74, 95% CI 0.18-3.03), local complications (risk ratio 0.86, 95% CI 0.52-1.43), or systemic complications (risk ratio 0.59, 95% CI 0.31-1.11). CochraneCochraneEarly routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis - Tse, F - 2012 | Cochrane Library

The absence of cholangitis does not itself exclude a retained duct stone, but it removes the immediate source-control rationale for ERCP. In this setting, establish whether a treatable ductal lesion is present before exposing the patient to an invasive procedure whose overall adverse-event rate is 6% to 15%. ScienceDirectScienceDirectASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis

Routine diagnostic ERCP has been displaced by EUS and MRCP. Detection rates for choledocholithiasis with ERCP, MRCP, and EUS are reported as comparable at greater than 90%, while EUS may better demonstrate microlithiasis that can be masked by contrast during ERCP. ScienceDirectScienceDirectBile Duct Dilatation - an overview

Obtain transabdominal ultrasound, clinical chemistry including liver tests, serum triglycerides and calcium, a complete prescription and over-the-counter medication review, and cross-sectional abdominal imaging as part of etiologic evaluation in acute pancreatitis. If this initial evaluation does not establish a cause and biliary disease remains plausible, advance to EUS or MRCP rather than diagnostic ERCP. BMJBMJUtility of endoscopic ultrasound in idiopathic acute recurrent pancreatitis | BMJ Open Gastroenterology

Choose EUS when occult stones, biliary sludge, or microlithiasis are leading concerns. Biliary sludge and microlithiasis may cause clinically significant pain, cholangitis, and pancreatitis; microlithiasis is often categorized clinically as small gallstones. BMJBMJConsensus definition of sludge and microlithiasis as a possible cause of pancreatitis | Gut In idiopathic acute recurrent pancreatitis, EUS diagnostic yield was 75% in one study, and biliary tract disease was the most common treatable etiology. BMJBMJUtility of endoscopic ultrasound in idiopathic acute recurrent pancreatitis | BMJ Open Gastroenterology

Choose MRCP when a noninvasive ductal map will answer the retained-stone question or define obstruction before intervention. MRCP can select patients with choledocholithiasis for therapeutic ERCP, avoiding procedure-related morbidity in patients without an actionable lesion. ScienceDirect+1ScienceDirectThe diagnostic accuracy of magnetic resonance cholangiopancreatography and ultrasound compared with direct cholangiography in the detection of choledocholithiasis - ScienceDirectScienceDirectBile Duct Dilatation - an overview

Use ERCP after EUS or MRCP when findings identify a ductal stone or obstruction requiring drainage. If imaging suggests a nonstone obstructive process, ERCP may provide direct ampullary evaluation and biopsy capability, whereas MRCP is useful for defining the cause and anatomic extent of perihilar obstruction. ScienceDirectScienceDirectBile Duct Dilatation - an overview

Discuss ERCP adverse events when the indication is elective or uncertain. The ASGE choledocholithiasis guideline reports adverse events in 6% to 15% of ERCPs. Acute pancreatitis is the most common complication; bleeding, infection, and perforation are other major adverse events. ScienceDirect+1ScienceDirectASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasisGastroenterologyComplications of Endoscopic Retrograde Cholangiopancreatography

When infection risk is increased because complete biliary drainage may not be achieved, use antibiotic prophylaxis. Examples include hilar strictures and primary sclerosing cholangitis; if drainage remains incomplete after ERCP, continue antibiotics after the procedure whether or not a stent was placed. ScienceDirectScienceDirectAcute biliary conditions

Monitor patients after ERCP for at least 4 hours in usual practice because most post-ERCP pancreatitis becomes symptomatic within hours. Selected low-risk patients may be discharged earlier only after a minimum of 2 hours, endoscopist review, and safety-net instructions. BMJBMJBritish Society of Gastroenterology Endoscopic Retrograde Cholangiopancreatography (ERCP) Quality Improvement Programme: minimum service standards and good practice statements | Frontline Gastroenterology

In recurrent acute pancreatitis without a cause after standard evaluation, pursue EUS and/or secretin-enhanced MRCP to identify a correctable biliary or pancreatic abnormality. EUS can identify duct stones or sludge, chronic pancreatitis features, pancreatic masses, and pancreas divisum; a dominant dorsal duct without communication between dorsal and ventral ducts supports pancreas divisum on EUS. BMJBMJUtility of endoscopic ultrasound in idiopathic acute recurrent pancreatitis | BMJ Open Gastroenterology

Treat a demonstrated biliary cause rather than labeling the episode idiopathic. Biliary sludge and microlithiasis can be associated with recurrent pancreatitis and may account for a portion of otherwise idiopathic cases; management in an EUS study was tailored with cholecystectomy for surgical causes or ERCP with sphincterotomy or stone extraction for endoscopically treatable disease. BMJ+1BMJConsensus definition of sludge and microlithiasis as a possible cause of pancreatitis | GutBMJUtility of endoscopic ultrasound in idiopathic acute recurrent pancreatitis | BMJ Open Gastroenterology

Avoid diagnostic ERCP, bile aspiration for crystals, and sphincter of Oddi manometry as routine early testing in unexplained recurrent pancreatitis because invasive evaluation can expose patients to substantial morbidity. ScienceDirectScienceDirectDiagnostic yield of ERCP and secretin-enhanced MRCP and EUS in patients with acute recurrent pancreatitis of unknown aetiology - ScienceDirect