GuidelineThe role of ERCP in benign diseases of the biliary tract
Introduction
ERCP was first reported in 1968 and was quickly accepted as a safe, direct technique for evaluating pancreaticobiliary disease.2 With the introduction of endoscopic sphincterotomy in 1974, therapeutic pancreaticobiliary endoscopy was developed.3, 4 Over the past several decades, ERCP has evolved from a diagnostic procedure to one that is almost exclusively therapeutic. Other imaging techniques, such as abdominal US, CT, MRCP, EUS, and intraoperative cholangiography, provide diagnostic information that allows appropriate selection of patients for therapeutic ERCP.5 ERCP with cholangiopancreatoscopy is a useful adjunctive technique for the evaluation and management of biliary and pancreatic disease.
Endoscopists who perform ERCP should have appropriate training and expertise in this procedure.5, 6 Preprocedure coagulation studies are not routinely indicated but should be considered in select patients, such as those with a history of coagulopathy or prolonged cholestasis.7 Endoscopists should consider correction of coagulopathy if sphincterotomy is anticipated, but specific international normalized ratio thresholds for this intervention have not been established and remain subject to the endoscopist’s judgment. Antibiotic prophylaxis is indicated in the setting of suspected biliary obstruction with anticipated incomplete drainage (including primary sclerosing cholangitis [PSC]), posttransplantation biliary strictures, or ductal leaks.8
Temporary pancreatic duct stenting and rectal indomethacin lower both the risk and severity of post-ERCP pancreatitis in high-risk populations, such as those undergoing precut biliary sphincterotomy or difficult biliary cannulation or with clinical suspicion of sphincter of Oddi dysfunction (SOD), a history of post-ERCP pancreatitis, pancreatic sphincterotomy, pneumatic dilation of an intact biliary sphincter, and ampullectomy.9, 10 Although rectal indomethacin alone appeared to be more effective for preventing post-ERCP pancreatitis in these high-risk patients than both pancreatic stent placement alone and the combination of indomethacin and pancreatic stent placement, a randomized, controlled trial comparing rectal indomethacin alone with indomethacin with pancreatic stent is needed.11
Section snippets
Benign biliary tract disease
ERCP is particularly useful in the management of patients with biliary obstruction due to choledocholithiasis and other benign diseases of the biliary tract such as biliary strictures and postoperative biliary leaks. Successful endoscopic cholangiography with relief of biliary obstruction should be technically achievable in more than 90% of patients.5 Adjunctive cholangioscopy at the time of ERCP can be helpful in the management and treatment of choledocholithiasis and for assessing
Recommendations
- 1.
We recommend that diagnostic ERCP not be undertaken for the evaluation of pancreaticobiliary-type pain in the absence of objective abnormalities on other pancreaticobiliary imaging or laboratory studies (⊕⊕⊕○).
- 2.
We recommend that routine ERCP before laparoscopic cholecystectomy not be performed in the absence of objective signs of biliary obstruction or stone. (⊕⊕⊕○)
- 3.
We recommend that ERCP in patients with acute biliary pancreatitis be limited to those with concomitant cholangitis or biliary
Disclosure
Dr Khashab is a consultant for and a member of the Medical Advisory Board of Boston Scientific, a consultant for Olympus America, and has received research support for Cook Medical. Dr Chathadi is a consultant for Boston Scientific. Dr Muthusamy is a consultant for Boston Scientific. Dr Hwang is on the speakers’ bureau of Novartis, is a consultant for US Endoscopy, and has received a research grant from Olympus. Dr Fisher is a consultant for Epigenomics. All other authors disclosed no financial
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This document was developed by the ASGE Standards of Practice Committee. This document was reviewed and approved by the governing board of the American Society for Gastrointestinal Endoscopy (ASGE).