3. Endoscopic Retrograde Cholangiopancreatography

Endoscopic Retrograde Cholangiopancreatography

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Endoscopic retrograde cholangiopancreatography (ERCP) is used both in the diagnosis and treatment of many pancreatic and biliary diseases. It was first used in the 1970s at which point its main use was in diagnosis - in contrast to nowadays when its use is mostly as a therapeutic tool.

Provides detailed and accurate information of the pancreaticobiliary system.

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  • Choledocholithiasis (eg gallstones in the common bile duct (CBD), and microlithiasis)
  • Acute pancreatitis due to biliary obstruction, sphincter of Oddi dysfunction or idiopathic, recurrent cases
  • Detection of pancreatic divisum (more common in patients who develop pancreatitis but may not necessarily be causal)[1]
  • Diagnosis of pancreatic and biliary malignancy (although endoscopic ultrasound may be superior)
  • Palliative therapy for inoperable pancreaticobiliary malignancies, eg drainage procedures
  • Dilatation of benign strictures, eg following orthoptic liver transplantation[2]
  • Chronic pancreatitis - very controversial but there may be a role for dilatation of strictures or stent insertion[3]
  • Manometry measures in sphincter of Oddi dysfunction

ERCP and choledocholithiasis[3]

One method for determining who should have an ERCP is to classify patients into low-risk, intermediate-risk or high-risk.

  • Low-risk patients should proceed to laparoscopic cholecystectomy without further intervention or imaging procedures.
  • Intermediate-risk patients include those with features, such as previous history of cholangitis or pancreatitis, slightly abnormal liver function tests (eg raised ALP but less than twice normal), dilated CBD between 8-10 mm. This group of patients should have further tests, eg endoscopic ultrasound, before deciding on further intervention.
  • High-risk patients include those with recent cholangitis, recent acute pancreatitis, jaundice, abnormal LFT's (ALP more than twice normal), and dilated CBD >10 mm. This group will benefit most from ERCP. However, even a third of these patients will fail to have a stone on ERCP and further investigation may be needed.

ERCP and acute pancreatitis

  • Acute pancreatitis with evidence of biliary tract obstruction should have urgent ERCP.
  • At ERCP, sphincterotomy may be performed to remove duct obstruction, eg gallstone.
  • However, there is a risk that pancreatitis may be worsened.
  • A meta-analysis of studies looking at the role of ERCP in acute biliary pancreatitis has confirmed that early ERCP reduces both complications and mortality rates.[1]
  • Sphincter of Oddi dysfunction can lead to pancreatitis, usually in women following cholecystectomy, and responds to isolated biliary sphincterotomy.
  • Endoscopic retrograde cholangiopancreatography (ERCP) is performed on an outpatient or inpatient basis
  • Patients have to fast overnight
  • Patients are usually sedated for the procedure, eg using midazolam, and analgesia is also given
  • Patients usually lie on their left side
  • The back of throat is sprayed with a local anaesthetic
  • The endoscope is passed down through to the stomach and then to the duodenum (where the ducts of the pancreaticobiliary system open, called Vater's ampulla)
  • Air may be pumped into the duodenum to allow better visualisation
  • Using a wire passed through the endoscope, contrast is injected through Vater's ampulla and X-rays obtained
  • These images will indicate areas of obstruction
  • Further intervention can be performed down the endoscope if necessary, eg stone removal, stent insertion, biopsies
  • Pancreatitis - 2-9% of patients will develop pancreatitis and it is seen especially in endoscopic sphincterotomy for sphincter of Oddi dysfunction.[1][4] The majority of cases are mild but 10% of cases are moderate-to-severe and may lead to multiorgan failure and even death. The chances of pancreatitis post-endoscopic retrograde cholangiopancreatography (ERCP) can be reduced by avoiding excessive cannulation trauma and stent insertion - the latter being the most effective method.[5] Stent insertion allows pancreatic secretions to pass freely.
  • Infection may occur - although rates are low.
  • Bleeding may occur - although severe haemorrhage is rare.
  • Perforation of the duodenum with development of an acute abdomen.
  • Failure of gallstone retrieval - may need to revert to open or more invasive procedures.
  • Prolonged pancreatic stenting is associated with stent occlusion, pancreatic duct obstruction, and pseudocyst formation.
Is endoscopic retrograde cholangiopancreatography (ERCP) being superseded by endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP)?
  • EUS is ultrasonography via an endoscope. It is used in many pancreatic and biliary disorders, especially choledocholithiasis and pancreatic lesions, eg neoplasms or cysts.
    • It was originally used solely for imaging purposes but, with improved techniques, it can now be combined with fine needle aspiration (FNA).
    • Some interventional techniques can also be performed with EUS, eg injection of bupivacaine into the coeliac ganglia for analgesia in irresectable pancreatic carcinoma.
    • EUS has a greater specificity than MRCP in detecting gallstones in the ducts (sensitivity is the same) - however, some stones can be missed by EUS.[3]
    • In pancreatitis, EUS will provide additional features, eg peripancreatic collections, and it is also more informative in chronic pancreatitis, especially when abdominal CT and ultrasound scanning fail to find an underlying cause.
  • MRCP, on the other hand, uses selective magnetic resonance imaging to look at the biliary and pancreatic tree in greater detail, and is used to diagnose disease in the pancreaticobiliary region; it does not offer any therapeutic options.
    • MRCP ,due to its noninvasive nature, does not have the same mortality or morbidity rates as ERCP.
    • The main down side is that some patients will need to go on and have an ERCP anyway.
    • MRCP is is comparable to ERCP for diagnostic purposes, especially in choledocholithiasis.
    • The role of MRCP in malignancy is less favourable than that of ERCP.[6]

In summary, ERCP has its role to play in pancreaticobiliary disorders. These are mainly therapeutic in nature. However, in cases where there is doubt regarding the diagnosis or presence of biliary obstruction, further imaging should be performed first. This may include MRCP if biliary obstruction alone is suspected or EUS in other conditions.

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Further reading & references

  1. Cherian JV, Selvaraj JV, Natrayan R, et al; ERCP in acute pancreatitis. Hepatobiliary Pancreat Dis Int. 2007 Jun;6(3):233-40.
  2. Solmi L, Cariani G, Leo P, et al; Results of endoscopic retrograde cholangiopancreatography in the treatment of biliary tract complications after orthotopic liver transplantation: our experience. Hepatogastroenterology. 2007 Jun;54(76):1004-8.
  3. Mesenas SJ; Does the advent of endoscopic ultrasound (EUS) sound the death knell for endoscopic retrograde cholangiopancreatography (ERCP)? Ann Acad Med Singapore. 2006 Feb;35(2):89-95.
  4. Abdel Aziz AM, Lehman GA; Pancreatitis after endoscopic retrograde cholangio-pancreatography. World J Gastroenterol. 2007 May 21;13(19):2655-68.
  5. Andriulli A, Forlano R, Napolitano G, et al; Pancreatic duct stents in the prophylaxis of pancreatic damage after endoscopic retrograde cholangiopancreatography: a systematic analysis of benefits and associated risks. Digestion. 2007;75(2-3):156-63. Epub 2007 Aug 6.
  6. Kaltenthaler E, Vergel YB, Chilcott J, et al; A systematic review and economic evaluation of magnetic resonance cholangiopancreatography compared with diagnostic endoscopic retrograde cholangiopancreatography. Health Technol Assess. 2004 Mar;8(10):iii, 1-89.
Original Author: Dr Gurvinder Rull Current Version:
Last Checked: 19/02/2010 Document ID: 2099  Version: 21 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.