CHAPTER 78
Endoscopic retrograde cholangiopancreatography

Todd H. Baron1 and Ryan J. Law2

¹University of North Carolina, Chapel Hill, NC, USA

²Mayo Clinic, Rochester, MN, USA

Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure utilized in the management of pancreatic and biliary conditions. Using a combination of endoscopic and fluoroscopic guidance, the common bile duct and/or the pancreatic duct can be accessed via the papillary orifice or surgical anastomoses to provide therapeutic intervention. Following advances in noninvasive cross‐sectional imaging modalities, namely magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP) and computed tomography (CT), and increasing availability of endoscopic ultrasound, ERCP is now primarily performed for therapeutic intervention. ERCP is one of the most technically demanding procedures to perform and, in turn, can be associated with various adverse events, including pancreatitis, hemorrhage, and perforation, with pancreatitis being the most common.

The primary role of ERCP is to restore normal drainage of the biliary and pancreatic ducts in the setting of obstruction (i.e., stones, strictures) and leaks. Less commonly, ERCP techniques are necessary for removal of ampullary masses (Figure 78.1). The most common indication for ERCP is for the removal of bile duct stones. Small stones (<10 mm) can generally be extracted with balloon catheters and baskets while for larger stones, ancillary techniques such as mechanical lithotripsy, large papillary balloon dilation, and/or intraductal lithotripsy with electrohydraulic (EHL) or laser lithotripsy can be used to achieve complete stone removal (Figure 78.2). Biliary strictures may be benign (e.g., surgical anastomosis, chronic pancreatitis) or malignant (e.g., due to pancreatic or hilar tumors), and are treated with balloon dilation of the stricture and placement of plastic or metal biliary stents (Figure 78.3). Biliary system leaks are treated with biliary sphincterotomy and transpapillary stent placement, with the goal of reducing the sphincter of Oddi pressure gradient, thereby promoting normal bile flow (Figure 78.4).

Improvements in endoscopic techniques have enabled ERCP to play an increasingly safe and effective role in the management of pancreatic diseases. ERCP for the treatment of pancreatic diseases is more technically challenging and higher risk than ERCP for most biliary indications, and therefore should ideally be performed at centers with extensive expertise in this field. Complications of chronic pancreatitis, including pancreatic duct stones, strictures, or leaks, are the main indications for ERCP. A small pancreatic orifice, the presence of a concomitant pancreatic stricture, and the hard, calcific nature of intraductal pancreatic stones make stone removal by ERCP technically difficult.

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