Indications for ERCP

ERCP was first introduced as a realistic endoscopic procedure in the early 1970s. Since then, the diagnostic and therapeutic clinical applications have changed significantly in parallel with improvements in noninvasive and invasive visualization of the biliary and pancreatic ductal systems. What was once predominantly a combined diagnostic endoscopic and radiographic modality, ERCP has taken on new roles as a more sophisticated diagnostic and therapeutic set of procedures including direct visualization of the ducts, tissue interrogation and sampling, and treatment of a wide variety of biliary and pancreatic disorders (Fig. 2.1a, b, c, d, e, f, g, h and i). In the USA, over 500,000 ERCPs were performed in 2008. In 2009, there were an estimated 1.1– 1.3 million cases worldwide. The number of diagnostic ERCPs decreased 6 % while therapeutic ERCPs increased by 12 % up to 2001 [1]. This interventional shift is attributed to the introduction, improvement, and acceptance of other diagnostic modalities such as endoscopic ultrasound (EUS), computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP). EUS combined with ERCP has become an appropriate alternative to percutaneous radiological access to an obstructed duct when ERCP alone fails or is not possible. Despite these changes in the role and range of therapeutic possibilities of ERCP, the basic indications have not. These can be divided into three main categories for the evaluation and treatment of: 1. Stone disease (jaundice, biliary pain, cholangitis, biliary pancreatitis, pancreatic duct stones) 2. Ampullary/papillary abnormalities (Sphincter of Oddi dysfunction (SOD), ampullary cancer) 3. Biliary and pancreatic ductal abnormalities (leaks, strictures, malignancies) As we shall discuss later in this chapter, there are significant complications of ERCP that one must consider before considering this procedure. Therefore, it is of paramount importance to have an appropriate indication for proceeding.