What is the role of endoscopic retrograde cholangiopancreatography (ERCP) in the workup of biliary obstruction?

Updated: Oct 16, 2019
  • Author: Jennifer Lynn Bonheur, MD; Chief Editor: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS  more...
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ERCP is an outpatient procedure that combines endoscopic and radiologic modalities to visualize both the biliary and pancreatic duct systems. Endoscopically, the ampulla of Vater is identified and cannulated. A contrast agent is injected into these ducts, and x-ray images are taken to evaluate their caliber, length, and course.

It is especially useful for lesions distal to the bifurcation of the hepatic ducts. Besides being a diagnostic modality, ERCP has a therapeutic application because obstructions can potentially be relieved by the removal of stones, sphincterotomy, and the placement of stents and drains. The addition of cholangioscopy to the ERCP, by advancing a smaller "baby" scope through the endoscope into the common duct, allows for biopsies and brushings within the ducts and better identification of lesions seen on cholangiogram.

ERCP has a limited capacity to image the biliary tree proximal to the site of obstruction. Also, it cannot be performed if altered anatomy prevents endoscopic access to the ampulla (eg, Roux loop).

Complications of this technique include pancreatitis, perforation, biliary peritonitis, sepsis, hemorrhage, and adverse effects from the dye and the drug used to relax the duodenum. The risk of any complication is less than 10%. Severe complications occur in less than 1%.

The sensitivity and specificity of ERCP are 89-98% and 89-100%, respectively. ERCP is still considered the criterion standard for imaging the biliary system, particularly if therapeutic intervention is planned.

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