ERCP and Pancreatic-Biliary Disorders: A Clinical Overview for MSRA

Disorders of the pancreas and biliary system frequently appear in the MSRA due to their clear diagnostic criteria, acute clinical presentations, and structured management pathways. Understanding the indications for ERCP, differentiating types of pancreatitis, and recognising biliary emergencies like cholangitis is key to excelling in the exam and real-life clinical practice.

🔍 What is ERCP?

Endoscopic Retrograde Cholangiopancreatography (ERCP) is a combined diagnostic and therapeutic endoscopic procedure used to examine and treat conditions affecting the biliary and pancreatic ducts. It involves inserting an endoscope through the mouth into the duodenum and injecting contrast into the ducts to visualise them under fluoroscopy.

Therapeutic Uses of ERCP:

• Stone removal from the common bile duct (CBD)

• Stenting for biliary or pancreatic duct obstruction

• Sphincterotomy (cutting the sphincter of Oddi to relieve obstruction)

• Drainage of infected bile ducts in cholangitis

• Brushings/biopsy in suspected malignancy

📌 When is ERCP Indicated?

✅ Indications for ERCP:

• Acute cholangitis (fever + jaundice + RUQ pain) — emergency decompression

• Gallstone pancreatitis with biliary obstruction (elevated bilirubin and/or ALT >150 IU/L, CBD dilation)

• Malignant biliary obstruction (e.g., pancreatic head cancer causing jaundice)

• Post-operative bile leaks or strictures

❌ When ERCP is not indicated:

• As a purely diagnostic test (use MRCP instead)

• Mild gallstone pancreatitis with no signs of obstruction

• Stable obstructive symptoms without infection — MRCP preferred

• Pancreatic cancer workup — CT and/or EUS preferred

🧪 MRCP vs ERCP: Know the Difference

Feature	MRCP (Magnetic Resonance Cholangiopancreatography)	ERCP
Role	Diagnostic	Therapeutic + Diagnostic
Invasiveness	Non-invasive	Invasive
Use	To visualise ducts non-invasively	To remove stones or stent
Risk	No radiation or complications	Risk of pancreatitis, bleeding, perforation
First-line?	Yes (for diagnosis)	No (unless intervention required)

⚠️ Acute Pancreatitis

Definition

An acute inflammatory condition of the pancreas, often reversible, but may be severe or life-threatening.

Diagnostic Criteria (Revised Atlanta)

At least 2 of 3:

1. Epigastric pain radiating to the back

2. Serum lipase/amylase ≥3× ULN

3. Imaging showing inflammation (CT, MRI, or US)

Aetiologies (GET SMASHED mnemonic):

• Gallstones (most common in UK)

• Ethanol (alcohol)

• Trauma

• Steroids

• Mumps/viral infections

• Autoimmune (IgG4-related)

• Scorpion sting

• Hypercalcaemia/hyperlipidaemia

• ERCP

• Drugs (e.g., azathioprine, valproate, thiazides)

Management:

• Supportive care: IV fluids, analgesia, NPO, oxygen

• Monitor vitals, urine output

• Enteral feeding when tolerated

• CT abdomen only if diagnosis unclear or deterioration occurs

🔎 Gallstone Pancreatitis: Key Diagnostic Clues

• ALT >150 IU/L: Strongly predictive of gallstone aetiology

• Dilated CBD on ultrasound

• No history of alcohol

• Jaundice ± vomiting at presentation

When ERCP is Needed:

• If there is evidence of biliary obstruction or cholangitis

• Timing: Ideally within 72 hours in gallstone pancreatitis with obstruction

🚨 Acute Cholangitis

Definition:

A potentially life-threatening infection of the biliary system secondary to obstruction.

Classic Features (Charcot's Triad):

• Fever

• Right upper quadrant pain

• Jaundice

Add confusion + hypotension → Reynolds’ Pentad (severe sepsis)

Investigations:

• Raised bilirubin, ALP, GGT

• Leucocytosis, deranged LFTs

• Ultrasound: Gallstones + dilated CBD

• Blood cultures

Management:

• Resuscitation + IV antibiotics

• Urgent ERCP for biliary decompression

🩺 Chronic Pancreatitis

Definition:

A progressive inflammatory condition causing irreversible pancreatic damage, fibrosis, and loss of exocrine and endocrine function.

Causes:

• Long-term alcohol misuse

• Genetic (PRSS1, CFTR)

• Autoimmune

• Recurrent acute pancreatitis

• Ductal obstruction (e.g., strictures, tumours)

Clinical Features:

• Persistent or recurrent epigastric pain

• Steatorrhoea (fat malabsorption)

• Weight loss

• New-onset diabetes

Investigations:

• Faecal elastase-1 (↓ indicates exocrine insufficiency)

• CT or MRCP: Pancreatic calcifications, ductal irregularity

• Glucose monitoring: For endocrine dysfunction

Management:

• Pancreatic enzyme replacement

• Insulin for diabetes

• Alcohol/smoking cessation

• Specialist referral for complications

🎗️ Pancreatic Cancer and Biliary Obstruction

Key Features:

• Painless obstructive jaundice

• Dark urine, pale stools, pruritus

• Courvoisier’s sign: Palpable gallbladder + jaundice

• Unexplained weight loss

• New-onset diabetes in older adults

Investigations:

• LFTs: Cholestatic pattern

• CA 19-9: Tumour marker (for monitoring, not diagnosis)

• CT with contrast: First-line for diagnosis

• ERCP with stenting: If obstructive jaundice needs palliation

🧠 Summary Table: ERCP and Related Disorders

Condition	ERCP Role	Key Points
Acute cholangitis	Urgent decompression	Life-saving; do within 24–48h
Gallstone pancreatitis with jaundice	Yes	Do within 72h
Mild gallstone pancreatitis, no jaundice	❌ Not needed	Cholecystectomy only
Pancreatic cancer (obstructive)	Palliative stenting	Only if inoperable
Diagnostic uncertainty	❌ Use MRCP	MRCP safer and non-invasive

🧭 Final Takeaway for MSRA Prep

• Use MRCP to diagnose, ERCP to treat

• Think ERCP urgently in cholangitis

• Don't rush to ERCP in mild or improving pancreatitis

• Look for ALT >150 IU/L to suggest gallstones

• Always stabilise before any intervention in sepsis