ERCP and EUS Procedures

• Audio chapter
  Single-voice audio, listen on the commute.
• ABIM-format MCQs
  5-option vignettes with full wrong-answer teaching.
• Study guide
  Tables, decision trees, primary sources.
• AI tutor
  Chapter-grounded, answers the question you're stuck on.

What this chapter covers

• Section 29.1: ERCP indications, cannulation, and PEP prophylaxis

  ERCP is a therapeutic procedure that carries pancreatitis risk, and every part of the workflow exists to keep that risk in check.

• Section 29.2: Sphincter of Oddi dysfunction in EPISOD era

  The Rome IV classification of post-cholecystectomy biliary pain, and the EPISOD trial that retired sphincterotomy for pain without objective abnormalities, are covered in Section 27.13.

• Section 29.3: Biliary stricture tissue acquisition

  The question of how to obtain tissue from a biliary stricture turns on the upstream clinical context: a transplant candidate, a patient awaiting neoadjuvant chemotherapy, a post-cholecystectomy patient with focal intrahepatic ductal dilation, or an indeterminate stricture after multiple negative ERCP brushings.

• Section 29.4: Ampullectomy and endoscopic papillectomy

  Ampullary adenomas are detected either as sporadic lesions found incidentally during EGD or ERCP, or as part of duodenal polyposis surveillance in familial adenomatous polyposis (FAP), where the ampulla is the most common site of duodenal adenoma.

• Section 29.5: Malignant biliary obstruction stenting

  Malignant biliary obstruction stenting strategy depends on the location of the obstruction, the resectability of the underlying tumor, and the anticipated life expectancy.

• Section 29.6: EUS-guided biliary drainage rescue

  EUS-guided biliary drainage is the modern rescue path when ERCP cannulation fails in a patient with a dilated bile duct.

• Section 29.7: ERCP in altered anatomy

  Surgical alteration of upper GI anatomy creates barriers between the side-viewing duodenoscope and the major papilla that drive procedural choice.

• Section 29.8: EUS and ERCP in pancreatitis

  The indication for ERCP and EUS in pancreatitis is structural disease or stone burden, and the threshold for action reflects the modest expected benefit of intervention against the substantial PEP risk that any ERCP carries.

• Section 29.9: Pancreatic fluid collections and EUS therapeutic drainage

  Symptomatic pancreatic fluid collections at 4 weeks or later (when the collection has formed a mature wall) are managed endoscopically through EUS-guided transmural drainage.

• Section 29.10: Direct endoscopic necrosectomy

  Direct endoscopic necrosectomy (DEN) is the through-LAMS debridement procedure performed when transmural drainage alone fails to clear solid debris in walled-off pancreatic necrosis.

• Section 29.11: EUS tissue acquisition

  EUS tissue acquisition decisions turn on three connected ideas: lesion identity follows sonographic layer, needle choice follows the diagnostic question, and the EUS layer informs the differential while the needle type informs the diagnostic yield.

• Section 29.12: EUS-guided celiac plexus neurolysis

  EUS-guided celiac plexus neurolysis (CPN) is performed for unresectable pancreatic cancer pain refractory to opioids, where opioid escalation produces unacceptable side effects (constipation, sedation, cognitive impairment) before achieving adequate pain control.

• Section 29.13: ERCP in pregnancy

  ERCP in pregnancy is performed when biliary obstruction with cholangitis, severe gallstone pancreatitis with persistent obstruction, large stone with refractory symptoms, or post-cholecystectomy bile leak demands intervention that cannot be deferred to postpartum.

• Section 29.14: ERCP complications and reprocessing

  ERCP complications are categorized by mechanism and frequency, with PEP and post-sphincterotomy bleeding the dominant concerns and duodenoscope reprocessing the quality and safety concern that has reshaped device design.

Podcast episodes

1. 01

   ERCP and EUS Procedures: Preventing Pancreatitis

   Post-ERCP pancreatitis is the complication that shapes every step of the procedure, and this episode follows a young woman with a bile duct stone through each decision. ERCP is reserved for therapy, because MRCP and EUS answer diagnostic questions without pancreatitis risk. Cannulation starts with a wire rather than contrast, and difficult cannulation escalates from the double-wire technique to septotomy, precut over a pancreatic stent, and EUS rendezvous. The episode then covers who is high risk and the three proven preventive measures: rectal indomethacin, a prophylactic pancreatic duct stent, and aggressive lactated Ringer's. A man with chronic pancreatitis shows why a scarred gland is protected.

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2. 02

   ERCP and EUS Procedures: Bile Duct and Ampulla

   This episode is about proving whether a narrowed bile duct is cancer and removing an ampullary adenoma without a Whipple. It starts with a hilar stricture in primary sclerosing cholangitis, where negative brushings do not reassure and sampling escalates to forceps biopsy, FISH, and cholangioscopy, with a ban on needling the primary in a transplant candidate. It then covers EUS for a pancreatic head mass and why pain alone after cholecystectomy is not a reason for ERCP. Next come ampullectomy candidacy, staging, technique, stenting, complications, and surveillance, ending with why familial adenomatous polyposis duodenal disease is different.

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3. 03

   ERCP and EUS Procedures: Malignant Duct Drainage

   Draining a bile duct blocked by cancer comes down to where the obstruction is, whether the tumor is resectable, and how long the patient will live. The episode starts with distal obstruction before neoadjuvant chemotherapy, which calls for a fully covered metal stent, and asks whether resectable tumors need drainage at all. It then turns to the hilum, where the stent choice reverses to uncovered metal, drainage is planned by viable liver volume, and plastic is reserved for short survival. Last, it covers failed ERCP and the EUS-guided rescues, chosen in order: rendezvous, choledochoduodenostomy, then hepaticogastrostomy, as the anatomy allows. It closes with the classic board traps.

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4. 04

   ERCP and EUS Procedures: Altered Anatomy Access

   Altered anatomy changes the question from how to perform ERCP to how to restore a face-on view of the papilla, or how to reach the anastomosis when the papilla is bypassed. The episode starts with Roux-en-Y gastric bypass, comparing laparoscopy-assisted ERCP, balloon enteroscopy, and EDGE, and the need to remove the stent and close the fistula afterward. It then turns to the hepaticojejunostomy after a Whipple, reached by enteroscopy with backups planned in advance. It ends with the Billroth two afferent limb, where perforation risk is highest and the sphincterotomy direction reverses.

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5. 05

   ERCP and EUS Procedures: Pancreatic Duct Therapy

   The organizing idea is that endoscopy can fix a discrete pancreatic duct obstruction, but the threshold for ERCP in pancreatitis stays high because the benefit is modest and post-ERCP pancreatitis is a real risk. The episode starts with a woman with painful chronic pancreatitis, a duct stone, and a stricture who declines surgery. It covers who does well with endotherapy, shock-wave lithotripsy for stones over five millimeters, and single plastic stenting of a dominant stricture. It then turns to a new isolated head obstruction that may be cancer, idiopathic recurrent pancreatitis with its workup, manometry, and divisum, and the autoimmune pancreatogram.

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6. 06

   Off Necrosis

   This episode is about draining walled-off necrosis through the stomach and cleaning it out from the inside. A woman six weeks after necrotizing pancreatitis shows the sequence. A collection is drained only after about four weeks, once the wall has matured, and imaging is checked for pseudoaneurysm first. Solid debris calls for a fifteen or twenty millimeter lumen-apposing metal stent, while a man with a simple pseudocyst shows what suits thin fluid. Necrosectomy follows only if response is inadequate, always with carbon dioxide. The episode then covers recurrent fever, bleeding through the stent, timed stent removal, and a tail cyst that must be aspirated before it is drained.

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7. 07

   ERCP and EUS Procedures: EUS Tissue and Safe ERCP

   This episode asks how to get the most from the needle and how to take the most care with ERCP. It starts with a subepithelial lesion identified by its EUS layer, then covers which lesions need tissue and which stains separate GIST from leiomyoma. Biopsy needles come next, followed by celiac plexus neurolysis for cancer pain versus a steroid block for benign pain. The ERCP half covers pregnancy, where only urgent indications qualify and radiation is kept minimal. It then turns to sphincterotomy bleeding in coagulopathy, perforation classification, post-ERCP cholangitis, and why duodenoscopes spread resistant bacteria.

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Key topics

• ·ERCP as therapy, not diagnosis
• ·Accepted ERCP indications
• ·Wire-guided cannulation
• ·Escalation for difficult cannulation
• ·Risk factors for post-ERCP pancreatitis
• ·Rectal indomethacin
• ·Prophylactic pancreatic duct stent
• ·Lactated Ringer's protocol
• ·Chronic pancreatitis as protective
• ·Board traps
• ·Brush cytology sensitivity in strictures
• ·Forceps biopsy, FISH, and cholangioscopy
• ·Transplant candidates and needle seeding
• ·Sampling suspicious lymph nodes
• ·EUS for pancreatic head masses
• ·Sphincter of Oddi dysfunction and ERCP
• ·Ampullary adenoma and ampullectomy
• ·Ampullectomy stents and complications
• ·Surveillance for recurrence
• ·Duodenal polyposis in familial adenomatous polyposis
• ·Stent choice in malignant biliary obstruction
• ·Fully covered metal stent for distal obstruction
• ·Same-session EUS biopsy and ERCP
• ·When to drain resectable pancreatic cancer
• ·Uncovered metal stents at the hilum
• ·Draining half of viable liver
• ·Plastic stents for short survival
• ·EUS-guided rendezvous
• ·EUS-guided choledochoduodenostomy with LAMS
• ·EUS-guided hepaticogastrostomy and its complications