Timing of endoscopic therapy for acute bilio-pancreatic diseases: a practical overview

Abstract

Diseases of the pancreas and hepatobiliary tree often require a therapeutic approach with endoscopic retrograde cholangiopancreatography (ERCP), generally following noninvasive imaging techniques. Appropriate indications and the correct timing for urgent ERCP would benefit both patients and clinicians and allow optimal utilization of health resources. Indications for urgent (<24 h) ERCP include severe acute cholangitis, acute biliary pancreatitis with cholangitis, biliary or pancreatic leaks, in the absence of percutaneous drainage, and severe acute cholecystitis in patients who are unfit for surgery and do not respond to conservative management. In patients who have severe acute biliary pancreatitis with ongoing biliary obstruction but without cholangitis, early (<48-72 h) ERCP is indicated. This overview aims to provide decisional flowcharts that can be easily used for managing patients with acute bilio-pancreatic disorders when they are referred to the Emergency Department.

Keywords: Cholangitis; ERCP; EUS; biliary leak; cholecystitis; pancreatitis.

Figure 1

Flowchart for acute cholangitis ERCP, endoscopic retrograde cholangiopancreatography

Figure 2

Flowchart for acute biliary pancreatitis ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasonography; MRCP, magnetic resonance cholangiopancreatography; CBD, common bile duct

Figure 3

Flowchart for bilio-pancreatic leaks ERCP, endoscopic retrograde cholangiopancreatography

Figure 4

Flowchart for acute severe cholecystitis *The best approach varies depending on local facilities TP-GBD, transpapillary drainage by endoscopic retrograde cholangiopancreatography; PT-GBD, percutaneous transhepatic ultrasound/computed tomography-guided biliary drainage; EUS-GBD, endoscopy ultrasound-guided transmural drainage; EUS-LAMS, endoscopy ultrasound-guided lumen-apposing metal stent