NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy.

OBJECTIVE To provide health care providers, patients, and the general public with a responsible assessment of currently available data regarding the use of endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy. PARTICIPANTS A non-Federal, non-advocate, 13-member panel representing the fields of gastroenterology, hepatology, clinical epidemiology, oncology, biostatistics, surgery, health services research, radiology, internal medicine, and the public. In addition, experts in these same fields presented data to the panel and to a conference audience of approximately 300. EVIDENCE Presentations by experts; a systematic review of the medical literature provided by the Agency for Healthcare Research and Quality; and an extensive bibliography of ERCP research papers, prepared by the National Library of Medicine. Scientific evidence was given precedence over clinical anecdotal experience. CONFERENCE PROCESS Answering predefined questions, the panel drafted a statement based on the scientific evidence presented in open forum and the scientific literature. The draft statement was read in its entirety on the final day of the conference and circulated to the experts and the audience for comment. The panel then met in executive session to consider these comments and released a revised statement at the end of the conference. The statement was made available on the World Wide Web at http://consensus.nih. gov immediately after the conference. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government. CONCLUSIONS In the diagnosis of choledocholithiasis, magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and ERCP have comparable sensitivity and specificity. Patients undergoing cholecystectomy do not require ERCP preoperatively if there is low probability of having choledocholithiasis. Laparoscopic common bile duct exploration and postoperative ERCP are both safe and reliable in clearing common bile duct stones. ERCP with endoscopic sphincterotomy (ES) and stone removal is a valuable therapeutic modality in choledocholithiasis with jaundice, dilated common bile duct, acute pancreatitis, or cholangitis. In patients with pancreatic or biliary cancer, the principal advantage of ERCP is palliation of biliary obstruction when surgery is not elected. In patients who have pancreatic or biliary cancer and who are surgical candidates, there is no established role for preoperative biliary drainage by ERCP. Tissue sampling for patients with pancreatic or biliary cancer not undergoing surgery may be achieved by ERCP, but this is not always diagnostic. ERCP is the best means to diagnose ampullary cancers. ERCP has no role in the diagnosis of acute pancreatitis except when biliary pancreatitis is suspected. In patients with severe biliary pancreatitis, early intervention with ERCP reduces morbidity and mortality compared with delayed ERCP. ERCP with appropriate therapy is beneficial in selected patients who have either recurrent pancreatitis or pancreatic pseudocysts. Patients with type I sphincter of Oddi dysfunction (SOD) respond to endoscopic sphincterotomy (ES). Patients with type II SOD should not undergo diagnostic ERCP alone. If sphincter of Oddi manometer pressures are >40 mmHg, ES is beneficial in some patients. Avoidance of unnecessary ERCP is the best way to reduce the number of complications. ERCP should be avoided if there is a low likelihood of biliary stone or stricture, especially in women with recurrent pain, a normal bilirubin, and no other objective sign of biliary disease. Endoscopists performing ERCP should have appropriate training and expertise before performing advanced procedures. With newer diagnostic imaging technologies emerging, ERCP is evolving into a predominantly therapeutic procedure.