Mistakes in endoscopic retrograde cholangiopancreatography and how to avoid them

July 27, 2016 By: Mathieu Pioche, Jérôme Rivory and Thierry Ponchon

Image courtesy of J. Rivory

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Mistakes in endoscopic retrograde cholangiopancreatography and how to avoid them

Endoscopic retrograde cholangiopancreatography (ERCP) is a widespread technique used for the treatment of different diseases of the bile and pancreatic ducts.

Endoscopic retrograde cholangiopancreatography (ERCP) is a widespread technique used for the treatment of different diseases of the bile and pancreatic ducts. The technique is, however, associated with rare but potentially severe morbidity.

Some of the adverse events associated with ERCP are directly linked to commonly made mistakes and can, therefore, be prevented. Here, we discuss 10 common and/or high-impact mistakes that are made during ERCP and how they can be avoided. 









Mistake 1 | Performing an ERCP without having a precise therapeutic aim

With the progress made by endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP), ERCP is now strictly limited to use in therapeutic situations, such as stone extraction and stenting. In fact, ERCP is not a good procedure to diagnose stones in the common bile duct, with only 70% sensitivity, whereas EUS has a sensitivity of 95%. Furthermore, the morbidity rate after ERCP is far from low and it is now clearly recommended that EUS and/or MRCP be used for diagnosis and then ERCP performed only when treatment is needed.1 The only remaining indication for diagnostic ERCP is tissue sampling at biliary stenosis, but even in this case stenting is frequently required to treat the stenosis and prevent cholangitis.

Mistake 2 | Beginning an ERCP procedure without informing the patient about the possible complications, such as pancreatitis, bleeding and perforation

Endoscopic cannulation of the bile duct, with associated sphincterotomy, can induce acute pancreatitis in approximately 5%, bleeding in 4.5%, and perforation in 0.1% of cases.2 The main risk factors for pancreatitis are well known. For example, young women who have Sphincter of Oddi dysfunction or those who have repeated cannulation or opacification of the main pancreatic duct are at greater risk of developing acute pancreatitis following ERCP.3 Pancreatitis is generally mild and self-limiting and conservative management is sufficient in more than 90% of cases.4 Bleeding and perforation complications occur in about 1% of cases5 and are mostly managed conservatively using endoscopic haemostasis, clipping or stenting. However, even more than for other endoscopic examinations, it is essential to give a clear explanation to the patient of the benefits and risks of the procedure, and this must be recorded in the patient medical file in order to limit the potential for medicolegal issues in case an adverse event occurs. 

Mistake 3| Systematically preferring sphincter dilation with a balloon to sphincterotomy to avoid bleeding

The ESGE (European Society of Gastrointestinal Endoscopy) does not recommend endoscopic papillary balloon dilation as an alternative to sphincterotomy in routine ERCP due to the risk of pancreatitis.6 However, endoscopic papillary balloon dilation may be advantageous in selected patients, such as those who are taking anticoagulant drugs without acute possible reversion and who need an emergency ERCP (i.e. due to septic shock).7 If this technique is used, the duration of dilation should be longer than 1 minute to get good sphincter dilation.4

Mistake 4 | Attempting cannulation repeatedly without changing the technique when the bile duct is not easily accessible and forgetting to prevent post-ERCP acute pancreatitis associated with pancreatic duct stenting by rectal administration of a nonsteroidal anti-inflammatory drug

In case of cannulation failure, the ESGE suggests changing the technique to reduce the number of cannulations as much as possible6 to reduce the risk of pancreatitis. The ESGE also suggests restricting the use of a pancreatic guidewire as a backup technique for biliary cannulation to cases in which there is repeated inadvertent cannulation of the pancreatic duct; if this method is used, deep biliary cannulation should be attempted using a guidewire rather than the contrast-assisted method and a prophylactic pancreatic stent should be placed.6 According to the ESGE, needle-knife fistulotomy should be the preferred precut technique in patients who have a bile duct dilated down to the papilla.6 Conventional precut and transpancreatic sphincterotomy have similar success and complication rates; if the conventional precut is selected and pancreatic cannulation is easily achieved, the ESGE advises attempting to place a small-diameter (3-Fr or 5-Fr) pancreatic stent to guide the cut and leaving the pancreatic stent in place at the end of ERCP for a minimum of 12–24 hours.6

The benefits of administering a rectal nonsteroidal anti-inflammatory drug (NSAID), such as diclofenac, for the prevention of acute pancreatitis post ERCP are debated because of the opposing results obtained in different studies.8,9 Nevertheless, many studies have demonstrated the efficacy of NSAIDs in this setting10 and administration of a rectal NSAID is nowadays recommended by the ESGE guidelines.6 The ESGE guidelines also recommend pancreatic stenting in high-risk patients (i.e. those with Sphincter of Oddi dysfunction, multiple pancreatic cannulations, young women etc.) with a 3-Fr or 5-Fr stent.6

Mistake 5 | Not obtaining complete opacification of the bile tract (complete mapping) and especially of the intrahepatic bile ducts to diagnose intrahepatic stones or stenosis

Except in cases of hilar stenosis, because of the risk of cholangitis (see below), complete mapping of the intrahepatic biliary tree is advised to detect additional diseases, such as intrahepatic stones or stenosis, which could explain the occurrence of recurrent cholangitis. Opacification should be conducted with a certain pressure, using, for example, an extraction balloon to avoid contrast leakage in the duodenum. Different pictures taken from different axes are needed to understand bile duct insertion and to avoid structure superposition. All the segmental intrahepatic bile ducts should be visible and analysed one by one. In fact, MRI (MRCP, magnetic resonance cholangiopancreatography) is also effective and combining MRI with ERCP is another option to reduce the opacification of the bile tract and exposure of the patient to X-rays.11

Mistake 6 | In case of hilar stenosis, beginning an ERCP for drainage without MRI mapping of the obstructed bile ducts (MRCP)

One of the major, classic mistakes to be avoided when performing ERCP is to begin the procedure in cases of hilar stenosis without first mapping the obstructed bile ducts with MRCP.11,12 Opacification of occluded bile ducts may lead to cholangitis if this duct cannot be drained with a stent.4 Prior ERCP, precise mapping and a precise drainage strategy are needed.12 Which technique should be used (ERCP, percutaneous drainage or immediate surgical resection)? Which duct should be drained? How many ducts should be drained? Having a strategy allows the catheterization and injection of only those areas that have to be drained. 

Mistake 7 | Inserting one or several noncovered metal stents in cases of hilar disease without having a histological diagnosis

The differential diagnosis between cholangitis and cholangiocarcinoma is challenging and may require histological analysis of several brushing or biopsy samples.13 Inserting one or more metal stents in case of primary sclerosing cholangitis or in case of neoplastic disease that is reversible by chemotherapy is a mistake because stent removal is usually impossible. Patients will present with stent obstruction and repeated cholangitis and are at risk of developing secondary sclerosing cholangitis and/or cholestatic cirrhosis.14,15 Furthermore, placement of a noncovered metallic stent can prevent further biliary sampling. The expert recommendation is usually, therefore, to insert plastic stents until the diagnosis is obtained or to perform a percutaneous drainage with a silicone tube.

Mistake 8 | In cases of biliary leakage, performing a sphincterotomy without having clear visualization of the fistula

ECRP can be very effective at stopping a biliary post-surgical leakage.16 Depending the location and the associated biliary lesions, different options (e.g. papillotomy alone, nasobiliary drainage, stenting, stone removal) have to be used. The first step is nevertheless to demonstrate the leakage by ERCP and the mistake is to perform any therapeutic manoeuvre without such a demonstration, especially when the leakage is from the intrahepatic bile ducts following a partial hepatectomy.16,17 Indeed, leakage can arise from intrahepatic biliary ducts isolated by the liver resection from the rest of the biliary tree. Prior to ERCP, MRCP is, therefore, essential to verify whether any sector is excluded or not and to localize the bile duct defect. Following ERCP, sphincterotomy is therefore not justified in the first instance while the leakage is not clearly seen, because it presents an additional risk of acute pancreatitis without any benefit for the patient.3 When a leakage is suspected but not demonstrated at the time of the first contrast injection, it is suggested to inject contrast medium under pressure, for example with an occluding balloon (expert recommendation). 

Mistake 9 | Mixing up the cystic duct stump and hepatic bile duct in cases of post-cholecystectomy biliary stenosis

Biliary stenosis following a difficult cholecystectomy is usually located at the level of the common hepatic duct. The stenosis is frequently complete and difficult to pass even with a hydrophilic guidewire. A frequent mistake is to mix up the cystic duct stump and the occluded common hepatic duct and to repeatedly push the guidewire into the cystic duct stump. The two channels superimpose on fluoroscopy, but there are two possible solutions. First, to always think that the cystic duct stump can superimpose and mimic the stenotic common hepatic duct. Second, to change the radiological exposure in order to separate both ducts on imaging. 

Mistake 10 | Ignoring the fact that Mirizzi syndrome can mimic or be associated with cholangiocarcinoma

Mirizzi syndrome type I is a common bile duct compression that is caused by a stone impacted at the neck of the gallbladder or at the cystic duct.18,19 The compression induces obstructive jaundice and its diagnosis and treatment are challenging. It has been reported that there is an association with gallbladder cancer in one third of Mirizzi cases and Mirizzi syndrome can also masquerade as cholangiocarcinoma. Thickening of the gallbladder or the cystic duct wall is not specific enough to rule out or confirm the presence of associated cholangiocarcinoma. Management of Mirizzi syndrome is usually a combination of endoscopy and surgery and repeated attempts to treat Mirizzi syndrome endoscopically should be avoided in patients at low surgical risk.19,20




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5. Christensen M, et al. Complications of ERCP: a prospective study. Gastrointest Endosc 2004; 60: 721–731.
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7. Veitch AM, et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut 2016; 65: 374–389.
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9. Sethi S, et al. A meta-analysis on the role of rectal diclofenac and indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Pancreas 2014; 43: 190–197.
10. Elmunzer BJ, et al. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med 2012; 366: 1414–1422. 
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18. Kumar A, et al. Mirizzi’s syndrome: lessons learnt from 169 patients at a single center. Korean J Hepato-Biliary-Pancreat Surg 2016; 20: 17–22.
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Article information

 © UEG 2016 Pioche et al.
Cite this article as: Pioche M, Rivory J and Ponchon T. Mistakes in endoscopic retrograde cholangiopancreatography and how to avoid them. UEG Education 2016: 16: 24–26.
Mathieu Pioche, Jérôme Rivory and Thierry Ponchon are at the Department of Endoscopy and Gastroenterology, Edouard Herriot Hospital, Lyon, France, and INSERM U1032, LabTau, Lyon, France.
Correspondence to: mathieu.pioche@chu-lyon.fr
Published online : 27 July 2016
Conflicts of interest: The authors declare there are no conflicts of interest.

A pdf of this article can be found in the UEG Education Library.


About the authors

Mathieu Pioche, is a physician at the Department of Endoscopy and Gastroenterology, Edouard Herriot Hospital, Lyon, France, and INSERM U1032, LabTau, Lyon, France. He is particularly interested in EUS, ERCP and endoscopic resections. One of his research topics is the treatment of superficial neoplasia in the digestive tract.

Jérôme Rivory is a physician at the Department of Endoscopy and Gastroenterology, Edouard Herriot Hospital, Lyon, France, and INSERM U1032, LabTau, Lyon, France. He is particularly interested in EUS, ERCP and endoscopic resections.

Thierry Ponchon is the Head of the Department of Endoscopy and Gastroenterology, Edouard Herriot Hospital, Lyon, France, and INSERM U1032, LabTau, Lyon, France. He leads many medical studies on therapeutic and diagnostic endoscopy and has a particular interest in the treatment of bile stones by EUS techniques.



Alaa Nouh, October 18, 2016 15:02
Thank you for your effort
Anja St.+Clair+Jones, October 18, 2016 12:39
Wide sphincterotomy in case of the presence of a diverticulum
MAHMOUD ABDELAZIZ MOHAMED, October 18, 2016 12:39
Carefully deal with such patient
, October 18, 2016 12:27
Mistake 8 . If on a suspicion of a bike leak once you have entered the CBD do a sphincterotomy even if you don't find an obvious leak
Awni Abu Sneineh, October 18, 2016 12:18
Good for trainees
Mustafa Ozdogan, October 18, 2016 10:19
Very nice topic
Diliara Iskhakova, October 18, 2016 09:40
Dan Adrian Bobeica, October 17, 2016 17:19
Congrats for the presentantion!!
Sameh Lashen, October 17, 2016 13:15
It's exhaustive maneuver but nice
khaled bamakhrama, October 17, 2016 12:59
Very noch presentation

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