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Early endoscopic retrograde cholangiopancreatography (ERCP) in acute gallstone pancreatitis without cholangitis

Early endoscopic retrograde cholangiopancreatography (ERCP) in acute gallstone pancreatitis without cholangitis

Best Practice Guidance

How up to date is this information?

Published January 2020 | Last reviewed September 2024

Using this guidance

The guidance set out here was reviewed extensively in the Autumn of 2024. There are no plans for any further reviews.

Medicine is constantly evolving and over time it is inevitable that the evidence base will change. Please use your own judgement and/or other sources of clinical guidance alongside the information set out here.

Please note this guidance is a recommendation and it should be used in the context of the overall care pathway and when all alternative interventions that may be available locally have been undertaken.

Summary

Early endoscopic retrograde cholangiopancreatography (ERCP) for acute gallstone pancreatitis without cholangitis is not recommended.

 

This guidance applies to adults aged 19 years and over.

Recommendation

Early ERCP in the treatment of acute gallstone pancreatitis, should only be performed if there is evidence of cholangitis or obstructive jaundice with imaging evidence of a stone in the common bile duct. Early ERCP refers to ERCP being performed on the same admission, ideally within 24 hours.

Rationale for recommendation

Gallstones are the most common cause of pancreatitis, causing up to 50% of cases. ERCP should be reserved for patients in whom therapeutic intervention is likely because ERCP is a very invasive procedure and carries a morbidity of 5-10% and a mortality rate of 0.1%- 0.5%. Risks associated with ERCP include risks of endoscopy and specific risks associated with ERCP, including pancreatitis, cholangitis, bleeding, and retroduodenal perforation.

ERCP is recommended for severe acute gallstone pancreatitis, dilatation of the common bile duct on imaging, jaundice, cholangitis or persistently abnormal and rising liver enzymes or if clinical deterioration occurs in patients with mild signs at presentation but who fail to improve after 48 hours.

Early ERCP for acute pancreatitis without cholangitis has been shown to have a higher mortality rate and is of little benefit in comparison to delayed ERCP.

Many gallstones are passed spontaneously.

Patient information

There is no specific EBI patient guidance for this intervention.

However, we recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.

Further information on patient involvement in EBI can be found on the EBI for patients section.

Make the most of your appointment using BRAN

2020

Coding

-- APCS Procedure
WHERE 1=1
-- Main Procedure
AND APCS.[Der_Procedure_All] LIKE '%J43[12389]%' 

--Diagnosis
AND (APCS.[Der_Diagnosis_All] LIKE '%K851%')
-- With no APCE Procedure within 30 days
AND (
CASE WHEN APCEP.[Primary_Procedure_Code] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Primary_Procedure_Date])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_2] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_2])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_3] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_3])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_4] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_4])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_5] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_5])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_6] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_6])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_7] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_7])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_8] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_8])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_9] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_9])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_10] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_10])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_11] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_11])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_12] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_12])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_13] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_13])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_14] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_14])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_15] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_15])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_16] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_16])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_17] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_17])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_18] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_18])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_19] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_19])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_20] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_20])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_21] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_21])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_22] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_22])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_23] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_23])<=3 THEN 1 ELSE 0 END +
CASE WHEN APCEP.[Procedure_Code_24] LIKE '%J43[12389]%' AND datediff(dd,apcs.Admission_Date,[Procedure_Date_24])<=3 THEN 1 ELSE 0 END 
)>0
Exclusions
 WHERE 1=1
-- Cancer Diagnosis Exclusion
AND (Any_Spell_Diagnosis not like '%C[0-9][0-9]%' 
AND Any_Spell_Diagnosis not like '%D0%' 
AND Any_Spell_Diagnosis not like '%D3[789]%' 
AND Any_Spell_Diagnosis not like '%D4[012345678]%' 
OR Any_Spell_Diagnosis IS NULL)
-- Private Appointment Exclusion
AND apcs.Administrative_Category<>'02'

References

  1. What is ERCP? (Endoscopic Retrograde Cholangio-Pancreatography) Patient leaflet.
  2. Tse F, YuanY. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev 2012:(5)CD009779.
  3. NICE guideline (2018) Pancreatitis [NG104].
  4. Schuster k, Holena D, salim A, savage S, crandall M, american association for the surgery of trauma emergency surgery guideline summaries: 2018, acute appendicitis, acute cholecysttis, acute diveritculis, acute pancreatitis, and small bowel obstruction. Trauam surg acute care open. 2019; 4: e000281.
  5. Uy MC, Daez ML,Sy PP,Banez VP,Espinosa WZ, Talingdan-Te MC. Early ERCP in acute gallstone pancreatitis without cholangitis: a meta-analysis. JOP 2009; 10: 299–305.
  6. Michael F Byrne, Gallstone pancreatitis – who really needs an ERCP? Can J Gastroenterol. 2006 Jan; 20(1): 15–17.PMCID: PMC2538962. PMID: 16432554.
  7. Malik HT, Marti J, Darzi A, Mossialos E. Savings from reducing low-value general surgical interventions. Br J Surg. 2018 Jan;105(1):13-25. doi:10.1002/bjs.10719
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