Early endoscopic retrograde cholangiopancreatography (ERCP) in acute gallstone pancreatitis without cholangitis
Best Practice Guidance
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.
Coding
Code Script
— 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
Code Definitions
Procedure codes (OPCS)
J431 Endoscopic retrograde cholangiopancreatography and biopsy of lesion of ampulla of Vater
J432 Endoscopic retrograde cholangiopancreatography and biopsy of lesion of biliary or pancreatic system NEC
J433 Endoscopic retrograde cholangiopancreatography and collection of bile
J438 Other specified diagnostic endoscopic retrograde examination of bile duct and pancreatic duct
J439 Unspecified diagnostic endoscopic retrograde examination of bile duct and pancreatic duct
J451 Endoscopic retrograde pancreatography and biopsy of lesion of pancreas
J452 Endoscopic retrograde pancreatography and collection of pancreatic juice
J453 Endoscopic retrograde pancreatography through accessory ampulla of Vater
J458 Other specified diagnostic endoscopic retrograde examination of pancreatic duct
J459 Unspecified diagnostic endoscopic retrograde examination of pancreatic duct
Diagnosis codes (ICD)
K851 Biliary acute pancreatitis
Exclusions
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and apcs.der_diagnosis_all not like '%D0%' and apcs.der_diagnosis_all not like '%D3[789]%' and apcs.der_diagnosis_all not like '%D4[012345678]%’
This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
for adults.
— Private Appointment Exclusion
AND apcs.Administrative_Category<>’02’
References
- What is ERCP? (Endoscopic Retrograde Cholangio-Pancreatography) Patient leaflet.
- 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.
- NICE guideline (2018) Pancreatitis [NG104].
- 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.
- 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.
- Michael F Byrne, Gallstone pancreatitis – who really needs an ERCP? Can J Gastroenterol. 2006 Jan; 20(1): 15–17.PMCID: PMC2538962. PMID: 16432554.
- 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
How up to date is this information?
Last revised December 2023
Changes
December 2023 - Coding updated. August 2022 - Coding updated
