Acute pancreatitis and ERCP

When to perform ERCP?

In patients with acute biliary pancreatitis and no cholangitis, the AGA suggests against the routine use of urgent ERCP. (Conditional recommendation, low quality evidence.) [AGA]

Inpatient biliary drainage by ERCP or PTC (percutaneous transhepatic cholangiopancreatography) should be considered for [NHS]:

• Severe gallstone pancreatitis with cholangitis (URGENT <24h) 
• Gallstone pancreatitis with obstructing common bile duct stone, where surgical bile duct exploration not considered appropriate 
• Gallstone pancreatitis with non‐obstructing common bile duct stone, where surgical bile duct exploration not considered appropriate  

Outpatient elective biliary drainage with ERCP should be considered for [NHS]:

• Gallstone pancreatitis with non‐obstructing common bile duct stone where not technically achievable during the index admission due to pancreatic swelling and surgical bile duct exploration not considered appropriate 
• Definitive treatment for gallstone pancreatitis where not surgically fit 

What does severe pancreatitis mean?

Severity is categorized based on the recent revised Atlanta classification [AGA, NHS].

Severity Assessment (ATLANTA classification) – Assess at admission, 24 hours and 48 hours.

• Severe: Persistent (>48 hrs) organ failure*, local complications (e.g. necrosis, peripancreatic fluid collections, pseudocyst, splenic & portal vein thromboses) or exacerbation of coexistent disease 
• Moderately severe: As above but transient only (<48 hours) 
• Mild: No organ failure, local complications or exacerbation of coexistent disease 

NB: If SIRS or organ failure present at admission then classify as SEVERE. If resolved at 48 hours can be reclassified as moderately severe.

Guidelines

American Gastroenterological Association (AGA) (2018)

NHS trust (2017)