ASGE Annual GI Advanced Practice Provider Course (On-demand) (Day One)

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This presentation reviews ERCP (Endoscopic Retrograde Cholangiopancreatography) and EUS (Endoscopic Ultrasound), focusing on definitions, indications, contraindications, preparation/consent, procedural components, and post-procedure care and follow-up.

ERCP combines endoscopy with fluoroscopy and contrast injection to image and, most commonly today, <em>treat</em> pancreaticobiliary duct disorders. Because lower-risk imaging (EUS, MRCP, ultrasound, CT, intraoperative cholangiogram) has largely replaced diagnostic ERCP, modern ERCP is primarily therapeutic. Core clinical applications include choledocholithiasis and cholangitis, malignant biliary obstruction (e.g., pancreatic cancer, cholangiocarcinoma), bile leaks after surgery, benign biliary strictures (post-cholecystectomy, transplant, PSC/SSC, radiation), chronic pancreatitis with ductal stones/strictures, and pancreatic duct injury/leak. Typical interventions include cannulation, sphincterotomy, stone extraction (balloons/baskets/lithotripsy), stricture dilation, tissue sampling (brushings/biopsy), stent placement (plastic or SEMS), and cholangioscopy when needed. Major adverse events include pancreatitis, bleeding, perforation, and cardiopulmonary complications (e.g., hypoxia). Preprocedure planning emphasizes ASA risk assessment, sedation/anesthesia decisions, selective antibiotic use (e.g., PSC, post-transplant, or anticipated inadequate drainage), and pancreatitis prophylaxis with rectal NSAIDs in high-risk patients. Antithrombotic management depends on bleeding risk (higher for sphincterotomy/dilation; lower for stents/brushings). Postprocedure care includes diet advancement after recovery, monitoring for clinical response/complications, and arranging follow-up such as stent exchange/removal or surgical consultation.

EUS combines endoscopy with high-frequency ultrasound (radial or linear scopes) and has expanding diagnostic and therapeutic roles. Indications include diagnosis (pancreatic lesions/cysts, subepithelial lesions, mediastinal nodes/masses, liver lesions, biliary dilation, choledocholithiasis), cancer staging (esophageal, gastric, pancreatic, rectal, lung, ampullary), and therapies such as pseudocyst drainage, biliary/gallbladder drainage, celiac plexus block, variceal coil/glue, EUS-guided ERCP, and lumen-apposing stent anastomosis creation. EUS with FNA or therapeutic intervention is higher bleeding risk and generally requires holding anticoagulants/antiplatelets (often continuing aspirin/NSAIDs). The talk emphasizes careful patient selection, preference for less invasive tests when appropriate, and early recognition and expert management of complications.

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John A. Martin, MD, FASGE

Keywords

ERCP

Endoscopic Retrograde Cholangiopancreatography

EUS

Endoscopic Ultrasound

choledocholithiasis

cholangitis

biliary obstruction

sphincterotomy

pancreatitis prophylaxis

EUS-guided FNA