On the Bleeding Edge: Mastering GI Emergencies and Inpatient GI Consultation (Live and Virtual)| September 2026-Chapman_Pancreaticobiliary

Chapman_Pancreaticobiliary_Dilemmas

Pdf Summary

This document is a lecture summary on pancreaticobiliary emergencies, acute pancreatitis, and prevention of post-ERCP pancreatitis. It emphasizes that ERCP should be used for therapeutic, not diagnostic, purposes, and that outcomes depend heavily on patient selection, operator experience, and center volume.<br /><br />Key biliary emergencies include ascending cholangitis, choledocholithiasis, malignant obstruction, bile leaks, and difficult cannulation. Cholangitis is a clinical diagnosis characterized by fever, pain, jaundice, and ductal dilation; severity determines timing of drainage. Mild cases may start with antibiotics, moderate cases need early ERCP within 24–48 hours, and severe cases require emergent drainage after resuscitation. If the patient is unstable or coagulopathic, temporary plastic stenting may be preferred over sphincterotomy. For malignant obstruction without infection, urgent overnight ERCP is usually not needed; staging with EUS/CT is preferred, with drainage only if indicated.<br /><br />For choledocholithiasis, patients should be risk-stratified before ERCP. Intermediate-risk patients should undergo EUS or MRCP rather than diagnostic ERCP, which also helps prevent unnecessary post-ERCP pancreatitis. Difficult stone management should escalate based on stone size and duct anatomy.<br /><br />Bile leaks after cholecystectomy are usually managed with ERCP and plastic stenting, with percutaneous drainage for bilomas. Post-sphincterotomy bleeding is treated endoscopically, with covered metal stents or IR rescue if needed.<br /><br />In acute pancreatitis, early ERCP is no longer recommended unless cholangitis or persistent biliary obstruction is present. Management now favors moderate lactated Ringer’s hydration, early feeding when tolerated, delayed intervention for necrosis until walled off, and same-admission cholecystectomy for mild biliary pancreatitis.<br /><br />To prevent post-ERCP pancreatitis, the lecture recommends wire-guided cannulation, early escalation in difficult cannulation, universal rectal indomethacin when not contraindicated, pancreatic duct stenting for high-risk cases, and careful use of fluids.

Keywords

pancreaticobiliary emergencies

acute pancreatitis

post-ERCP pancreatitis

ERCP

ascending cholangitis

choledocholithiasis

bile leaks

malignant obstruction

wire-guided cannulation

rectal indomethacin