Endoscopic management of biliary ductal stones

Comparison of Repeated Recurrence of Common Bile Duct Stones and Occurrence of Hepatolithiasis After Synchronous Laparoscopic Cholecystectomy Combined with Laparoscopic Common Bile Duct Exploration or with Endoscopic Sphincterotomy: a 10-Year Retrospective Study

BACKGROUND

The optimal treatment options for gallstones together with common bile duct stones (CBDS) remain controversial. The aim of this study was to further compare the recurrence rate of stones after synchronous laparoscopic cholecystectomy combined with laparoscopic common bile duct exploration (SLCL) and synchronous laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy (SLCE) and to determine which option is more effective in reducing the rate of repeated recurrence of CBDS and the incidence rate of hepatolithiasis.

METHODS

We retrospectively investigated the clinical data of patients who underwent SLCL or SLCE at our hepatobiliary center between August 2012 and August 2020. The primary and secondary endpoints of this study were the recurrence of CBDS and the occurrence of hepatolithiasis, respectively.

RESULTS

In total, 1005 patients were enrolled in this study, including 431 patients in the SLCL group and 574 patients in the SLCE group. SLCL was associated with a significantly decreased rate of CBDS recurrence (4.18% vs. 7.84%, P = 0.018), repeated CBDS recurrence (0.70% vs. 3.00%, P = 0.010), and incidence of hepatolithiasis (0.00% vs. 1.05%, P = 0.040). Compared with SLCE, SLCL was an independent protective predictor of the recurrence of CBDS (relative risk, 0.505; 95% confidence interval, 0.286-0.891; P = 0.018) and repeated recurrence of CBDS (relative risk, 0.226; 95% confidence interval, 0.066-0.777; P = 0.018).

CONCLUSIONS

SLCL is an optimal treatment option to SLCE for patients with gallstones combined with CBDS.

Stentolith in Bile Duct: A Neglected Entity-Case Report with Review of Literature

Stentolith is a forgotten stent that acts as a nidus for stone formation leading to a stone-stent complex. Once the planned procedure is completed, these stents should be removed within 4 to 6 weeks, but if they are required for a longer period, then they should be replaced every 3 to 6 months. Devastating complications may ensue —such as cholangitis, biliary stricture, or secondary biliary cirrhosis. Management primarily comprises surgical intervention with common bile duct exploration or endoscopic clearance. The majority of patients eventually develop symptoms that lead to their diagnosis and subsequent management. This article, however, details the case of a silent stentolith and how it may have led to disastrous complications if surgical intervention was not done promptly.

Difficult removal of an endoscopic nasobiliary drainage tube after laparoendoscopic rendezvous surgery

A 52-year-old female patient came to our hospital with upper abdominal pain for more than four days. Magnetic resonance cholangiopancreatography confirmed gallstones, common bile duct dilatation and suspected choledocholithiasis.

Innovation of endoscopic management in difficult common bile duct stone in the era of laparoscopic surgery

Common bile duct (CBD) stone is a common biliary problem, which often requires endoscopic approach as the initial treatment option. Roughly, 7%-12% of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management. In general, there are three classifications of difficult CBD stone, which are based on the characteristics of the stone (larger than 15 mm, barrel or square-shaped stones, and hard consistency), accessibility to papilla related to anatomical variations, and other clinical conditions or comorbidities of the patients. Currently, endoscopic papillary large balloon dilation (EPLBD) of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts. If failed extraction is still encountered, mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered. Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available. To our knowledge, conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches. The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.

Características anatómicas de las vías biliares en una muestra de cadáveres de población colombiana

Introducción. En comparación con otros países, los estudios sobre características anatómicas de vías biliares en población colombiana son escasos.Objetivo. Analizar las características anatómicas de las vías biliares en una muestra de 60 tractos gastrointestinales de población colombiana.Materiales y métodos. Se realizó un estudio descriptivo analítico transversal donde se emplearon y disecaron las vías biliares de 60 tractos gastrointestinales humanos.Resultados. Según la clasificación de Blumgart de las variaciones anatómicas del tracto biliar, se encontraron las siguientes variaciones: Tipo A (78.3%), Tipo B (5%), Tipo C2 (3.3%), Tipo D2 (1.7%), Tipo E1 (1.7%), Tipo E2 (8.3%) y Tipo F (1.7%). En cuanto a las dimensiones promedio de las vías biliares extrahepáticas, se encontraron los siguientes diámetros y longitudes: conducto hepático derecho, 3.62mm y 10.64mm; conducto hepático izquierdo, 3.66mm y 10.74mm; conducto hepático común, 4.97mm y 25.59mm, y conducto colédoco, 4.90mm y 39.58mm. En general, las características anatómicas observadas en la mayoría de la muestra fueron similares a las reportadas en la literatura.Conclusiones. En el 78.3% de los casos se observaron características anatómicas usuales, mientras que las variantes anatómicas estuvieron presentes en el 21.7%. La longitud y el diámetro de las vías biliares están dentro del promedio reportado en la literatura.

Forgotten metal stent (3 years) presenting with a high burden of intra- and extra-hepatic ducts stones and cholangitis

Forgotten stents may lead to serious complications. We present a case report of a forgotten common bile duct (CBD) fully covered metal stent presenting with recurrent cholangitis. A 79-years-old female patient presented with a history of recurrent cholangitis. Past surgical history was notable for open cholecystectomy for symptomatic cholelithiasis in 2016. Subsequently, she was found to have retained CBD stones in the same year. She had endoscopic retrograde cholangiopancreatography (ERCP), during which a complete clearance of the stone was not achieved and she was stented with a completely covered metal stent. She was lost to follow-up until 2019. A differential diagnosis of cholangitis secondary to a blocked stent was made. At ERCP, she had intra- and extra-hepatic stones, which could not be removed. A plastic stent was deployed. She later had an open bile duct exploration with Roux-en-Y hepaticojejunostomy. Forgotten stents can lead to serious complications. An electronic stent follow-up registry is recommended.

Large Balloon Dilatation Versus Mechanical Lithotripsy After Endoscopic Sphincterotomy in the Management of Large Common Bile Duct Stones in Cirrhotic Patients: A Randomized Study

BACKGROUND AND STUDY AIM

Removal of large common bile duct (CBD) stones is one of the challenges faced during endoscopic retrograde cholangiopancreatography, and it seems more difficult in cirrhotic patients because of suspected higher rates of adverse events, especially bleeding diathesis. This study aimed at comparing the success rate and complications between mechanical lithotripsy (ML) and large balloon dilation (LBD) after endoscopic sphincterotomy in patients with liver cirrhosis.

PATIENTS AND METHODS

Ninety-eight cirrhotic patients with calcular obstructive jaundice were included and randomly divided into 2 groups: group A comprising 49 patients treated by LBD and group B comprising 49 patients treated by ML. All patients underwent sphincterotomy initially. All patients were subjected to thorough history taking and complete clinical examination. Pancreatic enzyme concentrations were measured 4 hours before and 24 hours after the procedure, and complete blood cell count and liver function tests were performed before and the morning after the procedure. Before and during endoscopic retrograde cholangiopancreatography, stone size and number were verified.

RESULTS

The success rate for CBD clearance was 98% and 93.8% for LBD and ML, respectively. The rate of adverse events in this study was 10.2% (10/98), and bleeding was the commonest reported complication (5/10). Group B developed more (16.3%) adverse events than group A (4.1%), and the difference was statistically significant (P=0.04).

CONCLUSION

Endoscopic sphincterotomy followed by LBD is a safe and effective treatment for large CBD stones in cirrhotic patients in comparison with sphincterotomy followed by ML.

The efficacy of temporary placement of nasobiliary drainage following endoscopic metal stenting to prevent post-ERCP cholangitis in patients with cholangiocarcinoma

BACKGROUND/AIMS

Although endoscopic metal biliary endoprosthesis (EMBE) is widely accepted as the most suitable drainage method for patients with unresectable malignant obstruction, uncontrolled post-procedural cholangitis is still a problem. We aimed to validate a new treatment modality to prevent post-ERCP cholangitis in patients with unresectable cholangiocarcinoma.

PATIENTS AND METHODS

A total of 378 patients who were diagnosed with unresectable malignant biliary obstruction and underwent EMBE or temporary endoscopic nasobiliary drainage (ENBD) following EMBE placement, from January 2010 to July 2016, were enrolled in this retrospective study. Incidence of cholangitis, related infectious indicators, success rate of biliary drainage, and occurrence of complications were evaluated.

RESULTS

The risk of overall cholangitis and related infectious indicators was significantly lower in EMBE plus ENBD group than that in EMBE group. The occurrence of cholangitis was 2.4% versus 11.9% (P = 0.004). On further analysis of subgroups, although no difference was detected in nonhilar cholangiocarcinoma subgroup, the incidence of cholangitis and related infectious indicators in hilar cholangiocarcinoma subgroup with EMBE modality were distinctly higher than that with EMBE plus ENBD modality (type I + II was 18.5% vs 0%, P < 0.05; type III + IV was 19.8% vs 3.8%, P < 0.05). No significant difference was found in successful biliary drainage rate and procedure-related complications when all subgroups were compared.

CONCLUSIONS

The temporary placement of ENBD following EMBE is a simple and effective treatment modality to prevent post-ERCP cholangitis, especially in patients with hilar cholangiocarcinoma.

Forgotten CBD stent (102 months) with stone-stent complex: A case report

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Choledocholithiasis can be treated by endoscopic extraction with or without stenting or by surgery.

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Stents cam form nidus for development of stones in CBD,may lead to cholangitis.

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Patients should be informed about ill effects of stent in-situ and advised to review for stent removal after 6 weeks.

Introduction

Choledocholithiasis is presence of stone in Common bile duct (CBD) which can be treated by endoscopy or surgery [1]. Retained foreign bodies like stents forms a nidus for stone formation resulting in pain, fever, jaundice.

Case presentation

60 years female patient admitted in surgery ward with features of cholangitis with computed tomography showing cholangitic abscess with dilated common bile duct and sludge around stent in situ. Stone was found at proximal end of stent during surgery.

Discussion

Stents may remain without complications or may migrate, and rarely form nidus for stone formation. If kept for long time they lead to bacterial proliferation, biofilm formation and precipitation of calcium bilirubinate presenting as fever, pain, jaundice. Stent-stone complex can be treated endoscopically and surgically [6,7]. As stent can cause stone formation, infection and other complications, timely removal of stent should advised.

Conclusion

III-effects of stent in-situ should be explained, record should be maintained [8] and patient should be advised regular follow up and stent removal after 6 weeks.

Value of laparoscopy in reoperation for extrahepatic bile duct stones

AIM: To compare the clinical effects of laparoscopy vs open surgery in reoperation for extrahepatic bile duct stones.

METHODS: Two hundred and forty-four patients who underwent reoperation for extrahepatic bile duct stones were randomly divided into either a laparoscopy group (n = 121) or an open surgery group (n = 123). Operative parameters, postoperative recovery, and complications were compared for the two groups.

RESULTS: In the laparoscopy group, 116 cases had successful laparoscopic surgery, and 5 (4.13%) cases required conversion to open operation. Mean operative time for the laparoscopy group was significantly longer than that for the open surgery group (109.7 min ± 5.7 min vs 97.8 min ± 7.7 min, P < 0.05). Mean bleeding volume for the laparoscopy group was significantly less than that for the open surgery group (32.7 mL ± 4.2 mL vs 92.7 mL ± 6.5 mL, P < 0.05). The time to anal exhaust, the number of times of analgesia usage, and length of stay for the laparoscopy group were significantly lower than those for the open surgery group (1.7 d ± 0.1 d vs 3.0 d ± 0.6 d, 1.4 d ± 1.0 d vs 2.9 d ± 0.7 d, 8.5 d ± 0.9 d vs 12.0 d ± 1.2 d, P < 0.05). The rate of postoperative incision infection for the laparoscopy group was significantly lower than that for the open surgery group (0% vs 4.88%, P < 0.05).

CONCLUSION: Laparoscopic procedure has less surgical trauma, shorter postoperative recovery time, and fewer complications in patients with extrahepatic bile duct stones, and it is safe and feasible for experienced laparoscopic surgeons and should be the preferred method for those patients.

Nasobiliary drainage after endoscopic papillary balloon dilatation may prevent postoperative pancreatitis

AIM: To evaluate the necessity of endoscopic nasobiliary drainage (ENBD) catheter placement after clearance of common bile duct (CBD) stones.

METHODS: Patients enrolled in this study were randomly divided into two groups, according to whether or not they received ENBD after the removal of CBD stones. Group 1 (ENBD group) was then subdivided into three groups: G1a patients received an endoscopic papillary balloon dilatation (EPBD), G1b patients received an endoscopic sphincterotomy (EST), and G1c patients received neither. Group 2 (non-ENBD group) patients were also subdivided into three groups (G2a, G2b, and G2c), similar to Group 1. The maximum CBD diameter, the time for C-reactive protein (CRP) to normalize, levels of serum amylase, total serum bilirubin (TB) and alanine aminotransferase (ALT), and postoperative hospitalization duration (PHD) were measured.

RESULTS: A total of 218 patients (139 males, 79 females), with an average age of 60.1 ± 10.8 years, were enrolled in this study. One hundred and thirteen patients who received ENBD were included in Group 1, and 105 patients who did not receive ENBD were included in Group 2. The baseline clinical characteristics were similar in both groups. There were no significant differences in post-endoscopic retrograde cholangiopancreatography (ERCP)-related complications when Groups 1 and 2 were compared. Seventy-seven patients underwent EPBD, and 41 received an ENBD tube (G1a) and 36 did not (G2a). Seventy-three patients underwent EST, and 34 patients received an ENBD tube (G1b) and 39 did not (G2b). The remaining 68 patients underwent neither EPBD nor EST; of these patients, 38 received an ENBD tube (G1c) and 30 did not (G2c). For each of the three pairs of subgroups (G1a vs G2a, G1b vs G2b, G1c vs G2c), there were no significant differences detected in the PHD or the time to normalization of CRP, TB and ALT. In the EPBD group, the incidence of post-ERCP pancreatitis, hyperamylasemia and overall patient complications was significantly higher for G2a (post-ERCP pancreatitis: 6/36 vs 0/41, P = 0.0217; hyperamylasemia: 11/36 vs 4/41, P = 0.0215; overall patient complications: 18/36 vs 7/41, P = 0.0029).

CONCLUSION: After successful CBD stone clearance, ENBD is only beneficial when an EPBD procedure has been performed.

Factors significantly contributing to a failed conventional endoscopic stone clearance in patients with "difficult" choledecholithiasis: a single-center experience

The objective of this study is to retrospectively evaluate factors significantly contributing to a failed stone extraction (SE) in patients with difficult to extract bile duct stones (BDS). Patients and Methods. During a 10-year period 1390 patients with BDS underwent successfully endoscopic sphincterotomy. Endoscopic SE was graded as easy; relatively easy; difficult; and failed. Difficult SE was encountered in 221 patients while failed SE was encountered in 205. A retrospective analysis of the criteria governing the difficulty of endoscopic SE following the index endoscopic intervention was performed to evaluate their significance in determining failure of complete SE among patients with difficult to extract bile duct stones. Results. Age ≥ 85 years, periampullary diverticula, multiple CBD stones (>4), and diameter of CBD stones (≥15 mm) were all significant contributing factors to a failed SE in univariate statistical tests. In the definitive multivariate analysis age, multiple stones and diameter of stones were found to be the significant, independent contributors. Conclusion. Failed conventional endoscopic stone clearance in patients with difficult to extract BDS is more likely to occur in overage patients, in patients with multiple CBD stones >4, and in patients with CBD stone(s) diameter ≥15 mm.

Advances in the endoscopic management of common bile duct stones

Extraction of common bile duct stones by endoscopic retrograde cholangiopancreatography generally involves biliary sphincterotomy, endoscopic papillary balloon dilation or a combination of both. Endoscopic papillary large-balloon dilation after sphincterotomy has increased the safety of large stone extraction. Cholangioscopically directed electrohydraulic and laser lithotripsy using single-operator mother-daughter systems or direct peroral cholangioscopy using ultraslim endoscopes are increasingly utilized for the management of refractory stones. In this Review, we focus on advances in endoscopic approaches and techniques, with a special emphasis on management strategies for 'difficult' common bile duct stones.

Endoscopic papillary balloon dilatation in comparison with endoscopic sphincterotomy for the treatment of large common bile duct stone

BACKGROUND

There are concerns on the efficacy and safety of endoscopic papillary balloon dilatation (EPBD) as an alternative to endoscopic sphincterotomy (EST) in the treatment of choledocholithiasis. We compared the efficacy and safety of EPBD and EST for removing large common bile duct (CBD) stones.

MATERIALS AND METHODS

One hundred sixty patients with CBD stones of 10-20 mm were randomized to undergo EPBD or EST. A 15-mm dilatation balloon was used for EPBD. Cotton's criteria were used to determine the incidence of post-EPBD or post-EST complications. CBD stone removal and complications were compared between the two methods.

RESULTS

CBD stones were completely removed in 97.5% of the EPBD and 96.2% of the EST group (P = 0.5). The incidence of postoperative pancreatitis (11.2% vs 8.7%) and bleeding (1.2% vs 1.2%) were similar between the EPBD and EST groups (P > 0.05). Perforation did not occur in any patient.

CONCLUSIONS

EPBD with 15-mm dilator balloon appears to be equally safe and effective compared with EST for removal of large CBD stones. So because of low complication and high success rate we recommend EPBD as the preferred method for removal of large (10-20 mm) CBD stones.

Endoscopic management of chronic pancreatitis

Chronic pancreatitis (CP) is a common gastrointestinal illness, which affects the quality of life with substantial morbidity and mortality. The management includes medical, endoscopic and surgical approaches with the need for interaction between various specialties, calling for a concerted multidisciplinary approach. However, at the time of this publication, guidelines to establish care of these patients are lacking. This review provides the reader with a comprehensive overview of the studies summarizing the various treatment options available, including medical, surgical and endoscopic options. In addition, technological advances such as endoscopic retrograde cholangiopancreatogrophy, endoscopic shock wave lithotripsy and endoscopic ultrasound can now be offered with reasonable success for pancreatic decompression, stricture dilatation with stent placement, stone fragmentation, pseudocyst drainage, and other endoscopic interventions such as celiac plexus block for pain relief. We emphasize the endoscopic options in this review, and attempt to extract the most up to date information from the current literature. The treatment of CP and its complications are discussed extensively. Complications such as biliary strictures. pancreatic pseudocysts, and chronic pain are common issues that arise as long-term complications of CP. These often require endoscopic or surgical management and possibly a combination of approaches, however choosing amongst the various therapeutic and palliative modalities while weighing the risks and benefits, makes the management of CP challenging. Treatment goals should be not just to control symptoms but also to prevent disease progression. Our aim in this paper is to advocate and emphasize an evidence based approach for the management of CP and associated long term complications.

Endoscopic management of difficult common bile duct stones

Endoscopy is widely accepted as the first treatment option in the management of bile duct stones. In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones. Most biliary stones can be removed with an extraction balloon, extraction basket or mechanical lithotripsy after endoscopic sphincterotomy. Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients. Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed. Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.

Poorly expandable common bile duct with stones on endoscopic retrograde cholangiography

AIM: To describe characteristics of a poorly expandable (PE) common bile duct (CBD) with stones on endoscopic retrograde cholangiography.

METHODS: A PE bile duct was characterized by a rigid and relatively narrowed distal CBD with retrograde dilatation of the non-PE segment. Between 2003 and 2006, endoscopic retrograde cholangiography (ERC) images and chart reviews of 1213 patients with newly diagnosed CBD stones were obtained from the computer database of Therapeutic Endoscopic Center in Chang Gung Memorial Hospital. Patients with characteristic PE bile duct on ERC were identified from the database. Data of the patients as well as the safety and technical success of therapeutic ERC were collected and analyzed retrospectively.

RESULTS: A total of 30 patients with CBD stones and characteristic PE segments were enrolled in this study. The median patient age was 45 years (range, 20 to 92 years); 66.7% of the patients were men. The diameters of the widest non-PE CBD segment, the PE segment, and the largest stone were 14.3 ± 4.9 mm, 5.8 ± 1.6 mm, and 11.2 ± 4.7 mm, respectively. The length of the PE segment was 39.7 ± 15.4 mm (range, 12.3 mm to 70.9 mm). To remove the CBD stone(s) completely, mechanical lithotripsy was required in 25 (83.3%) patients even though the stone size was not as large as were the difficult stones that have been described in the literature. The stone size and stone/PE segment diameter ratio were associated with the need for lithotripsy. Post-ERC complications occurred in 4 cases: pancreatitis in 1, cholangitis in 2, and an impacted Dormia basket with cholangitis in 1. Two (6.7%) of the 28 patients developed recurrent CBD stones at follow-up (50 ± 14 mo) and were successfully managed with therapeutic ERC.

CONCLUSION: Patients with a PE duct frequently require mechanical lithotripsy for stones extraction. To retrieve stones successfully and avoid complications, these patients should be identified during ERC.

Endoscopic extraction of large common bile duct stones: A review article

Since therapeutic endoscopic retrograde cholangiopancreatography replaced surgery as the first approach in cases of choledocolithiasis, a plethora of endoscopic techniques and devices appeared in order to facilitate rapid, safe and effective bile duct stones extraction. Nowadays, endoscopic sphincterotomy combined with balloon catheters and/or baskets is the routine endoscopic technique for stone extraction in the great majority of patients. Large common bile duct stones are treated conventionally with mechanical lithotripsy, while the most serious complication of the procedure is “basket and stone impaction” that is predominately resolved surgically. In cases of difficult, impacted, multiple or intrahepatic stones, more sophisticated procedures have been used. Electrohydraulic lithotripsy and laser lithotripsy are performed using conventional mother-baby scope systems, ultra-thin cholangioscopes, thin endoscopes and ultimately using the novel single use, single operator SpyGlass Direct Visualization System, in order to deliver intracorporeal shock wave energy to fragment the targeted stone, with very good outcomes. Recently, large balloon dilation after endoscopic sphincterotomy confirmed its effectiveness in the extraction of large stones in a plethora of trials. When compared with mechanical lithotripsy or with balloon dilation alone, it proved to be superior. Moreover, dilation is an ideal alternative in cases of altered anatomy where access to the papilla is problematic. Endoscopic sphincterotomy followed by large balloon dilation represents the onset of a new era in large bile duct stone extraction and the management of “impaction” because it seems that is an effective, inexpensive, less traumatic, safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists. When complete extraction of large stones is unsuccessful, the drainage of the common bile duct is mandatory either for bridging to the final therapy or as a curative therapy for very elderly patients with short life expectancy. Placing of more than one plastic endoprostheses is better while the administration of Ursodiol is ineffective. The great majority of patients with large stones can be treated endoscopically. In cases of unsuccessful stone extraction using balloons, baskets, mechanical lithotripsy, electrohydraulic or laser lithotripsy and large balloon dilation, the patient should be referred for extracorporeal shock wave lithotripsy or a percutaneous approach and finally surgery.

Endoscopic retrograde cholangiopancreatography for non-gastroenterologists: what you need to know

Endoscopic retrograde cholangiopancreatography (ERCP) represents the most powerful and widely employed platform for pancreaticobiliary interventions. Endoscopic retrograde cholangiopancreatography allows diagnosis and treatment of a broad spectrum of diseases of the pancreaticobiliary tree that are both benign and malignant in nature. Endoscopic retrograde cholangiopancreatography continues to evolve rapidly, and non-gastroenterologists need to understand the indications, contraindications, limitations, and role of ERCP to effectively manage and coordinate the care of patients with known or suspected pancreaticobiliary disease. This article will review the role of ERCP in detail to further an understanding of the procedure as a whole and to assess when referral of a patient for an ERCP or other related test is indicated.