New classification system for indications for endoscopic retrograde cholangiopancreatography predicts diagnoses and adverse events

Abstract

Background: Indications for endoscopic retrograde cholangiopancreatography (ERCP) have received little attention, especially in scientific or objective terms.

Aim: To review the prevailing ERCP indications in the literature, and to propose and evaluate a new ERCP indication system, which relies on more objective pre-procedure parameters.

Methods: An analysis was conducted on 1758 consecutive ERCP procedures, in which contemporaneous use was made of an a-priori indication system. Indications were based on the objective pre-procedure parameters and divided into primary [cholangitis, clinical evidence of biliary leak, acute (biliary) pancreatitis, abnormal intraoperative cholangiogram (IOC), or change/removal of stent for benign/malignant disease] and secondary [combination of two or three of: pain attributable to biliary disease (‘P’), imaging evidence of biliary disease (‘I’), and abnormal liver function tests (LFTs) (‘L’)]. A secondary indication was only used if a primary indication was not present. The relationship between this newly developed classification system and ERCP findings and adverse events was examined.

Results: The indications of cholangitis and positive IOC were predictive of choledocholithiasis at ERCP (101/154 and 74/141 procedures, respectively). With respect to secondary indications, only if all three of ‘P’, ‘I’, and ‘L’ were present there was a statistically significant association with choledocholithiasis (χ²(1) = 35.3, p < .001). Adverse events were associated with an unusual indication leading to greater risk of unplanned hospitalization (χ²(1) = 17.0, p < .001).

Conclusions: An a-priori-based indication system for ERCP, which relies on pre-ERCP objective parameters, provides a more useful and scientific classification system than is available currently.

Keywords:

• Cholangiopancreatography
• endoscopic retrograde
• biliary tract diseases
• choledocholithiasis

Acknowledgements

The authors thank Dr. Linda Lee of The Brigham and Women’s Hospital, Boston, for her help in reviewing this paper.

Disclosure statement

No potential conflict of interest was reported by the authors.