ERCP and EUS Procedures

• Audio chapter
  Attending-narrated, listen on the commute.
• ABIM-format MCQs
  5-option vignettes with full wrong-answer teaching.
• Study guide
  Tables, decision trees, primary sources.
• AI tutor
  Chapter-grounded, answers the question you're stuck on.

What this chapter covers

• Section 29.1: ERCP indications, cannulation, and PEP prophylaxis

  ERCP is a therapeutic procedure that carries pancreatitis risk, and every part of the workflow exists to keep that risk in check.

• Section 29.2: Sphincter of Oddi dysfunction in EPISOD era

  The EPISOD trial reshaped how sphincter of Oddi dysfunction (SOD) is diagnosed and treated.

• Section 29.3: Biliary stricture tissue acquisition

  The question of how to obtain tissue from a biliary stricture turns on the upstream clinical context: a transplant candidate, a patient awaiting neoadjuvant chemotherapy, a post-cholecystectomy patient with focal intrahepatic ductal dilation, or an indeterminate stricture after multiple negative ERCP brushings.

• Section 29.4: Ampullectomy and endoscopic papillectomy

  Ampullary adenomas are detected either as sporadic lesions found incidentally during EGD or ERCP, or as part of duodenal polyposis surveillance in familial adenomatous polyposis (FAP), where the ampulla is the most common site of duodenal adenoma.

• Section 29.5: Malignant biliary obstruction stenting

  Malignant biliary obstruction stenting strategy depends on the location of the obstruction, the resectability of the underlying tumor, and the anticipated life expectancy.

• Section 29.6: EUS-guided biliary drainage rescue

  EUS-guided biliary drainage is the modern rescue path when ERCP cannulation fails in a patient with a dilated bile duct.

• Section 29.7: ERCP in altered anatomy

  Surgical alteration of upper GI anatomy creates barriers between the side-viewing duodenoscope and the major papilla that drive procedural choice.

• Section 29.8: EUS and ERCP in pancreatitis

  The indication for ERCP and EUS in pancreatitis is structural disease or stone burden, and the threshold for action reflects the modest expected benefit of intervention against the substantial PEP risk that any ERCP carries.

• Section 29.9: Pancreatic fluid collections and EUS therapeutic drainage

  Symptomatic pancreatic fluid collections at 4 weeks or later (when the collection has formed a mature wall) are managed endoscopically through EUS-guided transmural drainage.

• Section 29.10: Direct endoscopic necrosectomy

  Direct endoscopic necrosectomy (DEN) is the through-LAMS debridement procedure performed when transmural drainage alone fails to clear solid debris in walled-off pancreatic necrosis.

• Section 29.11: EUS tissue acquisition

  EUS tissue acquisition decisions turn on three connected ideas: lesion identity follows sonographic layer, needle choice follows the diagnostic question, and the EUS layer informs the differential while the needle type informs the diagnostic yield.

• Section 29.12: EUS-guided celiac plexus neurolysis

  EUS-guided celiac plexus neurolysis (CPN) is performed for unresectable pancreatic cancer pain refractory to opioids, where opioid escalation produces unacceptable side effects (constipation, sedation, cognitive impairment) before achieving adequate pain control.

• Section 29.13: ERCP in pregnancy

  ERCP in pregnancy is performed when biliary obstruction with cholangitis, severe gallstone pancreatitis with persistent obstruction, large stone with refractory symptoms, or post-cholecystectomy bile leak demands intervention that cannot be deferred to postpartum.

• Section 29.14: ERCP complications and reprocessing

  ERCP complications are categorized by mechanism and frequency, with PEP and post-sphincterotomy bleeding the dominant concerns and duodenoscope reprocessing the quality and safety concern that has reshaped device design.

Podcast episodes

1. 01

   ERCP Cannulation and PEP Prophylaxis

   This episode covers how to get into the duct safely: why ERCP is a therapy and not a test, the cannulation technique that holds post-ERCP pancreatitis in check, and the prophylaxis stack built to push that risk down.

2. 02

   ERCP Patient Selection and Complications

   This episode covers who belongs on the ERCP table: sphincter of Oddi dysfunction as a landmark trial rewrote it, the pregnant patient who has a radiation-free alternative, and the bleeding, perforation, and infection complications the whole workflow exists to prevent.

3. 03

   ERCP and EUS Procedures

   This episode covers the obstructed and indeterminate biliary tree: getting a diagnosis from a stricture, choosing and placing the right stent for a malignant obstruction, and resecting an ampullary lesion rather than stenting around it.

4. 04

   ERCP and EUS Procedures

   This episode covers what to do when the standard route fails: the EUS- guided rescues for a duct you cannot cannulate, and the altered surgical anatomy that puts the papilla out of a duodenoscope's reach.

5. 05

   Recurrent Pancreatitis and Duct Decompression

   This episode covers EUS and ERCP in the pancreatitis spectrum before the collections: working up idiopathic recurrent acute pancreatitis, the pancreas divisum trap, and decompressing the chronic dilated duct.

6. 06

   Fluid Collections and Necrosectomy

   This episode covers the collections the gland leaves behind: the maturation timing that decides when to drain, the pseudoaneurysm check that prevents a catastrophe, the step-up from transmural drainage to direct endoscopic necrosectomy, and the carbon dioxide rule that keeps necrosectomy from causing an air embolism.

7. 07

   ERCP and EUS Procedures

   This episode covers what EUS does beyond the ducts: reading the gut-wall layers to identify a subepithelial lesion, choosing the needle that answers the diagnostic question, and using the celiac plexus to control pancreatic cancer pain.