Approach to managing difficult biliary access during ERCP in adults

ERCP: endoscopic retrograde cholangiopancreatography; EUS: endoscopic ultrasound; PTC: percutaneous transhepatic cholangiography.

* Difficult biliary access during ERCP has been defined as the inability to cannulate the common bile duct using standard, guidewire-assisted technique within 5 to 10 minutes or up to 5 attempts. We inject a small pulse of contrast early in patients with multiple risk factors for post-ERCP pancreatitis, in those with small or tortuous ducts, and in those with a small papilla.

¶ For patients at higher risk of post-ERCP pancreatitis, we may access the pancreatic duct intentionally to place a pancreatic guidewire prior to attempting biliary access, to facilitate pancreatic stent placement after using a dual wire access method, or prior to using other advanced techniques.

Δ We place a pancreatic stent to reduce the risk of post-ERCP pancreatitis after deep pancreatic wire passage (regardless of biliary access technique), except for patients with tumor obstructing the pancreatic duct or for patients at very low risk for pancreatitis.

◊ We typically reserve transpancreatic precut sphincterotomy for patients with a small papilla, intradiverticular papilla, or unclear papillary anatomy. We generally avoid this technique in younger patients and in those with a normal pancreas to avoid pancreatic sphincterotomy and possible risk of stenosis.