ERCP in acute and recurrent acute pancreatitis

When applied in the appropriate settings, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) meaningfully impacts the natural history of acute gallstone pancreatitis. Among patients with concomitant acute cholangitis or predicted severe acute pancreatitis (AP) with biliary obstruction, early ERCP with biliary drainage significantly reduces morbidity and mortality. In select individuals with acute gallstone pancreatitis, same-stay ERCP reduces the likelihood of readmission and serves as a viable alternative to cholecystectomy in poor operative candidates. Given its risk profile, diagnostic ERCP has been appropriately replaced by less invasive imaging modalities for the first- and second-tier evaluation of patients with unexplained acute and recurrent acute pancreatitis (RAP). However, ERCP remains an important diagnostic and potentially therapeutic intervention in some cases. Future studies will need to clarify the relationship between AP and pancreas divisum as well as sphincter of Oddi dysfunction (SOD), and whether endoscopic intervention significantly alters the natural history of acute and RAP.