Endoscopic Sphincterotomy for Choledocholithiasis

  • Varun Kapur
  • Victor Sandoval
  • Jeffrey M. MarksEmail author


Symptomatic choledocholithiasis commonly presents as biliary colic, with abnormal liver function tests, most notably with conjugated hyperbilirubinemia and elevated alkaline phosphatase levels. Ultrasound or computed tomography (CT) imaging will reveal a dilated common bile duct, and occasionally a stone may be visualized within it. Sometimes, it may present as cholangitis or pancreatitis, which carry a much higher morbidity and will require more immediate attention. Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from being a pure diagnostic modality to primarily a therapeutic intervention for pancreaticobiliary duct pathologies, which are amenable to endoscopic treatment. It is commonly employed as an option for the management of common bile duct stones. ERCP may also be performed preoperatively, intraoperatively, or post-cholecystectomy for specific conditions. Most ERCPs can be performed safely under moderate sedation. The basic steps of ERCP include inserting and navigating the side-viewing duodenoscope to visualize the ampulla of Vater, cannulating the bile duct, and performing a cholangiogram, followed by a sphincterotomy if necessary. Bile duct cannulation is the most technically challenging part of the procedure, commonly performed using a standard catheter or a sphincterotome, with a guidewire used to assist. Complication rates with ERCP are higher than with most endoscopic procedures; however, the risk for severe or fatal complication is low in experienced hands. The most common complications after ERCP include pancreatitis, bleeding, perforation, and infection. Steps to minimize and prevent complications are discussed here. It is the responsibility of the training program to ensure adequate hands-on training under directed supervision to prepare the next generation of endoscopists to perform ERCP safely and competently. Simulation lab and animal lab courses conducted by experts can be used to augment training in ERCP.


Choledocholithiasis ERCP complications and management ERCP in pregnancy Indications for ERCP Accessories for ERCP ERCP for surgeons Basic ERCP technique Training in ERCP 

Supplementary material

Video 12.1

Two examples of sphincterotomy technique are shown (using a sphincterotome or needle-knife) (MP4 97900 kb)


  1. 1.
    Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut Liver. 2012;6(2):172–87.CrossRefGoogle Scholar
  2. 2.
    Cai J-S, Qiang S, Bao-Bing Y. Advances of recurrent risk factors and management of choledocholithiasis. Scand J Gastroenterol. 2016;52(1):1–10.Google Scholar
  3. 3.
    Liu TH, Consorti ET, Kawashima A, Tamm EP, Kwong KL, Gill BS, et al. Patient evaluation and management with selective use of magnetic resonance cholangiography and endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy. Ann Surg. 2001;234(1):33–40.CrossRefGoogle Scholar
  4. 4.
    Mitchell SE, Clark RA. A comparison of computed tomography and sonography in choledocholithiasis. AJR Am J Roentgenol. 1984;142(4):729–33.CrossRefGoogle Scholar
  5. 5.
    Giljaca V, Gurusamy KS, Takwoingi Y, Higgie D, Poropat G, Štimac D, et al. Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones. Cochrane Database Syst Rev. 2015;2:CD011549.Google Scholar
  6. 6.
    Möller M, Gustafsson U, Rasmussen F, Persson G, Thorell A. Natural course vs interventions to clear common bile duct stones. JAMA Surg. 2014;149(10):1008–13.CrossRefGoogle Scholar
  7. 7.
    Jeurnink SM, Steyerberg EW, Kuipers EJ, Siersema PD. The burden of endoscopic retrograde cholangiopancreatography (ERCP) performed with the patient under conscious sedation. Surg Endosc. 2012;26(8):2213–9.CrossRefGoogle Scholar
  8. 8.
    Garewal D, Powell S, Milan SJ, Nordmeyer J, Waikar P. Sedative techniques for endoscopic retrograde cholangiopancreatography. Cochrane Database Syst Rev. 2012;6:CD007274.Google Scholar
  9. 9.
    Mishkin D, Carpenter S, Croffie J, Chuttani R, DiSario J, Hussain N, Technology Assessment Committee, American Society for Gastrointestinal Endoscopy, et al. ASGE technology status evaluation report: radiographic contrast media used in ERCP. Gastrointest Endosc. 2005;62(4):480–4.CrossRefGoogle Scholar
  10. 10.
    Singhvi G, Dea SK. Guidewires in ERCP. Gastrointest Endosc. 2013;77(6):938–40.CrossRefGoogle Scholar
  11. 11.
    Cotton PB, Leung J. ERCP: the fundamentals. 2nd ed. West Sussex: Wiley; 2015.Google Scholar
  12. 12.
    Kethu SR, Adler DG, Conway JD, Diehl DL, Farraye FA, Kantsevoy SV, Kaul V, Kwon RS, Mamula P, Pedrosa MC, Rodriguez SA, The ASGE Technology Committee. ERCP cannulation and sphincterotomy devices. Gastrointest Endosc. 2010;71(3):435–45.CrossRefGoogle Scholar
  13. 13.
    Zagalsky D, Guidi M, Curvale C, Lasa J, de Maria J, Ianniccillo H, et al. Early precut is as efficient as pancreatic stent in preventing post-ERCP pancreatitis in high-risk subjects–a randomized study. Rev Esp Enferm Dig. 2016;108(9):558–62.Google Scholar
  14. 14.
    Garg PK, Tandon RK, Ahuja V, Makharia GK, Batra Y. Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones. Gastrointest Endosc. 2004;59(6):601–5.CrossRefGoogle Scholar
  15. 15.
    Amplatz S, Piazzi L, Felder M, Comberlato M, Benvenuti S, Zancanella L, et al. Extracorporeal shock wave lithotripsy for clearance of refractory bile duct stones. Dig Liver Dis. 2007;39:267–72.CrossRefGoogle Scholar
  16. 16.
    Prat F, Fritsch J, Choury AD, Frouge C, Marteau V, Etienne JP. Laser lithotripsy of difficult biliary stones. Gastrointest Endosc. 1994;40(3):290–5.CrossRefGoogle Scholar
  17. 17.
    Sauerbruch T, Stern M. Fragmentation of bile duct stones by extracorporeal shock waves. A new approach to biliary calculi after failure of routine endoscopic measures. Gastroenterology. 1989;96(1):146–52.CrossRefGoogle Scholar
  18. 18.
    Yıldırım A, Altun R, Ocal S, Kormaz M, Ozcay F, Selcuk H. The safety and efficacy of ERCP in the pediatric population with standard scopes: does size really matter? Spring. 2016;5:128.CrossRefGoogle Scholar
  19. 19.
    ASGE Standard of Practice Committee, Shergill AK, Ben-Menachem T, Chandrasekhara V, Chathadi K, Decker GA, Evans JA, et al. Guidelines for endoscopy in pregnant and lactating women. Gastrointest Endosc. 2012;76(1):18–24.CrossRefGoogle Scholar
  20. 20.
    ASGE Standards of Practice Committee, Chandrasekhara V, Khashab MA, Muthusamy VR, Acosta RD, Agrawal D, Bruining DH, et al. Adverse events associated with ERCP. Gastrointest Endosc. 2017;85(1):32–47.CrossRefGoogle Scholar
  21. 21.
    Freeman ML. Adverse outcomes of ERCP. Gastrointest Endosc. 2002;56(6B):a129028.CrossRefGoogle Scholar
  22. 22.
    Cotton PB, Lehman G, Vennes J, Geenen JE, Russell RC, Meyers WC, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc. 1991;37(3):383–93.CrossRefGoogle Scholar
  23. 23.
    FDA Executive Summary. Effective reprocessing of endoscopes used in endoscopic retrograde cholangiopancreatography (ERCP) procedures. May 2015. Accessed 08 Aug 2017.
  24. 24.
    Keswani RN, Soper NJ. Endoscopes and the “Superbug” outbreak. JAMA Surg. 2015;150(9):831–2.CrossRefGoogle Scholar
  25. 25.
    Masci E, Toti G, Mariani A, Curioni S, Lomazzi A, Dinelli M, et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol. 2001;96(2):417–23.CrossRefGoogle Scholar
  26. 26.
    Stapfer M, Selby RR, Stain SC, Katkhouda N, Parekh D, Jabbour N, et al. Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg. 2000;232(2):191–8.CrossRefGoogle Scholar
  27. 27.
    Genzlinger JL, McPhee MS, Fisher JK, Jacob KM, Helzberg JH. Significance of retroperitoneal air after endoscopic retrograde cholangiopancreatography with sphincterotomy. Am J Gastroenterol. 1999;94(5):1267–70.CrossRefGoogle Scholar
  28. 28.
    ASGE Standards of Practice Committee, Faulx AL, Lightdale JR, Acosta RD, Agrawal D, Bruining DH, Chandrasekhara V, et al. Guidelines for privileging, credentialing, and proctoring to perform GI endoscopy. Gastrointest Endosc. 2017;85(2):273–81.CrossRefGoogle Scholar
  29. 29.
    Pearl J, Fellinger E, Dunkin B, Pauli E, Trus T, Marks J, Fanelli R, Meara M, Stefanidis D, Richardson W. Guidelines for privileging and credentialing physicians in gastrointestinal endoscopy. Surg Endosc. 2016;30(8):3184–90.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Varun Kapur
    • 1
  • Victor Sandoval
    • 2
  • Jeffrey M. Marks
    • 3
    Email author
  1. 1.Department of General SurgeryUniversity Hospitals Case Medical CenterClevelandUSA
  2. 2.Department of General SurgeryUniversity Hospitals of ClevelandClevelandUSA
  3. 3.Department of General SurgeryUniversity Hospitals Cleveland Medical CenterClevelandUSA

Personalised recommendations