01Principles and purposeThe professional or clinical skill and the decisions it supports.
Biliary decompression is a therapeutic decision with a target, an indication and a planned duration. It can control infected obstruction, relieve disabling pruritus, restore bile flow before delayed or neoadjuvant treatment, or palliate incurable blockage. It can also cause pancreatitis, bleeding, perforation, bacteraemia and device failure. A stable jaundiced patient may benefit more from staging and prompt surgery than from routine preoperative drainage.
Route follows anatomy. Standard ERCP approaches the papilla and usually drains a distal lesion internally. Percutaneous transhepatic biliary drainage enters a selected intrahepatic sector and is useful when hilar systems are separated or endoscopic access fails. EUS-guided biliary drainage can create internal access after failed ERCP in expert centres. Surgical bypass is now selected rather than routine but may be appropriate in particular operative or long-term situations.
Device choice follows diagnostic certainty and time horizon. Plastic stents are removable and cheap but have smaller calibre and shorter patency. SEMS expands to a larger diameter and is generally preferred for malignant palliation. Covered metal stents can be removed but may migrate or block branch ducts; uncovered stents embed through tissue and should not be placed when benign disease remains possible. Hilar configuration must preserve side branches and adequate functioning liver volume.
Key points
- Drain bile for cholangitis and for selected severe symptomatic obstruction, treatment delay or neoadjuvant therapy; do not equate jaundice alone with an automatic preoperative stent.
- For stable suspected pancreatic cancer with obstructive jaundice, obtain pancreatic-protocol CT before drainage and usually proceed directly to resection when promptly operable.
- ERCP is generally suited to distal obstruction; percutaneous access can target separated proximal sectors, and specialist EUS-guided drainage is an option after failed ERCP where expertise exists.
- ESGE recommends a 10 mm self-expandable metal stent for malignant extrahepatic preoperative drainage when drainage is indicated, and SEMS for palliative extrahepatic obstruction.
- Do not use uncovered SEMS before the extrahepatic cause is confirmed; removable fully covered SEMS or multiple plastic stents are options for selected benign strictures.
- In perihilar disease, define future liver remnant and functioning sector volume before choosing unilateral or bilateral drainage.
- Give 100 mg diclofenac rectally immediately before ERCP to patients without NSAID contraindications, and use prophylactic pancreatic-duct stenting for defined high-risk cannulation events.
- Verify decompression clinically and biochemically, document stent type and location, and assign a removal, exchange or on-demand blockage plan.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Cholangitis with organ dysfunction creates a time-critical need for source control; drain the infected obstructed sectors rather than pursuing perfect elective staging first.
Intense cholestatic pruritus, nutritional consequence or renal deterioration may justify decompression when benefit exceeds procedural risk.
Delayed surgery or neoadjuvant systemic treatment in a jaundiced patient can require dependable bile flow and a device matched to the interval.
A stable, promptly resectable distal cancer without cholangitis often proceeds to surgery without preoperative stenting.
Recurrent jaundice, fever, rigors, pale stools or pain after initial improvement suggests occlusion, migration or tumour progression.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Cross-sectional staging imaging - Why
- Define cause, obstruction level, vascular relationships and metastases before elective drainage.
- Interpretation and limitations
- Use pancreatic-protocol CT for suspected pancreatic cancer and MRI/MRCP for proximal duct mapping; intervention before imaging may obscure or infect the system.
- 02
MRCP drainage map - Why
- Show which right and left sectors communicate and which liver volume requires decompression.
- Interpretation and limitations
- In hilar obstruction, the desired target is functioning or future-remnant liver; simply counting visible ducts or stents is inadequate.
- 03
Bilirubin, ALP, INR, FBC and renal profile - Why
- Measure cholestasis, infection, organ reserve and procedural bleeding risk.
- Interpretation and limitations
- Correct dehydration and reversible coagulopathy. A bilirubin plateau after drainage suggests insufficient liver volume, device dysfunction or parenchymal failure.
- 04
Blood and bile cultures - Why
- Identify pathogens in suspected cholangitis and guide narrowing after drainage.
- Interpretation and limitations
- Collect before antibiotics when this does not delay treatment; bile cultured during decompression may reveal organisms not found in blood.
- 05
ERCP cholangiography and sampling - Why
- Confirm intraductal anatomy, obtain brushings and deploy a stent when endoscopic therapy is indicated.
- Interpretation and limitations
- Minimise contrast in segments that cannot be drained and regard negative cytology as non-exclusionary when malignant probability remains high.
- 06
Post-intervention imaging - Why
- Investigate persistent or recurrent symptoms and locate stent, dilation, collections or undrained sectors.
- Interpretation and limitations
- BSG advises cross-sectional imaging for recurrent pain or suspected dysfunction before selecting repeat ERCP, EUS or percutaneous drainage.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked case: choose and verify distal drainageMatch the device to indication and diagnosisA 74-year-old with biopsy-confirmed unresectable distal cholangiocarcinoma has bilirubin 248 micromol/L, disabling itch, no fever and an accessible papilla; CT shows no hilar separation.+
- 1Confirm the palliative need for durable drainage. Assessment shows preserved renal function, satisfactory coagulation, no anticoagulant use and no NSAID contraindication, including proctitis, peptic bleeding, hypersensitivity or relevant cardiovascular disease such as NYHA II–IV heart failure. Anticipated complete drainage, no severe immunocompromise and no cholangioscopy mean routine antibiotic prophylaxis is not indicated in this afebrile case.
- 2Give diclofenac 100 mg rectally immediately before ERCP after those checks; obtain any required sampling and deploy a fully covered SEMS across the biopsy-confirmed distal CCA. Document its position and effective bile drainage.
- 3Within 48 hours urine is lighter, itch has improved and bilirubin falls to 181 micromol/L; there is no new abdominal pain, vomiting, fever or additional admission need for pancreatitis. PEP requires the clinical syndrome with new/worsened pain, pancreatic enzymes at least three times the upper limit at more than 24 hours, and admission or prolongation of admission; an isolated lipase rise is not the diagnosis.
- 4At oncology review bilirubin has fallen to 54 micromol/L; document stent model and position, give a 24-hour blockage contact and verify that systemic treatment can begin.
02Hilar strategyDrain functioning liver rather than every ductMRCP shows separate right anterior, right posterior and left systems above a perihilar malignant stricture.+
- 1Agree curative versus palliative intent and future-remnant anatomy at the HPB MDT before endotherapy.
- 2Select a percutaneous, endoscopic or combined route able to reach the intended viable sectors.
- 3Avoid injecting contrast into a sector that cannot be decompressed during that procedure.
- 4Verify bilirubin and fever response and re-image before adding another sector if improvement is inadequate.
03Failed ERCPEscalate by anatomy and expertiseThe endoscopist cannot cannulate the bile duct in a patient who still requires distal malignant drainage.+
- 1Stop repeated traumatic cannulation when risk outweighs further attempts and document contrast and guidewire passages.
- 2Discuss EUS-guided internal drainage in an expert audited service as an alternative after failed ERCP.
- 3Use percutaneous transhepatic drainage when EUS expertise is unavailable or anatomy favours that route.
- 4Confirm external-drain care or internal stent function and define how conversion, exchange or removal will occur.
04Preparation and pancreatic-stent follow-upApply prophylaxis to the actual procedural riskAn adult is being prepared for ERCP, with the intended drainage and cannulation risks defined.+
- 1Do not prescribe antibiotics routinely for every ERCP. ESGE suggests prophylaxis when drainage is expected to be incomplete, the patient is severely immunocompromised or cholangioscopy is planned; choose Gram-negative cover matched to local microbiology. Established cholangitis instead requires treatment antibiotics and source control.
- 2Give the source-supported rectal NSAID when eligible and use a prophylactic pancreatic stent for the selected high-risk pancreatic guidewire/contrast events, according to endoscopic assessment.
- 3For the general ERCP short prophylactic pancreatic stent, arrange confirmation of passage within 5–10 days and endoscopic removal if it remains. Record the result and responsible clinician; papillectomy-specific planned retrieval follows its separately described context.
05Relevant medicines and safetySpecific regimens and precautions when the skill involves prescribing.
Rectal diclofenac for post-ERCP pancreatitis prevention
ESGE-supported off-label ERCP prophylaxis is diclofenac 100 mg as a single rectal suppository immediately before ERCP in an eligible adult; ERCP prevention is outside this product’s licensed indications. This is one dose, not a post-procedure course. Count all diclofenac exposure against the product maximum of 150 mg in 24 hours and avoid another systemic NSAID.Do not use with NSAID-triggered asthma, angioedema, urticaria or rhinitis, product hypersensitivity, active/recurrent peptic ulcer or GI bleeding, previous NSAID-related GI bleeding/perforation, proctitis, established heart failure NYHA II–IV, ischaemic heart disease, peripheral arterial or cerebrovascular disease, or severe renal/hepatic failure. Avoid concomitant systemic NSAIDs; assess anticoagulation, bowel inflammation, dehydration and renal perfusion. Diclofenac is contraindicated in the third trimester. Earlier pregnancy requires a clearly necessary indication with the lowest dose/shortest exposure: from week 20 fetal renal dysfunction/oligohydramnios and ductus arteriosus constriction can occur; several days of exposure warrant consideration of antenatal monitoring and discontinuation if these develop.
06Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- After ERCP, check pain, observations, bleeding and vomiting; investigate pancreatitis, perforation or cholangitis according to symptoms rather than routine enzyme testing alone.
- Record stent material, diameter, length, position, access route and whether sphincterotomy or duct sampling occurred so later teams can intervene safely.
- Trend bilirubin, ALP, renal function and inflammatory markers until the intended clinical response is demonstrated; do not call technical deployment a successful decompression by itself.
- Give a specific removal or exchange date for temporary devices and an on-demand plan for malignant SEMS dysfunction.
- Recurrent pain, fever or biochemical obstruction requires cross-sectional imaging before repeat intervention to identify tumour progression, migration and undrained sectors.
- When a prophylactic pancreatic stent was inserted during general ERCP, track the 5–10-day passage check and removal of a retained device; biliary SEMS follow-up is a separate plan.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Drainage needs a target
Write which lobe or sector is meant to drain and why; a stent across an image is not proof of functioning liver decompression.
Coverage changes removability
Covered metal devices can be retrieved but may migrate, while uncovered mesh embeds and should not cross an uncertain benign stricture.
Patency matters over time
A larger-calibre SEMS generally suits malignant palliation, whereas short diagnostic intervals may favour a removable temporary option.
ERCP is not neutral
Papillary instrumentation creates pancreatitis, bleeding, perforation and infection risk, so each procedure must deliver a defined therapeutic gain.
Biochemistry verifies physiology
Falling bilirubin after drainage demonstrates useful bile flow; absent response calls the anatomical and hepatic assumptions back into question.
08Common pitfallsFrequent interpretation and management errors.
- 01
Draining every stable malignant jaundice before complete imaging exposes patients to complications and may delay curative resection.
- 02
Choosing a stent solely by price ignores patency, removability, side-branch occlusion and expected treatment duration.
- 03
Deploying an uncovered SEMS across an unconfirmed extrahepatic stricture can make later benign management or removal very difficult.
- 04
Calling an ERCP successful because a stent was released ignores bilirubin response, liver volume and unresolved infection.
- 05
Failing to assign device follow-up allows temporary plastic stents to remain until they occlude and cause cholangitis.