Synopsis
Decide when biliary decompression is necessary, choose an anatomically appropriate route and removable or durable device, prevent ERCP harm, and verify that the intended liver volume drains.
- 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.
Key red flags
Do not fill a hilar duct with contrast unless it can be drained; an opacified isolated sector can become infected.
A recurrent fever, jaundice or pain after stenting indicates possible occlusion or migration and requires same-day clinical reassessment.
An uncovered metal stent should not be deployed across extrahepatic obstruction of unconfirmed cause because it cannot readily be removed.
Recurrent jaundice, fever, rigors, pale stools or pain after initial improvement suggests occlusion, migration or tumour progression.
Reasoning priorities
Define cause, obstruction level, vascular relationships and metastases before elective drainage.
Use pancreatic-protocol CT for suspected pancreatic cancer and MRI/MRCP for proximal duct mapping; intervention before imaging may obscure or infect the system.
Worked reasoning
A 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.
- Confirm 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.
- Give 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.
- Within 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.
- At 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.