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Gastroenterology Societyof KenyaAdvancing Digestive Health Care
Last updated: November 2022

ERCP Guidelines

Recommendations for Endoscopic Retrograde Cholangiopancreatography (ERCP) practice in Kenya—aligned to international evidence and adapted to local realities.

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Introduction

Endoscopic Retrograde Cholangiopancreatography (ERCP) is an advanced endoscopic procedure used for the diagnosis and treatment of diseases of the biliary tract and pancreas. These guidelines provide recommendations for ERCP practice in Kenya, taking into consideration the availability of resources, training, and expertise.

Indications for ERCP

Primary scenarios where ERCP offers diagnostic or therapeutic benefit

Biliary Indications

  • Choledocholithiasis
  • Biliary obstruction (malignant or benign)
  • Bile leak
  • Primary sclerosing cholangitis (for dominant strictures)
  • Sphincter of Oddi dysfunction (Type I)
  • Ampullary adenoma requiring endoscopic ampullectomy
  • Biliary stent placement or exchange
  • Facilitation of cholangioscopy

Pancreatic Indications

  • Acute recurrent pancreatitis of unclear etiology
  • Pancreatic duct leaks or disruptions
  • Symptomatic pancreatic duct stones or strictures
  • Facilitation of pancreatic tissue sampling
  • Drainage of symptomatic pancreatic pseudocysts communicating with the main pancreatic duct
  • Suspected main pancreatic duct intraductal papillary mucinous neoplasm (IPMN)

Contraindications

Situations where ERCP should be avoided or carefully weighed

Absolute

  • Acute pancreatitis (unless caused by gallstones with persistent biliary obstruction)
  • Recent myocardial infarction or pulmonary embolism (<3 months)
  • Patient refusal after informed consent
  • Hemodynamic instability
  • Coagulopathy that cannot be corrected
  • Inadequate training or local facilities to manage potential complications

Relative

  • Altered surgical anatomy (e.g., Roux-en-Y gastric bypass)
  • Large duodenal diverticulum
  • Pregnancy (especially first trimester)
  • Significant cardiopulmonary disease
  • Recent gastrointestinal perforation

Pre-procedure Considerations

Consent, infection risk, and antithrombotic management

Informed Consent

Discuss indications, benefits, alternatives, and complications (approximate rates):

  • Post-ERCP pancreatitis (3–10%)
  • Hemorrhage (1–2%)
  • Perforation (<1%)
  • Cholangitis (1–3%)
  • Adverse effects of sedation/anesthesia
  • Death (rare, <0.5%)

Antibiotic Prophylaxis

Recommended for:

  • Suspected/known biliary obstruction where complete drainage may not be achieved
  • History of liver transplantation
  • Known/suspected pancreatic pseudocyst
  • History of endocarditis or prosthetic heart valves
  • Severe neutropenia

Antithrombotic Management

General approach:

  • Continue aspirin for all ERCP procedures.
  • Consider temporary interruption of thienopyridines (e.g., clopidogrel) for high-risk procedures.
  • For oral anticoagulants (high-risk procedures):
    • Warfarin: Stop 5 days prior; check INR.
    • DOACs: Stop 48–72 hours prior.
  • Decisions should be made with the prescribing physician.

Technical Considerations

Preferred techniques, device selection, and complication prevention

Stone Extraction

  • Endoscopic sphincterotomy recommended for most cases.
  • Balloon dilation as alternative/adjunct to sphincterotomy.
  • Choose balloons/baskets based on stone size and anatomy.
  • For stones > 1 cm: consider mechanical or electrohydraulic/laser lithotripsy.
  • For multiple/large stones without full clearance: place temporary biliary stent.

Biliary Stenting

  • Plastic stents: temporary drainage / benign disease.
  • Metal stents: malignant obstruction preferred.
  • Covered SEMS: consider for benign strictures or bile leaks.
  • Uncovered SEMS: preferred for hilar strictures.
  • Diameter: 10 Fr plastic or 10 mm metal commonly recommended.
  • Length: extend ≥1–2 cm beyond proximal/distal stricture margins.

Preventing Post-ERCP Pancreatitis

  • Rectal NSAIDs (100 mg diclofenac/indomethacin) for average-risk patients.
  • Pancreatic duct stent for high-risk patients (e.g., suspected SOD, pancreatic sphincterotomy).
  • Wire-guided cannulation technique.
  • Minimize contrast injection into the pancreatic duct.
  • Avoid repeated pancreatic duct cannulation.

Training, Competency & Resource-Limited Settings

Maintaining standards while scaling access across Kenya

Training & Competency

  • Minimum of 200 supervised ERCP procedures during training.
  • Selective cannulation rate ≥ 90% before independent practice.
  • Maintain ≥ 25 ERCPs per year.
  • Ongoing tracking of quality metrics and complication rates.
  • Participation in ERCP-specific CPD.
  • Establish referral networks for complex cases.

Resource-Limited Settings

  • Concentrate ERCP services in regional centers to sustain volumes.
  • Develop efficient referral pathways.
  • Share high-cost equipment across institutions where possible.
  • Prioritize therapeutic over diagnostic ERCP.
  • Use EUS/MRCP for diagnostics when available.
  • Mentorship programs to expand the ERCP workforce.

Citation

Gastroenterology Society of Kenya. (2022). Clinical Practice Guideline for Endoscopic Retrograde Cholangiopancreatography. GSK Guidelines 2022. Nairobi, Kenya.

Feedback or Updates

Help us keep these guidelines current. Email guidelines@gsk.or.ke.