Episode three takes the stone into the bile duct, and the whole problem sits on a probability question, because ERCP carries its own complication profile, headlined by post-ERCP pancreatitis. You earn the right to do an ERCP by raising the pretest probability of a retrievable stone high enough to justify the procedural risk, so high-probability patients go straight to ERCP while intermediate patients confirm the stone first with MRCP or endoscopic ultrasound. When the same stone turns septic, cholangitis runs on a hydraulic mechanism: the obstruction raises intraductal pressure and refluxes bacteria into the blood, which is why antibiotics alone cannot fix it and decompression is mandatory. The Tokyo grade scales the timing, and clinical improvement on antibiotics is never mistaken for a relieved obstruction. Topics covered Post-ERCP pancreatitis and the probability tiers High, intermediate, and low probability features MRCP versus endoscopic ultrasound Large stones and post-cholecystectomy stones Cholangitis and the hydraulic mechanism Charcot triad and Reynolds pentad Tokyo grading and decompression timing Empiric antibiotics and rescue drainage Key decisions High-probability duct stone requires any one of a stone seen on imaging, ascending cholangitis, or a bilirubin over four with a duct dilated above six millimeters, and any one of those sends the patient straight to ERCP. Intermediate-probability patients should not go straight to ERCP; confirm or refute the stone first with MRCP, or endoscopic ultrasound when small stones or sludge are suspected. MRCP misses stones under six millimeters while endoscopic ultrasound catches sludge and microlithiasis, so small-stone disease favors EUS and an anatomic duct survey favors MRCP. Stones a centimeter or larger exceed what a conventional sphincterotomy can extract, so first-line therapy is sphincterotomy plus large-balloon dilation, with cholangioscopy-directed lithotripsy as the alternative. In cholangitis, decompression is the central intervention because antibiotics only suppress bacteremia while the closed obstructed duct keeps reseeding. Tokyo severe cholangitis with any organ dysfunction needs biliary decompression within twenty-four hours, moderate disease needs ERCP within forty-eight hours, and ERCP within forty-eight hours reduces mortality across all three grades. Empiric antibiotics target enteric gram-negatives and anaerobes with a third-generation cephalosporin plus metronidazole, piperacillin-tazobactam, or a carbapenem in healthcare-associated or immunocompromised patients. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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