Episode one of the ERCP and EUS Procedures chapter starts from the single fact that reorganizes everything: ERCP is a therapy, not a test, so you earn the right to do it only when a non-invasive study cannot answer the question. From there the whole episode is risk management. Wire-guided cannulation replaces the hydraulic contrast push that floods the pancreatic duct, difficult-cannulation maneuvers each solve one anatomic problem, and the prophylaxis stack is held by mechanism because the mechanisms tell you who needs which. The organizing thread: find the duct by guidance, then stack indomethacin, a pancreatic duct stent, and lactated Ringer on the patient whose risk factors say the pancreas will react. Topics covered ERCP as therapy, not a diagnostic test Post-ERCP pancreatitis risk and mechanism Wire-guided versus contrast-first cannulation Difficult-cannulation escalation and EUS rendezvous Rectal indomethacin prophylaxis Prophylactic pancreatic duct stent Aggressive lactated Ringer hydration High-risk patient profile and protective chronic pancreatitis Key decisions Reserve ERCP for therapeutic intent (stone extraction, stricture stenting, cholangitis decompression, leak repair); if you only need to image the ducts, order MRCP or EUS, which carry no pancreatitis risk. Use wire-guided cannulation rather than contrast-first, because threading a soft hydrophilic guidewire avoids the hydraulic acinarization injury that flooding the pancreatic duct with contrast produces. Give rectal indomethacin one hundred milligrams before every native-papilla ERCP, timed pre-procedure so the drug is therapeutic at the moment of cannulation. In high-risk patients keep the prophylactic pancreatic duct stent on top of indomethacin, not instead of it, since indomethacin alone was not non-inferior to indomethacin plus a stent. Run lactated Ringer at three milliliters per kilogram per hour during the procedure, a twenty milliliter per kilogram bolus immediately after, then three milliliters per kilogram per hour for eight hours, chosen over saline because lactate buffers acidosis. Concentrate the full stack on high-risk patients (suspected sphincter of Oddi dysfunction, prior PEP, female sex, normal bilirubin, difficult cannulation, acinarization), remembering a normal bilirubin raises risk and burnt-out chronic pancreatitis runs it backwards. Do not use octreotide, gabexate, or intravenous secretin; they sound plausible but do not reduce post-ERCP pancreatitis. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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