Episode two is about the decision that comes before cannulation and the restraint it takes to decline the procedure when objective evidence for benefit is absent. A landmark sham-controlled trial retired type three sphincter of Oddi dysfunction as a sphincterotomy indication, so pain with normal labs and a normal duct becomes a functional pain disorder, not an ERCP. Pregnancy raises the threshold highest because a second patient absorbs all the risk and none of the benefit. The back half turns on two failure mechanisms, the cut that bleeds and the elevator that harbors biofilm, and each names the patient to protect and the device choice that protects them. Topics covered Sphincter of Oddi dysfunction types and the landmark trial Post-cholecystectomy duct dilation as physiologic compensation ERCP in pregnancy and radiation minimization Sedation and positioning in pregnancy Post-sphincterotomy bleeding risk factors Balloon dilation versus sphincterotomy in coagulopathy Perforation and the Stapfer classification Duodenoscope biofilm and single-use scopes Key decisions Do not offer sphincterotomy for type three sphincter of Oddi dysfunction (pain with normal enzymes and a non-dilated duct); a sham did at least as well, so manage it as a functional pain disorder with neuromodulators and behavioral therapy. Treat type one dysfunction (pain, elevated enzymes, dilated duct) with biliary sphincterotomy without manometry, and treat type two as shared decision-making with mandatory indomethacin, lactated Ringer, and a pancreatic duct stent since manometry is the highest-PEP procedure. Read a ten to twelve millimeter duct in a post-cholecystectomy patient with normal enzymes as physiologic compensation, not sphincter dysfunction, so it alone does not justify ERCP. In pregnancy avoid diagnostic ERCP entirely: use non-contrast MRCP or EUS, shield the uterus, run pulsed fluoroscopy at four to eight pulses per second aiming under one minute, prefer the second trimester, and keep fetal dose under the fifty milligray threshold. Prefer propofol for sedation in pregnancy, accept moderate-dose fentanyl, avoid midazolam especially in the first trimester, and position the patient left-lateral to avoid aortocaval compression. In cirrhosis or coagulopathy choose endoscopic papillary balloon dilation over full sphincterotomy for stone extraction, trading the cut for a stretch to avoid a bleeding bed the mucosa cannot control. Prevent duodenoscope-transmitted infection with disposable elevator caps or single-use duodenoscopes rather than double high-level disinfection or ethylene oxide, which add no benefit because they cannot reach the elevator interior. 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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