Table 4

Practical considerations for cholangiogram acquisition31

Positioning The prone position is favoured during ERCP as this is considered optimal for cannulating the papilla and for high-quality fluoroscopic images.
The supine position may improve visualisation of hilar anatomy, facilitate airway management or improve patient comfort.32
The left lateral position is as effective as the prone position but may incur higher rates of unintentional pancreatic duct cannulation.33
The positioning of the fluoroscopy and endoscopy monitors can affect ergonomics and fluoroscopy time.20
Image capture Capture early and delayed images. Obtain scout film as a baseline and after a procedure.
Factors associated with reduced fluoroscopy dose include16:
Endoscopist factors:

  1. High volume (>200 procedures per year).

  2. Years of experience.

  3. Understanding of the expected pathology and anticipated anatomy before ERCP.


Procedural factors 18:

  1. Actively limiting fluoroscopy time.

  2. Collimating the X-ray beam to the smallest practical size.

  3. Selecting the lowest reasonable image quality.

  4. Avoiding unnecessary magnification.

  5. Using pulsed instead of continuous fluoroscopy.

  6. Selecting the lowest acceptable image quality.

  7. Use of endoscopic ultrasound guided ERCP/cholangioscopy.21 22

Contrast injection Contrast injection should precede negative suctioning/aspiration with the syringe in vertical position. Applying a 50:50 mix of contrast with normal saline facilitates flushing. Gentle contrast injection should be given by the endoscopist rather than assistant and should start with tip of the sphincterotome just below the hilum. This prevents small stones/debris disappearing in the intrahepatic ducts. Obtaining an occlusion cholangiogram using an appropriately sized balloon is essential for documenting stone clearance.
Different scenarios Pregnancy: fluoroscopy may be safe if performed outside the first trimester with lead shielding of the uterus/fetus. Non-fluoroscopic ERCP could be considered if expertise is available.22
Contrast allergy: true contrast allergy is uncommon. The patient may be reassured as contrast is injected intraductally and not intravenously. Alternative agents, for example, non-iodine contrast / Primovist could be used. Resuscitation facilities containing epinephrine, hydrocortisone and antihistamines should be available.
Hilar obstructions: adequate assessment of pathology and anatomy is required before contrast injections after wire-guided cannulation. Contrast must be avoided in an obstructed system where deep wire guided cannulation has not been achieved.

  • ERCP, endoscopic retrograde cholangiopancreatography.