ERCP for Bile Duct Stones: Frontline Gastroenterology | August 2026

Introduction:

ERCP remains central to the management of common bile duct (CBD) stones, with established BSG and ESGE recommendations guiding patient selection, difficult stone management, and prevention of post-ERCP pancreatitis. This national survey assessed real-world guideline adherence among ERCP practitioners and identified factors associated with better practice.

Why was this study needed?

Guideline adherence is essential for safe, high-quality ERCP.

Real-world compliance with CBD stone recommendations is poorly understood.

Some aspects, particularly sphincterotomy technique and intraprocedural imaging, remain inadequately standardized.

Identifying practice gaps could guide future ERCP quality-improvement programs.

Results:

Among 389 ERCP practitioners, guideline adherence varied from 72% to 90%, depending on the clinical scenario.

Adherence was highest for appropriate ERCP selection and management of irretrievable stones, but lower for large CBD stones and prophylactic pancreatic stenting.

Better adherence was associated with EUS practice, younger age, fewer years in practice, and recent ERCP-related continuing professional development (CPD).

Considerable variation remained in sphincterotomy technique and radiographic documentation, highlighting areas lacking standardized practice.

Clinical Impact:

Most ERCP practitioners follow established guidelines, but important gaps remain in difficult stone management and post-ERCP pancreatitis prevention. The association between better adherence and recent CPD emphasizes the importance of continuous education, multidisciplinary pancreatobiliary practice, and standardized ERCP quality measures.

Bottom Line:

Real-world adherence to ERCP guidelines for bile duct stones is generally good but remains inconsistent in several important areas. Regular ERCP-focused education and greater standardization of difficult stone management, pancreatic stenting, sphincterotomy, and imaging could further improve procedural quality and safety.