ERCP Procedure Report

ERCP Procedure Report

Date of Procedure: [date]

Start/End Time: [scope-in/scope-out times]

Location: [facility, unit, room]

Primary Endoscopist: [name]

Assistant(s): [name(s)] (Include if applicable.)

Patient: [name, DOB, MRN]

Procedure Overview

[Brief summary of procedure performed, including any adjuncts such as cholangioscopy, EUS-guided access, or intraductal lithotripsy; primary indication(s); and key outcome.] (State clearly if the procedure was aborted or incomplete and the reason.)

Indication and Pre-Procedure Context

• [Primary indication(s) using standard terminology]
• [Pre-procedure working diagnosis or clinical question]
• [Relevant prior interventions affecting plan: prior sphincterotomy, existing stent, altered anatomy, prior failed cannulation] (Include only if applicable.)
• [Clinical justification if indication is non-standard]

Consent and Safety Attestation

[Informed consent obtained; risks discussed including pancreatitis, bleeding, perforation, infection, and anesthesia-related risks.] [Time-out performed prior to start.] [Pregnancy status if fluoroscopy used: [not applicable / negative / positive / unknown].] [Relevant allergies: contrast, antibiotics, NSAIDs, latex.] (Include allergies only if present. If high-risk features for post-ERCP pancreatitis are present, briefly note the risk drivers.)

Sedation

[Sedation type: [general anesthesia / MAC / moderate sedation]]; [Sedation provider: [anesthesiologist / CRNA / endoscopist-directed]]. [Patient tolerance: [tolerated well / events or instability summarized]]. (Medication details may be referenced in the anesthesia record.)

Prophylaxis

(This section must document whether prophylaxis was given or not given; do not leave blank.)

Antibiotic Prophylaxis: [given / not given]. [If given: agent, dose, timing.] [If not given: rationale, e.g., not indicated due to anticipated complete drainage.] [If incomplete drainage occurred: continuation plan and agent.]

PEP Prophylaxis: [Rectal NSAID: [given (agent/dose/timing) / contraindicated (reason) / refused (reason) / not indicated]]. [Prophylactic pancreatic duct stent: [placed (size/type/length) / attempted but unsuccessful (reason) / not indicated]]. [Aggressive IV hydration: [used / not used]]. (Include hydration only if used for PEP prevention.)

Procedure Narrative

[Concise chronological narrative: scope advancement and duodenal intubation; papilla identification (native vs. prior sphincterotomy); major decision points; difficulty encountered and how addressed; termination condition.] (Keep to 3–6 sentences focused on key procedural steps and decisions.)

Cannulation Details

Papilla: [native / prior biliary sphincterotomy / prior pancreatic sphincterotomy]. [Periampullary diverticulum: [present / absent]]. [Altered anatomy requiring modified access: [description] or none].

Target(s) and Intent: [biliary: [diagnostic / therapeutic]] [pancreatic: [diagnostic / therapeutic]] (List each target cannulated.)

Technique and Difficulty: [Primary technique: [wire-guided / contrast-assisted]]; [devices used]. [Time-to-cannulation and/or attempt count if tracked]. [Unintended pancreatic duct guidewire entries: [none / count]]; [Unintended pancreatic opacification: [no / yes (extent)]]. [Difficult cannulation criteria met: [no / yes (specify: >5 min, >5 contacts, or unintended PD events)]]. [Rescue strategy if used: [double-guidewire / transpancreatic septotomy / needle-knife precut / pancreatic stent-assisted / other]].

Outcome: [Deep biliary cannulation: [achieved / not achieved]]. [If failed: summarize attempts, duration, and contingency plan.] (If pancreatic duct not cannulated or opacified, explicitly state: "Pancreatic duct not cannulated or opacified.")

Imaging Findings

Cholangiogram

• [Extent of opacification: distal CBD through intrahepatics; cystic duct/gallbladder if visualized]
• [Duct caliber: CBD diameter (mm); CHD diameter (mm); intrahepatic dilation [present / absent]]
• [Filling defects: number, estimated size, and location (distal/mid/proximal)]
• [Strictures: location, estimated length, upstream dilation; appearance (smooth vs. irregular)] (Use "suggestive of" or "indeterminate" rather than definitive malignant diagnoses without tissue.)
• [Leaks: location and estimated severity] (Include only if present.)
• [Other findings: pneumobilia, anatomic variants, postsurgical changes]

Pancreatogram

[Main duct caliber, strictures, side-branch changes, or disruptions.] (Include only if pancreatography was performed. Omit this subsection entirely if no pancreatogram was obtained.)

Therapeutic Interventions

(Document interventions in order performed. Omit categories not performed.)

Sphincterotomy: [biliary / pancreatic]; [new / extension]; [estimated size]; [hemostasis required: [no / yes (method)]].

Dilation: [target: [papilla / stricture (location)]]; [balloon diameter (mm)]; [duration (seconds)]; [adjunct to sphincterotomy / primary modality].

Stone Extraction: [devices used: balloon (size), basket (type), lithotripsy (type)]; [stone burden: estimated number, size, location]. [Clearance status: [complete / incomplete]]. [Clearance confirmation method: [final occlusion cholangiogram / direct visualization / other]]. [If incomplete: reason and next steps.]

Stent Placement: [duct: [biliary / pancreatic]]; [type: [plastic / SEMS]; [covered / uncovered]]; [diameter (Fr or mm)]; [length (cm)]; [target segment]; [across papilla: [yes / no]]. [For prophylactic pancreatic stent: planned removal/passage timeline.] (Repeat for each stent.)

Tissue Sampling: [brushings / biopsies]; [site]; [number of passes]. [Bile aspirate/culture if obtained.]

Fluoroscopy and Radiation

Fluoroscopy Time: [minutes] (Do not leave blank; use "pending" only if awaiting equipment data, and update before finalizing.)

Radiation Dose: [DAP and/or air kerma values] (State "dose metrics not captured" if unavailable.)

Contrast: [agent]; [estimated volume]

Specimens and Implants

Estimated Blood Loss: [minimal / quantified amount]

Specimens: [site, method, destination (pathology/microbiology) for each]

Implants: [summary of stents placed: duct, type, diameter, length, position]

Complications

[No immediate complications.] OR [Complication: [type: bleeding / perforation / suspected pancreatitis / cholangitis / cardiopulmonary event / contrast reaction]; [severity: mild / moderate / severe]; [management provided].] (This section must be completed—do not leave blank.)

Impression

• [Problem-oriented procedural diagnoses/findings in order of clinical priority] (Use qualifiers such as "indeterminate" or "suspicious for" when tissue confirmation is pending.)
• [What was accomplished vs. not accomplished]

Plan

• Disposition: [recovery location]; [discharge / admit / observation]
• Diet/Activity: [post-procedure instructions]
• Medications: [antibiotic continuation/discontinuation with rationale tied to drainage status]; [analgesics/antiemetics as indicated]
• Stent Follow-Up: [removal or exchange plan with target timeframe and responsible party] (Required if stent placed.)
• Pathology Follow-Up: [who will review and communicate results]
• Escalation Instructions: [symptoms requiring urgent evaluation: escalating abdominal pain, fever, GI bleeding]
• [Next steps or follow-up expectations if no further interventions planned]