Biliary strictures arise from diverse benign and malignant etiologies, and accurate differentiation is pivotal for prognosis and treatment selection. Conventional endoscopic retrograde cholangiopancreatography (ERCP)-based sampling (brush cytology and forceps biopsy) suffers from limited sensitivity despite high specificity, leaving a substantial proportion as indeterminate biliary strictures. Peroral cholangioscopy (POCS) enables direct intraductal visualization and targeted biopsies, thereby enhancing diagnostic yield. This review summarizes technological evolution from fiber-optic mother–baby systems to digital single-operator cholangioscopy and direct POCS, as well as the integration of image-enhanced endoscopy and emerging wide-channel scopes. Visual criteria for malignancy—tumor vessels, irregular granular or papillary/villous patterns, and friability—achieve high sensitivity and interobserver reliability with proposed classifications (Monaco, Mendoza). For cholangiocarcinoma, POCS-guided mapping biopsies precisely assess longitudinal intraepithelial tumor spread, informing R0 surgical planning. Randomized trials indicate higher or at least comparable sensitivity of POCS-guided biopsies relative to ERCP sampling, while novel forceps and larger working channels increase specimen size and reduce the number of biopsies. Artificial intelligence (AI) applied to POCS images shows promise for real-time risk stratification and improved targeting. Therapeutically, POCS guides intraductal lithotripsy with high clearance rates, and facilitates management in surgically altered anatomy in concert with endoscopic ultrasound-guided biliary drainage or transendosonographically/ guided created route procedure. Adverse events, chiefly pancreatitis and cholangitis, warrant attention to intraductal pressure control and CO2 insufflation. POCS has established an essential role in the diagnostic algorithm for biliary strictures; future advances will likely come from enhanced imaging, AI assistance, and next-generation digital cholangioscopes with larger biopsy devices.
Endoscopic retrograde cholangiopancreatography (ERCP) has played a central role in the development of pancreaticobiliary endoscopy in Korea. This review traces the historical evolution of ERCP in Korea, from its first clinical application in the early 1970s to the establishment and growth of an academic society dedicated to pancreaticobiliary diseases. The first ERCP in Korea was performed in 1973, followed by early therapeutic advances such as endoscopic sphincterotomy in the late 1970s. Despite initial technical and infrastructural limitations, a group of dedicated pioneers fostered the dissemination and education of ERCP through regular case-based meetings. In 1991, these efforts culminated in the launch of the ERCP Study Group, which provided a nationwide platform for case discussion, skill acquisition, and professional solidarity among gastroenterologists. The group expanded its academic scope beyond ERCP procedures to encompass a broader spectrum of pancreatic and biliary diseases, leading to the formal establishment of the Korean Pancreatobiliary Association in 1995. Subsequent milestones included the publication of educational atlases, initiation of live demonstration courses, adoption of video endoscopy, and the integration of emerging techniques such as endoscopic ultrasonography (EUS). The society’s progressive expansion, interdisciplinary collaboration, and international engagement ultimately resulted in its reorganization as a full-fledged academic society in 2007 and its official recognition by the Korean Academy of Medical Sciences in 2011. This historical overview highlights how collective enthusiasm, technological innovation, and sustained educational efforts transformed ERCP from a novel procedure into a cornerstone of pancreaticobiliary medicine in Korea, laying the foundation for future academic and clinical advancements.
Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy (SAA) is technically challenging, not only because of the difficulty in reaching the target site but also in performing subsequent therapeutic procedures. To overcome these challenges, balloon enteroscopy-assisted ERCP has been introduced into clinical practice and has been reported to be both effective and safe. Recently, short-type balloon enteroscopes, with a working length of approximately 150 cm and a 3.2-mm working channel, have been widely adopted, making procedures more efficient. These short-type scopes facilitate the use of larger accessories in various procedures, such as stone extraction or self-expandable metallic stent placement. In addition, several new technologies and devices have recently been introduced to help manage difficult cases. Despite these advancements, multiple technical hurdles remain before procedures can be successfully completed. It is important to identify the key factors that contribute to procedural difficulty in order to improve success rates. At the same time, endoscopists must remain aware of the potential for adverse events, such as perforation, which can occur due to adhesions specific to SAA. In this review, we provide technical tips for short-type single-balloon enteroscopy-assisted ERCP in patients with SAA, aimed at improving procedural success rates and reducing adverse events, while also highlighting recent advancements in technology and devices.
Pancreatic cancer is a highly aggressive malignancy with a poor prognosis, with approximately 80% of patients presenting with unresectable disease at the time of diagnosis. However, with the recent introduction of effective chemotherapy regimens such as FOLFIRINOX and gemcitabine+nab-paclitaxel (GnP), conversion surgery has become feasible in selected patients with initially unresectable locally advanced pancreatic cancer. Recent large-scale studies from Japan have demonstrated that patients undergoing conversion surgery achieve a 5-year overall survival rate of 37.2%, offering new hope for patients with advanced pancreatic cancer. Although various studies have proposed multiple criteria for referral to conversion surgery, standardization has not yet been established, and individualized patient assessment remains important. The most appropriate approach is to proceed with conversion surgery after at least 6 months of adequate neoadjuvant chemotherapy when imaging demonstrates surgical resectability, tumor markers have sufficiently decreased, and multidisciplinary evaluation confirms the patient's fitness for surgery. Preoperative chemotherapy with FOLFIRINOX has been shown to provide superior survival outcomes compared to GnP, and maintaining the same chemotherapy regimen as adjuvant therapy following surgical resection is recommended. The anticipated results from the ongoing PREOPANC-4 study in the Netherlands are expected to provide important standardized guidelines for surgical management of locally advanced pancreatic cancer.
Selective bile duct cannulation constitutes a crucial step for successful therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Despite recent advances in devices and techniques, difficult biliary cannulation remains a significant risk factor for post-ERCP pancreatitis (PEP) and procedure failure. This comprehensive review presents evidence-based and practical techniques to optimize the success rate of selective cannulation. Meta-analyses have demonstrated that guidewire-assisted cannulation reduces PEP risk by approximately 49% compared to contrast-guided approaches. Additionally, early precut sphincterotomy performed within 5-12 minutes of failed cannulation attempts significantly reduces PEP incidence while maintaining high success rates. Recent studies have also shown that pancreatic stent‑assisted needle‑knife papillotomy can further improve selective biliary cannulation in difficult cases while maintaining an acceptable safety profile. Advanced techniques including double guidewire technique, precut sphincterotomy, and prophylactic pancreatic stenting are discussed with clinical evidence. A systematic and algorithmic approach tailored to specific clinical scenarios is essential to achieve an initial success rate of ≥90%. Specific technical adaptations and endoscopic ultrasound-guided approaches are discussed for special anatomic situations such as periampullary diverticula, postsurgical altered anatomy, and failed conventional ERCP.
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have demonstrated remarkable efficacy in the management of diabetes and obesity; however, their potential association with acute pancreatitis has been debated since their early clinical use. Numerous cases of suspected GLP-1 RA-related pancreatitis have been reported in the literature and pharmacovigilance databases, raising concerns about their safety. This review aims to examine the clinical and mechanistic evidence linking GLP-1 RA use to acute pancreatitis, including recent clinical studies, meta-analyses, and pathophysiological investigations. Based on the latest clinical evidence and practice guidelines, we propose strategies for the safe and appropriate use of GLP-1 RAs in clinical practice.
This case describes a male with a history of type 1 autoimmune pancreatitis (AIP) who had a concomitant branch-duct intraductal papillary mucinous neoplasm under long-term surveillance. During follow-up, new high-risk radiologic features developed within the pancreatic cyst, raising concern for malignant transformation and ultimately leading to surgical resection. However, final histopathologic examination revealed recurrent type 1 AIP rather than malignant progression of branch-duct intraductal papillary mucinous neoplasm, a finding that represents an uncommon and diagnostically challenging manifestation. This case suggests that when new imaging changes are observed during surveillance of pancreatic cystic lesions, clinicians should consider not only malignant transformation but also the possibility of recurrence or coexistence of underlying diseases such as AIP.
Acute pancreatitis (AP) is a prevalent and potentially life-threatening condition with rising global incidence and substantial morbidity, mortality, and healthcare costs. Early management centers on supportive care, with fluid resuscitation being a pivotal intervention during the acute phase. However, recent evidence has questioned the efficacy of aggressive fluid administration, previously thought to improve outcomes by mitigating hypovolemia and complications. This review synthesizes current data regarding fluid resuscitation strategies in AP, emphasizing the variability in individual fluid needs, the central roles of endothelial and glycocalyx integrity, and the risks of both under- and over-hydration. Notably, findings from large randomized controlled trials, including the influential WATERFALL study, demonstrate that aggressive fluid resuscitation increases the incidence of fluid overload without improving clinical outcomes compared to moderate strategies. Subsequent meta-analyses and guideline updates now endorse a moderate fluid resuscitation approach, as reflected in the 2024 American College of Gastroenterology recommendations. The review concludes that while fluid therapy remains the cornerstone of early AP management, a shift toward tailored, moderate fluid administration is warranted to optimize outcomes and minimize harm. Continued research is essential to refine individualized resuscitation protocols, with particular attention to biomarkers of endothelial dysfunction and fluid requirements.
Anomalous union of the pancreaticobiliary duct (AUPBD) is a congenital malformation in which the pancreatic and biliary ducts join outside the duodenal wall, forming an elongated common channel. Because sphincter action does not directly affect this junction, reciprocal reflux of pancreatic juice and bile occurs, increasing the risk of biliary tract cancer. AUPBD is frequently associated with choledochal cysts and is a known risk factor for biliary malignancies. We report a case of a 70-year-old woman diagnosed with gallbladder cancer with liver metastases, accompanied by AUPBD without choledochal cysts. She presented with upper abdominal pain, obstructive jaundice, and a large hepatic mass on imaging. Endoscopic retrograde cholangiopancreatography confirmed pancreatobiliary-type AUPBD. Despite biliary drainage, her condition rapidly deteriorated and she died soon after. This case underscores the role of AUPBD in carcinogenesis and the need for early recognition and management.
Mirizzi syndrome is infrequently associated with fistula formation, particularly a unique biliopleural fistula. The ideal therapeutic strategy remains diverse across guidelines, which usually includes surgical excision to eliminate the source of infection. We reported a case of a 60-year-old jaundiced female with pleural effusion resulting from a biliopleural fistula. Imaging revealed a cystic lesion close to the periphery of the upper right diaphragm, connected to the gallbladder. Following initial pleural drainage, an abdominal exploration was conducted to excise the fistula and remove the gallbladder. A multidisciplinary approach is essential for obtaining optimal outcomes for patients with biliopleural fistula.
Choledocholithiasis occurs in approximately 10-20% of patients with gallstones and can lead to severe complications, including obstructive jaundice, acute cholangitis, and acute pancreatitis. This review evaluates the diagnostic and therapeutic approaches for choledocholithiasis in patients scheduled for cholecystectomy. Diagnosis is based on clinical history, laboratory tests, ultrasonography, endoscopic ultrasound, and magnetic resonance cholangiopancreatography. Management strategies include the one-step approach, combining laparoscopic cholecystectomy and bile duct exploration, and the two-step approach, performing endoscopic retrograde cholangiopancreatography (ERCP) before cholecystectomy. The one-step approach offers advantages such as shorter hospitalization but requires experienced surgeons. The two-step approach is more suitable for patients with acute cholangitis, pancreatitis, narrow bile ducts, impacted stones, or multiple stones. In South Korea, the two-step approach is predominantly favored due to the widespread availability of advanced endoscopic techniques and the expertise of gastroenterologists. ERCP is highly standardized and effective for biliary drainage, particularly in emergency settings. Effective management of choledocholithiasis requires a tailored approach that considers patient condition, stone characteristics, and available resources. Collaboration between gastroenterologists and surgeons is critical to achieving optimal outcomes. Further research, particularly large-scale multicenter studies, is necessary to refine treatment guidelines and improve patient care.
Spontaneous perforation of the common bile duct (SPCBD) is a rare but potentially fatal condition in adults, with early diagnosis often challenging due to nonspecific symptoms. This report presents a rare case of SPCBD in a 73-year-old male who presented with nonspecific abdominal pain and fever. Imaging confirmed SPCBD associated with common bile duct stones. Following initial failure with percutaneous drainage, additional surgical intervention successfully managed the SPCBD and associated severe pancreatic abscess. We report this case to highlight the early identification and management of SPCBD in a patient with nonspecific abdominal symptoms.
Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an important alternative to transpapillary biliary drainage by endoscopic retrograde cholangiopancreatography (ERCP) for malignant biliary obstruction (MBO), especially in cases with failed ERCP. Given the increasing evidences of safety and effectiveness of EUS-BD, EUS-BD as primary biliary drainage has been investigated in clinical trials. However, there are still obstacles that need to be addressed prior to clinical application. In this narrative review, clinical outcomes, hurdles and future perspectives of primary EUS-BD for MBO are discussed.
Duodenoscopes, which are used for endoscopic retrograde cholangiopancreatography (ERCP), structurally differ from gastrointestinal endoscopes due to their elevator mechanisms and complex internal channels. These features increase the risk of contamination with patient fluids and organic debris, posing significant infection risks. Despite multiple revisions of general endoscopic disinfection guidelines, specific guidelines tailored for duodenoscope reprocessing do not exist in our society and leaving gaps in infection control. Thus, the ERCP/endoscopic ultrasound (EUS) Research Group under the Korean Pancreatobiliary Association’s Quality Management Committee developed dedicated reprocessing guidelines focusing on pre-cleaning, cleaning, high-level disinfection, rinsing, drying, and storage procedures specifically for duodenoscopes. Recommendations are graded by strength (“strong” or “weak”) and based on evidence levels (A to D). These practical guidelines aim to enhance patient safety by standardizing duodenoscope reprocessing practices, minimizing infection transmission, and promoting continuous quality improvement within clinical practice.
Chronic pancreatitis frequently leads to pancreatic exocrine insufficiency, resulting in impaired digestion and absorption of fat-soluble vitamins. Among these, vitamin D deficiency plays a key role in calcium homeostasis and bone metabolism, contributing to decreased bone mineral density and increased risk of osteopenia and osteoporosis. As symptoms are often absent in early stages, these metabolic bone complications may be underrecognized. Recent guidelines from ESPEN, AGA, and JSGE emphasize the importance of routine screening and appropriate supplementation in patients with chronic pancreatitis. This review focuses on the pathophysiology of vitamin D deficiency and related bone disease in chronic pancreatitis, discusses diagnostic strategies, therapeutic approaches, and monitoring protocols. By comparing key recommendations from major clinical guidelines, this article aims to provide a practical and comprehensive framework for improving the care of patients with chronic pancreatitis and associated vitamin D deficiency-related bone complications.
Coronavirus disease 2019 (COVID-19) has been linked to various gastrointestinal symptoms, including acute pancreatitis (AP). Emerging evidence suggests that severe acute respiratory syndrome coronavirus 2 may directly and indirectly contribute to pancreatic injury. Additionally, COVID-19-induced systemic inflammation, including cytokine storms, exacerbates pancreatic injury. Clinical studies indicate that COVID-19-associated AP often presents with severe complications, including necrotizing pancreatitis, higher rates of intensive care unit admission, and increased mortality. However, the clinical characteristics and precise mechanisms remain unclear, partly due to the lack of standardized diagnostic criteria and insufficient research into alternative AP etiologies. Current evidence suggests that COVID-19 may increase the risk and severity of AP, particularly in the absence of traditional causes such as gallstones or alcohol use. Further studies should focus on differential diagnosis and mechanisms of pancreatic injury, contributing to improved recognition and management of AP in the context of the ongoing pandemic.
