Current ESGE guidelines recommend endoscopic ultrasound (EUS) or MRCP before ERCP to confirm choledocholithiasis, minimizing unnecessary therapeutic procedures¹. Additionally, the ASGE recommends evaluating patients by assessing the risk of choledocholithiasis before any therapeutic intervention^2,3. Patients with intermediate and high risk were evaluated. We evaluated the diagnostic impact of EUS performed before ERCP in such cases, focusing on small-stone and sludge detection and on avoidance of negative ERCPs.

We retrospectively analyzed 524 patients with EUS examination in which 24 patients with pancreatico-biliary emergencies (acute biliary pancreatitis, acute cholangitis, or cholestatic jaundice) and inconclusive imaging (only normal / dilated common bile duct or intrahepatic bile ducts described on US, CT, or MR/MRCP) admitted over 36 months. All underwent EUS before ERCP according to local emergency-unit protocol. EUS findings, ERCP results, therapeutic yield, and complications were compared with historical controls managed by ERCP-first strategy.

Among 24 patients (mean age 65 ± 15 years; 29.2 % female), EUS identified bile-duct stones or sludge in 66.70 % of cases despite inconclusive cross-sectional imaging. ERCP confirmed stones in 93.75 % of EUS-positive cases. In 45.80% of patients with negative EUS, ERCP was avoided, thus reducing overall ERCP rate.

EUS before ERCP significantly improves diagnostic accuracy and prevents unnecessary invasive procedures in pancreatico-biliary emergencies with inconclusive imaging. Adoption of an “EUS-first” strategy, even in resource-limited emergency hospitals, aligns with ESGE guidelines and enhances patient safety, procedural efficiency, and cost-effectiveness.