Unnecessary ERCPs: Is Spontaneous Stone Passage the Sole Determinant?

Endoscopic retrograde cholangiopancreatography (ERCP) is the cornerstone in the management of choledocholithiasis. Despite continuous advancements in technique and safety, ERCP carries a risk of significant complications, underscoring the importance of avoiding unnecessary procedures. The principal contributor to potentially avoidable ERCPs in patients with known choledocholithiasis is the spontaneous passage of common bile duct stones. Small stone size and a long interval between diagnosis and the procedure have increasingly been found to favor this event. Moreover, despite the development of well-defined risk stratification scores for patients with suspected choledocholithiasis, the incidence of negative ERCPs within this patient population remains considerable, even when a high suspicion of choledocholithiasis is evident. This review summarizes current evidence on the incidence and predictors of avoidable ERCPs in these contexts, with particular emphasis on spontaneous stone passage. It also discusses the role of endoscopic ultrasound (EUS) as a diagnostic tool to reduce unnecessary procedures when initial imaging fails to confirm the presence of stones despite persistent high clinical suspicion. By integrating and critically appraising recent findings, we provide practical guidance for clinicians on decision-making regarding ERCP, particularly in situations where spontaneous stone passage is likely or imaging results are inconclusive.