Cholangioscopy-guided ERCP: expanding diagnostic and therapeutic applications

Endoscopic retrograde cholangiopancreatography (ERCP) remains a cornerstone technique for managing pancreaticobiliary diseases, but conventional ERCP relies mainly on fluoroscopic images and cannot directly evaluate mucosal abnormalities in bile ducts. Cholangioscopy has expanded the diagnostic and therapeutic scope of ERCP by enabling direct visualization of the biliary tree, targeted tissue sampling, and visual control of intraductal interventions. The technology has evolved from dual-operator systems to single-operator cholangioscopy, high-resolution digital disposable platforms, and ultraslim endoscopes. Cholangioscopy-guided ERCP is most established for indeterminate biliary strictures and difficult bile duct stones. For indeterminate strictures, cholangioscopy should be interpreted within a multimodality diagnostic framework including cross-sectional imaging, conventional ERCP sampling, and endoscopic ultrasound. For difficult stones, cholangioscopy-guided electrohydraulic or laser lithotripsy improves targeted fragmentation and duct clearance when conventional ERCP techniques fail. Emerging applications include assessment of intraductal papillary neoplasms, surveillance of intraductal neoplasms, primary sclerosing cholangitis-associated strictures, and post-transplant biliary complications.