Proving the stone, protecting the pancreas, and staging duct plus gallbladder

(A) Refuse diagnostic ERCP: even high-risk criteria leave 12.9% without stones, and tandem EUS first let 15.2% of non-cholangitic high-risk patients avoid a diagnostic scope — since diagnostic ERCP should be avoided outright.^[6] Confirm with either test: Cochrane pooling gives EUS 0.95/0.97 against MRCP 0.93/0.96 with no difference, and the intermediate-likelihood randomisation found both 92 to 98% sensitive — so scope only the test-positive duct.^[7][9]

(B) Protect every pancreas with rectal NSAID 100 mg and add a 5-Fr stent at high risk — repeated pancreatic entries qualify — since indomethacin alone failed non-inferiority against the combination (14.9% against 11.3% pancreatitis).^[2][10] Rescue the difficult papilla with early precut: cannulation equals persistence at 90%, yet pancreatitis halves to 2.5% against 5.3% — cut early in experienced hands rather than persisting.^[13]

(C) Offer either stage honestly: 14 studies with 1,849 patients tie single-stage exploration against ERCP-plus-cholecystectomy on success, retained stones, mortality, morbidity and stay — so choose by unit expertise, not dogma.^[16] Then book the gallbladder within 72 hours: early operation probably cuts conversion and recurrent biliary events with moderate certainty — delay is what brings the patient back septic.^[18]