ERCP — Endoscopic Retrograde Cholangiopancreatography

What Is ERCP

Endoscopic Retrograde Cholangiopancreatography (ERCP) is a specialized endoscopic procedure that combines fluoroscopy (X-ray imaging) with endoscopy to diagnose and treat conditions affecting the bile ducts and pancreatic duct. During the procedure, a flexible endoscope is passed through the mouth, esophagus, and stomach into the duodenum, where the opening of the bile and pancreatic ducts (the papilla of Vater) is located. A thin catheter is then inserted through the endoscope into the ductal system, and contrast dye is injected to visualize the ducts on X-ray. ERCP is predominantly a therapeutic procedure — most diagnostic evaluations are now performed through magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS), and ERCP is reserved for cases where an intervention is anticipated.

When ERCP May Be Indicated

ERCP is recommended in a variety of biliary and pancreatic conditions where therapeutic intervention is needed:

• Common bile duct stones (choledocholithiasis) — the most frequent indication for ERCP. Stones that migrate from the gallbladder into the bile duct can cause pain, jaundice, or life-threatening infections. ERCP allows their removal without open surgery.
• Obstructive jaundice — when a tumor, stricture, or stone blocks bile flow, ERCP can relieve the obstruction by placing a stent or removing the cause.
• Acute cholangitis — an infection of the bile ducts that requires urgent drainage. ERCP is considered the first-line treatment for biliary decompression in cholangitis.
• Biliary strictures — narrowing of the bile ducts, whether benign (post-surgical, inflammatory) or malignant (cholangiocarcinoma, pancreatic head tumors), can be managed with stent placement or balloon dilation during ERCP.
• Bile leaks — following cholecystectomy or hepatic surgery, bile leaks can be sealed by placing a temporary biliary stent during ERCP.
• Biliary pancreatitis — when gallstones cause acute pancreatitis with evidence of persistent biliary obstruction or cholangitis, early ERCP is indicated to clear the bile duct.

Therapeutic Interventions During ERCP

ERCP is much more than a diagnostic test. A wide range of therapeutic maneuvers can be performed during the same session:

Sphincterotomy

A small incision is made in the sphincter of Oddi (the muscular valve controlling the opening of the bile duct) using electrocautery. This widens the opening and allows stones to pass or be extracted. Sphincterotomy is the cornerstone of most therapeutic ERCP procedures.

Stone Extraction

After sphincterotomy, bile duct stones are removed using a retrieval balloon or a Dormia basket. For very large stones (greater than 15 mm), mechanical lithotripsy — a technique that crushes the stone within a metal basket — may be employed.

Biliary Stenting

Plastic or self-expanding metal stents are placed across strictures or obstructions to restore bile flow. Plastic stents are used for temporary drainage and need replacement every 3 months, while metal stents are used for longer-term palliation of malignant strictures.

Balloon Dilation

Strictures can be dilated using specialized balloons passed through the endoscope. This is particularly useful for benign strictures following surgery or in primary sclerosing cholangitis.

Nasobiliary Drainage

A thin tube is left through the nose into the bile duct for continuous external drainage. This is used in severe cholangitis or when close monitoring of bile output is needed post-procedure.

Preparation for ERCP

Proper preparation ensures the procedure is safe and effective:

• Fasting: You must not eat or drink anything for at least 8 hours before the procedure. An empty stomach is essential to reduce the risk of aspiration during sedation.
• Blood tests: Recent blood work will be reviewed, including coagulation parameters (INR, platelet count), liver function tests, and a complete blood count. These results help assess bleeding risk and guide the procedure.
• Medication adjustments: Blood thinners (warfarin, clopidogrel, direct oral anticoagulants) may need to be paused several days before ERCP — your doctor will provide specific instructions. Diabetes medications and insulin doses may also need adjustment due to fasting. Continue all other regular medications unless instructed otherwise.
• What to bring: Bring your identification, insurance documents, a list of current medications, and recent imaging results (ultrasound, CT, MRCP) if available. Wear comfortable, loose clothing.
• Transportation: Because you will receive sedation, you will not be able to drive afterward. Arrange for a companion to drive you home and stay with you for the first few hours.

Step by Step During the Procedure

1. Arrival and check-in: You will arrive at the endoscopy unit, confirm your identity and procedure details, and change into a hospital gown. The nursing team will verify your fasting status and review your medical history.
2. Intravenous access: A cannula (IV line) is placed in your arm or hand to administer fluids, sedation, and any necessary medications.
3. Sedation: ERCP is typically performed under deep sedation (propofol) administered by an anesthesiologist. You will be comfortable and unaware during the procedure. In some cases, general anesthesia may be used.
4. Positioning: You are placed in a prone or semi-prone position on the X-ray table. Monitoring equipment tracks your heart rate, blood pressure, and oxygen levels throughout the procedure.
5. Endoscope insertion: The duodenoscope — a specialized side-viewing endoscope — is gently advanced through the mouth, down the esophagus and stomach, and into the duodenum.
6. Cannulation: The papilla of Vater is identified, and a catheter or sphincterotome is inserted into the bile duct (or pancreatic duct, depending on the indication). This is the most technically demanding step of the procedure.
7. Contrast injection and imaging: Contrast dye is injected, and real-time X-ray images (fluoroscopy) reveal the anatomy of the ductal system — showing stones, strictures, or other abnormalities.
8. Therapeutic intervention: Based on the findings, the appropriate treatment is performed — sphincterotomy, stone removal, stent placement, or dilation.
9. Recovery room: After the endoscope is removed, you are transferred to the recovery area where you are monitored for 1 to 2 hours as the sedation wears off. Vital signs are checked regularly, and any discomfort is managed promptly.

Possible Risks

ERCP is generally safe when performed by an experienced endoscopist, but like any invasive procedure, it carries certain risks:

• Post-ERCP pancreatitis (3-5%): The most common complication. Inflammation of the pancreas can occur after manipulation of the papilla. It is usually mild and resolves within a few days with conservative treatment (fasting, IV fluids, pain management). Prophylactic measures such as rectal indomethacin and pancreatic duct stenting reduce this risk.
• Bleeding (1-2%): Particularly after sphincterotomy. Most bleeding is minor and stops spontaneously or can be controlled endoscopically. Significant bleeding requiring transfusion is rare.
• Perforation (<1%): A small tear in the duodenal wall or bile duct may occur. Most perforations are managed conservatively with antibiotics and temporary fasting, though surgical repair is occasionally needed.
• Cholangitis (<1%): Infection of the bile ducts can develop if drainage is incomplete. Antibiotics and repeat drainage may be required.

After the Procedure

• Monitoring: You will remain in the recovery area for 1 to 2 hours. The medical team will watch for early signs of complications such as abdominal pain, fever, or bleeding.
• Diet resumption: You may begin drinking clear fluids a few hours after the procedure, progressing to a light meal if you feel well. Avoid heavy, fatty foods for the first 24 hours.
• Resuming activities: Rest at home for the remainder of the day. Most patients can return to normal activities within 24 to 48 hours. Avoid strenuous exercise and heavy lifting for one week.
• Warning signs — contact your doctor immediately if you experience:
  • Severe or worsening abdominal pain
  • Fever above 38 °C (100.4 °F)
  • Persistent nausea or vomiting
  • Black or bloody stools
  • Increasing jaundice (yellowing of the skin or eyes)

Practical Tips for Patients

• Ask your doctor in advance whether you need to stop any medications and when to restart them.
• Arrange reliable transportation home — public transport or taxis are acceptable as long as someone accompanies you.
• Have a light, easily digestible meal ready at home (soup, toast, rice) for when you feel ready to eat.
• Keep the discharge instructions and emergency contact numbers easily accessible.
• It is normal to have mild throat discomfort and abdominal bloating for 24 hours after the procedure — these symptoms resolve on their own.
• Attend all follow-up appointments, especially if a stent was placed, as stent exchange or removal will be scheduled.