ERCP
- Investigation
A camera through the mouth reaches the bile duct opening in the duodenum, and X-rays with dye guide removal of stones or placing a stent.
What it is
Endoscopic retrograde cholangiopancreatography (ERCP) combines a side-viewing endoscope passed through the mouth to the second part of the duodenum with fluoroscopy. The endoscopist finds the major papilla, passes a catheter into the bile duct (or pancreatic duct) and injects contrast to outline it. Because MRCP and endoscopic ultrasound now give the diagnosis without these risks, ERCP is used mainly as a treatment: cutting the papilla (sphincterotomy) to extract common bile duct stones, draining an obstructed and infected duct in acute cholangitis, placing plastic or metal stents across benign or malignant strictures, treating bile leaks after cholecystectomy, and taking brushings or biopsies from strictures. It is done under deep sedation or general anaesthesia, usually prone, and takes longer than a diagnostic endoscopy. It carries the highest complication rate of the routine endoscopic procedures. The most common is post-ERCP pancreatitis; others are bleeding after sphincterotomy, perforation, cholangitis and sedation problems. Selecting patients carefully, a rectal NSAID before the procedure and, in high-risk cases, a temporary pancreatic duct stent reduce the risk of pancreatitis.
Indications
- Common bile duct stones (choledocholithiasis) seen on imaging or highly likely: sphincterotomy and stone extraction.
- Acute cholangitis: urgent drainage when the patient is septic or does not respond to treatment.
- Obstructive jaundice from a malignant stricture (pancreatic cancer, cholangiocarcinoma): stent and brushings for cytology.
- Bile leak after cholecystectomy or liver surgery, and benign strictures (including primary sclerosing cholangitis).
- Gallstone pancreatitis with cholangitis or persistent biliary obstruction.
Contraindications
- Diagnostic questions that MRCP or endoscopic ultrasound can answer: these are safer.
- Unfit for deep sedation or anaesthesia, or uncorrected haemodynamic instability.
- Uncorrected coagulopathy or low platelets when sphincterotomy is planned.
- Altered anatomy (for example after gastric bypass) makes ERCP difficult: specialist techniques or percutaneous drainage.
- Pregnancy: possible when needed, with fluoroscopy minimised and the uterus shielded.
Preparation and what happens
- Explain ERCP, its benefits and risks (pancreatitis, bleeding, perforation) and alternatives, and get consent — the risk is higher than EGD.
- Check blood count, clotting, liver tests and renal function — sphincterotomy bleeds if clotting is poor.
- Plan anticoagulants and antiplatelets with the guideline — sphincterotomy is a high-bleeding-risk procedure.
- Ask about contrast and other allergies and pregnancy — contrast is used and fluoroscopy uses ionising radiation.
- Fast as the unit instructs; give antibiotics if indicated (cholangitis, incomplete drainage expected) — infected bile can cause sepsis.
- Rectal NSAID before the procedure unless contraindicated, as per protocol — it lowers the risk of post-ERCP pancreatitis.
- Deep sedation or anaesthesia, prone position, fluoroscopy — the side-viewing scope must face the papilla.
- The papilla is cannulated, contrast outlines the ducts, then sphincterotomy, stone removal or stenting — the image guides each step.
- Recovery with observations and pain review; stay nil by mouth or on clear fluids as advised — pain may be early pancreatitis.
Complications after ERCP: when they appear and the clues
| Complication | When | Clues | First step |
|---|---|---|---|
| Pancreatitis | Hours after the procedure | Epigastric pain to the back, vomiting, amylase or lipase at least three times normal | Fluids, analgesia, severity assessment |
| Bleeding | During or days later | Haematemesis, melaena, falling haemoglobin | Resuscitate, repeat endoscopy |
| Perforation | During or within hours | Pain out of proportion, surgical emphysema, free or retroperitoneal air on CT | Nil by mouth, antibiotics, surgical review |
| Cholangitis | Days after | Fever, jaundice, right upper quadrant pain | Blood cultures, antibiotics, check drainage |
Risks and complications
- Post-ERCP pancreatitis: the most common; risk higher in younger women, prior post-ERCP pancreatitis, difficult cannulation and pancreatic duct injection.
- Bleeding after sphincterotomy, immediate or delayed, more likely with coagulopathy or antithrombotics.
- Perforation: duodenal wall, at the sphincterotomy (retroperitoneal) or by a guidewire; may show only as pain and air on CT.
- Cholangitis and sepsis, especially when drainage is incomplete (hilar strictures, primary sclerosing cholangitis).
- Sedation and cardiopulmonary events; stent occlusion or migration later.
Next step
- Read the report: what was found, whether the duct was cleared, stents placed (type and number) and samples sent.
- Pain after ERCP: check amylase or lipase and examine; severe or atypical pain or fever needs a senior and often a CT for perforation.
- Watch the bilirubin fall and the sepsis settle; a rising bilirubin or fever suggests a blocked stent or incomplete drainage.
- Gallstone disease: refer for cholecystectomy; malignancy: cytology result, staging and the multidisciplinary team.
- Plastic stents block with time: book the planned exchange or removal and record it in the discharge letter.
Test yourself
Think of the answer, then tap the question to see it.
Why is ERCP now used mainly for treatment rather than diagnosis?
MRCP and endoscopic ultrasound image the bile and pancreatic ducts with much less risk, while ERCP can remove stones, drain and stent.
What is the most common complication of ERCP, and how is it defined?
Post-ERCP pancreatitis: new or worse typical abdominal pain with amylase or lipase at least three times the upper limit, needing admission or a longer stay.
Which measures lower the risk of post-ERCP pancreatitis?
Careful patient selection, a rectal NSAID before the procedure, gentle cannulation with a guidewire and a temporary pancreatic duct stent in high-risk cases.
What should follow ERCP clearance of common bile duct stones in a patient with a gallbladder?
Cholecystectomy, often in the same admission for mild disease, because stones in the gallbladder will otherwise cause further episodes.
Elsewhere in DurgiPedia
- Jaundice: prehepatic, hepatic and posthepatic
- Bile and the enterohepatic circulation
- Iodinated contrast: reactions and the kidney
- Radiation in medical imaging: risk, ALARA and pregnancy
Connections
In Pharmacology4
Educational content; it does not replace supervised hands-on training, your institution's protocols or a prescriber's order. A procedure is learnt with a teacher and done only once you are trained to do it.
Sources: Endoscopic Retrograde Cholangiopancreatography (StatPearls (NCBI Bookshelf), 2025).
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Representative model, for educational purposes only.