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ERCP (Endoscopic Retrograde Cholangiopancreatography)

ERCP is an advanced endoscopic procedure used to diagnose and treat problems of the bile ducts, pancreas, and gallbladder.

What is ERCP?

ERCP is a specialized procedure used to diagnose and treat problems of the:

  • Bile ducts
  • Gallbladder
  • Pancreatic duct
  • Pancreas

It combines:

  • Endoscopy (a flexible camera tube passed through the mouth)
  • Fluoroscopy/X-ray imaging

Unlike a normal endoscopy, ERCP is mainly a therapeutic procedure used to remove stones, relieve blockage, place stents, or treat duct problems.


Anatomy Involved

The procedure evaluates:

  • Common bile duct (CBD)
  • Pancreatic duct
  • Liver drainage system
  • Gallbladder drainage pathway

When is ERCP Required?

Common Indications

1. Common Bile Duct Stones (Choledocholithiasis)

Most common reason for ERCP.

Symptoms:

  • Severe upper abdominal pain
  • Jaundice
  • Fever
  • Vomiting

2. Obstructive Jaundice

When bile flow is blocked due to:

  • Stones
  • Strictures
  • Tumors
  • Pancreatic disease

3. Cholangitis (Bile Duct Infection)

A medical emergency.

Symptoms:

  • Fever
  • Jaundice
  • Abdominal pain

ERCP helps drain infected bile.

4. Bile Duct Strictures

Narrowing caused by:

  • Surgery
  • Chronic inflammation
  • Cancer
  • Pancreatitis

5. Pancreatic Duct Problems

  • Chronic pancreatitis
  • Pancreatic duct leak
  • Pancreatic strictures
  • Certain pancreatic cyst problems

6. Bile Leak

Can occur after:

  • Gallbladder surgery
  • Liver surgery
  • Trauma

7. Tumors

Used for:

  • Stent placement
  • Tissue sampling
  • Relieving blockage

Common cancers:

  • Pancreatic cancer
  • Cholangiocarcinoma
  • Ampullary tumors
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Symptoms That May Need ERCP

  • Yellow discoloration of eyes/skin
  • Severe abdominal pain
  • Fever with jaundice
  • Recurrent pancreatitis
  • Dilated bile duct on ultrasound
  • Abnormal liver function tests
  • Persistent vomiting due to biliary obstruction

Investigations Before ERCP

Usually advised:

  • CBC
  • Liver function test (LFT)
  • Kidney function test (RFT)
  • PT/INR
  • Viral markers:
    • HIV
    • HBsAg
    • HCV
  • ECG
  • Sometimes 2D Echo in elderly/high-risk patients

Imaging may include:

  • Ultrasound abdomen
  • CT scan
  • MRCP
  • MRI abdomen

How is ERCP Performed?

Step-by-Step Procedure

Step 1: Sedation

  • Patient is given sedation or short anesthesia.
  • Most patients sleep during the procedure.

Step 2: Endoscope Insertion

A flexible tube with camera is passed:

  • Mouth → food pipe → stomach → duodenum

Step 3: Cannulation

A small catheter enters the bile duct opening (papilla).

Step 4: Dye Injection

Contrast dye is injected and X-rays are taken.

This shows:

  • Stones
  • Blockages
  • Narrowing
  • Leaks

Step 5: Treatment During ERCP

Depending on findings, doctor may:

  • Remove stones
  • Cut sphincter muscle (sphincterotomy)
  • Place stent
  • Dilate narrowing
  • Take biopsy/brush cytology
  • Drain infected bile
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Common Procedures Done During ERCP

Stone Removal

ERCP Stone Extraction

Special balloons or baskets remove bile duct stones.


Stent Placement

Biliary Stents

Stents help keep ducts open when blocked.

Types:

  • Plastic stents
  • Metal stents

Is ERCP Painful?

Usually:

  • Not painful during procedure because of sedation.
  • Mild throat discomfort may occur later.
  • Some abdominal bloating can happen temporarily.

Duration of Procedure

  • 30 minutes to 1 hour
  • Complex procedures may take longer

Recovery After ERCP

Immediately After Procedure

  • Observation for few hours
  • Monitoring pulse, BP, oxygen

Diet

  • Liquids after recovery
  • Then soft diet if stable

Hospital Stay

Depends on condition:

  • Some patients go home same day
  • Others require admission

Risks & Complications

Most Important Complication: Pancreatitis

ERCP Complications

Occurs in some patients after ERCP.

Symptoms:

  • Severe abdominal pain
  • Vomiting
  • Fever

Other Complications

  • Bleeding
  • Infection
  • Perforation
  • Reaction to sedation
  • Cholangitis
  • Stent blockage/migration

Warning Signs After ERCP

Seek urgent medical attention if:

  • Severe abdominal pain
  • Fever
  • Persistent vomiting
  • Black stools
  • Breathing difficulty
  • Jaundice worsening

Who Should Avoid ERCP?

Relative contraindications:

  • Unstable patients
  • Severe heart/lung disease
  • Uncorrected bleeding disorder
  • Certain pregnancy situations

Doctor decides risk vs benefit individually.


Preparation Before ERCP

Usually advised:

  • Fasting 6–8 hours
  • Inform doctor about:
    • Blood thinners
    • Diabetes medicines
    • Allergies
    • Pregnancy
  • Arrange attendant after procedure

Success Rate

ERCP has a high success rate when performed by experienced gastroenterologists/endoscopists.

It is considered one of the most important life-saving procedures for bile duct obstruction and cholangitis.

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