ERCP is the gold standard for therapeutic management of biliary and pancreatic ductal disorders, combining endoscopy and fluoroscopy to both diagnose and treat conditions such as choledocholithiasis, strictures, leaks, and tumors.

1. What Is ERCP?

Endoscopic Retrograde Cholangiopancreatography (ERCP) is a minimally invasive procedure that uses a side-viewing duodenoscope passed through the mouth into the duodenum. Under fluoroscopic guidance, contrast dye is injected into the biliary or pancreatic ducts to obtain cholangiograms or pancreatograms, allowing direct visualization, intervention, and sample collection through the endoscope’s working channel.

2. Indications

ERCP is primarily therapeutic. Key indications include:

• Choledocholithiasis: Stone removal from common bile duct in symptomatic or complicated gallstone disease.

• Ascending Cholangitis: Urgent biliary decompression reduces mortality, especially if performed within 24–48 hours.

• Biliary Strictures: Malignant or benign strictures requiring dilation, stenting, or biopsy.

• Bile Leaks: Postoperative or traumatic leaks managed with stent placement to divert bile flow.

• Ampullary Lesions: Adenomas or small tumors amenable to endoscopic ampullectomy and ductal stenting.

• Pancreatic Duct Disorders: Selective pancreatography for strictures or leaks (less common).

3. Contraindications

ERCP carries higher complication rates than other endoscopies. Absolute and relative contraindications include:

• Lack of Informed Consent (unless emergent).

• Active GI Perforation above the papilla.

• Unstable Hemodynamics without resuscitation.

• Severe Coagulopathy uncorrected pre-procedure.

• Altered Upper GI Anatomy precluding duodenoscope access (e.g., Roux-en-Y).

4. Preparation

• Fasting: NPO for at least 6–8 hours.

• Medication Review: Hold anticoagulants as per internal guidelines; review allergy history.

• Consent Discussion: Risks (pancreatitis, bleeding, infection, perforation), benefits, and alternatives reviewed.

5. Procedure Steps

1. Sedation & Positioning: Conscious sedation or general anesthesia; patient in prone or left lateral decubitus position.

2. Endoscope Insertion: Duodenoscope advanced to second part of duodenum.

3. Papilla Identification: Visualize major (and minor) duodenal papilla.

4. Cannulation: Selective cannulation of bile or pancreatic duct using a catheter and guidewire.

5. Contrast Injection: Radiopaque dye injected to outline ductal anatomy under fluoroscopy.

6. Therapeutic Interventions:

   • Sphincterotomy for stone extraction or stent placement.

   • Balloon dilation of strictures.

   • Stone removal with baskets or lithotripsy.

   • Tissue sampling via brush cytology or forceps biopsy.

7. Stent Placement: Plastic or metal stents to relieve obstruction or divert leaks.

6. Risks and Complications

Overall complication rate ~5–10%, with pancreatitis being most common (3–7%), followed by infection (cholangitis), bleeding, and perforation:

7. Post-Procedure Care

• Observation: Monitor for abdominal pain, fever, or bleeding for 4–6 hours.

• Diet: Clear liquids advancing as tolerated once stable.

• Follow-Up Imaging: Repeat cholangiogram if stent placed (typically 4–6 weeks) for removal or exchange.

8. Advantages over Alternatives

ERCP remains indispensable when intervention is required, whereas MRCP and EUS serve as safer diagnostic adjuncts.