ERCP — Advanced Biliary & Pancreatic Procedures

Advanced endoscopy

What ERCP is

ERCP stands for endoscopic retrograde cholangiopancreatography. A side-viewing endoscope is passed through the mouth into the duodenum, where the bile duct and pancreatic duct open into the bowel. Through this natural opening, instruments can be advanced into the ducts to remove stones, relieve blockages, place stents and take samples.

ERCP has changed significantly over the last two decades. It is no longer primarily a way of looking at the ducts — MRCP, CT and endoscopic ultrasound do that non-invasively and more safely. ERCP today is principally a therapeutic procedure: it is performed when something needs to be done that cannot be done another way.

When ERCP is the right treatment

• Common bile duct stones
• Obstructive jaundice
• Cholangitis (bile duct infection)
• Bile duct strictures
• Bile leak after gallbladder surgery
• Stent placement or exchange
• Sphincter of Oddi dysfunction
• Pancreatic duct stones or strictures
• Large stones needing lithotripsy
• Post-operative biliary complications

What can be done during ERCP

• Sphincterotomy — a controlled cut at the opening of the bile duct to allow access and let stones pass.
• Stone extraction — removal of bile duct stones using a balloon catheter or basket, with mechanical lithotripsy for large stones.
• Stenting — placement of plastic or metal stents to hold a narrowed duct open.
• Stricture dilatation — balloon or bougie dilatation of a narrowed segment of duct.
• Brush cytology and biopsy — sampling of the duct lining when a tumour is suspected.
• Bile leak management — stenting to divert bile and allow a leak to seal.

The specifics of your procedure will be explained beforehand. In some cases the exact plan is modified during the procedure, depending on the findings — and you will be told what was actually done.

Preparation

• Fasting: nothing to eat or drink for at least 6–8 hours before.
• Blood tests: recent complete blood count, coagulation profile, liver function and kidney function are needed before ERCP.
• Blood thinners: anticoagulants and antiplatelet medicines usually need to be stopped or bridged in advance, coordinated with the doctor who prescribed them.
• Antibiotics: may be given before the procedure, especially if cholangitis is suspected.
• Consent: ERCP carries higher risks than routine endoscopy, so the discussion before consent is detailed. Please ask questions.

After ERCP

You will be observed for several hours, sometimes overnight. Blood tests are often repeated the following morning — particularly amylase or lipase, to detect post-ERCP pancreatitis early. Most patients can eat within a few hours and go home the same day or the next day. If a stent has been placed, you will be told its type, why it was placed and when it needs to be reviewed or removed — plastic stents in particular usually require a planned exchange after a set period.

Risks

ERCP is the most technically demanding routine endoscopic procedure, and its risks are correspondingly higher than for diagnostic endoscopy:

• Post-ERCP pancreatitis — the most common significant complication; usually mild but occasionally severe.
• Bleeding — after sphincterotomy, usually mild and self-limiting.
• Cholangitis or sepsis — reduced by appropriate drainage and antibiotics.
• Perforation — uncommon, potentially serious.
• Failure to complete the procedure — sometimes the duct cannot be accessed, requiring an alternative approach such as EUS-guided or percutaneous drainage.

These risks are why ERCP is performed only when there is a clear indication, and why the alternative options — including surgery and radiological drainage — are considered alongside it.