What is ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines endoscopy and fluoroscopy for the diagnosis and treatment of certain disorders of the biliary tree or the pancreatic duct.

It is a specialised procedure in which the physician advances a side-viewing endoscope through the stomach and the first part of the duodenum, as far as the junction of the common bile duct and the pancreatic duct (the ampulla of Vater). Contrast medium can then be injected into the ducts of the biliary tree and the pancreas so that they become visible on X-ray images.

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When is ERCP needed

ERCP is used mainly for the diagnosis and treatment of conditions of the bile ducts and the main pancreatic duct, including gallstones, inflammatory strictures (scarring), leaks (from trauma and surgery) and cancer. The most common indications are:

  • Stones that have passed into the common bile duct (choledocholithiasis)
  • Jaundice caused by obstruction of the bile ducts
  • Cholangitis, an infection of the bile ducts behind an obstruction
  • Benign or malignant strictures of the bile ducts that need dilation or a stent
  • Bile leaks after surgery or trauma
  • Stones or strictures of the pancreatic duct, as in chronic pancreatitis
  • Tissue sampling for the diagnosis of tumours of the bile ducts or the pancreas

The conditions most often treated this way are gallstones of the bile duct and strictures, including those caused by cholangiocarcinoma, where cholangioscopy allows targeted biopsy from the stricture itself.

Today ERCP is mainly a therapeutic procedure. When the question is still diagnostic, for example whether there is a stone in the common bile duct, magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound usually comes first, so that ERCP is performed when there is something specific to treat.

Key figures

  • MRCP is diagnostic, ERCP is primarily therapeutic
  • Cholangioscopy allows targeted biopsy from the stricture itself
  • Post-ERCP pancreatitis is the most important complication
  • ERCP is not used as a diagnostic test when imaging suffices

What can be done during ERCP

  • Sphincterotomy, a small incision in the sphincter of Oddi that widens the outlet of the bile duct
  • Stone removal with a special balloon or basket. Difficult stones may need large-balloon dilation or fragmentation (lithotripsy)
  • Stent placement to keep the bile ducts open across a stricture or when a stone cannot be removed straight away
  • Dilation of strictures with a balloon
  • Biopsies or cell sampling from strictures and suspicious areas
  • Cholangioscopy, for direct vision inside the ducts

Cholangioscopy

In selected cases the gastroenterologist can advance a miniature endoscope through the working channel of the standard endoscope into the biliary tree and obtain direct visualisation of its lumen. This technique is called cholangioscopy and it serves to fragment large stones by lithotripsy or to take targeted biopsies from specific points of the biliary tree and the pancreatic duct for the diagnosis of malignancy.

How it is performed and how long it takes

ERCP is performed in hospital, in a room equipped with fluoroscopy, because imaging of the ducts requires X-rays during the procedure.

The procedure is usually performed after the intravenous administration of medication for sedation, with continuous monitoring of the patient’s cardiorespiratory vital parameters. This allows for a calm, essentially painless and thorough examination. The side-viewing endoscope is then introduced through the mouth into the oesophagus, the stomach and, through the pylorus, into the duodenum, where the ampulla of Vater is located. The sphincter of Oddi is a muscular valve that controls the opening of the ampulla. When required, your physician may perform a small incision (sphincterotomy), which facilitates access so that stones can be removed or other treatment can be carried out with ease.

The duration depends on what needs to be done. A simple procedure can be completed in less than half an hour, while complex treatment, such as difficult stones, strictures or cholangioscopy, takes longer. Preparation and recovery from sedation add to the total time.

Preparation

The patient fasts for 6 to 8 hours before the procedure. It is important to tell the doctor about all the medication you take, especially anticoagulants, antiplatelet drugs and medication for diabetes, as well as any allergies. Women should mention any possibility of pregnancy, since the procedure uses fluoroscopy.

Depending on the medical history, blood tests may be requested, for example a coagulation check in patients on anticoagulants or with jaundice. Because the procedure is performed under sedation, you will need someone to accompany you home, and it is wise to bring what you would need for an overnight stay, in case it is required.

After ERCP

The patient is monitored until the effect of sedation wears off. After a therapeutic procedure, such as stone removal, an overnight stay in hospital may be needed. Eating resumes gradually, starting with fluids and then light food, according to the instructions you will be given.

Driving is not allowed for the rest of the day. A sore throat or mild bloating is expected and settles soon. Contact the doctor immediately in case of severe or worsening abdominal pain, fever or shivering, vomiting blood or black stools.

Plastic stents are temporary. They are removed or replaced after an interval that depends on the reason they were placed.

Complications and safety

Complications of ERCP are not common, although it remains a specialised and invasive procedure. Irritation of the pancreas occurs in 5% of cases, while others such as bleeding or infection occur in about 1% of patients.

Pancreatitis after ERCP is the most common complication and in the large majority of cases it is mild or moderate. Its prevention relies on specific measures: a rectal anti-inflammatory drug given immediately before the procedure when there is no contraindication and, in high-risk patients, temporary placement of a small stent in the pancreatic duct.

The risk depends both on the patient’s characteristics and on the difficulty of the procedure. This is why the indication is carefully established before ERCP is decided.

Note: This article does not replace the detailed explanation of the ERCP and cholangioscopy procedure given by your gastroenterologist.

Frequently asked questions about ERCP

MRCP is a purely diagnostic magnetic resonance study that maps the ducts without any instrument entering the body. ERCP is an endoscopic procedure that is primarily therapeutic: it removes stones, dilates strictures and places stents. Diagnostic questions are answered first by MRCP or endoscopic ultrasound, and ERCP is reserved for treatment.

It allows direct visual inspection inside the bile duct and targeted biopsies from the stricture itself, which imaging cannot provide. This matters because distinguishing a malignant stricture from a benign one is not always possible on imaging alone, and the distinction changes management entirely.

The most important is post-ERCP pancreatitis. Risk is reduced by careful patient selection, technique, and preventive measures where indicated. This is why ERCP is not used as a diagnostic test: when the aim is only to look, MRCP or endoscopic ultrasound carry no such risk.

It depends on the procedure. A simple ERCP can be completed in less than half an hour, while removal of difficult stones, treatment of strictures or cholangioscopy take longer. Preparation and recovery from sedation add to the total time.

No. It is performed under sedation with continuous monitoring of vital parameters, so the patient does not feel pain during the procedure. Afterwards there may be a sore throat or mild bloating, which settle soon.

It depends on the procedure. After a simple ERCP the patient can go home the same day, after a few hours of observation. After therapeutic procedures, such as stone removal, an overnight stay for observation may be needed. In any case, driving is not allowed on the same day.

It is a small incision in the sphincter of Oddi, the muscular valve at the ampulla of Vater where the common bile duct and the pancreatic duct open. The incision widens the opening so that stones can be removed or a stent placed, and it is performed through the endoscope during ERCP.

The cost depends on the hospital where the procedure takes place, on what needs to be done (sphincterotomy, stone removal, stent placement, cholangioscopy), on whether a hospital stay is needed and on the cover provided by your insurance. Insurance cover usually requires a referral or pre-approval. An accurate estimate is given after your case has been assessed.

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Content last updated: October 2026 (09/10/2026).