Medically Reviewed By: Dr. Neeraj Goel, MCh (GI Surgery)
Director – GI Oncology, GI & HPB Surgery
Dharamshila Narayana Superspeciality Hospital, Delhi
Review Date: October 2, 2026
Endoscopic Retrograde Cholangiopancreatography (ERCP) is an advanced, specialized procedure that combines upper gastrointestinal endoscopy with real-time fluoroscopic X-ray imaging to diagnose and definitively treat conditions affecting the biliary and pancreatic ductal systems. These channels transport digestive bile from the liver and gallbladder, as well as digestive enzymes from the pancreas, into the duodenum (small intestine).
Historically utilized for diagnostic purposes, ERCP has evolved into an almost exclusively therapeutic intervention due to the advent of non-invasive magnetic resonance imaging (MRCP). During an ERCP, a specialized flexible side-viewing endoscope (duodenoscope) is guided through the mouth and stomach into the duodenum to cannulate the major duodenal papilla (ampulla of Vater). Contrast dye is injected retrograde into the bile and pancreatic ducts under X-ray visualization. Once the site of pathology is mapped, interventional endoscopists and GI surgeons can extract lodged gallstones, perform sphincterotomies, dilate strictures, sample tissue biopsies, and deploy plastic or self-expanding metal stents. Working in seamless coordination with advanced HPB surgical services, Dr. Neeraj Goel utilizes ERCP for rapid biliary decompression, clearance of complex choledocholithiasis, and targeted pre-operative preparation prior to curative robotic surgery.
ERCP is indicated when structural blockage, ductal disruption, or mucosal pathology impedes normal biliary or pancreatic drainage. Primary indications include:
ERCP is performed under monitored anesthesia care (MAC) or general anesthesia with the patient positioned in a prone or semi-prone position on an X-ray table:
Biliary and pancreatic outflow obstructions manifest with characteristic clinical signs ranging from gradual icterus to overwhelming sepsis.
Because ERCP is an advanced invasive therapeutic intervention, it carries recognized procedural risks that require careful patient selection and expert technique:
Careful pre-procedural imaging and laboratory profiling are essential to verify indications and formulate a personalized intervention strategy:
ERCP offers an expansive array of therapeutic instruments to address complex ductal pathologies:
Following electrosurgical division of the ampullary sphincter, extraction balloons or Dormia wire baskets are swept through the common bile duct to drag stones into the duodenum, where they pass harmlessly through the stool. For giant or impacted stones (>15 mm), mechanical lithotripsy or cholangioscopy-guided laser/electrohydraulic lithotripsy (EHL) is used to shatter stones into extractable fragments.
Stents bypass blockages and restore unhindered bile flow. Plastic stents (polyethylene) are ideal for temporary drainage (e.g., bile leaks, temporary stone bridge, or benign strictures). Self-Expanding Metal Stents (SEMS)—either bare, partially covered, or fully covered—provide large-diameter, long-term patency for malignant biliary obstruction, preventing tumor ingrowth.
ERCP is closely integrated with surgical gastrointestinal and oncology care to provide complete solutions for complex hepatobiliary disease:
Following ERCP, patients remain in the post-anesthesia recovery area for 2 to 4 hours under close hemodynamic monitoring. Most uncomplicated therapeutic procedures are managed on a daycare basis or require an overnight observation stay. Clear liquids are initiated once the sedation completely clears, followed by light meals. Routine follow-up includes repeat liver function tests to confirm falling bilirubin levels, and timely clinic consultations to plan elective gallbladder removal or schedule stent removal/exchange within 3 to 6 months.
Dr. Neeraj Goel is an accomplished Hepato-Pancreato-Biliary (HPB) and GI surgical oncologist with comprehensive mastery over complex biliary disorders, post-cholecystectomy bile duct injuries, and advanced gastrointestinal malignancies. Operating at Dharamshila Narayana Superspeciality Hospital, Delhi, Dr. Goel in conjunction with expert team of gastroenterologists coordinates cutting-edge interventional endoscopy with advanced robotic surgical platforms. Whether coordinating urgent biliary sepsis clearance, managing complex biliary strictures, or performing definitive robotic reconstructive surgery, Dr. Goel delivers evidence-based clinical precision and individualized patient care.
ERCP stands for Endoscopic Retrograde Cholangiopancreatography. It is a specialized medical procedure combining upper endoscopy and fluoroscopic X-rays to treat diseases of the bile ducts, gallbladder, and pancreas. While originally used as a diagnostic tool, modern non-invasive scans like MRCP have replaced diagnostic ERCP. Today, ERCP is almost exclusively therapeutic—used to remove stuck bile duct stones, open narrowed ducts, insert drainage stents, and seal bile leaks.
A standard upper endoscopy or colonoscopy primarily examines the lining of the stomach, esophagus, or large intestine. ERCP, however, uses a specialized side-viewing endoscope (duodenoscope) designed to locate the tiny opening where the bile and pancreatic ducts drain into the small intestine (the ampulla of Vater). A catheter is threaded directly into these narrow ducts under X-ray visualization, allowing interventions inside the liver and pancreatic drainage network that standard endoscopes cannot reach.
No, you will not feel pain during the procedure. ERCP is conducted under monitored anesthesia care (deep sedation) or general anesthesia administered by an anesthesiologist. You will be asleep, comfortable, and completely unaware of the intervention. After waking up, you may experience a mild, temporary sore throat, abdominal bloating, or mild gas discomfort, which typically resolves within 24 hours.
After guiding the duodenoscope to the ampulla of Vater, the specialist performs an endoscopic sphincterotomy—a tiny, precise electrosurgical cut that widens the muscular opening of the bile duct. A miniature balloon catheter or wire mesh basket (Dormia basket) is then advanced into the duct above the stones. The balloon is inflated and gently pulled downward, sweeping the stones out of the bile duct into the intestine, where they pass harmlessly through your digestive tract.
An endoscopic sphincterotomy is a small, controlled cut made in the sphincter of Oddi—the muscular valve controlling bile flow into the duodenum. By dividing this muscle using specialized electrocautery current, the duct opening is permanently widened. This allows stones to be extracted easily and dramatically reduces the risk of future gallstones becoming impacted in the common bile duct.
A biliary stent is a small, flexible plastic tube or expandable metal mesh tube placed across a narrowed or blocked duct segment to keep it open and ensure free bile drainage. Plastic stents are generally temporary and must be removed or replaced within 3 to 4 months to prevent clogging and infection. Self-expanding metal stents (SEMS) are wider, longer-lasting, and are frequently used for permanent drainage in malignant blockages or specialized benign conditions.
While ERCP is a highly safe and routine procedure in expert hands, recognized complications can occur. The most common is Post-ERCP Pancreatitis (PEP), occurring in 3% to 5% of patients due to temporary inflammation of the pancreatic duct. Other rare risks include bleeding from the sphincterotomy site (1%), infection (cholangitis), and duodenal or duct perforation (under 1%). Experienced surgical and endoscopic teams take strict precautions—such as administering rectal NSAIDs and placing protective temporary pancreatic stents—to minimize these risks.
No. ERCP only reaches and clears stones that have escaped into the common bile duct or formed within the biliary drainage channels. It cannot enter the gallbladder itself to clear stones. Therefore, if your gallbladder still contains stones, elective laparoscopic cholecystectomy is strongly recommended after your ERCP to permanently remove the gallbladder and eliminate the source of recurrent stones.
MRCP (Magnetic Resonance Cholangiopancreatography) is a completely non-invasive, radiation-free MRI scan that provides detailed 3D diagnostic images of the bile and pancreatic ducts without requiring any tubes, scopes, or sedation. However, MRCP cannot treat conditions. ERCP is an invasive, therapeutic procedure involving endoscopy, X-rays, and sedation, utilized to actively treat conditions (extracting stones, dilating strictures, or placing stents) identified on prior MRCP scans.
A routine therapeutic ERCP generally takes between 30 and 60 minutes, depending on the complexity of the stones or stricture. Most uncomplicated procedures are performed on a daycare basis, allowing patients to return home after 3 to 4 hours of post-anesthesia observation. Patients with severe acute cholangitis, complex stenting, or underlying medical conditions may be admitted overnight for monitoring and IV hydration.
You must fast completely (no food or liquids) for at least 6 to 8 hours before the procedure to ensure your stomach and duodenum are completely empty, providing a clear view and preventing aspiration. You must also inform your doctor about all medications you take, particularly blood thinners (such as aspirin, clopidogrel, or warfarin), which usually need to be paused several days prior to prevent bleeding during sphincterotomy.
While serious problems are rare, you should seek emergency medical attention or contact your specialist immediately if you develop: severe, persistent abdominal pain (especially pain that worsens and radiates to your back), high fever with shaking chills, recurrent vomiting, black or bloody stools, or new yellowing of your eyes or skin.
