What is ERCP?
Endoscopic Retrograde Cholangiopancreatography (ERCP) is a highly specialised endoscopic procedure that uses a side-viewing duodenoscope — a flexible camera with a side-facing lens — guided through the mouth, oesophagus, stomach, and into the second portion of the duodenum to access the ampulla of Vater (where the bile duct and pancreatic duct open into the duodenum).
Through this opening, fine instruments are passed to inject contrast dye into the bile and pancreatic ducts, which are then visualised using real-time X-ray (fluoroscopy). This allows Dr. Ahuja to identify blockages, stones, strictures, or leaks — and simultaneously treat them with procedures like sphincterotomy (cutting open the sphincter), stone extraction, stent placement, or stricture dilation.
ERCP has evolved into a primarily therapeutic procedure. Safer diagnostic tools like MRCP and EUS are now used first to confirm the diagnosis — ERCP is performed when treatment is needed, maximising its benefit while minimising unnecessary risk.
What Does ERCP Treat?
Bile Duct Stones (Choledocholithiasis)
Gallstones that have migrated into the common bile duct — removed using balloon or basket extraction during ERCP.
Obstructive Jaundice
Yellow discolouration from blocked bile ducts — stents placed to restore bile flow without open surgery.
Acute Cholangitis
Life-threatening bile duct infection from obstruction — urgent ERCP to drain the infected bile is critical.
Bile Duct Strictures
Narrowing of the bile duct from cancer, inflammation, or post-surgery scarring — dilated and stented during ERCP.
Biliary Pancreatitis
Gallstone-triggered acute pancreatitis with bile duct obstruction — ERCP removes the causative stone urgently.
Post-surgical Bile Leaks
Bile duct leaks after cholecystectomy or liver surgery — sealed with stent placement during ERCP without reoperation.
Biliary / Pancreatic Cancer
Malignant bile duct or pancreatic head tumours blocking bile flow — metal stents placed for palliative drainage.
PSC / Sphincter of Oddi Dysfunction
Primary sclerosing cholangitis — stricture dilation; SOD type I — sphincterotomy to relieve pain and biliary pressure.
Pancreatic Duct Disorders
Pancreatic duct strictures or stones in chronic pancreatitis — drained and stented through ERCP to relieve pain.
What Procedures Are Done During ERCP?
💎 Bile Duct Stone Extraction
After sphincterotomy (cutting open the sphincter of Oddi), stones in the common bile duct are removed using a retrieval balloon or Dormia basket. Very large stones may be broken first using mechanical lithotripsy (crushing with a specialised device) or cholangioscopy-guided laser lithotripsy before removal.
ERCP achieves complete bile duct stone clearance in over 90–95% of patients — eliminating the need for open bile duct surgery (choledochotomy).
🪱 Biliary Stent Placement
Plastic or self-expanding metal stents (SEMS) are placed across a bile duct obstruction to bypass it and restore bile flow into the duodenum. Plastic stents are used for benign strictures and bile leaks (replaced every 3 months). Metal stents (covered or uncovered) are used for malignant obstruction and have a longer patency of 6–12 months.
Stent placement immediately relieves obstructive jaundice and prevents cholangitis — often within 24–48 hours.
✂️ Endoscopic Sphincterotomy (EST)
Using a specialised electrosurgical wire (sphincterotome), the sphincter of Oddi at the ampulla of Vater is precisely cut open under fluoroscopic guidance. This widens the opening of the bile duct into the duodenum, allowing stones to pass or be extracted, and provides long-term drainage without re-narrowing.
Sphincterotomy is performed in virtually all therapeutic ERCP procedures as the first step before stone removal or stent placement.
🔍 Stricture Dilation & Biopsy
Narrowing of the bile duct (benign or malignant stricture) is treated by passing progressively larger dilating balloons or bougies across the stricture to widen it. A stent is then placed to maintain patency. If the cause of the stricture is uncertain, brush cytology or intraductal biopsies are taken under fluoroscopy for pathological diagnosis.
Indications for ERCP — Biliary & Pancreatic
| Condition / Indication | ERCP Role & Procedure |
|---|---|
| Choledocholithiasis (bile duct stones) | Sphincterotomy + stone extraction via balloon / basket. Gold standard treatment. 95% success |
| Obstructive Jaundice (benign) | CBD stone removal or plastic stent placement. Immediate bilirubin relief within 24–48 hours. |
| Obstructive Jaundice (malignant — pancreatic/bile duct cancer) | Covered metal stent (SEMS) for palliative biliary drainage. Palliation |
| Acute Cholangitis (Charcot's triad / Reynold's pentad) | Emergency ERCP for urgent biliary decompression — life-saving intervention. |
| Biliary Pancreatitis with obstruction / cholangitis | Early ERCP (within 24–48h) to remove the impacted stone and prevent worsening pancreatitis. |
| Post-cholecystectomy bile leak | Plastic biliary stent placement to reduce pressure gradient — heals the leak without re-surgery. First-line |
| Benign Biliary Stricture (post-surgery, PSC, chronic pancreatitis) | Sequential plastic stent placement with 3-monthly exchanges until stricture resolves. |
| Sphincter of Oddi Dysfunction (Type I) | Biliary sphincterotomy to relieve biliary hypertension and recurrent pain. |
| Chronic Pancreatitis — pancreatic duct stones / strictures | Pancreatic sphincterotomy, stone removal, pancreatic duct stenting to relieve pain. |
| Cholangioscopy (direct bile duct visualisation) | Spyglass cholangioscopy for difficult stricture characterisation or laser lithotripsy of large stones. |
ERCP vs MRCP vs Surgery
| Parameter | ERCP | MRCP | Open / Lap Surgery |
|---|---|---|---|
| Purpose | Diagnosis + Treatment | Diagnosis only | Treatment (complex cases) |
| Invasiveness | Endoscopic | Non-invasive (MRI) | Surgical incision |
| Stone Removal | ✓ Yes | ✗ No | ✓ Yes |
| Stent Placement | ✓ Yes | ✗ No | ✓ Yes |
| Anaesthesia | Sedation | None (loud MRI) | General anaesthesia |
| Hospital Stay | Same-day / 1 night | Outpatient | 3–5 days |
| Recovery | 1–2 days | Immediate | 2–4 weeks |
| Radiation | Low-dose fluoroscopy | None | Minimal |
| Success for Stones | 90–95% | N/A | 95%+ |
| Risk Profile | Low (1–5% complications) | Negligible | Moderate–High |
Clinical practice: MRCP or EUS is used first to confirm bile duct stones or obstruction. ERCP is then performed specifically for treatment — avoiding unnecessary risk. This "diagnose first, treat with ERCP" approach has become the international standard.
The ERCP Procedure — Step by Step
Pre-Procedure Evaluation & Consent
Blood tests (LFT, bilirubin, CBC, coagulation), ultrasound, MRCP or CT to confirm indication. All current medications reviewed — blood thinners stopped 5–7 days prior. IV access placed. Antibiotic prophylaxis given for complex cases or biliary obstruction.
Day before / Day of procedureSedation & Positioning
Moderate-to-deep sedation (or general anaesthesia for complex cases) administered through IV. You are positioned on your left side or prone (face-down) for optimal access. Throat spray applied to suppress gag reflex. Vital signs continuously monitored.
Completely comfortable — no pain feltDuodenoscope Insertion to Ampulla
The side-viewing duodenoscope is carefully guided through the mouth → oesophagus → stomach → pylorus → duodenum until the ampulla of Vater (the bile duct opening) is clearly visualised on the monitor. This is the most technically demanding step — Dr. Ahuja's experience ensures safe, accurate access.
Cannulation, Contrast Injection & Fluoroscopy
A thin catheter is passed into the bile duct or pancreatic duct through the ampulla. Contrast dye is injected and live X-ray (fluoroscopy) is activated, showing the duct anatomy on a fluoroscopy monitor — revealing stones, strictures, dilatation, or leaks in real time.
Live X-ray imaging used throughoutTherapeutic Intervention
Based on findings: sphincterotomy is performed (if needed), followed by stone extraction with balloon or basket, or stent placement across a stricture or obstruction. Cholangioscopy, brush cytology, or lithotripsy performed if indicated. All in the same 30–60 minute session.
Diagnosis + treatment in one sittingRecovery, Observation & Discharge
After the procedure, you recover for 2–4 hours under monitoring. Blood pressure, pulse, and abdomen are checked. Diet starts with clear liquids, progressing to soft food. Most patients are discharged the same evening or next morning. Dr. Ahuja reviews findings and next steps with you and your family before discharge.
How to Prepare
Before the Procedure
- Fast for at least 6–8 hours (nothing to eat or drink)
- Stop aspirin, clopidogrel, warfarin 5–7 days before (as directed)
- Bring all previous reports — ultrasound, MRCP, CT, LFT results
- Inform Dr. Ahuja of all medications, allergies, and prior surgeries
- Diabetic medications may need adjustment — confirm with the team
- Arrange a responsible adult to accompany and drive you home
- Plan to stay at the facility for 4–6 hours on the day
After the Procedure
- Start with sips of water and clear liquids after 1–2 hours
- Soft diet for 24 hours after the procedure
- Resume normal diet next day if no abdominal pain
- Do not drive or operate machinery for 24 hours post-sedation
- Resume blood thinners only when instructed by Dr. Ahuja
- Seek immediate care if fever, severe abdominal pain, or vomiting blood develops
- Follow-up appointment for stent exchange (if stent placed) at 8–12 weeks
Go to the emergency department immediately if you develop fever above 38.5°C, severe worsening abdominal pain, persistent vomiting, or blood in stools after ERCP — these may indicate post-ERCP pancreatitis, cholangitis, or bleeding requiring urgent evaluation.
Risks & Complications of ERCP
ERCP is the most technically complex standard endoscopic procedure and carries a higher complication rate than routine endoscopy — approximately 3–5% overall. However, serious complications are uncommon and the risk-benefit ratio is strongly favourable when properly indicated. Dr. Hardik Ahuja's extensive ERCP experience minimises these risks.
Post-ERCP Pancreatitis (2–5%)
The most common complication — inflammation of the pancreas triggered by contrast injection or sphincterotomy. Usually mild and self-limiting with bowel rest. Prophylactic rectal indomethacin is given to reduce risk.
Bleeding (1–2%)
Minor bleeding at the sphincterotomy site. Usually stops spontaneously or is controlled endoscopically with adrenaline injection or clips. Serious bleeding requiring transfusion is rare (<0.5%).
Cholangitis / Infection (1–3%)
Bile duct infection — more common when biliary drainage is incomplete. Prophylactic antibiotics are given. Treated with IV antibiotics and repeat drainage if needed.
Perforation (<1%)
A rare tear in the duodenum or bile duct. May require surgical repair in severe cases. More common with difficult sphincterotomies — Dr. Ahuja's meticulous technique minimises this risk.