ERCP - Endoscopic Retrograde Cholangiopancreatography
ERCP cannot tell a surgeon anything an MRCP scan would not show more safely, and guidelines no longer use it to diagnose. What it can do is remove a bile duct stone, open a duct blocked by a tumor or seal a leak through the mouth, under sedation, without a cut in the skin.
About This Department
ERCP stopped being a test years ago. The procedure now clears a blocked bile duct through the mouth, with no operation.
ERCP, short for endoscopic retrograde cholangiopancreatography, reaches the bile duct and the pancreatic duct with a flexible endoscope and treats what it finds under X-ray, whether that turns out to be a stone, a narrowing, a leak or a tumor pressing on the duct. No skin is cut. A survey of 21 prospective studies covering 16,855 patients found that 93 in every 100 had no complication of any kind, and that three quarters of the complications that did occur were mild or moderate.
Doctors write ERCP. The full name, which gives this page its title ERCP - Endoscopic Retrograde Cholangiopancreatography, describes the route. An endoscope goes in, contrast dye runs backward, or retrograde, up the bile duct (cholangio) and the pancreatic duct (pancreato), and X-ray pictures (graphy) record it.
What ERCP is
ERCP brings two tools into one room. One of them, the duodenoscope, is a flexible endoscope with its camera on the side. It passes through the mouth and the stomach into the duodenum, the first part of the small bowel, where the bile duct and the pancreatic duct drain through a small raised opening called the papilla. An X-ray machine supplies the second view. The doctor slides a thin catheter through the endoscope into the papilla, injects contrast dye, and watches the ducts fill on the screen.
Everything after that is treatment. A small cut in the ring of muscle at the papilla, called a sphincterotomy, widens the opening. Balloons and wire baskets pull stones out. Plastic or metal tubes called stents hold a narrowed duct open, and brushes and tiny forceps take samples from a narrowing that looks suspicious.
6 to 15 in 100The range of adverse events after ERCP quoted in the 2019 guideline of the American Society for Gastrointestinal Endoscopy. That figure explains why guidelines keep ERCP for treatment and leave diagnosis to scans.
ERCP, MRCP or endoscopic ultrasound?
Twenty years ago doctors used ERCP to look. Two safer tests do the looking now. MRCP, a magnetic resonance scan of the ducts, needs no endoscope and no radiation, and endoscopic ultrasound, known as EUS, places an ultrasound probe in the duodenum right beside the bile duct. European guidance recommends one of those two whenever a bile duct stone is suspected and an ordinary ultrasound with blood tests has not settled the matter.
This table scrolls sideways on a narrow screen. Swipe or drag to see every column.
| Feature | ERCP | MRCP | EUS |
|---|---|---|---|
| How it is done | Endoscope through the mouth plus X-ray | Scanner, 20 to 30 minutes, nothing enters the body | Endoscope with an ultrasound tip |
| Sedation | Deep sedation or general anesthesia | None | Sedation |
| Can it treat? | Yes. Stones, stents, samples | No | Samples only, in most cases |
| Main risk | Pancreatitis in 3 to 4 in 100 | None of note | Very low |
| Best used for | A problem already shown on a scan | A first look at the ducts | Small stones and tumors that MRCP can miss |
Anyone offered ERCP purely to find out what is wrong should ask why a scan is not being done first.
What ERCP treats
Stones in the bile duct
Most stones form in the gallbladder and slip into the duct, where they block the flow of bile and cause pain, jaundice, infection or pancreatitis. Manes and colleagues, in the guideline of the European Society of Gastrointestinal Endoscopy published in 2019, recommend offering removal to every patient with a bile duct stone who is fit enough for the procedure, whether or not the stone has caused symptoms yet. After a sphincterotomy the doctor sweeps the duct with a balloon or a basket. Large stones need more. For those the guideline names a limited sphincterotomy combined with a large dilating balloon as the first choice, and for stones that still will not move, a miniature camera passed into the duct itself, called cholangioscopy, lets the doctor break them with a laser or a shock-wave probe. Few stones survive all three steps. Those that do are bypassed with a stent while the surgeons and the endoscopist decide on the next move.
Infection of a blocked duct, called cholangitis, turns a planned procedure into one that cannot wait. Drainage within 12 hours for a patient in septic shock, and within 48 to 72 hours for moderate infection, is what the same guideline asks for.
A duct blocked by a tumor
Cancers of the pancreas, the bile duct and the gallbladder often announce themselves as painless jaundice. ERCP does two jobs here. A stent restores the flow of bile, which clears the jaundice and the itching within days and makes surgery or chemotherapy possible, and a brush or forceps collects cells for the pathologist. Chemotherapy and radiotherapy are both given at Biruni Hospital on the same site, so a patient whose samples confirm cancer can move to the oncology team without a transfer of records.
Leaks, scars and the pancreatic duct
A bile leak after gallbladder surgery seals within weeks once a stent lowers the pressure in the duct. Scars take longer. Narrowings from surgery or chronic pancreatitis are stretched and held open with stents that the doctor changes every few months for up to a year, and stones and narrowings inside the pancreatic duct itself get the same treatment in selected patients with chronic pancreatitis.
Who should wait, or choose something else
Several groups should not book a flight for ERCP. Fever, shaking chills and jaundice together mean cholangitis, and that patient needs the nearest hospital today. People who only need a diagnosis need MRCP or EUS. Those whose stomach or bowel has been rearranged by surgery, for example a gastric bypass, can still be treated, and the route is longer and harder, so the operation report has to be seen before any promise is made. Pregnancy, a serious reaction to contrast dye in the past, and severe heart or lung disease that makes anesthesia risky all call for a discussion between specialists first.
Blood thinners raise a planning issue, never a barrier. Declare them in the first message.
The procedure from start to finish
Before the day
Blood tests for liver function, clotting and blood count are taken, the scans are reviewed, and an anesthesiologist checks the heart, the lungs and the airway.
Blood thinners
Most patients continue aspirin. Clopidogrel, warfarin and the newer anticoagulants such as apixaban or rivaroxaban are paused for a set number of days before a sphincterotomy, and the doctor who prescribed them has to agree to the plan, because stopping carries its own risk for people with heart stents or an irregular heartbeat.
Fasting and regular tablets
Nothing to eat for six to eight hours and nothing to drink for two. Blood pressure and heart tablets are taken with a sip of water, and the anesthesiologist adjusts diabetes medication for the fasting period, since insulin without food is dangerous.
In the endoscopy room
You lie on your front or left side on the X-ray table. Most units in this market use deep sedation or general anesthesia given by an anesthesiologist, so you sleep through it. A mouth guard protects the teeth, the endoscope is passed, and the work inside the duct takes 30 to 90 minutes depending on what has to be done. Published programs in Turkey quote that range, and a difficult stone sits at the upper end of it.
The first hours afterward
One to two hours in the recovery area come first. A sore throat and bloating from the air used during the procedure are normal and fade within a day.
Clear fluids start after a few hours if there is no pain. A light meal follows in the evening. Nurses ask about abdominal pain before anything else. Pain in the hours after ERCP gives the earliest warning of pancreatitis, and a patient who reports it early gets fluids and pain relief early, which shortens the illness.
Risks, with their rates
How often things go wrong
ERCP carries more risk than any other routine endoscopy, and a patient deserves the figures, which Andriulli and colleagues pooled from 21 prospective studies with 16,855 patients in the American Journal of Gastroenterology in 2007. Complications caused by the procedure occurred in 6.85 percent. They were mild or moderate in 5.17 percent and severe in 1.67 percent, and 0.33 percent of patients, or one in 300, died. Those averages include emergency procedures in very sick and very old patients, and a planned ERCP in a stable person sits at the lower end of every one of them.
Pancreatitis, 3.5 in 100
Infection, 1.4 in 100
Bleeding, 1.3 in 100
Perforation, 0.6 in 100
How the risk is lowered
One cheap measure has the best evidence. Elmunzer and colleagues randomized 602 patients at high risk of pancreatitis to a single indomethacin suppository or a placebo straight after ERCP and reported the result in the New England Journal of Medicine in 2012. Pancreatitis followed in 9.2 percent with indomethacin and 16.9 percent with placebo. On the strength of that and later trials, the 2020 guideline on ERCP-related adverse events by Dumonceau and colleagues recommends 100 milligrams of rectal diclofenac or indomethacin for every patient who can take such drugs, and a temporary stent in the pancreatic duct for those at highest risk. Ask whether both are standard where you are treated.
How long to stay, and when to fly
Plan three to four days in Istanbul for a straightforward ERCP.
Private hospitals in the city publish same-day discharge or a single night on the ward, and their programs advise one to three further days nearby before the flight. At least one published Turkish package keeps patients two nights in hospital and two in a hotel for exactly this reason, which is to rule out pancreatitis before anyone boards an aircraft. The logic holds. Pancreatitis declares itself within the first 24 hours, infection within 48, and a patient who is eating normally, free of pain and free of fever on the third morning has passed the period in which nearly all early complications appear. Delayed bleeding after a sphincterotomy remains possible for up to two weeks, so carry the procedure report on the flight and know the warning signs. Patients who had a metal stent placed for a tumor, or who take blood thinners that were paused, stay a day or two longer while the jaundice is seen to fall and the medication is restarted.
The doctor gives the flight date in writing at discharge.
If the plan changes
Scans guide the plan, and the duct sometimes holds a surprise.
The stone will not come out
Some stones need two visits. Very large or tightly wedged ones resist the first attempt. Guidelines recommend leaving a temporary plastic stent so that bile drains safely, and returning for a second session with a large balloon or cholangioscopy, which for a traveler means either a longer stay or a second trip. Raise that possibility before the first procedure whenever the scan shows a stone over 15 millimeters.
The duct cannot be entered
Swelling, a pouch in the bowel wall beside the papilla, or a tumor sometimes stops the catheter from entering the bile duct. It happens in a minority of patients, and four routes remain, namely a second attempt after a day or two, drainage guided by endoscopic ultrasound, a drain placed through the skin by a radiologist, or surgery.
The samples show cancer
Pathology takes several days. With medical oncology, radiotherapy and surgery on the same site, the next step can be planned in Istanbul, or the slides and the report can travel home with the patient for treatment there.
What the cost depends on
Two patients booked for ERCP receive very different quotes, and the difference comes from what happens inside the duct. Devices drive it. A procedure that ends after a look and a sweep with a balloon uses few of them, stone removal adds a sphincterotome and a balloon or a basket, and a self-expanding metal stent for a tumor ranks among the costliest single items in endoscopy, many times the figure for a plastic one. Cholangioscopy with laser or shock-wave lithotripsy adds a disposable camera and a second set of specialist equipment. Anesthesia time counts. So do the nights on the ward and any scans done beforehand, such as MRCP or EUS. The patient's own circumstances come last, since blood thinners, diabetes, heart disease and previous stomach surgery lengthen both the preparation and the stay, and an emergency admission for cholangitis costs more than a planned day case. Every item belongs on the quote.
Packages that hospitals in Istanbul and medical travel agencies publish for ERCP cover the consultation, blood tests, anesthesia, the procedure with standard devices, one night in a private room, transfers and an interpreter. They leave out flights, the hotel, metal stents, a second session, the treatment of a complication and any new condition found along the way. Read that second list closely. When a quote arrives, check four things. They are the devices it assumes, the nights it allows, whether a repeat ERCP is priced, and what a complication would cost.
No figure means much until a specialist has read the scans, and that reading costs nothing.
The trip
A coordinator from the international patients office takes the case from the first message and stays with it through discharge. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and brings in interpreters for other languages, which matters most at the consent conversation, where the doctor explains the risks above and you should understand every sentence. An appointment confirmation and an invitation letter naming the hospital and the treating doctor go out ten days before travel for the visa application. The same office books the hotel. It also runs the airport transfers and the rides to the hospital.
Bring someone with you. Nobody should be alone on the first night after sedation. If you are admitted, the room has a bed for your companion. The kitchen prepares halal, vegetarian and diabetic meals, a prayer room is on site, and a request for a female doctor is met whenever the rota allows.
After you fly home
If a stent was placed
A plastic stent is temporary. It clogs with time and has to be removed or changed after three months, and a forgotten stent causes the very infection it was placed to prevent. Before you leave, settle who will take it out. Removal takes place either in Istanbul on a return visit or with an endoscopist at home, and the discharge file contains the stent type, size and date, the X-ray images, and a letter in English for that doctor.
The gallbladder question
Removing stones from the duct does not remove their source. Keyhole removal of the gallbladder within two weeks of ERCP is the recommendation of the European stone guideline, because waiting raises the chance of another stone, another attack of pancreatitis or an infection. So decide before you travel where that operation will happen. Both fit into one trip. Or the surgery waits for the week you return home.
Questions about the report, the stent or the pathology result go to the coordinator. The WhatsApp number stays the same once you are back home.
ERCP - Endoscopic Retrograde Cholangiopancreatography FAQ
Is ERCP painful?
How long does an ERCP take?
How long should I stay in Istanbul after ERCP, and when can I fly?
Who removes the stent after I go home?
Do I still need my gallbladder removed after ERCP?
Can a relative stay with me, and will staff speak my language?
References
- Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, Pilotto A, Forlano R. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol. 2007;102(8):1781-8.
- Elmunzer BJ, Scheiman JM, Lehman GA, et al. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med. 2012;366(15):1414-22.
- Dumonceau JM, Kapral C, Aabakken L, et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020;52(2):127-149.
- Manes G, Paspatis G, Aabakken L, et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2019;51(5):472-491.
- Buxbaum JL, Abbas Fehmi SM, Sultan S, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc. 2019;89(6):1075-1105.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Assistant Professor Koray KOÇHAN, Gastroenterology.
Medically reviewed by
Assistant Professor Koray KOÇHAN
Gastroenterology
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