What is ERCP? How is it Performed?

ERCP (Endoscopic Retrograde Cholangiopancreatography)

ERCP is an endoscopic procedure that combines upper gastrointestinal endoscopy and X-ray imaging. It is used primarily for the visualization, examination, and treatment of diseases of the bile ducts and pancreatic duct.

Who performs the ERCP procedure?

ERCP should be performed by endoscopists who have received formal specialized training and have specific experience in this procedure.

How is ERCP performed?

In our Ankara clinic, ERCP is performed under sedation (sedoanalgesia) after at least 8 hours of fasting and 4 hours without drinking. The procedure typically takes about 30–45 minutes. Unlike standard endoscopy, ERCP is performed using a side-viewing duodenoscope.

The endoscope is advanced into the second part of the duodenum (the small intestine) where the ampulla (papilla) — the opening where the bile and pancreatic ducts empty — is located. Through this ampulla, thin catheters specifically designed for the procedure are inserted into the bile duct or pancreatic duct, guided by a special wire also designed for ERCP.

Depending on the patient’s condition, once the desired duct is accessed, a contrast agent is injected and X-ray images are taken to identify the problem. Based on the findings, the sphincter of the ampulla is usually cut using a technique called sphincterotomy, which is done with a special catheter that applies electrocautery.

Where is ERCP used?

ERCP is a specialized procedure used to address a wide range of issues related to the bile ducts and pancreas. It must be performed by experienced endoscopists. The most common indication is the treatment of bile duct obstructions. These obstructions are most often caused by stones that have migrated from the gallbladder into the ducts or have formed spontaneously within the bile ducts. Through the previously cut sphincter, specially designed tools called balloons or baskets are used to extract the stones and release them into the intestines.

In recent years, techniques such as laser fragmentation and pressure-based stone extraction have become increasingly common. In cases where the stones are too large or adhere to the duct wall, they may not be removable in a single session. In such instances, a stent may be placed alongside the stone to allow bile to flow, and removal may be postponed to another session.

Other causes of bile duct obstruction include tumors originating in the bile duct, pancreatic head tumors, external compression of the bile duct, or injury to the bile ducts during gallbladder surgery. In such cases, plastic or metallic stents are used to relieve the obstruction. In some situations involving bile duct strictures due to injury, balloon dilation may be sufficient. ERCP is a procedure in which decisions about what interventions to perform are often made in real time based on imaging and findings during the procedure.

Bile duct leaks can also occur after gallbladder or liver surgery. ERCP is used to identify the site of the leak and treat it by placing a stent or catheter into the bile duct.

ERCP may also be necessary for certain pancreatic disorders. In patients with chronic pancreatitis, stones can form within the dilated pancreatic duct and are a common source of pain.

As with bile duct stones, the pancreatic duct can be accessed using similar techniques to remove stones and place stents to relieve obstructions when needed. Additionally, damage to the pancreatic duct (loss of ductal integrity) may result in leaks, which can be treated with the placement of stents or drainage catheters to promote healing and resolve the leak.

What types of stents are used in ERCP?

When bile duct stones cannot be removed, in patients with cholangitis (bile duct infection) who are critically ill and require a quick resolution, or in the treatment of bile duct leaks, temporary plastic stents are typically used. For bile duct strictures, especially after dilation, single or multiple plastic stents or removable covered metallic stents are preferred. In cases of obstruction due to tumors, covered or uncovered metallic stents are used to maintain long-term bile flow.

What are the risks of ERCP?

ERCP is an interventional endoscopic procedure that carries its own specific complications (adverse events),as with all invasive procedures. Even in experienced endoscopists, complications such as pancreatitis, bleeding, perforation, and cholangitis can occur at a rate of 1-5%.

Patients without complications can usually be discharged after 2-3 hours of observation following the procedure. In cases where complications develop, treatment and hospitalization are required depending on the type and severity of the complication. In some severe cases (such as severe pancreatitis or perforation),the hospital stay may be prolonged, and surgical intervention may be necessary for some patients.