ERCP

ERCP (Endoscopic Retrograde Cholangiopancreatography) is a procedure that uses a flexible camera tube and X-rays to examine and treat problems in the bile ducts (the tubes that carry digestive fluid from the liver and gallbladder) and the pancreatic duct (the tube that carries enzymes from the pancreas into the small intestine).

During ERCP, a long flexible tube called an endoscope is passed through your mouth, down the throat, through the stomach, and into the first part of the small intestine. From there, the doctor guides a tiny instrument into the duct openings and injects a special dye so the ducts show up clearly on X-ray images. If a problem is found — such as a gallstone blocking a duct — the doctor can often treat it during the same session, without a separate operation.

ERCP is used when a doctor suspects a blockage, injury, or disease affecting the bile ducts or pancreatic duct, and wants both to confirm the diagnosis and, where possible, to clear the problem in one step. It is recommended only when other imaging tests — such as an ultrasound or MRI — have already suggested an abnormality that needs closer investigation or treatment.

• Gallstones (hard deposits) that have moved from the gallbladder into the bile ducts and are causing a blockage
• Jaundice (yellowing of the skin and eyes) caused by a blocked bile duct
• Bile duct strictures (abnormal narrowings) due to scarring, previous surgery, or inflammation
• Primary sclerosing cholangitis (a long-term condition that scars and narrows the bile ducts)
• Bile leaks after gallbladder surgery or an injury
• Tumours or growths pressing on or blocking the bile ducts or pancreatic duct
• Chronic pancreatitis (long-term inflammation of the pancreas) complicated by duct blockage or stones
• Pancreatic pseudocysts (fluid-filled sacs near the pancreas) that need drainage
• Collection of a tissue sample (biopsy) from inside a duct when cancer is suspected

ERCP is not suitable for everyone. Your doctor will weigh up the risks and benefits for your individual situation. It is generally avoided, or performed with extra caution, in the following cases:

• Patients who cannot safely receive sedation or general anaesthesia
• Severe blood-clotting disorders that cannot be corrected before the procedure
• Recent heart attack or other unstable heart conditions
• Pregnancy (especially the first trimester), unless the benefit clearly outweighs the risk of X-ray exposure
• Known allergy to the contrast dye used — though the team can often take steps to manage this
• Anatomical changes from previous surgery (such as a gastric bypass) that make it impossible to reach the duct openings

ERCP is a relatively safe procedure when performed by an experienced specialist, but like any invasive procedure it carries recognised risks that your doctor will discuss with you beforehand.

• Pancreatitis (inflammation of the pancreas) — the most common complication, causing abdominal pain that can range from mild to severe and may require a hospital stay
• Bleeding — most often at the site where the duct opening is widened; usually minor and stops on its own, but occasionally requires further treatment
• Infection of the bile ducts (cholangitis) — the doctor usually prescribes antibiotics to reduce this risk
• Perforation (a small tear in the lining of the digestive tract) — rare, but may need surgery to repair
• Reaction to the sedation or anaesthetic — including nausea, low blood pressure, or, very rarely, breathing difficulties
• Allergic reaction to the contrast dye used to highlight the ducts on X-ray
• Incomplete procedure — in some patients the duct opening cannot be reached, and an alternative approach is needed
• Radiation exposure from X-rays — kept as low as possible, but relevant for pregnant patients

Good preparation makes the procedure safer and more effective. Your medical team will give you detailed instructions tailored to your situation, but the following describes what is typically involved.

Fasting and medications: You will usually be asked to have nothing to eat or drink for at least six hours before the procedure, so that your stomach is empty and the doctor has a clear view. If you take blood thinners (medicines that prevent clots), the team will advise whether to pause them for a few days beforehand — stopping or adjusting these medicines is always done under medical guidance, never on your own. If you are diabetic and take insulin or other diabetes medicines, the team will give specific instructions about timing. Smoking and alcohol are best avoided for at least 24 hours before the procedure, as both can affect sedation and the body's healing response.

Pre-procedure tests: Before ERCP, your doctor will usually arrange some or all of the following tests to plan the procedure safely:

• Blood tests — to check liver function, kidney function, blood-clotting ability, and general health markers
• Ultrasound (USG) or MRI of the abdomen — to see the ducts and identify the location of any blockage or stone
• Chest X-ray and heart tracing (EKG) — sometimes requested, particularly for older patients or those with heart or lung conditions
• Allergy review — you will be asked about any known allergies, especially to contrast dye or iodine

What happens during the procedure: The steps below describe a typical ERCP. The exact sequence and duration vary depending on what the doctor finds and what treatment is needed.

• 1. You change into a hospital gown and a small tube (cannula) is placed in a vein in your arm to deliver sedation and any medicines needed during the procedure.
• 2. You are given sedation — usually a moderate level that keeps you drowsy and comfortable but not fully unconscious — or, in some hospitals, a light general anaesthetic. Your breathing, heart rate, and blood pressure are monitored throughout.
• 3. A local anaesthetic spray is applied to the back of your throat to reduce the gag reflex.
• 4. You are positioned lying on your left side or on your stomach on the procedure table.
• 5. The doctor gently passes the endoscope (a thin, flexible tube with a camera and light at the tip) through your mouth and guides it down to the duodenum (the first part of the small intestine), where the bile duct and pancreatic duct open.
• 6. A tiny tube called a catheter is passed through the endoscope into the duct opening. Contrast dye is injected to make the ducts visible on the X-ray screen.
• 7. X-ray images (fluoroscopy — a live moving X-ray) are taken to show the ducts clearly.
• 8. If a problem is identified, the doctor carries out the appropriate treatment during the same session. This may include: widening a narrowed opening (sphincterotomy), removing gallstones with a small basket or balloon, placing a stent (a tiny tube to hold a duct open), or collecting a tissue sample.
• 9. The endoscope is carefully withdrawn. The procedure typically takes between 30 minutes and one hour, though it may take longer if complex treatment is needed.

After ERCP, you will be monitored in a recovery area until the sedation has worn off and your vital signs are stable. Most patients are able to go home the same day, but an overnight stay is sometimes needed — particularly if a treatment was carried out, if you experience any discomfort, or if your doctor wants to observe you for early signs of complications such as pancreatitis. Because sedation affects your judgement and reactions for the rest of the day, you will need a responsible adult to take you home and stay with you for at least that evening.

• Eating and drinking: You will usually be allowed to sip water once you can swallow comfortably, then progress to light food over the following hours. The team will confirm when it is safe to eat normally.
• Throat discomfort: A mildly sore throat or bloating (from air used during the procedure) is common and usually settles within a day or two.
• Activity: Rest for the remainder of the day of the procedure. Most people can return to light daily activities within one to two days, but your doctor will advise based on what was done.
• Driving and operating machinery: Avoid driving or using heavy machinery for at least 24 hours after sedation.
• Medicines: If a stent was placed or a sphincterotomy (widening of the duct opening) was performed, the team may prescribe antibiotics or adjust your blood-thinning medicines — always follow the team's specific instructions.
• Warning signs to report promptly: Severe abdominal pain, fever, chills, vomiting, yellowing of the skin or eyes, or dark urine appearing after you leave hospital should be reported to your medical team without delay.
• Follow-up appointments: Your doctor will arrange a follow-up visit to review the results of any samples taken, check how the treated area is healing, and decide whether further procedures — such as stent removal or replacement — are needed.
• Lifestyle: If gallstones or liver disease were the underlying reason for the procedure, the team will usually discuss longer-term dietary and lifestyle advice as part of your ongoing care.