At a glance
ERCP (Endoscopic Retrograde Cholangiopancreatography) is a procedure that uses a flexible camera and X-ray to examine, and when needed, treat problems inside the bile ducts and pancreatic duct, the narrow tubes that carry digestive juices from the liver and pancreas into the small intestine. A long, thin tube called an endoscope is passed through the mouth, down the throat, through the stomach, and into the first part of the small intestine, where the bile and pancreatic ducts open.
Once the endoscope is in position, a small tube is threaded through it and into the duct openings. A dye that shows up on X-ray is then injected so the doctor can see blockages, narrowings, or stones. If a problem is found, the doctor can often treat it in the same session, for example by removing a stone, widening a narrowed duct, or placing a small tube called a stent to keep a duct open.
Medical Condition
ERCP is used when a doctor suspects a problem in the bile ducts, the gallbladder drainage system, or the pancreatic duct that cannot be fully assessed by ultrasound or other scans alone. It is chosen when there is both a need to see inside the ducts and a likely need to treat what is found.
- Gallstones that have moved from the gallbladder into the bile duct, causing pain, jaundice (yellowing of the skin and eyes), or infection
- Cholangitis (a bacterial infection of the bile duct) that needs urgent drainage
- Narrowing or stricture of the bile duct caused by scarring, inflammation, or pressure from a nearby tumour
- Primary sclerosing cholangitis (PSC), a long-term condition that scars and narrows the bile ducts
- Blocked or damaged pancreatic duct causing pancreatitis (inflammation of the pancreas) or a fluid-filled pocket called a pseudocyst
- Suspected tumour or cancer in the bile duct or pancreas, to take a tissue sample (biopsy) or to relieve jaundice with a stent
- Leaking bile duct after gallbladder surgery or a liver transplant
ERCP is not the right choice in some situations. Doctors generally avoid it when a less invasive test such as MRCP (Magnetic Resonance Cholangiopancreatography, an MRI scan of the ducts) can answer the question without treatment, or when the patient has conditions that make the procedure unsafe.
- Patients who cannot safely receive sedation or anaesthesia
- Patients with a severely altered stomach or bowel anatomy, for example after certain types of gastric bypass surgery, which may make reaching the duct opening very difficult
- Patients with active, uncontrolled bleeding disorders where the risk of internal bleeding is too high
- Situations where the suspected problem is clearly upstream in the liver and can be reached more safely from outside the body through the skin (a procedure called PTCD)
Risks & Complications
ERCP carries a higher risk than most other endoscopic procedures because it enters the pancreatic and bile ducts directly. Most people come through without any serious problem, but every patient should understand the recognised complications before agreeing to the procedure.
- Pancreatitis (inflammation of the pancreas): the most common complication, causing abdominal pain that may require a hospital stay of several days; usually mild but occasionally severe
- Bleeding: may occur at the site where the duct opening is widened (a cut called a sphincterotomy); most cases stop on their own or are controlled during the procedure
- Infection (cholangitis): bacteria can enter the bile duct during the procedure; treated with antibiotics
- Perforation (a small tear): rarely, the endoscope or instruments can make a small hole in the oesophagus, stomach, or small intestine, which may need surgery to repair
- Reaction to the sedative or contrast dye: allergic reactions are uncommon but possible, especially in patients with known allergies
- Stent blockage or migration: if a stent is placed, it can become blocked over time or shift from its original position, requiring a further procedure
- Missed or incomplete treatment: stones or strictures are sometimes too large or complex to remove fully in one session
Preparation & Procedure
Preparing well before ERCP reduces the chance of complications and helps the procedure go smoothly. The steps below cover what patients are usually asked to do in the days and hours before, as well as what happens on the day.
In the days before the procedure, the medical team will review all current medications. Blood thinners such as warfarin or clopidogrel are usually paused for several days beforehand because they raise the risk of bleeding, especially if a sphincterotomy is planned. Patients with diabetes will receive specific instructions about their glucose-lowering medication. The team will also ask about any allergies, particularly to contrast dye or seafood, since the dye used in ERCP contains iodine.
Patients are asked to stop eating solid food at least six hours before the procedure and to stop drinking even clear fluids usually two hours before. Smoking and alcohol are best avoided for at least 24 hours beforehand, as both can affect how the stomach empties and how the body handles sedation.
Standard pre-procedure tests often include blood tests to check clotting, kidney function, and liver enzymes, as well as an ultrasound or CT scan if not already done. The team may also take a blood pressure reading and an ECG (a heart tracing) on the day.
- 1. The patient changes into a hospital gown and an intravenous (IV) line is placed in the arm to deliver sedation and any medications needed during the procedure.
- 2. The patient lies on their left side or on their stomach on the procedure table.
- 3. A mouth guard is placed between the teeth to protect both the teeth and the endoscope.
- 4. Sedation is given through the IV line; most patients are deeply relaxed or lightly asleep during the procedure.
- 5. The doctor gently passes the endoscope through the mouth, down the oesophagus (food pipe), through the stomach, and into the duodenum (the first section of the small intestine).
- 6. The small opening where the bile and pancreatic ducts empty into the duodenum is located using the camera.
- 7. A thin plastic tube is passed through the endoscope into the duct opening, and contrast dye is injected.
- 8. X-ray images are taken to show the shape of the ducts and to find any stones, narrowings, or blockages.
- 9. If a problem is found, the doctor performs the needed treatment, which may include cutting the duct opening wider (sphincterotomy), removing stones with a small basket or balloon, placing a stent, or taking a tissue sample.
- 10. The endoscope is gently withdrawn, and the patient is moved to a recovery area.
Aftercare
After ERCP, patients are observed in a recovery area until the sedation wears off, which usually takes between 30 minutes and two hours. Most patients who had a straightforward diagnostic procedure or a simple stone removal can go home the same day, but those who had more complex treatment or who develop any symptoms are kept in hospital for observation, sometimes for several days.
- Eating and drinking: the throat may feel sore and the stomach bloated from the air used during the procedure; clear fluids are usually offered first, then a light diet once the patient feels ready, often a few hours after waking
- Driving: patients must not drive for at least 24 hours after sedation, and a responsible adult should accompany them home
- Pain: mild abdominal discomfort and bloating are common for a day or two; persistent or worsening abdominal pain, fever, vomiting, or yellowing skin after going home are signs that need prompt medical attention
- Stent care: if a stent was placed, the doctor will schedule a follow-up appointment to check it and, for plastic stents, to replace it before it blocks, usually within a few months
- Blood thinners and other medications: the medical team will advise when it is safe to restart any medications that were paused before the procedure
- Activity: heavy lifting and strenuous exercise are usually avoided for a few days, particularly if a sphincterotomy was performed
- Follow-up imaging or tests: a repeat blood test or scan is often arranged within a week or two to confirm that the bile ducts have cleared and that the liver and pancreas are recovering normally
- Long-term monitoring: patients with conditions such as PSC or pancreatic duct disease will need regular follow-up with their gastroenterologist, as ERCP may need to be repeated over time
Cost & What Determines It
The cost of ERCP varies widely from one patient to the next because the procedure can range from a quick diagnostic look to a lengthy treatment session involving multiple instruments and devices. Where the procedure is done, how complex the underlying problem is, and what equipment is needed all pull the price in different directions.
- Complexity of the case: a simple diagnostic ERCP costs considerably less than one that involves stone removal, sphincterotomy, stent placement, and biopsy combined in a single session
- Number of stones or strictures treated: more stones or multiple narrowings requiring treatment in one sitting increase the operating time and the materials used
- Type and number of stents: metal stents (self-expanding metal stents, or SEMS) cost more than plastic stents and are usually billed as a separate device charge
- Hospital class and country: prices differ significantly between public hospitals, private hospitals, and internationally accredited facilities, and between countries in Southeast Asia, East Asia, Europe, and beyond
- Anaesthesia or sedation type: deep sedation or general anaesthesia adds an anaesthesiologist's fee and extended recovery room time
- Pre-procedure workup: blood tests, ultrasound, MRCP, or CT scans done as part of the admission are often billed separately from the procedure itself
- Length of hospital stay: patients who develop pancreatitis or another complication may need several nights of inpatient care, with each day adding ward, nursing, and medication costs
- Specialist fees: the gastroenterologist and, if involved, a radiologist or surgeon may each bill separately depending on the hospital's billing model
- Repeat procedures: if a stent needs changing or stones were not fully cleared in the first session, a second ERCP adds its own full cost
Hospital packages for ERCP typically cover the endoscopy room fee, basic sedation, the endoscopist's fee, standard consumables such as guide wires and catheters, and one night of inpatient care if required. Items that are commonly billed on top include stents (especially metal ones), specialised stone-retrieval baskets or balloons, contrast dye, additional imaging taken during or after the procedure, pathology fees if a biopsy is sent, and any extended hospital stay.
BPJS Kesehatan and most Indonesian private health insurance plans do not reimburse treatment received abroad, so patients travelling overseas for ERCP almost always pay out of pocket or through an international private health insurance policy that explicitly covers treatment outside Indonesia. Before travelling, ask the hospital for a written cost estimate that separates the base procedure fee from potential add-ons such as stents or extra nights of care. Getting this in writing before departure is the most reliable way to avoid unexpected bills after treatment.
Frequently Asked Questions
Does ERCP hurt?
Most people feel little to no pain during the procedure because a sedative is given beforehand to keep you relaxed and drowsy. A thin, flexible tube called an endoscope is passed through your mouth into the small intestine, so you may feel some pressure or mild discomfort in your throat or abdomen, but it is usually manageable. Afterwards, a bloated or gassy feeling is common and typically settles within a few hours.
How long does ERCP take?
The procedure itself usually takes between 30 minutes and one hour, though it can run longer if the doctor needs to remove a stone, place a stent (a small tube that keeps a duct open), or treat a blockage. You will also need time before the procedure for preparation and monitoring, and at least a couple of hours of recovery in hospital afterwards before you are cleared to go home.
How many sessions of ERCP will I need?
Most patients need only one session, because ERCP combines diagnosis and treatment in a single procedure. If a complex problem is found, such as multiple stones or a narrowing that needs staged treatment, your doctor may recommend a follow-up session. The number depends on what is found and how your body responds.
How much does ERCP cost?
The cost of ERCP varies depending on whether the procedure is diagnostic only or also includes a treatment such as stone removal or stent placement, the class of hospital you choose, the length of your stay for observation, and any specialist fees. Requesting a written cost estimate directly from the hospital is the most reliable way to get a figure that reflects your specific situation.
This page is general information, not a substitute for medical advice. Every case is different. Your doctor decides what is right for you.
