Endoscopic Retrograde Cholangiopancreatography (ERCP)

Home » Endoscopic Retrograde Cholangiopancreatography (ERCP)

what is endoscopic retrograde cholangiopancreatography. — An endoscopic retrograde cholangiopancreatography is a diagnostic, and therapeutic measure that enables doctors to have a better visualisation of the bile and pancreatic ducts, and gallbladder.

What is an Endoscopic Retrograde Cholangiopancreatography (ERCP)?

Endoscopic Retrograde Cholangiopancreatography (ERCP) is a specialised diagnostic, and therapeutic procedure that allows doctors to examine the bile ducts, pancreatic duct, and gallbladder. These ducts are part of your digestive system, and are essential for transporting bile, and enzymes that help digest fats.

ERCP is used not only to diagnose problems such as blockages, stones, and tumours, but also to provide immediate treatment when necessary, thereby often avoiding the need for open surgery.

This dual-purpose procedure is especially useful when imaging tests such as ultrasound or magnetic resonance imaging (MRI) suggest abnormalities that need further evaluation or direct intervention.

How does ERCP work?

ERCP combines endoscopy (using a flexible camera tube) with fluoroscopy (real-time X-ray imaging) to examine, and treat issues in the bile and pancreatic ducts.

Here is a step-by-step overview of how the procedure is carried out:

STEPS	PROCESS
Sedation	You will be given a sedative or light general anaesthesia to keep you comfortable, and relaxed. You will not feel any pain or discomfort
Insertion of Endoscope	A flexible tube called a duodenoscope is gently passed through your mouth, down the oesophagus, through the stomach, and into the duodenum.
Accessing the Ducts	The surgeon locates the opening of the bile, and pancreatic ducts, known as the ampulla of Vater.
Contrast Dye Injection	A thin catheter is inserted through the endoscope into the bile duct, and special contrast dye is injected to enhance visibility.
X-ray Imaging	Real-time X-rays are taken to identify blockages, stones, structures or growths in the ducts.
Therapeutic Intervention	Depending on the findings, the surgeon may: Widening the opening to facilitate further treatment if the biliary condition (sphincterotomy)Insert a stent to relieve a blockageRemove bile duct stones (link to bile duct stones page)Take a tissue biopsyTreat strictures
Scope Removal	Once completed, the scope is gently removed, and you will be taken to an observation room until the anaesthesia wears off.

When is an ERCP procedure recommended?

The procedure may be recommended for patients experiencing the following symptoms:

Bile duct blockages or narrowing, for example, from stones or cancer.
Post-surgical complications involving the bile ducts or pancreatic fistula/leakage
Biopsy of suspected bile duct tumours.

What conditions can be diagnosed or treated with ERCP?

As ERCP can be used for both diagnostic, and therapeutic purposes, some of the conditions that can be diagnosed or treated include:

Bile duct stones (choledocholithiasis).
Bile duct strictures (narrowing).
Biopsy of bile duct lesions to exclude cancer
Biliary leaks.
Pancreatic duct stones.
Pancreatic or bile duct cancers, including Klatskin tumours.
Post-surgical complications.

What are the possible risks or complications of ERCP?

Although ERCP is generally safe, it does carry a small risk of complications. These risks are higher when therapeutic steps are often.

Some of the possible risks or complications include:

RISK / COMPLICATION	DESCRIPTION
Allergic Reaction	To the contrast dye or sedative, like any other medication.
Bleeding	Especially after sphincterotomy.
Infection	Infection in the bile or pancreatic ducts, especially if there is an obstruction. In such cases, antibiotics or drainage may be required.
Pancreatitis	Pancreatic inflammation (link to pancreatic inflammation page) often occurs in 5 – 10% of cases, and may require hospitalisation. Most cases are mild, but some can be severe.
Perforation	A rare, but serious complication where the wall of the duodenum or duct is torn. If perforation occurs, emergency surgery is needed.
Stent-related Issues	Stents may become blocked or migrate, requiring follow-up or replacement.

What is the difference between ERCP and a conventional endoscopy?

Both ERCP, and endoscopy use a flexible tube with a camera to visualise parts of the digestive system. However, they serve different purposes, and access different anatomical areas.

FEATURE	STANDARD ENDOSCOPY	ERCP
Purpose	Examine the oesophagus, stomach, and duodenum.	Examine, and treat bile, and pancreatic ducts.
Imaging Technique	Direct visual inspection.	Combines endoscopy with fluoroscopy.
Therapeutic Capabilities	Limited to biopsy, and bleeding control.	Can remove stones, insert stents, and even take biopsies.
Contrast Dye Use	Not typically used.	Yes, for duct visualisation.
Conditions Treated	Ulcers, gastritis, reflux, and bleeding.	Bile duct stones, strictures, cancers, and leakage of bile duct and pancreas.

What should I expect after the procedure?

After an ERCP, you will be taken to a recovery area, and closely monitored as the sedative wears off. During this time, you may experience:

Abdominal bloating
Fatigue
Gas
Mild throat discomfort
Nausea

Aftercare Guidelines

Additionally, it is encouraged that you adhere to the following instructions:

Do not eat or drink until instructed by the doctor and nurses.
Avoid alcohol, driving or operating machinery for 24 hours.
Rest for the day, and resume light activities the following day unless advised otherwise.
In the event biopsies were taken or a therapeutic procedure was performed, you may need a short course of antibiotics, and follow-up imaging.

Aside from following the aftercare instructions, do remember to be mindful of these warning signs. These warning signs indicate urgent medical attention:

Bleeding from the mouth or in the stools
Fever or chills
Persistent vomiting
Severe abdominal pain
Worsening jaundice

How many ERCP sessions will I need?

ercp downtime. — An ERCP is a minimally invasive procedure with little to no downtime.

For many patients, a single ERCP session is sufficient to diagnose, and treat the underlying issue. However, multiple sessions may be required in certain situations:

A stent was placed, and needs periodic replacement (usually every 3 – 6 months).
Follow-up biopsies or surveillance is needed.
Multiple or large stones need to be removed gradually.
There is a recurring or chronic condition, such as bile duct stricture or tumour.

Rest assured, Dr Tan Siong San will assess your response to treatment, and advise on the need for future sessions. In some cases, ERCP may be combined with other treatments such as surgery or imaging-guided procedures for comprehensive care.

Summary

It goes without saying that an ERCP is a powerful tool for diagnosing, and treating conditions affecting the bile, and pancreatic ducts. If you are experiencing symptoms such as jaundice or abdominal discomfort, get in touch with our team to discuss whether ERCP is right for you.

Frequently Asked Questions (FAQs)

Is an endoscopic retrograde cholangiopancreatography painful?

Most patients do not feel pain during the procedure, as you will be sedated or lightly anaesthetised to ensure comfort throughout. You may experience mild discomfort such as a sore throat or abdominal bloating afterwards, but these typically resolve within a day. If therapeutic steps are taken, some mild cramping or fatigue may occur.

Is ERCP considered a surgery?

ERCP is an endoscopic procedure, not a traditional open surgery. It uses an endoscope, and X-ray technology to diagnose, and treat conditions affecting the bile ducts, and pancreas. Although it can involve therapeutic steps such as stone removal or stent placement, there are no external cuts or incisions.

How should I prepare for the procedure?

To ensure a safe and effective ERCP, follow these preparation steps:

Do not eat or drink for at least 6 – 8 hours before the procedure.
Inform our doctor about any medications, especially blood thinners or diabetes medications as you may need to pause or adjust them.
Tell your doctor if you have any allergies, especially to iodine, contrast dyes or anaesthetics.
Arrange for someone to accompany you, as you will not be able to drive or operate machinery for 24 hours after sedation.

How soon will I know my results?

In many cases, your doctor will discuss the initial findings immediately after the procedure, once you are awake and alert. If a therapeutic step was done, this will also be explained.
If biopsies or tissue samples were taken, the results typically take a few days. In these scenarios, our care team will schedule a follow-up appointment to review the results, and plan any further treatment if necessary.

What foods should I avoid after ERCP?

After ERCP, it is best to start with light, soft foods such as porridge, soup or toast. Avoid greasy, spicy or heavy meals for at least 24 – 48 hours. If a stent was placed or our doctor advises dietary restrictions, follow the personalised plan given to you at discharge.

Is ERCP safe for elderly patients?

Yes, ERCP is generally safe for elderly patients, particularly when performed by an experienced specialist. However, the risks may be slightly higher for individuals with underlying health conditions.

Dr. Tan Siong San

Adjunct Assistant Prof (Duke-NUS)
MBBS (NUS)
MRCS (Edinburgh)
FRCS (Edinburgh)
M.Med (Singapore)
FAMS

Committed to Giving My Best for Every Patient.

This article has been medically reviewed by Dr. Tan Siong San

Dr Tan is a Senior Consultant Surgeon with over 25 years of clinical experience in the field of Hepato-Pancreato-Biliary (HPB) surgery treating conditions affecting gallbladder, liver and pancreas.