ERCP (Endoscopic Retrograde Cholangiopancreatography) is an endoscopic procedure used to treat problems in the bile ducts and pancreas.

Think of it as:

An endoscopic treatment procedure, not just a diagnostic test.

It is mainly used to relieve obstruction or infection, not simply to “look”.

This guide focuses on when to refer, when it’s urgent, and what juniors need to do on the ward.

✅ What is ERCP? (simple explanation)

A scope is passed to the duodenum → bile duct is cannulated → contrast injected → interventions performed.

It allows:

Stone removal
Stent insertion
Sphincterotomy
Drainage

So practically:

👉 ERCP = unblock the bile duct

✅ First principle (very important)

Before requesting ERCP, always ask:

Does this patient need a therapeutic intervention?

Because:

ERCP has risks
It’s not first-line imaging

If you only want a diagnosis → do MRCP or CT instead.

🚨 URGENT ERCP indications (same day / within 24–48h)

These are the classic emergencies.

Do not delay.

🔴 Acute cholangitis (most important)

Charcot’s triad:

Fever
Jaundice
RUQ pain

Often:

Septic
Hypotensive
Raised bilirubin/ALP

Because:

Infected, obstructed bile duct → life-threatening

Needs:

IV antibiotics
Fluids
URGENT ERCP for drainage

Antibiotics alone are not enough.

This is the most important ERCP indication you will see on call.

🔴 Obstructive jaundice with sepsis or deterioration

Rising bilirubin
Clinical worsening

Needs urgent decompression.

🔴 Impacted CBD stone causing ongoing obstruction

If:

Persistent jaundice
Worsening LFTs
Pain

Needs early intervention.

⚠️ Early / planned ERCP (during admission or urgent outpatient)

Not crashing, but still needs intervention.

🟡 Confirmed CBD stone (choledocholithiasis)

MRCP or ultrasound shows:

CBD stone
Dilated duct

Needs:

ERCP for removal

Common pathway:
MRCP → ERCP → cholecystectomy

🟡 Malignant biliary obstruction

Pancreatic cancer
Cholangiocarcinoma
Biliary stricture

Needs:

Stent placement
Symptom relief

Often palliative.

🟡 Post-op bile leak

ERCP helps:

Stent
Reduce leak

🟡 Recurrent pancreatitis from biliary cause

Therapeutic sphincterotomy may be needed.

❌ When ERCP is NOT indicated (common mistakes)

Very important for juniors.

❌ Just abnormal LFTs

Do ultrasound/MRCP first

❌ Suspected stones without imaging

Confirm first

❌ Pancreatitis without obstruction

Most pancreatitis does NOT need ERCP

Only if:

cholangitis
persistent obstruction

❌ Diagnostic purposes only

Use MRCP/EUS instead

Remember:
ERCP is invasive and risky

✅ ERCP vs MRCP (quick comparison)

MRCP

Imaging only
Non-invasive
First-line investigation

ERCP

Therapeutic
Invasive
Used to fix problems

Rule:
👉 Diagnose with MRCP, treat with ERCP

✅ What juniors should do before ERCP

Practical ward steps:

Bloods (FBC, U&E, LFTs, coag, group & save)
IV access
Antibiotics if cholangitis
NBM
Check anticoagulation
Consent usually by endoscopy team

Don’t just “refer and forget”.

✅ After ERCP – what to monitor

Very important.

Common complications:

🔴 Post-ERCP pancreatitis (most common)

Abdominal pain
Vomiting
Raised amylase

Watch for new pain post-procedure.

🔴 Bleeding

Especially after sphincterotomy

🔴 Perforation

Severe pain, sepsis

🔴 Sepsis

If patient deteriorates after ERCP:
👉 escalate early

✅ Common real-life scenarios

Scenario 1

Fever + jaundice + hypotension
→ cholangitis → urgent ERCP

Scenario 2

MRCP shows CBD stone, stable
→ planned ERCP

Scenario 3

Pancreatitis but improving, no obstruction
→ no ERCP

Scenario 4

Painless jaundice + mass
→ likely malignant obstruction → stent via ERCP

❌ Common junior mistakes

Referring for ERCP without imaging
Delaying cholangitis referral
Using ERCP as “diagnostic test”
Forgetting antibiotics
Not monitoring for pancreatitis after

Remember:
ERCP solves obstruction, not uncertainty.

✅ Simple ward rule

When thinking about ERCP:

Ask:

Is the duct obstructed?
Is the patient septic or jaundiced?
Do they need drainage/stent/stone removal?

If yes → ERCP
If no → imaging first

✅ Take-home concept

ERCP is for treatment, not diagnosis.
Urgent for cholangitis.
Most other cases → MRCP first, then ERCP if needed.