ERCP Explained: Procedure for Stone Removal and Bile Duct Problems

What Is Endoscopic Retrograde Cholangiopancreatography and When Is It Used

Endoscopic retrograde cholangiopancreatography, or ERCP, is a specialist procedure that combines a flexible camera with X-ray to access and treat blockages in your bile and pancreatic ducts. A doctor advances a side-viewing instrument called a duodenoscope through your mouth, past your stomach, into the first section of your small intestine. From there, the doctor enters the duct opening and injects contrast dye to identify stones, strictures, or leaks under live X-ray. ERCP was once a diagnostic test, but non-invasive scans like MRCP now handle diagnosis alone. Today, doctors recommend ERCP only when you need active treatment, stone removal, stent placement, or stricture repair.

ERCP Indications: Which Conditions Require This Procedure

Your doctor recommends ERCP only when imaging confirms a duct problem that needs active treatment.

Common Bile Duct Stones (Choledocholithiasis)

Common bile duct stones are the single most frequent ERCP indication in India. At Government Medical College Kottayam, Kerala, CBD stones were the primary indication across 216 ERCP cases, with a 93% successful cannulation rate. Globally, around 10-15% of patients with gallstone disease also develop stones in the common bile duct that require removal. A 2025 study from Sher-i-Kashmir Institute of Medical Sciences (SKIMS), North India, reported a CBD stone clearance rate of 95.3% across 682 ERCP procedures; all non-difficult stones were cleared in a single session with 100% success [1].

Obstructive Jaundice from Biliary Strictures

A narrowed bile duct from scarring, chronic inflammation, or a tumour blocks bile flow and causes jaundice. ERCP places a plastic or metal stent across the stricture to restore drainage immediately. For patients with pancreatic or gallbladder cancer, stent placement relieves both jaundice and infection without open surgery.

Acute Cholangitis

Cholangitis is a bacterial infection of the bile duct that demands urgent drainage. Without timely ERCP, the risk of sepsis and multi-organ failure rises sharply. ERCP clears the obstruction and places a drainage stent to allow infected bile to exit.

Post-Surgery Bile Leaks

Bile leaks after cholecystectomy collect inside the abdomen and cause pain and infection. ERCP places a stent inside the bile duct to remove the pressure gradient at the leak site. The stent stays in place for four to six weeks, then a doctor removes it by upper endoscopy.

Gallstone Pancreatitis

When a gallstone lodges at the shared opening of the bile and pancreatic ducts, it triggers acute pancreatitis. Around 20% of patients with symptomatic gallstone disease have a stone lodge in the bile duct and need endoscopic removal. ERCP extracts the stone early and prevents repeat episodes of inflammation [2].

Pancreatic Duct Obstruction

Chronic pancreatitis or pancreatic head tumours block the pancreatic duct and cause persistent pain and enzyme build-up. ERCP places a pancreatic duct stent or removes duct stones to restore flow. This is the only non-surgical route to pancreatic duct decompression in eligible patients.

How the ERCP Procedure Works: Step-by-Step Process

An ERCP takes between 30 and 60 minutes, and a specialist gastroenterologist performs it under sedation; you feel no pain during the procedure.

Step 1: Pre-Procedure Preparation

Your doctor asks you to fast for six to eight hours before the procedure. Blood tests, a recent ultrasound or MRCP, and a review of your current medications, especially blood thinners, are part of the standard pre-procedure assessment.

Step 2: Sedation and Patient Positioning

You receive intravenous sedation before the procedure starts. The nursing team positions you on your left side or stomach on the procedure table. The sedation keeps you comfortable and relaxed throughout the entire procedure.

Step 3: Duodenoscope Insertion

The doctor passes a thin, flexible side-viewing camera called a duodenoscope through your mouth, down your oesophagus, through your stomach, and into the first section of your small intestine, the duodenum.

Step 4: Cannulation of the Bile Duct

The doctor identifies the ampulla of Vater, the small opening where your bile and pancreatic ducts drain into the duodenum. A thin catheter passes through the duodenoscope and enters this opening under fluoroscopic X-ray guidance.

Step 5: Contrast Dye Injection and Cholangiography

The doctor injects contrast dye into the duct through the catheter. Live X-ray imaging, called cholangiography, then shows the full shape of your bile or pancreatic duct and clearly reveals any stones, strictures, or blockages.

Step 6: Sphincterotomy

If your duct opening is too narrow for stone removal or stent placement, the doctor uses a sphincterotome, a wire-tipped catheter, to make a small controlled cut at the ampulla. This widens access to the duct for treatment.

Step 7: Stone Removal

The doctor removes stones with a balloon catheter or a wire basket called a Dormia basket. For large stones above 15mm, mechanical lithotripsy breaks the stone into smaller fragments before extraction. Stones pass harmlessly into the duodenum after removal.

Step 8: Stent Placement (When Required)

If the duct has a stricture, tumour, or bile leak, the doctor places a plastic or metal stent across the narrowed area to restore drainage. Plastic stents are for temporary use; self-expanding metal stents are for long-term or malignant blockages.

Step 9: Post-Procedure Recovery

After the procedure, you rest in a monitored recovery area for two to four hours. Most patients stay one night for observation. You start on clear liquids and progress to soft food within 24 hours, with a follow-up scheduled within four to six weeks.

ERCP Risks, Complications, and What to Expect After the Procedure

Endoscopic retrograde cholangiopancreatography carries the highest complication risk of any routine endoscopic procedure; a 2025 systematic review across 380 studies confirmed an overall adverse event rate of 9.4% to 15.9% [3].

• Post-ERCP pancreatitis is the most common complication, with a 4.6% incidence globally and 6.6% in Indian studies. Rectal indomethacin before or after the procedure cuts this risk by approximately 50%.
• Post-sphincterotomy bleeding occurs in 1.5% of cases. Patients on blood thinners or with low platelet counts face the highest risk before the procedure.
• Cholangitis affects 2.5% of patients, mainly from incomplete bile duct drainage. Fever, chills, and returning jaundice within 72 hours need immediate hospital review.
• Perforation occurs in 0.5% of cases and carries a 0.2% procedure-related mortality rate. Most periampullary perforations receive management via a covered stent without open surgery.
• Most patients recover within 24-48 hours on clear liquids, progressing to soft food the next day. Severe abdominal pain, black stools, or fever after discharge needs urgent assessment.

MRCP vs ERCP: Which One Does Your Doctor Recommend

MRCP is a safe, non-invasive imaging test that diagnoses bile and pancreatic duct problems, while ERCP is an invasive therapeutic procedure that treats blockages; your doctor chooses based on whether you need diagnosis alone or active treatment.

Here’s a quick comparison table between MRCP and ERCP:

ERCP at Eskag Sanjeevani: Expertise You Can Trust

Eskag Sanjeevani’s gastroenterology team, Dr Argha Chatterjee, Dr Deepak Kumar, Dr Amitava Dutta, and Dr Sahiz Aziz, collectively perform 6-10 ERCP procedures monthly, reflecting consistent procedural volume that directly correlates with higher cannulation success rates, lower complication rates, and better patient outcomes than low-volume centres.