Clinical urgency
Fever, rigors, jaundice, hypotension or altered mental state are assessed for cholangitis and urgent drainage.
ERCPDOKTORU.COM · BILIARY & PANCREATOBILIARY ENDOSCOPY
From jaundice to the right ERCP decision.
Modern ERCP is used mainly to treat a confirmed or highly likely bile-duct or pancreatic-duct problem, rather than simply to diagnose one. The problem, need for MRCP/EUS, therapeutic goal and follow-up should be clear before the procedure.
ESGEASGEACGUEGEvidence-led pancreatobiliary decision architecture
FOCUS PROCEDUREERCPEndoscopic Retrograde Cholangiopancreatography
01
WHERE ARE YOU STARTING?
Six entry points built around the patient’s real question.
02A bile-duct stone was found
Understand when ultrasound, MRCP/EUS and therapeutic ERCP are used.
→ 03I have a biliary strictureReview benign/malignant assessment, tissue diagnosis, drainage and stenting together.
→ 04Fever + jaundice / possible cholangitisCholangitis may require urgent assessment; drainage timing depends on clinical severity.
→ 05ERCP has been recommendedReview the therapeutic goal, sphincterotomy, stone removal, sampling/stenting and risk reduction.
→ 06I want a second opinionLearn how MRCP, CT, EUS, labs and prior ERCP records can be reviewed.
→02
AN ERCP DECISION IS MORE THAN “THERE IS SOMETHING IN THE DUCT”
Symptoms → labs/imaging → MRCP/EUS → therapeutic target → ERCP → follow-up
Initial assessment
Liver tests and ultrasound establish the first framework for obstruction and likely cause.
MRCP or EUS
When stone/stricture probability is uncertain, confirmatory imaging can help avoid unnecessary ERCP.
Therapeutic target
Stone extraction, biliary drainage, stricture sampling/stenting or selected pancreatic-duct therapy is explicitly defined.
ERCP + risk reduction
Cannulation, sphincterotomy, extraction or stenting is planned alongside strategies to reduce pancreatitis, bleeding, infection and perforation.
Stent / result follow-up
Temporary stent removal/exchange, pathology/cytology and clinical-laboratory response are linked to a written plan.
03
WHAT DOES ERCP TREAT?
More than imaging: ERCP focuses on treating a ductal problem.
ERCPEndoscopic Retrograde Cholangiopancreatography
A side-viewing endoscope reaches the duodenum and accesses the bile or pancreatic duct for therapy such as sphincterotomy, stone extraction, sampling, dilation or stenting when appropriate.
- 01Reach the papillaThe duct opening is visualised with a side-viewing duodenoscope.
- 02Guidewire cannulationControlled access to the bile/pancreatic duct is obtained.
- 03Targeted therapyStone extraction, drainage, stricture therapy, sampling or stenting may be performed.
- 04Follow-up planAdverse-event observation and any stent/pathology schedule are documented.
Important distinction
MRCP and EUS can diagnose many ductal problems. The modern role of ERCP is mainly therapeutic, so the question “What are we planning to treat during ERCP?” should be clear before the procedure.
04
ERCP, MRCP OR EUS?
They are not interchangeable; they answer different clinical questions.
| Method | Main role | When it stands out |
|---|---|---|
| MRCP | Non-invasive MRI imaging | Mapping bile/pancreatic ducts non-invasively and clarifying suspected stones or strictures. |
| EUS | High-resolution imaging + tissue when needed | Can be important for small duct stones, pancreatic masses or defining the cause of a stricture. |
| ERCP | Therapeutic duct intervention | When a stone needs removal, obstruction needs drainage, a stricture needs sampling/therapy, or a stent is required. |
Guidelines on bile-duct stones and biliary strictures support combining clinical probability, MRCP/EUS and context to avoid unnecessary diagnostic ERCP and direct the right patient to therapeutic ERCP.
05
COMMON PATHWAYS THAT MAY LEAD TO ERCP
The same procedure can serve very different therapeutic goals.
CLINICAL PATHWAYGallstones and Bile-Duct Stones
Stones forming in the gallbladder that can cause pain, inflammation or migrate into the bile duct.
→CLINICAL PATHWAYBile-Duct ObstructionFailure of bile flow due to stone, stricture, tumour or injury, requiring timely assessment.
→CLINICAL PATHWAYBiliary StricturesNarrowing of the bile duct from benign injury/inflammation or malignancy, requiring coordinated diagnosis and drainage.
→CLINICAL PATHWAYAcute CholangitisA potentially severe infection in an obstructed bile duct that may require urgent drainage as well as antibiotics.
→CLINICAL PATHWAYGallstone PancreatitisAcute pancreatitis triggered by a gallstone obstructing the shared duct outlet.
→CLINICAL PATHWAYPancreatic CancerCancer arising from the pancreas that requires rapid staging and multidisciplinary care.
→SG06
REFERENCES · EVIDENCE-FIRST
ERCP decisions are linked to visible, current evidence.
European Society of Gastrointestinal Endoscopy (ESGE) · 2026Biliary stricture management: European Society of Gastrointestinal Endoscopy (ESGE) GuidelineOpen source ↗ASGE · 2019ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasisOpen source ↗ESGE · 2020ERCP-related adverse events: ESGE GuidelineOpen source ↗ASGE · 2024American Society for Gastrointestinal Endoscopy guideline on the role of therapeutic EUS in the management of biliary tract disorders: summary and recommendationsOpen source ↗NIDDK – U.S. National Institutes of Health · CurrentERCP (Endoscopic Retrograde Cholangiopancreatography)Open source ↗American Society for Gastrointestinal Endoscopy (ASGE) · CurrentASGE Clinical Practice GuidelinesOpen source ↗
INTERNATIONAL PATIENTS
Clarify why ERCP is needed, what it aims to treat and what alternatives exist before you travel.
Sharing MRCP/CT images, laboratory results, EUS reports and prior ERCP/stent information in advance makes record review more meaningful.
01Share records02Clarify obstruction/stone/stricture03Define ERCP target04Travel / procedure05Stent & follow-up plan
International Patient Guide →START WITH THE RIGHT QUESTION
Do you already have MRCP, EUS, an ERCP recommendation or stent information?
Review the relevant guide first, then contact the team for an appointment or second opinion when appropriate.
